Florida Administrative Code

Rulemaking Authority 409.026(8), 409.910(22), (23), 409.919 FS. Law Implemented 409.910(20), 624.424(9), 641.261, 641.411 FS. History-New 11-14-89, Formerly 10C-7.0302, Amended 11-13-91, Formerly 10C-35.0211, Amended 10-3-96, Repealed 9-24-18.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.910(1), (3) FS. History-New 11-13-91, Formerly 10C-35.023, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.910 FS. History-New 11-13-91, Formerly 10C-35.032, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 120.53(1)(b), (c), 409.026(8), 409.910(23), 409.919 FS. Law Implemented 120.53(1)(b), (c), 409.910 FS. History-New 11-13-91, Formerly 10C-35.0322, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 120.53(1), 409.026(8), 409.910(23), 409.919 FS. Law Implemented 120.53(1), 409.910 FS. History-New 11-13-91, Formerly 10C-35.0331, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.910 FS. History-New 11-13-91, Formerly 10C-35.0332, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 20.05, 120.53(1)(b), (c), 409.026(8), 409.285, 409.910(23), 409.919 FS. Law Implemented 120.53(1)(b), (c), 120.57, 120.58, 409.285, 409.902, 409.910 FS. History-New 11-13-91, Formerly 10C-35.034, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.910 FS. History-New 11-13-91, Formerly 10C-35.035, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.051, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.053, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.054, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(21), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS.; 42 U.S.C. ss. 1396a(a)(25), (a)(27), (a)(45), 1396k (Social Security Act ss. 1902(a)(25), (a)(27), (a)(45), 1912); 42 C.F.R. ss. 433.135-43…

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.057, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.058, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.902, 409.907, 409.908, 409.910, 409.912, 409.913, 409.920 FS. History-New 11-13-91, Formerly 10C-35.0581, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 120.53, 409.026(8), 409.910(23), 409.919 FS. Law Implemented 120.57, 120.58, 120.68, 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.060, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 120.53, 409.026(8), 409.910(23), 409.919 FS. Law Implemented 120.57, 120.58, 120.68, 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.0601, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.061, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.062, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.063, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 120.58, 409.257, 409.901, 409.902, 409.910, 409.920(2)(a), (c) FS. History-New 11-13-91, Formerly 10C-35.064, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.026(8), 409.910(23), 409.919 FS. Law Implemented 409.910 FS. History-New 11-13-91, Formerly 10C-35.073, Amended 10-3-96, Repealed 5-10-12.

Rulemaking Authority 409.9124, 409.919 FS. Law Implemented 409.9124(1) FS. History-New 3-9-81, Amended 7-9-84, Formerly 10C-7.524, Amended 4-5-89, Formerly 10C-7.0524, Amended 8-4-02, 1-23-05, 5-9-06, Repealed 8-18-15.

Rulemaking Authority 409.919 FS. Law Implemented 409.906(11), 409.912(7) FS. History-New 9-20-88, Formerly 10C-7.0381, Amended 2-13-96, Repealed 7-26-09.

Rulemaking Authority 409.919 FS. Law Implemented 409.9121, 409.9122 FS. History-New 6-10-91, Formerly 10C-7.067, Amended 12-18-94, Repealed 8-18-15.

(1) Purpose. A Florida Medicaid recipient (herein referred to as an enrollee) who is required to enroll in the Statewide Medicaid Managed Care (SMMC) program, may request to change managed care plans. Requests must be submitted via telephone or in writing to the Agency for Health…

Individuals enrolled as Child Health Services targeted case managers must be in compliance with the Child Health Services Targeted Case Management Coverage and Limitations Handbook, June 2012, https://www.flrules.org/Gateway/reference.asp?No=Ref-01329, which is incorporated by re…

(1) Pursuant to Section 409.967(3)(b), Florida Statutes (F.S.), the Agency for Health Care Administration (hereafter referred to as Agency) shall contract with independent certified public accountants to conduct compliance audits of Florida Medicaid prepaid health plans. (a) Cert…

Rulemaking Authority 409.266(15) FS. Law Implemented 409.026(1), (6), 409.266 FS. History-New 7-16-79, Amended 7-5-81, 1-2-84, 10-15-85, Formerly 10C-7.58, Amended 12-21-87, 5-17-90, Formerly 10C-7.058, Repealed 7-26-09.

(1) Purpose. This rule provides notice of administrative sanctions imposed upon a provider, entity, or person for each violation of any Medicaid-related law. (2) Applying and reporting sanctions. Notice of the application of sanctions will be by way of written correspondence, and…

Rulemaking Authority 490.014(5), 491.014(5) FS. Law Implemented 490.014(5), 491.014(5) FS. History-New 2-10-93, Formerly 21-33.001, 61-33.001, Repealed 5-7-12.

Rulemaking Authority 154.308 FS. Law Implemented 154.308 FS. History-New 12-29-77, Formerly 10C-26.01, 10C-26.001, Repealed 3-16-16.

The following words and phrases shall have the following meanings for the purpose of this rule chapter. (1) Act: The Florida Health Care Responsibility Act (HCRA or Program). (2) Adequate Third Party Insurance: Coverage of the hospitalization by a third party insurer that would b…

(1) The maximum amount of HCRA funds that a county can allocate for in-county reimbursement is up to 1/2 of its total HCRA funds. No county shall have the authority to use out-of-county designated funds to supplement its in-county reimbursement amount above the aforementioned one…

(1) The Agency's Financial Analysis Unit shall determine and certify by August 31 of each year, those hospitals that meet the charity care obligation as defined in subsection 59H-1.0035(10), F.A.C., based on audited actual experience for the hospital's fiscal year ending within t…

(1) Covered services are limited to hospital services as defined in Rules 59G-4.160 and 59G-4.150, F.A.C., and the Florida Medicaid - Outpatient Hospital Services Coverage Policy, incorporated by reference in Rule 59G-4.160, F.A.C., unless otherwise specified in this rule. Copies…

(1) For a hospital to receive reimbursement for hospital services under the act, an individual must meet the following conditions: (a) Be a certified resident of a county in the state of Florida; (b) Be a qualified indigent patient or spend-down provision eligible patient; and, (…

(1) The county of residence has the primary responsibility for determining eligibility for individuals applying for coverage, using the eligibility determination procedures described in this section. The Agency shall conduct eligibility determinations only when the county demonst…

(1) The hospital shall send the application to the certifying agency for the county indicated on the application as the county of residence for the determination of eligibility and certification of the county of residence of the applicant. (2) The county has 60 days from the date…

(1) The hospital shall use the universal hospital claim form, UB 04/CMS-1450, to submit claims to the county for eligible individuals who received covered hospital care. (2) Each county shall designate an office or agency that will pay claims. The name, title, address, and phone …

(1) The hospital shall pursue all third party payors prior to submitting a claim to a county. This requirement shall not preclude submission of the application within time frames established in Rule 59H-1.008, F.A.C. The county, through the HCRA, shall serve as payor of last reso…

(1) If a hospital has not received payment from the responsible county for an eligible individual within 90 days of receipt of a claim, or if the claim is disputed and payment is not received from the county determined to be responsible within 60 days after all legal and administ…

All disputes among counties, the agency, a participating hospital or a regional referral hospital shall be resolved by order as provided in Chapter 120, F.S. Hearings shall be conducted as provided in Section 120.57, F.S., except that the hearing officer's order shall be the fina…

(1) Hospitals shall follow utilization review procedures established under the approved hospital utilization review plan for Medicaid. (2) Disputes between counties and hospitals over the appropriateness of an admission, length of stay, and medical necessity of the services provi…

(1) The hospital may appeal any decision made by the certifying agency concerning an applicant's eligibility under the Act. A fair hearing shall be conducted in accordance with Chapter 120, F.S. (2) Applicants or designated representatives are responsible for keeping appointments…

Rulemaking Authority Chapter 88-294, Section 27, Laws of Florida. Law Implemented 409.2673 FS. History-New 3-29-89, Amended 12-24-90, Formerly 10C-34.003, Amended 6-7-00, Repealed 12-22-09.

Rulemaking Authority Chapter 88-294, Section 27, Laws of Florida. Law Implemented 409.2673(4), (7), (9) FS. History-New 3-29-89, Amended 12-24-90, Formerly 10C-34.004, Amended 6-7-00, Repealed 12-22-09.

Rulemaking Authority Chapter 88-294, Section 27, Laws of Florida. Law Implemented 409.2673(9) FS. History-New 3-29-89, Amended 12-24-90, Formerly 10C-34.005, Amended 6-7-00, Repealed 12-22-09.

Rulemaking Authority Chapter 88294, Section 27, Laws of Florida. Law Implemented 409.2673(2) FS. History-New 32989, Amended 122490, Formerly 10C-34.006, Amended 6-7-00, Repealed 12-22-09.

Rulemaking Authority Chapter 88-294, Section 27, Laws of Florida. Law Implemented 409.2673(2), (8), (9) FS. History-New 3-29-89, Amended 12-24-90, Formerly 10C-34.008, Amended 6-7-00, Repealed 12-22-09.