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.