2019 Florida Statutes
Definitions; ss. 409.901-409.920.
Definitions; ss. 409.901-409.920.
409.901 Definitions; ss. 409.901-409.920.—As used in ss. 409.901-409.920, except as otherwise specifically provided, the term:
(1) “Affiliate” or “affiliated person” means any person who directly or indirectly manages, controls, or oversees the operation of a corporation or other business entity that is a Medicaid provider, regardless of whether such person is a partner, shareholder, owner, officer, director, agent, or employee of the entity.
(2) “Agency” means the Agency for Health Care Administration. The agency is the Medicaid agency for the state, as provided under federal law.
(3) “Applicant” means an individual whose written application for medical assistance provided by Medicaid under ss. 409.903-409.906 has been submitted to the Department of Children and Families, or to the Social Security Administration if the application is for Supplemental Security Income, but has not received final action. This term includes an individual, who need not be alive at the time of application, whose application is submitted through a representative or a person acting for the individual.
(4) “Benefit” means any benefit, assistance, aid, obligation, promise, debt, liability, or the like, related to any covered injury, illness, or necessary medical care, goods, or services.
(5) “Change of ownership” means:
(a) An event in which the provider ownership changes to a different individual entity as evidenced by a change in federal employer identification number or taxpayer identification number;
(b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a provider is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange; or
(c) When the provider is licensed or registered by the agency, an event considered a change of ownership for licensure as defined in s. 408.803.
A change solely in the management company or board of directors is not a change of ownership.
(6) “Claim” means any communication, whether written or electronic (electronic impulse or magnetic), which is used by any person to apply for payment from the Medicaid program or its fiscal agent for each item or service purported by any person to have been provided by a person to any Medicaid recipient.
(7) “Collateral” means:
(a) Any and all causes of action, suits, claims, counterclaims, and demands that accrue to the recipient or to the recipient’s legal representative, related to any covered injury, illness, or necessary medical care, goods, or services that necessitated that Medicaid provide medical assistance.
(b) All judgments, settlements, and settlement agreements rendered or entered into and related to such causes of action, suits, claims, counterclaims, demands, or judgments.
(c) Proceeds, as defined in this section.
(8) “Convicted” or “conviction” means a finding of guilt, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere, regardless of whether an appeal from judgment is pending.
(9) “Covered injury or illness” means any sickness, injury, disease, disability, deformity, abnormality disease, necessary medical care, pregnancy, or death for which a third party is, may be, could be, should be, or has been liable, and for which Medicaid is, or may be, obligated to provide, or has provided, medical assistance.
(10) “Emergency medical condition” means:
(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:
1. That there is inadequate time to effect safe transfer to another hospital prior to delivery.
2. That a transfer may pose a threat to the health and safety of the patient or fetus.
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(11) “Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital.
(12) “Legal representative” means a guardian, conservator, survivor, or personal representative of a recipient or applicant, or of the property or estate of a recipient or applicant.
(13) “Managed care plan” means a health maintenance organization authorized pursuant to chapter 641 or a prepaid health plan authorized pursuant to s. 409.912.
(14) “Medicaid” means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. s. 1396 et seq., and regulations thereunder, as administered in this state by the agency.
(15) “Medicaid agency” or “agency” means the single state agency that administers or supervises the administration of the state Medicaid plan under federal law.
(16) “Medicaid program” means the program authorized under Title XIX of the federal Social Security Act which provides for payments for medical items or services, or both, on behalf of any person who is determined by the Department of Children and Families, or, for Supplemental Security Income, by the Social Security Administration, to be eligible on the date of service for Medicaid assistance.
(17) “Medicaid provider” or “provider” means a person or entity that has a Medicaid provider agreement in effect with the agency and is in good standing with the agency.
(18) “Medicaid provider agreement” or “provider agreement” means a contract between the agency and a provider for the provision of services or goods, or both, to Medicaid recipients pursuant to Medicaid.
(19) “Medicaid recipient” or “recipient” means an individual whom the Department of Children and Families, or, for Supplemental Security Income, by the Social Security Administration, determines is eligible, pursuant to federal and state law, to receive medical assistance and related services for which the agency may make payments under the Medicaid program. For the purposes of determining third-party liability, the term includes an individual formerly determined to be eligible for Medicaid, an individual who has received medical assistance under the Medicaid program, or an individual on whose behalf Medicaid has become obligated.
(20) “Medicaid-related records” means records that relate to the provider’s business or profession and to a Medicaid recipient. Medicaid-related records include records related to non-Medicaid customers, clients, or patients but only to the extent that the documentation is shown by the agency to be necessary to determine a provider’s entitlement to payments under the Medicaid program.
(21) “Medical assistance” means any provision of, payment for, or liability for medical services by Medicaid to, or on behalf of, any recipient.
(22) “Medical services” or “medical care” means medical or medically related institutional or noninstitutional care, goods, or services covered by the Medicaid program. The term includes any services authorized and funded in the General Appropriations Act.
(23) “MediPass” means a primary care case management program operated by the agency.
(24) “Minority physician network” means a network of primary care physicians with experience managing Medicaid or Medicare recipients that is predominantly owned by minorities as defined in s. 288.703, which may have a collaborative partnership with a public college or university and a tax-exempt charitable corporation.
(25) “Payment,” as it relates to third-party benefits, means performance of a duty, promise, or obligation, or discharge of a debt or liability, by the delivery, provision, or transfer of third-party benefits for medical services. To “pay” means to do any of the acts set forth in this subsection.
(26) “Proceeds” means whatever is received upon the sale, exchange, collection, or other disposition of the collateral or proceeds thereon and includes insurance payable by reason of loss or damage to the collateral or proceeds. Money, checks, deposit accounts, and the like are “cash proceeds.” All other proceeds are “noncash proceeds.”
(27) “Third party” means an individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid. A third party includes a third-party administrator; a pharmacy benefits manager; a health insurer; a self-insured plan; a group health plan, as defined in s. 607(1) of the Employee Retirement Income Security Act of 1974; a service benefit plan; a managed care organization; liability insurance, including self-insurance; no-fault insurance; workers’ compensation laws or plans; or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
(28) “Third-party benefit” means any benefit that is or may be available at any time through contract, court award, judgment, settlement, agreement, or any arrangement between a third party and any person or entity, including, without limitation, a Medicaid recipient, a provider, another third party, an insurer, or the agency, for any Medicaid-covered injury, illness, goods, or services, including costs of medical services related thereto, for personal injury or for death of the recipient, but specifically excluding policies of life insurance on the recipient, unless available under terms of the policy to pay medical expenses prior to death. The term includes, without limitation, collateral, as defined in this section, health insurance, any benefit under a health maintenance organization, a preferred provider arrangement, a prepaid health clinic, liability insurance, uninsured motorist insurance or personal injury protection coverage, medical benefits under workers’ compensation, and any obligation under law or equity to provide medical support.
History.—s. 30, ch. 91-282; s. 1, ch. 95-393; s. 4, ch. 96-199; s. 1, ch. 96-387; s. 1, ch. 96-417; s. 183, ch. 99-8; s. 11, ch. 2000-163; s. 48, ch. 2000-256; s. 7, ch. 2003-405; s. 2, ch. 2004-365; s. 11, ch. 2008-246; s. 58, ch. 2009-223; s. 201, ch. 2014-19; s. 18, ch. 2017-129.