(1) This rule
applies to providers rendering Florida Medicaid services to
recipients.
(2) Requirement.
Recipients are responsible for paying all applicable copayment and coinsurance
amounts directly to the provider who furnished Florida Medicaid covered
services.
(3) Amounts. The copayment
and coinsurance amounts, as specified in Section
409.9081, F.S., are as follows:
|
SERVICE
|
FEE
|
|
Chiropractor services, per provider or group
provider, per day
|
$1.00
|
|
Community behavioral health services, per provider,
per day
|
$2.00
|
|
Home health services, per provider, per day
|
$2.00
|
|
Hospital outpatient services, per visit
|
$3.00
|
|
Federally qualified health center visit, per clinic,
per day
|
$3.00
|
|
Independent laboratory services, per provider, per
day
|
$1.00
|
|
Non-emergency transportation services, per each
one-way trip
|
$1.00
|
|
Nurse practitioner services, per provider or group
provider, per day
|
$2.00
|
|
Optometrist services, per provider or group provider,
per day
|
$2.00
|
|
Physician and physician assistant, per provider or
group provider, per day
|
$2.00
|
|
Podiatrist services, per provider or group provider,
per day
|
$2.00
|
|
Portable x-ray services, per provider, per day
|
$1.00
|
|
Rural health clinic visit, per clinic, per day
|
$3.00
|
|
Use of the hospital emergency department for
non-emergency services
|
5% of the first $300.00 of the Florida Medicaid
payment (maximum $15.00)
|
(4)
Exemptions. The following categories of recipients are not required to pay a
copayment or coinsurance:
(a) Individuals
under the age of 21 years.
(b)
Pregnant women - for pregnancy-related services, including services for medical
conditions that may complicate the pregnancy. This exemption includes the six
week period following the end of the pregnancy.
(c) Individuals receiving services in an
inpatient hospital setting, long-term care facility, or other medical
institution if, as a condition of receiving services in the institution, that
individual is required to spend all of his or her income for medical care costs
with the exception of the minimal amount required for personal needs.
(d) Individuals who require emergency
services after the sudden onset of a medical condition which, if left
untreated, would place their health in serious jeopardy.
(e) Individuals receiving services or
supplies related to family planning.
(5) Recipients Unable to Pay. Providers may
not deny services to a recipient based solely on the recipient's inability to
pay a Florida Medicaid copayment or coinsurance amount. Providers may bill the
recipient for the unpaid copayment or coinsurance amount.
(6) Third-Party Coverage. Recipients who have
third-party liability coverage (including recipients eligible for Medicare) are
required to pay copayment or coinsurance amounts, unless:
(a) The recipient is otherwise
exempt.
(b) The Medicare or
third-party payment is equal to, or exceeds, the Florida Medicaid fee for the
service. Providers must reimburse recipients who have paid a Florida Medicaid
copayment when the Medicare or third-party liability payment is equal to or
exceeds the Florida Medicaid fee for the
service.
Notes
Fla. Admin.
Code Ann. R. 59G-1.056
Rulemaking Authority 409.919 FS. Law Implemented 409.9081
FS.
Adopted by
Florida
Register Volume 42, Number 130, July 6, 2016 effective
7/17/2016.
