Fla. Med­i­caid funds in jeop­ardy over state’s lim­its on ER vis­its

Modern Healthcare - - REGIONAL NEWS - —Vir­gil Dick­son

The CMS may cut mil­lions in federal Med­i­caid funds to Florida over a state prac­tice that vi­o­lates federal law.

The pol­icy in ques­tion comes from the state’s de­ci­sion to re­im­burse hos­pi­tals for only six emer­gency room vis­its per Med­i­caid ben­e­fi­ciary each year.

The pol­icy is in­con­sis­tent with federal Med­i­caid laws, which sets the bar at 12 vis­its a year, ac­cord­ing to the CMS. Florida’s law specif­i­cally refers to non-preg­nant Med­i­caid ben­e­fi­cia­ries 21 and over.

In an ef­fort to cut the budget, Florida de­cided in Au­gust 2012 to re­duce the num­ber of ER vis­its it would cover. It sent the CMS a pro­posed amend­ment to its state Med­i­caid plan cov­er­age pro­vi­sions on Sept. 14, 2012. The CMS de­nied the amend­ment on Dec. 13, 2012, in­di­cat­ing that the lim­i­ta­tion on out­pa­tient ser­vices was not con­sis­tent with federal law. De­spite the red light, the state has con­tin­ued to en­force the six ER-visit rule, ac­cord­ing to the CMS.

“Florida has in­sti­tuted this visit limit and CMS in­tends to re­duce a por­tion of federal Med­i­caid ad­min­is­tra­tive pay­ments, un­less the state quickly sub­mits a plan to come into com­pli­ance with Med­i­caid law. We hope the state will re­align its Med­i­caid pro­gram with federal stan­dards to avoid this penalty,” a rep­re­sen­ta­tive from the CMS said.

The CMS has given Florida state of­fi­cials 30 days from the re­ceipt of the Feb. 20 let­ter to re­quest a hear­ing on the cuts. This would be sep­a­rate from a meet­ing that Florida of­fi­cials and the CMS al­ready have sched­uled for Septem­ber to dis­cuss the pol­icy, ac­cord­ing to state of­fi­cials.

If a hear­ing does take place, and the two par­ties are un­able to re­solve their dif­fer­ences, the CMS will re­duce federal fund­ing for the state’s ad­min­is­tra­tive Med­i­caid op­er­a­tions by 10% start­ing the next fis­cal quar­ter af­ter the hear­ing. The with- hold­ing per­cent­age will in­crease by 5% ev­ery quar­ter in which the state re­mains out of com­pli­ance, up to a max­i­mum with­hold­ing per­cent­age of 100%. Federal records show that Florida re­ceives just over $20 mil­lion an­nu­ally from the federal govern­ment to cover Med­i­caid ad­min­is­tra­tive costs.

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