Florida Senate - 2015 CS for SB 322
By the Committee on Fiscal Policy; and Senators Stargel, Gaetz,
and Hays
594-04179-15 2015322c1
1 A bill to be entitled
2 An act relating to Medicaid reimbursement for hospital
3 providers; amending s. 409.908, F.S.; defining terms;
4 requiring the Agency for Health Care Administration to
5 provide written notice, pursuant to ch. 120, F.S., of
6 reimbursement rates to providers; specifying
7 procedures and requirements to challenge the
8 calculation of or the methodology used to calculate
9 such rates; providing that the failure to timely file
10 a certain challenge constitutes acceptance of the
11 rates; specifying limits on and procedures for the
12 correction or adjustment of the rates; providing
13 applicability; prohibiting the agency from being
14 compelled by an administrative body or a court to pay
15 additional compensation that exceeds a certain amount
16 to a hospital for specified matters unless an
17 appropriation is made by law; prohibiting certain
18 periods of time from being tolled under specified
19 circumstances; specifying that an administrative
20 proceeding is the exclusive means for challenging
21 certain issues; reenacting ss. 383.18, 409.8132(4),
22 and 409.905(5)(c) and (6)(b), F.S., relating to
23 contracts for the regional perinatal intensive care
24 centers program, the Medikids program component, and
25 mandatory Medicaid services, respectively, to
26 incorporate the amendment made to s. 409.908, F.S., in
27 references thereto; providing that the act is
28 remedial, intended to confirm and clarify law, and
29 applies to proceedings pending on or commenced after
30 the effective date; providing an effective date.
31
32 Be It Enacted by the Legislature of the State of Florida:
33
34 Section 1. Paragraph (e) is added to subsection (1) of
35 section 409.908, Florida Statutes, to read:
36 409.908 Reimbursement of Medicaid providers.—Subject to
37 specific appropriations, the agency shall reimburse Medicaid
38 providers, in accordance with state and federal law, according
39 to methodologies set forth in the rules of the agency and in
40 policy manuals and handbooks incorporated by reference therein.
41 These methodologies may include fee schedules, reimbursement
42 methods based on cost reporting, negotiated fees, competitive
43 bidding pursuant to s. 287.057, and other mechanisms the agency
44 considers efficient and effective for purchasing services or
45 goods on behalf of recipients. If a provider is reimbursed based
46 on cost reporting and submits a cost report late and that cost
47 report would have been used to set a lower reimbursement rate
48 for a rate semester, then the provider’s rate for that semester
49 shall be retroactively calculated using the new cost report, and
50 full payment at the recalculated rate shall be effected
51 retroactively. Medicare-granted extensions for filing cost
52 reports, if applicable, shall also apply to Medicaid cost
53 reports. Payment for Medicaid compensable services made on
54 behalf of Medicaid eligible persons is subject to the
55 availability of moneys and any limitations or directions
56 provided for in the General Appropriations Act or chapter 216.
57 Further, nothing in this section shall be construed to prevent
58 or limit the agency from adjusting fees, reimbursement rates,
59 lengths of stay, number of visits, or number of services, or
60 making any other adjustments necessary to comply with the
61 availability of moneys and any limitations or directions
62 provided for in the General Appropriations Act, provided the
63 adjustment is consistent with legislative intent.
64 (1) Reimbursement to hospitals licensed under part I of
65 chapter 395 must be made prospectively or on the basis of
66 negotiation.
67 (e)1. As used in this paragraph, the term:
68 a. “Appropriation made by law” has the same meaning as
69 provided in s. 11.066.
70 b. “Reimbursement rate” means the audited hospital cost
71 based per diem reimbursement rate for inpatient or outpatient
72 care established by the agency.
73 2. Pursuant to chapter 120, the agency shall furnish
74 written notice of a reimbursement rate to providers. The written
75 notice constitutes final agency action. A substantially affected
76 provider seeking to correct or adjust the calculation of a
77 reimbursement rate, based on a challenge other than a challenge
78 to a methodology used to calculate a reimbursement rate as
79 described in subparagraph 3., may request an administrative
80 hearing by filing a petition with the agency within 180 days
81 after receipt of the written notice by the provider. The failure
82 to timely file a petition in compliance with this subparagraph
83 is deemed conclusive acceptance of the reimbursement rate.
84 3. An administrative proceeding pursuant to s. 120.569 or
85 s. 120.57 which challenges a methodology that is specified in an
86 agency rule or in a reimbursement plan incorporated by reference
87 in such rule and that is used to calculate a reimbursement rate
88 may not result in a correction or an adjustment of a
89 reimbursement rate for a rate period that occurred more than 5
90 years before the date the petition initiating the proceeding was
91 filed.
92 4. This paragraph applies to any challenge described in
93 subparagraph 2. or subparagraph 3., including a right to
94 challenge which arose before July 1, 2015. A correction or
95 adjustment of a reimbursement rate which is required by an
96 administrative order or appellate decision:
97 a. Must be reconciled in the first rate period after the
98 order or decision becomes final; and
99 b. May not serve as the basis for a challenge to correct or
100 adjust hospital rates required to be paid by a Medicaid managed
101 care provider pursuant to part IV of chapter 409.
102 5. The agency may not be compelled by an administrative
103 body or a court to pay compensation that exceeds $5 million to a
104 hospital relating to the establishment of reimbursement rates by
105 the agency or for remedies relating to such rates, unless an
106 appropriation made by law is enacted for the exclusive, specific
107 purpose of paying such additional compensation.
108 6. A period of time specified in this paragraph is not
109 tolled by the pendency of an administrative or appellate
110 proceeding.
111 7. An administrative proceeding pursuant to chapter 120 is
112 the exclusive means to challenge a reimbursement rate as
113 described under subparagraph 2. before, on, or after July 1,
114 2015, and to challenge a methodology used to calculate a
115 reimbursement rate as described under subparagraph 3.
116 Section 2. For the purpose of incorporating the amendment
117 made by this act to section 409.908, Florida Statutes, in a
118 reference thereto, section 383.18, Florida Statutes, is
119 reenacted to read:
120 383.18 Contracts; conditions.—Participation in the regional
121 perinatal intensive care centers program under ss. 383.15-383.19
122 is contingent upon the department entering into a contract with
123 a provider. The contract shall provide that patients will
124 receive services from the center and that parents or guardians
125 of patients who participate in the program and who are in
126 compliance with Medicaid eligibility requirements as determined
127 by the department are not additionally charged for treatment and
128 care which has been contracted for by the department. Financial
129 eligibility for the program is based on the Medicaid income
130 guidelines for pregnant women and for children under 1 year of
131 age. Funding shall be provided in accordance with ss. 383.19 and
132 409.908.
133 Section 3. For the purpose of incorporating the amendment
134 made by this act to section 409.908, Florida Statutes, in a
135 reference thereto, subsection (4) of section 409.8132, Florida
136 Statutes, is reenacted to read:
137 409.8132 Medikids program component.—
138 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
139 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
140 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
141 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
142 to the administration of the Medikids program component of the
143 Florida Kidcare program, except that s. 409.9122 applies to
144 Medikids as modified by the provisions of subsection (7).
145 Section 4. For the purpose of incorporating the amendment
146 made by this act to section 409.908, Florida Statutes, in
147 references thereto, paragraph (c) of subsection (5) and
148 paragraph (b) of subsection (6) of section 409.905, Florida
149 Statutes, are reenacted to read:
150 409.905 Mandatory Medicaid services.—The agency may make
151 payments for the following services, which are required of the
152 state by Title XIX of the Social Security Act, furnished by
153 Medicaid providers to recipients who are determined to be
154 eligible on the dates on which the services were provided. Any
155 service under this section shall be provided only when medically
156 necessary and in accordance with state and federal law.
157 Mandatory services rendered by providers in mobile units to
158 Medicaid recipients may be restricted by the agency. Nothing in
159 this section shall be construed to prevent or limit the agency
160 from adjusting fees, reimbursement rates, lengths of stay,
161 number of visits, number of services, or any other adjustments
162 necessary to comply with the availability of moneys and any
163 limitations or directions provided for in the General
164 Appropriations Act or chapter 216.
165 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
166 all covered services provided for the medical care and treatment
167 of a recipient who is admitted as an inpatient by a licensed
168 physician or dentist to a hospital licensed under part I of
169 chapter 395. However, the agency shall limit the payment for
170 inpatient hospital services for a Medicaid recipient 21 years of
171 age or older to 45 days or the number of days necessary to
172 comply with the General Appropriations Act. Effective August 1,
173 2012, the agency shall limit payment for hospital emergency
174 department visits for a nonpregnant Medicaid recipient 21 years
175 of age or older to six visits per fiscal year.
176 (c) The agency shall implement a prospective payment
177 methodology for establishing reimbursement rates for inpatient
178 hospital services. Rates shall be calculated annually and take
179 effect July 1 of each year. The methodology shall categorize
180 each inpatient admission into a diagnosis-related group and
181 assign a relative payment weight to the base rate according to
182 the average relative amount of hospital resources used to treat
183 a patient in a specific diagnosis-related group category. The
184 agency may adopt the most recent relative weights calculated and
185 made available by the Nationwide Inpatient Sample maintained by
186 the Agency for Healthcare Research and Quality or may adopt
187 alternative weights if the agency finds that Florida-specific
188 weights deviate with statistical significance from national
189 weights for high-volume diagnosis-related groups. The agency
190 shall establish a single, uniform base rate for all hospitals
191 unless specifically exempt pursuant to s. 409.908(1).
192 1. Adjustments may not be made to the rates after October
193 31 of the state fiscal year in which the rates take effect,
194 except for cases of insufficient collections of
195 intergovernmental transfers authorized under s. 409.908(1) or
196 the General Appropriations Act. In such cases, the agency shall
197 submit a budget amendment or amendments under chapter 216
198 requesting approval of rate reductions by amounts necessary for
199 the aggregate reduction to equal the dollar amount of
200 intergovernmental transfers not collected and the corresponding
201 federal match. Notwithstanding the $1 million limitation on
202 increases to an approved operating budget contained in ss.
203 216.181(11) and 216.292(3), a budget amendment exceeding that
204 dollar amount is subject to notice and objection procedures set
205 forth in s. 216.177.
206 2. Errors in source data or calculations discovered after
207 October 31 must be reconciled in a subsequent rate period.
208 However, the agency may not make any adjustment to a hospital’s
209 reimbursement more than 5 years after a hospital is notified of
210 an audited rate established by the agency. The prohibition
211 against adjustments more than 5 years after notification is
212 remedial and applies to actions by providers involving Medicaid
213 claims for hospital services. Hospital reimbursement is subject
214 to such limits or ceilings as may be established in law or
215 described in the agency’s hospital reimbursement plan. Specific
216 exemptions to the limits or ceilings may be provided in the
217 General Appropriations Act.
218 (6) HOSPITAL OUTPATIENT SERVICES.—
219 (b) The agency shall implement a methodology for
220 establishing base reimbursement rates for outpatient services
221 for each hospital based on allowable costs, as defined by the
222 agency. Rates shall be calculated annually and take effect July
223 1 of each year based on the most recent complete and accurate
224 cost report submitted by each hospital.
225 1. Adjustments may not be made to the rates after October
226 31 of the state fiscal year in which the rates take effect,
227 except for cases of insufficient collections of
228 intergovernmental transfers authorized under s. 409.908(1) or
229 the General Appropriations Act. In such cases, the agency shall
230 submit a budget amendment or amendments under chapter 216
231 requesting approval of rate reductions by amounts necessary for
232 the aggregate reduction to equal the dollar amount of
233 intergovernmental transfers not collected and the corresponding
234 federal match. Notwithstanding the $1 million limitation on
235 increases to an approved operating budget under ss. 216.181(11)
236 and 216.292(3), a budget amendment exceeding that dollar amount
237 is subject to notice and objection procedures set forth in s.
238 216.177.
239 2. Errors in source data or calculations discovered after
240 October 31 must be reconciled in a subsequent rate period.
241 However, the agency may not make any adjustment to a hospital’s
242 reimbursement more than 5 years after a hospital is notified of
243 an audited rate established by the agency. The prohibition
244 against adjustments more than 5 years after notification is
245 remedial and applies to actions by providers involving Medicaid
246 claims for hospital services. Hospital reimbursement is subject
247 to such limits or ceilings as may be established in law or
248 described in the agency’s hospital reimbursement plan. Specific
249 exemptions to the limits or ceilings may be provided in the
250 General Appropriations Act.
251 Section 5. The amendment made by this act to s. 409.908,
252 Florida Statutes, is remedial in nature, confirms and clarifies
253 existing law, and applies to all proceedings pending on or
254 commenced after this act takes effect.
255 Section 6. This act shall take effect upon becoming a law.