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Florida Medicaid Reimbursement for Outpatient Hospital Services


Outpatient hospital services are preventive, diagnostic, therapeutic or palliative care, and service items provided in an outpatient setting. The services must be provided under the direction of a licensed physician or dentist.

Medicaid reimburses licensed, Medicaid-participating hospitals for outpatient services. Medicaid reimbursement includes medical supplies, nursing care, therapeutic services, and pharmacy services. Primary care services provided in an outpatient hospital setting, hospital-owned clinic, or satellite facility are not considered outpatient hospital services and are not reimbursable under the Florida Medicaid (Title XIX) Outpatient Hospital Reimbursement Plan.

LIMITATIONS

Reimbursement for outpatient hospital services is limited to $1,500 per recipient, per Florida state fiscal year (July 1 through June 30) for recipients who are 21 years of age and older. There is no reimbursement limitation for children 20 years of age or younger.

EXCEPTIONS

Exceptions to the outpatient fiscal year (July 1 through June 30) limitation are made for surgical procedures performed in an outpatient setting, infant delivery, chemotherapy services, and dialysis services. Examples of outpatient surgery are cataract surgery, myringotomy, ligation and stripping of varicose lower limb veins, inguinal hernia repair, tubal ligation, ligation of vas deferens, and dilation and curettage.

Medicaid will reimburse outpatient hospital services furnished by a non-Medicaid-participating hospital in an emergency, for the duration of the emergency.

ELIGIBILITY

Medicaid reimburses for outpatient hospital services for all eligible Medicaid recipients who have full benefits.

PAYMENT

Outpatient reimbursement is based on a payment plan in the form of a prospective rate as established in the Florida Medicaid (Title XIX) Outpatient Hospital Reimbursement Plan. The plan can be found on the Agency’s website at http://ahca.myflorida.com/Medicaid/cost_reim/plans.shtml. An exception is diagnostic laboratory procedures, which are reimbursed the maximum Medicaid fee or the provider’s customary fee, whichever is less. Another exception to the outpatient prospective rate is newborn hearing screening and emergency department screening, which are reimbursed using an established fee.

COPAY

There is a $3 recipient copayment for each scheduled hospital outpatient or clinic visit, unless the recipient is exempt.

COINSURANCE

There is a five percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive non-emergency services not to exceed $15, unless the recipient is exempt.

Also see Florida Medicaid Reimbursement for Inpatient Hospital Services


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