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Florida Medicaid Reimbursement for Inpatient Hospital Services


Medicaid reimburses licensed, Medicaid-participating hospitals for inpatient services. The services must be provided under the direction of a licensed physician or dentist.

Medicaid reimbursement for inpatient hospital services include room and board, medical supplies, diagnostic and therapeutic services, use of hospital facilities, drugs and biologicals, nursing care, and all supplies and equipment necessary to provide the appropriate care and treatment of patients.

To participate in Medicaid, the hospital must be maintained primarily for the care and treatment of patients with disorders other than mental diseases.

LIMITATIONS

For adults 21 years of age and older, reimbursement for inpatient hospital care is limited to 45 days per Florida Medicaid’s fiscal year (July 1 through June 30). There is no limit on the number of days that Medicaid can reimburse for recipients 20 years of age or younger.

Inpatient admissions for Medicaid recipients must be prior authorized. Certain categories of recipients and circumstances are exempt from the prior authorization requirement. Some recipient exemptions are:

Recipients eligible for both Medicare and Medicaid, excluding delivery services.

Recipients enrolled in the Children’s Medical Service (CMS) Network.

EXCEPTIONS

Medicaid will reimburse inpatient hospital services to a non-Medicaid-participating hospital in an emergency, for the duration of the emergency, subject to established limitations.

ELIGIBILITY

Medicaid reimburses for inpatient hospital services for all Medicaid recipients. However, recipients in the Presumptively Eligible Pregnant Women Program are not eligible for services associated with labor, delivery, postpartum, and inpatient hospitalization. The Department of Children and Families must complete an eligibility determination and find the recipient eligible under another coverage group in order for the recipient to be eligible for these services. Undocumented aliens are eligible for emergency services only.

PAYMENT

Medicaid reimburses for inpatient hospital services prospectively based on cost-reported, per diem rates that are subject to caps. Teaching, specialty, and community health education hospitals are exempt from caps contingent upon counties contributing to the state’s share of the cost of the exemption. Additional payments are made to disproportionate share hospitals. Details of the reimbursement plan are found in the Florida Medicaid (Title XIX) Inpatient Hospital Reimbursement Plan. The plan is available on the Agency’s website at http://ahca.myflorida.com/Medicaid/cost_reim/plans.shtml.

Inpatient newborn hearing screening services are reimbursed an established fee. These are the only inpatient services to which the per diem reimbursement does not apply. Medicaid does not pay for routine newborn circumcision.

COPAY

There is a $3 recipient copayment for each admission to a hospital, unless the recipient is exempt.

Also see Florida Medicaid Reimbursement for Outpatient Hospital Services


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