I. Cost Finding and Cost Reporting

Transcription

1 FLORIDA TITLE XIX OUTPATIENT HOSPITAL REIMBURSEMENT PLAN VERSION XXVII EFFECTIVE DATE: July 1, 2016 I. Cost Finding and Cost Reporting Hospital Outpatient Plan Version XXVII A. Each hospital participating in the Florida Medicaid program shall file a cost report postmarked no later than five calendar months after the close of its cost-reporting year. A hospital filing a certified cost report that has been audited by the independent auditors of the hospital shall be given a 30-day extension if the Agency for Health Care Administration (AHCA) is notified in writing that a certified report is being filed. The hospital cost reporting year adopted for the purpose of this plan shall be the same as that for Title XVIII or Title V cost reporting, if applicable. A complete, electronic copy of the cost report shall be filed with the Medicare intermediary and AHCA s designated audit contractor. B. All hospitals are required to detail their costs for their entire reporting year, making appropriate adjustments as required by this plan for determination of allowable costs. New hospitals shall adhere to requirements of section , Provider Reimbursement Manual, Centers for Medicare and Medicaid Services (CMS PUB as incorporated by reference in Rule 59G-6.030, Florida Administrative Code, (F.A.C.). A prospective reimbursement rate shall not be established for a new hospital based on a cost report for a period less than 12 months. For a new hospital or a new provider with no cost history, excluding new providers resulting from a change in ownership where the previous provider participated in the program, the interim rate shall be the lesser of: the county reimbursement ceiling for variable costs (including outpatient fixed costs), or the budgeted rate in compliance with CMS PUB as incorporated by reference in Rule 59G-6.030, F.A.C. and section III of the Outpatient Hospital Reimbursement Plan, as applied to the budget submitted by the provider. Interim rates shall be cost settled for the interim rate period. Interim per diem rates shall not be approved for new providers resulting from a change in ownership. Florida Medicaid reimbursement is hospital specific and is not provider specific. 1

2 C. The cost report shall be prepared in accordance with generally accepted accounting principles as established by the American Institute of Certified Public Accountants except as modified by the method of reimbursement and cost finding of Title XVIII (Medicare) Principles of Reimbursement described in 42 Code of Federal Regulations (CFR) , further interpreted by the Provider Reimbursement Manual (CMS PUB as incorporated by reference in Rule 59G , Florida Administrative Code (F.A.C.), and as further modified by this plan. D. Hospitals shall file an electronic and complete cost report within five months, or six months if a certified report is being filed, after the close of its reporting period. Medicare-granted exceptions to these time limits shall be accepted by AHCA. E. If a provider files a cost report late, after the five month period, and that cost report would have been used to set a lower reimbursement rate for a rate semester had it been filed within five months, then the provider s rate for that rate semester shall be retroactively calculated using the new cost report, and full payments at the recalculated rate shall be affected retroactively. Medicare granted exceptions to these time limits shall be accepted by AHCA. F. A hospital which voluntarily (or involuntarily) ceases to participate in the Florida Medicaid program or experiences a change of ownership, shall file a final cost report in accordance with section , CMS PUB as incorporated by reference in Rule 59G-6.030, F.A.C. For the purposes of this plan, filing a final cost report is not required when: the capital stock of a corporation is sold, partnership interest is sold as long as one of the original general partners continues in the partnership, one of the original limited partners becomes a general partner, or control remains unchanged. Any change of ownership shall be reported to AHCA within 45 days after such change of ownership. G. All Florida Medicaid participating hospitals are required to maintain the Florida Medicaid Log and financial and statistical records regarding outpatients in accordance with 42 CFR (a)-(c). For purposes of this plan, statistical records shall include the medical records of eligible Florida Medicaid recipients. These records shall be available upon demand to representatives, employees or contractors of AHCA, the Auditor General of the State of Florida, the General Accounting Office (GAO) or the United States Department of Health and Human Services (HHS). A Florida 2

3 Medicaid recipient's medical records shall be released to the above named persons for audit purposes upon proof of the recipient's consent. H. Records of related organizations as defined by 42 CFR shall be available upon demand to representatives, employees or contractors of AHCA, the Auditor General, GAO, or HHS. I. AHCA shall retain all uniform cost reports filed for a period of at least five years following the date of submission of such reports and shall maintain those reports pursuant to the record-keeping requirements of 45 CFR Access to filed cost reports shall conform with Chapter 119, Florida Statue (F.S.). J. A cost report may be reopened for inspection, correction, or referral to a law enforcement agency at any time by AHCA or its designated contractor if program payments appear to have been obtained by fraud, similar fault, or abuse. K. Cost reports must include the following statement immediately preceding the dated signature of the provider s administrator or chief financial officer: I certify that I am familiar with the laws and regulations regarding the provision of health care services under the Florida Medicaid program, including the laws and regulations relating to claims for Medicaid reimbursements and payments, and that the services identified in this cost report were provided in compliance with such laws and regulations. L. AHCA reserves the right to submit any provider found to be out of compliance with any of the policies and procedures regarding cost reports to the Bureau of Medicaid Program Integrity for investigations. M. Providers shall be subject to sanctions pursuant to section (15)(c), F.S., for late cost reports. The amount of the sanctions can be found in 59G-9.070, F.A.C. A cost report is late if it is not received by AHCA, Bureau of Medicaid Program Finance, Division of Cost Reimbursement, on the first cost report acceptance cut-off date after the cost report due date. N. AHCA shall implement a methodology for establishing base reimbursement rates for each hospital based on allowable costs. The base reimbursement rate is defined in section V.A. and V.B. of AHCA s Outpatient Hospital Reimbursement Plan. Rates shall be calculated annually and take 3

4 effect July 1 of each year based on the most recent complete and accurate cost report filed by each hospital. II. Audits A. Background A hospital common audit program has been established to reduce the cost of auditing filed cost reports and avoid duplicate auditing efforts. The purpose is to have one audit of a participating hospital which shall serve the needs of all governmental programs reimbursing the hospital for services rendered. B. Hospital Audits AHCA shall be responsible for performance of desk and field audits. AHCA, or its designated contractor shall: l. Determine the need for on-site full scope audits and determine the scope and format for such audits when selected. 2. Desk audit all cost reports within 12 months after receipt by AHCA s designated contractor. The review may not include Medicare auditor settlements if they are not available in the CMS Healthcare Cost Report Information System (HCRIS) database. 3. Ensure all audits are performed in accordance with generally accepted auditing standards of the AICPA as incorporated by reference in Rule 61H F.A.C. 4. Ensure that only those expense items that the plan has specified as allowable costs under section III of this plan have been included by the hospital in the computation of the costs of the various services provided under Rule 59G F.A.C. 5. Review to determine that the Florida Medicaid Log is properly maintained and current in those hospitals where its maintenance is required. 5. Issue, upon the conclusion of each full scope audit, a report which shall meet generally accepted auditing standards of the AICPA as incorporated by reference in Rule 61H , F.A.C. and shall declare the auditor's opinion as to whether, in all material respects, the cost filed by a hospital meets the requirements of this plan. C. Retention 4

5 All audit reports received from AHCA s designated contractor or issued by AHCA shall be kept in accordance with 45 CFR D. Overpayments and Underpayments l. Overpayments for those years or partial years as determined by desk or field audits using prior approved state plans shall be reimbursable to AHCA, as shall overpayments attributable to unallowable costs only. 2. Overpayments in outpatient hospital services shall not be used to offset underpayments in inpatient hospital services and, conversely, overpayments in inpatient hospital services shall not be used to offset underpayments in outpatient hospital services. 3. The results of desk or field audits of outpatient hospital services shall be identified separately from the results of desk or field audits of inpatient hospital services. 4. Any overpayment or underpayment that resulted from a rate adjustment due to an error in either reporting or calculation of the rate shall be refunded to AHCA or to the provider as appropriate. 5. Any overpayment or underpayment that resulted from a rate based on a budget shall be refunded to AHCA or to the provider as appropriate. 6. The terms of repayments shall be in accordance with section , F.S. 7. All overpayments shall be reported by AHCA to CMS as required, under the authority of 42 CFR 433, Subpart F. All underpayments will be subject to the time limitations under the authority of 45 CFR Information intentionally misrepresented by a hospital in the cost report shall result in a suspension of the outpatient hospital from the Florida Medicaid program. 9. AHCA or its designated contractor shall furnish to providers written notice of the audited E. Administrative Hearing hospital cost-based per diem reimbursement rate for inpatient and outpatient care. The written notice constitutes final agency action. 1. A substantially affected provider seeking to correct or adjust the calculation of the audited hospital cost-based per diem reimbursement rate for inpatient and outpatient care, 5

6 other than a challenge to the methodologies set forth in the rules of AHCA and in reimbursement plans incorporated by reference therein used to calculate the reimbursement rate for inpatient and outpatient care, may request an administrative hearing to challenge the final agency action by filing a petition with AHCA within 180 days after receipt of the written notice. The petition must include all documentation supporting the challenge upon which the provider intends to rely at the administrative hearing and may not be amended or supplemented except as authorized under uniform rules adopted pursuant to s (5), F.S. Failure to timely file a petition in compliance with this subparagraph is deemed conclusive acceptance of the audited hospital costbased per diem reimbursement rate for inpatient and outpatient care established by AHCA. 2. A correction or adjustment of an audited hospital cost-based per diem reimbursement rate for inpatient and outpatient care which is required by an administrative order or appellate decision: a. Must be reconciled in the first rate period after the order or decision becomes final. b. May not be the basis for any challenge to correct or adjust hospital rates required to be paid by any Medicaid managed care provider pursuant to part IV of this chapter. 3. AHCA may not be compelled by an administrative body or a court to pay additional compensation to a hospital relating to the establishment of audited hospital cost-based per diem reimbursement rates by the agency or for remedies relating to such rates, unless an appropriation has been made by law for the exclusive, specific purpose of paying such additional compensation. As used in this subparagraph, the term appropriation made by law has the same meaning as provided in s , Florida Statutes. 4. The exclusive means to challenge a written notice of an audited hospital cost-based per diem reimbursement rate for inpatient and outpatient care for the purpose of correcting or 6

7 adjusting such rate before, on, or after July 1, 2015, or to challenge the methodologies set forth in the rules of AHCA and in reimbursement plans incorporated by reference therein used to calculate the reimbursement rate for inpatient and outpatient care is through an administrative proceeding pursuant to chapter Any challenge to the methodologies set forth in the rules of AHCA and in reimbursement plans incorporated by reference therein used to calculate the reimbursement rate for inpatient and outpatient care may not result in a correction or an adjustment of a reimbursement rate for a rate period that occurred more than five years before the date the petition initiating the proceeding was filed. 6. This section regarding Administrative Hearings applies to any challenge to final agency action which seeks the correction or adjustment of a provider s audited hospital costbased per diem reimbursement rate for inpatient and outpatient care and to any challenge to the methodologies set forth in the rules of the agency and in reimbursement plans incorporated by reference therein used to calculate the reimbursement rate for inpatient and outpatient care, including any right to challenge which arose before July 1, Any change in this Plan in this Section regarding Administrative Hearings is remedial in nature, confirms and clarifies existing law, and applies to all proceedings pending on or commenced after July 1, III. Allowable Costs Allowable costs shall be determined using generally accepted accounting principles, except as modified by Title XVIII (Medicare) Principles of Reimbursement as described in 42 CFR , the inpatient routine nursing salary cost differential, and the guidelines in the Provider Reimbursement Manual (CMS PUB as incorporated by reference in Rule 59G-6.030, F.A.C.) and as further modified by Title XIX of the Social Security Act (SSA), this plan, requirements of licensure and certification, and the duration and scope of benefits provided under the Florida Medicaid program. These include: 7

8 A. Costs incurred by a hospital in meeting: l. The definition of a hospital contained in 42 CFR and 42 CFR in order to meet the requirements of sections 1902(a)(13) and (20) of the Social Security Act (SSA). 2. The requirements established by AHCA found in 42 CFR Any other requirements for licensing under the state law which are necessary for providing outpatient hospital services. B. Florida Medicaid reimbursements shall be limited to an amount, if any, by which the rate calculation for an allowable claim exceeds the amount of a third party recovery during the Florida Medicaid benefit period. In addition, the reimbursement shall not exceed the amount established in 42 CFR C. Malpractice insurance costs shall be apportioned to Florida Medicaid in the ratio of Florida Medicaid outpatient costs to total hospital costs, if not already included in the cost report being used to establish the Medicaid hospital outpatient rates. D. Under this plan, hospitals shall be required to accept Florida Medicaid reimbursement as payment in full for covered services provided during the benefit period and billed to the Florida Medicaid program; therefore, there shall be no payments due from Florida Medicaid recipients. As a result, for Florida Medicaid cost reporting purposes, there shall be no Florida Medicaid bad debts generated by Florida Medicaid recipients. Bad debts shall not be considered as an allowable expense. E. All physician orders and records that result in costs being passed on by the hospital to the Florida Medicaid program through the cost report shall be subject to review by AHCA or AHCA's authorized representative. F. Certain revenue centers are not reimbursed by Florida Medicaid. Service rendered under these centers shall not be recorded on the Florida Medicaid log and shall not be billed to Florida Medicaid. The list of covered revenue centers is attached as Appendix A. Modifications of this list subsequent to the implementation of this plan shall appear in the most recent version of the Florida Medicaid Outpatient Hospital Services Coverage policy incorporated by reference in Rule 8

9 59G-4.160, F.A.C.. Revenue code 510, Clinic/General is reimbursable by Florida Medicaid, in accordance with the most recent version of the Florida Medicaid Outpatient Hospital Services Coverage policy, for health care services, in outpatient clinic facilities where a non-state government owned or operated facility assumed the fiscal and operating responsibilities of one or more primary care centers previously operated by the Florida Department of Health or the local county government. G. The revenue assessments, and any fines associated with those assessments, mandated by the Health Care Access Act of 1984, section , F.S., shall not be considered an allowable Florida Medicaid cost and shall not be allocated as a Florida Medicaid allowable cost for purposes of cost reporting. IV. Standards A. In accordance with Chapter 120, F.S., Administrative Procedures Act, and 42 CFR , this plan shall be promulgated as an administrative rule and as such shall be made available for public inspection. A public hearing shall be held so that interested members of the public shall be afforded the opportunity to review and comment on this plan. B. Reimbursement ceilings shall be established prospectively for each Florida county. Additional ceilings based on the target rate system shall also be imposed. For purposes of establishing reimbursement ceilings, each hospital within the state shall be classified as general, teaching, specialized, rural, or as a Community Hospital Education Program (CHEP) hospital. Outpatient reimbursement ceilings shall be established for and applied to general hospitals. Rural and specialized psychiatric hospitals shall be excluded from the calculation and application of the outpatient reimbursement ceilings. Teaching, specialized, Community Hospital Education Program (CHEP) hospitals, shall be included in the calculation but are exempt from the application of the outpatient reimbursement ceilings. C. Effective July 1, 2011, there will be one rate setting period from July 1 through June 30. D. Changes in individual hospital rates shall be effective from July l through June 30 of each year. E. For the initial period, the last cost report received from each hospital shall be used to establish the reimbursement ceilings. In the absence of sufficient information from the above source, claims 9

10 payment data from the Florida Medicaid fiscal agent shall be used. Should none of the above sources provide acceptable information, the hospital shall be excluded from the reimbursement ceiling calculations. The hospital shall then have a rate assigned that equals the lowest computed rate in the county in which the hospital is located, or the lowest rate in the AHCA District in which the hospital is located, if there are no other hospitals in the county in question. F. For subsequent periods, all cost reports received by AHCA as of each April 15 shall be used to establish the reimbursement ceilings. G. Effective July 1, 2016, all amended cost reports must be filed with AHCA by July 31 st to be used for the current rate setting. All amended cost reports filed after July 31 st will be reconciled in the subsequent rate setting year. H. The individual hospital's prospectively determined rate shall be adjusted only under the following circumstances: 1. An error was made by AHCA s designated contractor or AHCA in the calculation of the hospital's unaudited rate. 2. A hospital files an amended unaudited cost report to supersede the unaudited cost report used to determine the rate in effect. There shall be no change in rate if an amended cost report is filed beyond three years of the effective date the rate was established, or if the change is not material, or if the cost report has been audited. Effective July 1, 2016, a hospital must submit an amended cost report by July 31st of the state fiscal year the rates are effective. 3. Further desk or field audits of cost reports used in the establishment of the prospective rate disclose material changes in these reports. 4. Where the charge structure of a hospital changes and the application of the lower of cost or charges limitations is reconsidered. I. Under no circumstances shall any rate adjustment exceed the reimbursement ceiling established, except as provided for in section IV.B. 10

11 J. The reimbursement rates for laboratory and pathology services shall be the lower of the hospital's V. Method charges or the Florida Medicaid fee schedule technical component as provided for in Rule 59G , F.A.C. Payment for Clinic Diagnostic Laboratory (CDL) outpatient hospital rates are based on a state-developed fee schedule, which is the same as both governmental and private outpatient hospitals. The agency s CDL outpatient hospital rates were set as January 1, 2016 effective for services on or after this date. The fee schedules are published at : Rates do not exceed Medicare rates for the same codes on a per test basis as required by Section 1903(i)(7). This section defines the methodologies to be used by the Florida Medicaid program in establishing reimbursement ceilings and individual hospital reimbursement rates. A. Setting Reimbursement Ceilings. l. Review and adjust the hospital cost report available to AHCA as of each April 15 as follows: a. To reflect the results of desk or field audits. b. To reduce the Florida Medicaid outpatient costs and charges for laboratory and pathology costs and charges. 2. Reduce a hospital's general routine operating costs if they are in excess of the limitations established in 42 CFR Determine Florida Medicaid outpatient variable costs defined in section X. 4. Adjust Florida Medicaid outpatient variable costs for the number of months between the midpoint of the hospital's fiscal year and December 31, the midpoint of the rate semester for which the new rate is being calculated. The adjustment shall be made utilizing the latest available projections at the time of rate setting for the Data Resources Incorporated (DRI) Type Hospital Market Basket Index as detailed in Appendix B. 11

12 5. Divide the inflated Florida Medicaid outpatient variable costs by the latest available Health Care Component of the Florida Price Level Index (FPLI) for the county in which the hospital is located. 6. Divide the results of step five for each hospital by the total Florida Medicaid outpatient occasions of service excluding occasions of service for laboratory and pathology resulting in an occasion of service rate. 7. Array the occasions of service rates in step six from the lowest to the highest rate with the associated occasions of service. 8. Establish the reimbursement ceilings as the lower of: a. The cost based ceilings for variable costs per occasion of service at the occasion of service rate associated with the 80th percentile of occasions of service, times the FPLI component utilized in step five for the county in which the hospital is located. Rural and specialized psychiatric hospitals are excluded from the calculation and application of this cost based ceiling. The following types of hospitals are included in the calculation, but are exempt from the application of this cost based ceiling except for the limitations described in 9 through 11 below: i. Teaching hospitals. ii. iii. iv. Specialized hospitals. Community Hospital Education Program (CHEP). Those mentioned in 9 through 11 below v. Hospitals with Level III Neonatal Intensive Care Units that have a minimum of three of the following designated tertiary services as regulated under the certificate of need program: pediatric bone marrow transplantation, pediatric open heart surgery, pediatric cardiac catheterization and pediatric heart transplantation. 12

13 For hospitals participating in the Florida Medicaid program that are located out of state, the FPLI used shall be equal to b. The target ceiling shall be calculated by multiplying the previous rate period s ceiling by the target inflation factor as calculated in the following formula: Midpoint of the prospective rate period x [ using appendix B -1 ] Midpoint of the current rate period using Appendix B This target ceiling shall not apply to rural, specialized, teaching, and Community Hospital Education Program (CHEP) hospitals, and those hospitals defined in 9 through 11 below. This target ceiling shall not apply to the following: i. Teaching hospitals. ii. iii. iv. Specialized hospitals. Community Hospital Education Program (CHEP). Those mentioned in 9 through 11 below v. Hospitals with Level III Neonatal Intensive Care Units that have a minimum of three of the following designated tertiary services as regulated under the certificate of need program: pediatric bone marrow transplantation, pediatric open heart surgery, pediatric cardiac catheterization and pediatric heart transplantation. 9. The outpatient hospital reimbursement ceilings will be eliminated for hospitals whose charity care and Medicaid days as a percentage of total adjusted hospital days equals or exceeds 11 percent. For any public hospital or any leased public hospital found to have sovereign immunity or hospital with graduate medical education positions that does not qualify for the elimination of the outpatient ceilings, such hospitals shall be exempt from the outpatient reimbursement ceilings. AHCA shall use the average of the 2007, 2008 and 2009 audited DSH data available as of March 1, In the event AHCA does not have the prescribed three years of audited DSH data for a hospital, AHCA shall use the 13

14 average of the audited DSH data for 2007, 2008 and 2009 that are available. Any hospital that was exempt from the outpatient reimbursement ceiling in the prior state fiscal year, due to their charity care and Medicaid days as a percentage to total adjusted hospital days equaling or exceeding 11 percent, but no longer meet the 11 percent threshold, because of updated audited DSH data shall remain exempt from the outpatient reimbursement ceilings for a period of two years. 10. The outpatient hospital reimbursement ceilings will be eliminated for hospitals that have a minimum of ten licensed Level II Neonatal Intensive Care Beds and are located in Trauma Services Area The outpatient reimbursement ceilings will be eliminated for hospitals whose Medicaid days, as a percentage of total hospital days, exceed 7.3 percent, and are designated or provisional trauma centers. This provision shall apply to all hospitals that are designated or provisional trauma centers on July 1, 2010 or became a designated or provisional trauma center during Fiscal Year Included in these funds are the annualized amounts to offset the reductions taken against certified trauma centers as identified in section 13, chapter , Laws of Florida. AHCA shall use the average of the 2007, 2008 and 2009 audited DSH data available as of March 1, In the event AHCA does not have the prescribed three years of audited DSH data for a hospital, AHCA shall use the average of the audited DSH data for 2007, 2008 and 2009 that are available. B. Setting Individual Hospital Rates. This section V.B. defines the methodologies and steps to be used by the Florida Medicaid program in establishing individual hospital reimbursement rates. Additions and changes to this section from the preceding year(s) are intended to clarify the rate-setting process, not to make substantive changes to it. 1. Review and adjust the hospital cost report available to AHCA as of each April 15 as follows: a. To reflect the results of desk and field audits. 14

15 b. To reduce the Florida Medicaid outpatient costs and charges for laboratory and pathology costs and charges. 2. Reduce the hospital's general routine operating costs if they are in excess of the limitations established in 42 CFR Determine Florida Medicaid outpatient variable costs as defined in section X. 4. Adjust Florida Medicaid outpatient variable costs for the number of months between the midpoint of the hospital's fiscal year and December 31, the midpoint of the following rate semester. The adjustment shall be made utilizing the DRI Regional Hospital Input Price Index as detailed in Appendix B. 5. Establish the variable cost rate as the lower of: a. The inflated rate by dividing the inflated allowable Florida Medicaid outpatient variable costs by the total Florida Medicaid outpatient occasions of service for the hospital excluding occasions of service for laboratory and pathology. b. The target rate by inflating the variable cost rate in the previous rate period by the target inflation factor calculated in section V.A.8.b. in establishing target ceilings. This target rate shall not apply to rural, specialized, teaching, Community Hospital Education Program (CHEP) hospitals, and those hospitals defined in Section V.A. 9 through 11. i. Set the rate for the hospital as the lower of the result of step five, the reimbursement ceiling in section V.A.8 for the county in which the hospital is located, or the result of inflated Florida Medicaid outpatient charges divided by total Florida Medicaid outpatient occasions of service excluding charges and occasions of service for laboratory and pathology. 6. Effective July 1, 2005, a recurring rate reduction shall be established until an aggregate total estimated savings of $16,796,807 is achieved each year. This reduction is the Medicaid trend adjustment (MTA). In reducing hospital outpatient rates, rural hospitals and hospitals with 20,000 or more combined Medicaid managed care and fee-for-service inpatient days shall not 15

16 have their outpatient rates reduced below the final rates that are effective on the prior June 30 of each year. The 2002 Financial Hospital Uniform Reporting System (FHURS) data shall be used to determine the combined inpatient Medicaid days. This recurring rate reduction amount is referred to as MTA number 1. This rate setting methodology step utilizes each hospital s outpatient rate which is calculated without the MTA based on the hospital s current submitted cost report and using Florida Medicaid outpatient occasions of service based on the current cost report. Each hospital s rate without the MTA is proportionally reduced until the saving of $16,796,807 is achieved. 7. Effective January 1, 2008, an additional MTA shall be applied to achieve a recurring annual reduction of $17,211,796. This recurring rate reduction amount is referred to as MTA number 2. This step begins with the rates calculated after MTA number 1 has been established. The resulting MTA number 1 rates are proportionally reduced until the saving of $17,211,796 is achieved using the hospital s Florida Medicaid occasions of service based on the current cost report. After this reduction, a recurring annual buy-back of $4,068,064 is applied to offset a proportion of the MTA number 2 reduction to trauma centers/trauma hospitals only using the hospital s Florida Medicaid outpatient occasions of service. 8. Effective July 1, 2008, an additional MTA shall be applied to achieve a recurring annual reduction of $36,403,451. This recurring rate reduction amount is referred to as MTA number 3. This step begins with the rates calculated after MTA number 2 and after the trauma buyback has been applied. The resulting rates are then proportionally reduced until the saving of $36,403,451 is achieved using the hospital s Florida Medicaid outpatient occasions of service based on the current cost report. 9. Effective March 1, 2009, AHCA shall implement a recurring methodology to reduce individual outpatient hospital rates proportionately until the required $19,384,437 annual savings is achieved. Hospitals that are licensed as a children s specialty hospital and whose Medicaid days plus charity care days divided by total adjusted patient days equals or exceeds 30 percent are excluded from this reduction. This recurring rate reduction amount is referred to as MTA number 4. This step begins with the rates calculated after MTA number 3 is 16

17 established. The resulting MTA number 3 rates are then proportionally reduced until the saving of $19,384,437 is achieved using the hospital s Florida Medicaid outpatient occasions of service based on the current cost report. 10. Effective July 1, 2009, the recurring rate reduction referred to as MTA number 5 was not necessary based on the established rate setting unit cost being less than the unit cost used in establishing the budget. The rates after MTA number 5 would be the same as the rates after MTA number Effective July 1, 2010, the recurring rate reduction referred to as MTA number 6 was not necessary based on the established rate setting unit cost being less than the unit cost used in establishing the budget. The rates after MTA number 6 would be the same as the rates after MTA number Effective July 1, 2011, AHCA shall establish rates at a level that ensures no increase in statewide expenditures resulting from a change in unit costs. 13. Effective July 1, 2011, $99,045,233 will be used for a reduction in outpatient hospital reimbursement rates. Hospitals that are licensed as a children s specialty hospital and whose Medicaid days plus charity care days divided by total adjusted patient days equals or exceeds 30 percent and rural hospitals as defined in s , are excluded from this reduction. This recurring rate reduction amount is referred to as MTA number 7. This step begins with the rates calculated after MTA number 6 is established. The resulting MTA number 6 rates are then proportionally reduced until the saving of $99,045,233 is achieved using the hospital s Florida Medicaid outpatient budgeted occasions of service (fee-for-service only) which are the same as those used in the July 1, 2015 rate setting calculation. 14. Effective July 1, 2012, AHCA shall implement a recurring methodology in the Title XIX Outpatient Hospital Reimbursement Plan to achieve a $49,078,485 annual reduction. This recurring rate reduction amount is referred to as MTA number 8. This step begins with the rates calculated after MTA number 7 is established. The resulting MTA number 7 rates are then proportionally reduced until the saving of $49,078,485 is achieved using the hospital s 17

18 Florida Medicaid outpatient budgeted occasions of service (fee-for-service only) which are the same as those used in the July 1, 2015 rate setting calculation Effective July 1, 2012, $10,656,238 is provided to partially restore the July 1, 2012 reduction in outpatient hospitals. This step begins with the rates calculated after MTA number 8. A recurring annual buy-back of $10,656,238 is applied to offset a portion of the MTA number 8 reduction except for hospitals that are licensed as a children s specialty hospital and the Medicaid days plus charity care days divided by total adjusted patient days equals or exceeds 30 percent and rural hospitals as defined in s F.S., as they are excluded from this buy-back. 16. As required by paragraph number 12 above, the rate setting unit cost as of June 30, 2011, which was $141.51, is compared to the current rate setting unit cost. The rate setting unit cost calculation is determined as following; Rate Setting Unit Cost = (Total Estimated XIX Payment / (Total Florida Medicaid Outpatient Budgeted Occasions of Service Children s & Rural Occasions of Service)). If the current rate setting unit cost is less than the June 30, 2011 unit cost, no additional rate reduction is necessary. If the rate setting unit cost is greater than the June 30, 2011unit cost, the rates shall be proportionally reduced by the reduction percentage. The reduction percentage is calculated by the following formula; 1-(rate setting unit cost / $141.51). 17. The next step is referred to as the Tier Cap Calculation. The Tier Cap Calculation is determined based on a hospital s classification and allowable percent of exemption. The hospitals in the classification exemption category for the Tier Cap Calculation are those hospitals who qualified under the parameters for ceiling and target limitations for hospital reimbursement. The qualifying hospitals are allowed to receive a specific percentage of the exemption based on the hospital s classification % - Specialty Children s; % - Public/Statutory Teaching; % - Designated Trauma, Specialty Hospitals, Specialty Legislative, Medicaid and Charity Utilization, Community Hospital Education Program; 1.50% - Trauma Add-on; and explicit dollar amount Pediatric Add-on. 18

19 18. $26,131,167 is provided for qualifying hospitals to allow for exemptions from outpatient reimbursement limitations. The rates from the Tier Cap Calculation step are allowed a buyback of $26,131,167 which is applied to offset all reductions for hospitals. The total buy-back amount for each hospital is added to the hospital s estimated Medicaid payment after the results from the Tier Cap Calculation. This calculation produces a new estimated Medicaid payment. Based on the new estimated Medicaid payment, a new outpatient rate is calculated by dividing the new estimated Medicaid payment by the Florida Medicaid outpatient budgeted occasions of service. The new outpatient rate is compared to the Tier Rate calculated in the Tier Cap Calculation step and the difference is the maximum buy-back amount. The lessor of maximum buy-back amount and the allowable buy-back amount calculated in the Tier Cap Calculation step is added to the Tier Rate and becomes the final rate. 19. Effective July 1, 2014, the outpatient rates will not include any self-funded IGT rate enhancements for exemptions and buybacks. VI. Payment Assurance The State shall pay each hospital for services provided in accordance with the requirements of the most recent version of the Florida Title XIX Outpatient Hospital Reimbursement Plan. The payment amount shall be determined for each hospital according to the standards and methods set forth in the most recent version of the Florida Title XIX Outpatient Hospital Reimbursement Plan. VII. Provider Participation This plan is designed to assure adequate participation of hospitals in the Florida Medicaid Program, the availability of hospital services of high quality to recipients, and services which are comparable to those available to the general public. This is in accordance with 42 CFR VIII. Revisions 19

20 The plan shall be revised as operating experience data are developed and the need for changes is necessary in accordance with modifications in the Code of Federal Regulations. IX. Payment in Full Participation in the Program shall be limited to hospitals of service which accept as payment in full for covered services the amount paid in accordance with the most recent version of the Florida Title XIX Outpatient Hospital Reimbursement Plan. X. Glossary A. Acceptable cost report - A completed, legible cost report that contains all relevant schedules, worksheets and supporting documents. B. Adjusted patient days - The sum of acute care patient days and intensive care patient days as reported to AHCA divided by the ratio of inpatient revenues generated from acute, intensive, ambulatory, and ancillary patient services to gross revenues C. AHCA - Agency for Health Care Administration. D. Allowable costs - An item or group of items of cost chargeable to one or more objects, processes, or operations in accordance with generally accepted accounting principles except as modified by the Principles of Reimbursement for Provider Costs, as defined in CMS PUB as incorporated by reference in 59G F.A.C., and as further defined in the most recent version of the Florida Title XIX Outpatient Hospital Reimbursement Plan. E. Base rate - A hospital s per diem reimbursement rate before a Florida Medicaid trend adjustment or a buy back is applied. F. Benefit period - The period of time where medical benefits for services covered by the Florida Medicaid program, with certain specified maximum limitations, are available to the Florida Medicaid beneficiary. G. Buy-back - The buy back provision potentially allows a hospital to decrease their Florida Medicaid trend adjustment from the established percent down to zero percent. 20

21 H. Community Hospital Education Program (CHEP) hospitals Hospitals that participate in a program that offers continuing medical education programs for interns and residents established on a statewide basis. I. Cost reporting year - A 12-month period of operation based upon the provider's accounting year. J. Eligible Florida Medicaid recipient - "Recipient" or "Florida Medicaid recipient" means any individual whom the Florida Department of Children and Families, or the SSA on behalf of AHCA, determines is eligible, pursuant to federal and state law, to receive medical or allied care, goods, or services for which the department may make payments under the Florida Medicaid program and is enrolled in the Florida Medicaid program. For the purposes of determining third party liability, the term includes an individual formerly determined to be eligible for Florida Medicaid, an individual who has received medical assistance under the Florida Medicaid program, or an individual on whose behalf Florida Medicaid has become obligated. K. Filing due date - No later than five calendar months after the close of the hospital s cost- reporting year. L. Florida Medicaid log - A schedule to be maintained by a hospital listing each Florida Medicaid patient's recipient number, dates of admission and discharge, and the charges and payments for services and goods received from the hospital's revenue centers. M. Florida Medicaid outpatient charges the hospital s usual and customary charges for outpatient services rendered to Florida Medicaid patients excluding charges for laboratory and pathology services. These charges shall be the allowable charges as reconciled with the hospital Florida Medicaid log and found on the Florida Medicaid paid claims report. N. Florida Medicaid outpatient costs Allowable operating costs as apportioned to Florida Medicaid by cost finding methods in the CMS 2552 cost report. O. Florida Medicaid outpatient occasions of service Based on the fiscal year end of the hospital s cost report, the number of distinct revenue center code line items listed on a valid claim that a hospital has filed with the fiscal agent, excluding laboratory and pathology revenue center code line items, and that have been paid by the fiscal agent, which represent covered Florida Medicaid outpatient services. 21

22 P. Florida Medicaid outpatient variable costs - Allowable operating costs excluding laboratory and pathology costs less return on equity as apportioned to Florida Medicaid by cost finding methods in the CMS 2552 cost report. Q. Florida price level index - A spatial index which measures differences from county to county in the cost of purchasing a specified market basket of items at a particular point in time. The items in the market basket range from various food products to hospital lab fees, and are grouped into the components of food, housing, apparel, transportation, and health, recreation and personal services. A county index for each of the five components is developed bi-annually by the Florida Executive Office of the Governor. County indices are population weighted to average 100 percent. An index of for a given county means that the basket of goods in that county costs percent more than the State average. Changes to the methodology utilized in the development of the FPLI will constitute changes in this plan and will require a formal plan amendment. R. General hospital A hospital in this state that is not classified as a specialized hospital. S. HHS - Department of Health and Human Services. T. Late cost report - A cost report is late when it is filed with AHCA s designated audit contractor, after the Filing Due Date, and after the Rate Setting Due Date. U. Legislative unit cost - The average weighted per diem of the State anticipated expenditure after all rate reductions but prior to any buy back. V. CMS PUB Health Insurance Manual No. 15, also known as the Provider Reimbursement Manual, as incorporated by reference in Rule 59G-6.030, F.A.C. W. Non-covered services - Those goods and services which are not medically necessary for the care and treatment of outpatients as defined in CMS PUB 15.1 as incorporated by reference in Rule 59G-6.030, F.A.C. X. Provider service network (PSN) is defined in s , F.S., as a network established or organized and operated by a health care provider, or group of affiliated health care providers, which provides a substantial proportion of the health care items and services under a contract directly through the provider or affiliated group of providers. 22

23 Y. Rate semester - January 1 through June 30 of a given year, or July 1 through December 31 of a given year. Effective July 1, 2011, the rate semester begins on July 1 and runs through June 30. Z. Rate setting due date - All cost reports postmarked by March 321 and received by AHCA by April 15 shall be used to establish the reimbursement rates. AA. Rate setting unit cost - The weighted average per diem after all rate reductions but prior to any buy backs based on filed cost reports. BB. Reimbursement ceiling - The upper limit for Florida Medicaid Outpatient Variable Cost rate reimbursement for an individual hospital. CC. Reimbursement ceiling period - January 1 through June 30 of a given year or July 1 through December 31, of a given year. DD. Rural hospital - An acute care hospital licensed under Chapter 395, F.S., with 100 licensed beds or less, which has an emergency room and is located in an area defined as rural by the United States Census, and which is: 1. The sole provider within a county with a population density of no greater than 100 persons per square mile. 2. An acute care hospital, in a county with a population density of no greater than 100 persons per square mile, which is at least 30 minutes of travel time, on normally traveled roads under normal traffic conditions, from any other acute care hospital within the same county. 3. A hospital supported by a tax district or subdistrict whose boundaries encompass a population of 100 persons or less per square mile. 4. A hospital in a constitutional charter county with a population of over 1 million persons that has imposed a local option health service tax pursuant to law and in an area that was directly impacted by a catastrophic event on August 24, 1992, for which the Governor of Florida declared a state of emergency pursuant to chapter 125, and has 120 beds or less that serves an agricultural community with an emergency room utilization of no less than 20,000 visits and a Florida Medicaid inpatient utilization rate greater than 15 percent. 5. A hospital with a service area that has a population of 100 persons or fewer per square mile. As used in this subparagraph, the term "service area" means the fewest number of zip codes 23

24 that account for 75 percent of the hospital's discharges for the most recent 5-year period, based on information available from the hospital inpatient discharge database in the Florida Center for Health Information and Policy Analysis at AHCA. 6. A hospital designated as a critical access hospital, as defined in s F.S. Population densities used in this paragraph must be based upon the most recently completed United States census. A hospital that received funds under s F.S. for a quarter beginning no later than July 1, 2002, is deemed to have been and shall continue to be a rural hospital from that date through June 30, 2021, if the hospital continues to have up to 100 licensed beds and an emergency room. An acute care hospital that has not previously been designated as a rural hospital and that meets the criteria of this paragraph shall be granted such designation upon application, including supporting documentation to AHCA. 7. A hospital that was licensed to continue to be a rural hospital during fiscal year or shall continue to be a rural hospital from the date of designation through June 30, 2021, if the hospital continues to have up to 100 licensed beds and an emergency room. EE. Specialized hospital - A licensed hospital primarily devoted to TB, psychiatric care, pediatric, eye, or cardiac care and treatment; or a licensed hospital that has ten or more residency training programs. FF. Teaching Hospital - any hospital formally affiliated with an accredited medical school that exhibits activity in the area of medical education as reflected by at least seven different resident physician specialties and the presence of 100 or more resident physicians. GG. Title XVIII - Health Insurance for the Aged, Blind or Disabled (Medicare) as provided for in the SSA, certified in 42 United States Code (U.S.C.) xx. HH. Title XIX - Grants to States for medical assistance programs (Medicaid) as provided for in the SSA, certified in 42 U.S.C p. II. Total Outpatient Charges - Total patient revenues assessed for all outpatient services excluding charges for laboratory and pathology. XI. Purpose of the Plan 24