Florida Regulations 59G-6.025: Reimbursement Methodology for Cancer Hospitals
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(1) This rule applies to Florida Medicaid providers that render inpatient and outpatient hospital services to recipients through the fee-for-service delivery system. The providers must be considered as a cancer hospital and:
(a) Be members of the Alliance of Dedicated Cancer Centers.
(b) Meet the criteria under Title 42, United States Code, section 1395ww(d)(1)(B)(v).
(2) Definitions.
(a) Upper Payment Limit (UPL) – The annual maximum amount Florida Medicaid may pay in the aggregate to inpatient hospitals for inpatient and outpatient services rendered under the Florida Medicaid fee-for-service delivery system.
(b) UPL Gap – The difference between the annual maximum amount Medicare would pay to a cancer hospital for inpatient and outpatient hospital services rendered to recipients and the actual amount paid by Florida Medicaid for those services.
(c) Valid Claim – A “”clean claim”” as defined in Fl. Admin. Code R. 59G-1.010, for inpatient and outpatient hospital services that meet all of the following:
1. Provided by a cancer hospital under the fee-for-service delivery system.
2. Provided to Florida Medicaid recipients who are not also eligible for Medicare.
(3) Reimbursement.
(a) Effective October 26, 2017, Florida Medicaid reimburses cancer hospitals for inpatient and outpatient hospital services rendered to eligible Florida Medicaid recipients in an amount up to each hospital’s UPL, in accordance with Title 42, Code of Federal Regulations (CFR), section 447.272.
(b) Florida Medicaid calculates supplemental payments to cancer hospitals based upon the UPL gap.
(c) Florida Medicaid reimbursement to providers for state fiscal year (SFY) 2017-2018 will be prorated by using the ratio of effective dates within SFY 2017-2018 and multiplying the ratio by the UPL gap for hospital inpatient and outpatient services. The calculated ratio for SFY 2017-2018 is 0.6795.
(d) Florida Medicaid will calculate supplemental payments quarterly, based on valid claims that have a paid date within the previous three months.
Rulemaking Authority 409.919 FS. Law Implemented 409.905, 409.908 FS. History-New 5-13-19.
Terms Used In Florida Regulations 59G-6.025
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
(b) Meet the criteria under Title 42, United States Code, section 1395ww(d)(1)(B)(v).
(2) Definitions.
(a) Upper Payment Limit (UPL) – The annual maximum amount Florida Medicaid may pay in the aggregate to inpatient hospitals for inpatient and outpatient services rendered under the Florida Medicaid fee-for-service delivery system.
(b) UPL Gap – The difference between the annual maximum amount Medicare would pay to a cancer hospital for inpatient and outpatient hospital services rendered to recipients and the actual amount paid by Florida Medicaid for those services.
(c) Valid Claim – A “”clean claim”” as defined in Fl. Admin. Code R. 59G-1.010, for inpatient and outpatient hospital services that meet all of the following:
1. Provided by a cancer hospital under the fee-for-service delivery system.
2. Provided to Florida Medicaid recipients who are not also eligible for Medicare.
(3) Reimbursement.
(a) Effective October 26, 2017, Florida Medicaid reimburses cancer hospitals for inpatient and outpatient hospital services rendered to eligible Florida Medicaid recipients in an amount up to each hospital’s UPL, in accordance with Title 42, Code of Federal Regulations (CFR), section 447.272.
(b) Florida Medicaid calculates supplemental payments to cancer hospitals based upon the UPL gap.
(c) Florida Medicaid reimbursement to providers for state fiscal year (SFY) 2017-2018 will be prorated by using the ratio of effective dates within SFY 2017-2018 and multiplying the ratio by the UPL gap for hospital inpatient and outpatient services. The calculated ratio for SFY 2017-2018 is 0.6795.
(d) Florida Medicaid will calculate supplemental payments quarterly, based on valid claims that have a paid date within the previous three months.
Rulemaking Authority 409.919 FS. Law Implemented 409.905, 409.908 FS. History-New 5-13-19.