Q & A – CATEGORY – Hospitals:

** What is the status of the Upper Payment Limit (UPL)?
This topic is beyond the scope of this Q&A. The transition from UPL to Low Income Pool (LIP) Cost Limit is part of the Florida Medicaid Reform Section 1115 Demonstration running from July 1, 2006 to June 30, 2011. You may contact us for two relevant documents:

1. CMS Special Terms and Conditions of the Demonstration
2. Reimbursement and Funding Methodology related to the waiver as updated 5/29/2007
1. In accordance with the Special Terms and Conditions (STCs) for waiver number 11-W-00206/4, Medicaid reform Section 1115 Demonstration, the State of Florida, Agency for Health Care Administration (AHCA), Medicaid program, (the State) submits to the Centers for Medicare and Medicaid Services (CMS) this Reimbursement and Funding Methodology document.
2. In addition to the Reimbursement and Funding Methodology document, the State is providing the definition of expenditures eligible for Federal matching funds and the entities eligible to receive reimbursement.

• Permissible expenditures are discussed in STC 94; “Funds from the LIP may be used for health care expenditures (medical care costs or premiums) that would be within the definition of medical assistance in Section 1905(a) of the Act. These healthcare expenditures may be incurred by the State, by hospitals, clinics, or by other provider types for uncompensated medical care costs of medical services for the uninsured, Medicaid shortfall (after all other Title XIX payments are made) may include premium payments, payments for provider access systems (PAS) and insurance products for such services provided to otherwise uninsured individuals, as agreed upon by the State and CMS.”

3. Included in this document is the methodology used for the distribution of the $1 billion annual LIP funds as provided for in the STC.

** How will it benefit the Hospitals to participate?
This happens in several ways as follows:

• Also see Q & A under “Primary Care Physician” and “Cost Based Providers” above.
• Hospitals will receive 100% of Medicaid while a Fee For Service PSN.
•  Hospitals will receive a negotiated rate in excess of Medicaid from Prepaid or Capitated PSN / HMO
• Hospitals will receive a negotiated rate in excess of Medicare rate from applicable Medicare Special Needs Plan (SNP)
• A primary element in the rural Disproportionate Share (s. 409.9116, F.S.) Hospital (DSH) formula includes Medicaid days which will continue.
• ADVANTAGE FLORIDA HEALTH PLAN will do everything possible to see that the enrollee receives services within network facilities.
• ADVANTAGE FLORIDA HEALTH PLAN will work with stakeholders to utilize the natural flow of referrals to tertiary facilities and specialists.
• ADVANTAGE FLORIDA HEALTH PLAN will work with stakeholders on a clinical integration model for enrollees to help address any reduction in income to rural hospitals due to the effect of 2008 Medicare Severity DRGs.
• By participation, Hospitals will comply with conditions required in order to receive LIP funds. Wording of such conditions in the LIP document includes:
• Cooperate with a Medicaid Health Plan;
• Agree to accept all patients, regardless of ability to pay, on a functional space-available basis;
• Agree to provide backup and referral services to low-income providers within the hospital's service area, including the development of written agreements between these organizations and the hospital