1. Health & Human Services and Public Safety Pre-Session Webinar Susan Harbin, HHS Advocate Lisa Hurley, Public Safety Advocate 2/11/13

2. HHS Pre-Session Webinar Outline  Medicaid County Share of Cost  Background  HB 5301  FAC Policy Statement and Proposals for 2013 Session  Next Steps  HHS Priority Issues  Bills to Watch  Questions and Feedback

3. County Share of Cost for Medicaid Services BACKGROUND  Florida is one of 28 states that require counties to share in the cost of the Medicaid program.  Pursuant to sec. 409.915, F.S., counties are responsible for a portion of inpatient hospitalization and nursing home costs.  Inpatient hospitalization costs are defined in terms of inpatient days. Counties are responsible for 35% of the hospital’s daily Medicaid rate for inpatient days 11 through 45.  Nursing home payments are defined per patient, per month. A county’s responsibility for nursing home payments start when a patient’s monthly cost exceeds $170. The county share cannot exceed $55 per month, per patient.  The Agency for Health Care Administration (AHCA) bills counties each month for their respective shares of cost for these services.  Counties are only responsible for services provided to their residents.  Medicaid eligibility and county residency are determined by the Department of Children and Families. 10/15/2015 3

4. County Share of Cost for Medicaid Services HB 5301  HB 5301, a budget conforming bill, passed in 2012 and significantly amended sec. 409.915, F.S.  Specific to the county cost-share, HB 5301:  Removed the requirement that the State work “in consultation” with the counties to determine who is an “eligible recipient” of that county.  Stipulated that each county’s eligible recipients will be determined by the address contained in the Medicaid eligibility system maintained by DCF.  Directed AHCA to certify each county’s “backlog” of disputed and unpaid bills from November 1, 2001 – April 30, 2012. 10/15/2015 4

5. County Share of Cost for Medicaid Services HB 5301  HB 5301, continued:  Allowed counties to challenge their backlogs through administrative hearings. Counties that opted not to challenge received a 15% discount.  Beginning in May 2012, required AHCA to certify to the Department of Revenue (DOR) each county’s monthly Medicaid statement by the 7 th of each month.  Directed the DOR to automatically deduct a county’s certified monthly bill amount from the county’s monthly half-cent sales tax distribution.  Required AHCA, in consultation with DOR and the Florida Association of Counties, to develop a process for refund requests. 10/15/2015 5

6. County Share of Cost for Medicaid Services Implementing HB 5301  The Governor committed to counties that they would only have to pay bills that they rightfully owed.  AHCA and FAC staff visited all 67 counties last summer.  AHCA re-reviewed all backlog claims, resulting in a final certified amount of $167M – less than half of what AHCA originally claimed was owed.  AHCA certified $0 for the first month’s certification, maintaining our 60-day billing cycle (June 1 st instead of May 1 st )  AHCA developed an advance refund request process, allowing counties to dispute claims prior to payment. Pursuant to the administrative rule, this process sunsets on April 30, 2013.  AHCA allows counties to pre-pay bills each month to avoid half-cent sales tax deduction. 10/15/2015 6

7. County Share of Cost for Medicaid Services Administrative Rules  Rule 59G-1.020 (County of Residence) and Rule 59G- 1.025 (Medicaid County Billing) were both updated in October 2012.  Rule 59G-1.020 – residency  County of residency determined by address information in DCF system.  For nursing home claims, address is based on prior address. If prior address is from out-of-state, the nursing home address is used for billing purposes.  Counties are not responsible for children in DCF custody. 10/15/2015 7

8. County Share of Cost for Medicaid Services Administrative Rules  Rule 59G-1.025 – county billing  Outlines billing and payment processes for both retrospective (backlog) and prospective bills.  Advance refund request process – expires on April 30, 2013.  Back end refund request process.  For refund requests, AHCA either denies the request and re- bills the county on a subsequent bill, or transfers the claim to another county. 10/15/2015 8

9. County Share of Cost for Medicaid Services FAC Policy Statement 10/15/2015 9 FAC SUPPORTS the dissolution of the current county-state Medicaid contributory relationship in a manner that: (1) absolves counties of all financial responsibilities related to the provision of Medicaid services in Florida; (2) eliminates associated administrative burdens for the counties and the state; and, (3) equitably mitigates any potential fiscal impact for all affected parties. However, absent the identification of strategies to achieve the aforementioned goals in the referenced proscribed manner, FAC SUPPORTS retaining the current Medicaid billing system, but only with certain statutory modifications. At a minimum, these modifications should include: (1) allowing counties to review their bills prior to payment; (2) allowing counties to pay from a revenue source of their choosing within a specified time period; (3) allowing the state to withhold county revenue sharing for nonpayment within a specific time period; and (4) requiring the state, in consultation with the counties, to develop an accurate, reliable, and equitable billing process.

10. County Share of Cost for Medicaid Services FAC Policy Statement  Based on direction from the Health & Human Services Policy Committee and the Legislative Executive Committee, FAC is pursuing two Medicaid policy options:  Streamline the County Medicaid Contributions  Fix the Existing Billing System 10/15/2015 10

11. County Share of Cost for Medicaid Services Legislative Proposals Streamlining the County Medicaid Contribution:  Determine an aggregate base amount for the county contribution, allocated among the 67 counties based on accurate, fully-disputed billing and payment data.  Set a growth rate based on actual state Medicaid spending, not to exceed a capped amount each year.  Allow counties to continue to pay by a revenue source of their choosing by a certain date each month, to avoid half-cent sales tax reduction.  Preserve administrative challenge process for backlog claims.  Maintain language requiring taxing hospital districts to contribute their proportionate shares of Medicaid costs. 10/15/2015 11

12. County Share of Cost for Medicaid Services Governor’s Conforming Bill Governor’s Conforming Bill Base Amount = $278.4M $20M base increase for FY13-14 only County total contribution shall change by 75% of rate of growth in total state’s share total share of Medicaid spending Includes chart of county contribution rates, based on AHCA data collected since May 2012 County can pay by 7 th of the month to avoid reduction of half-cent sales tax distribution Deletes provisions of statute detailing services counties are responsible for paying FAC Modifications Base amount = $220M $20M base increase for FY13-14 only County total contribution shall change 75% of the rate of growth in total state Medicaid spending, not to exceed 6% annually. Individual county shares will be allocated based on 12 months of fully disputed billing data. County can pay by 7 th of the month to avoid reduction of half-cent sales tax distribution Deletes provisions of statute detailing services counties are responsible for paying 10/15/2015 12

13. County Share of Cost for Medicaid Services Governor’s Conforming Bill Governor’s Conforming Bill Deletes provision of statute exempting counties from contributing toward cost of new exemptions on inpatient ceilings for teaching hospitals, specialty hospitals and for special Medicaid payments that came into effect after July 1, 2000. Allows counties with special taxing districts to divide the county’s financial responsibility based on the proportionate amount paid by districts Refund request process allowed through May 2013. Prior to 2018 session, REC shall prepare, in consultation with FAC, a report examining the growth rate and county shares and adjustments. FAC Modifications Deletes provision of statute exempting counties from contributing toward cost of new exemptions on inpatient ceilings for teaching hospitals, specialty hospitals and for special Medicaid payments that came into effect after July 1, 2000. Allows counties with special taxing districts to divide the county’s financial responsibility based on the proportionate amount paid by districts. Extends ARR/BERR process development (AHCA, DOR, and FAC working together) from May 2012 through May 2013. Prior to 2016 Session, REC shall prepare, in consultation with FAC, a report examining the growth rate and county shares and adjustments. 10/15/2015 13

14. County Share of Cost for Medicaid Services Legislative Proposals Fixing the Existing Billing System:  Codify the ARR and BERR processes in statute  Remove ARR expiration date  Require AHCA, DCF, providers, and FAC to develop a process for verifying and updating addresses in the DCF eligibility database  Prevent counties from being billed for claims for which the addresses cannot be verified  Continue allowing counties to pay by check or wire transfer by a certain date each month in order to avoid half-cent sales tax withholding. 10/15/2015 14

15. Health & Human Services – Priority Statements County Health Departments County Health Departments (CHDs): SUPPORT maintaining state general revenue funding for CHDs, and OPPOSE any state reductions to the County Health Department Trust Funds. SUPPORT efforts to enable CHDs to transition to managed care under the Statewide Medicaid Managed Care Program without impacting service capacity. SUPPORT reinstating the exemption from rate control for county health departments. SUPPORT maintaining a coordinated system of county health departments (CHDs) that is centrally housed within the Department of Health (DOH). OPPOSE efforts to decentralize the public health system by transferring authority over CHDs from the DOH to the respective county governments. SUPPORT preserving the ability of CHDs to provide primary care and direct patient care services, particularly in communities without adequate substitutes or alternative providers for these services. OPPOSE efforts, legislative or otherwise, to limit or eliminate the provision of primary care services in CHDs. 10/15/2015 15

16. Other Bills to Watch 10/15/2015 16

17. Smoking Preemption/Florida Clean Indoor Air Act HB 439 and SB 258 Sponsors: Rep. Hager and Sen. Bradley Currently, sec. 386.209, F.S. preempts the regulation of smoking to the state, except that school districts can further restrict smoking on school district property Bills would remove counties and cities from the preemption, allowing them to further restrict smoking on their outdoor property if they choose do to so (home rule!) Neither bill has been heard in committee yet; language will likely change to address concerns (beaches, sidewalks, etc.) 10/15/2015 17

18. Disposition of Human Remains HB 171 and SB 370 Sponsors: Rep. Rooney and Sen. Sachs Clarifies and updates the statutes relating to unclaimed and indigent burials Provides that counties may adopt policies and procedures for the final disposition of unclaimed human remains Authorizes counties to make final disposition of unclaimed human remains under certain circumstances New language: allows certain veterans organizations to assist with recovery and interment of unclaimed cremated remains of veterans HB 171 passed its first committee of reference unanimously; SB 370 has not yet been heard 10/15/2015 18

19. Regulation of Family or Medical Leave Benefits SB 726 Sponsor: Sen. Simmons Bill would preempt the regulation of family and medical leave benefits to the state Political subdivisions would not be able to require employers to provide family or medical leave benefits to employees, or otherwise regulate such leave Sets out rights that employees are entitled to, in addition to any benefits otherwise available under the applicable federal and state laws Bill would not limit the authority of a political subdivision to establish family or medical leave benefits for employees of the political subdivision 10/15/2015 19

20. Appropriations Issues  Transportation Disadvantaged  Mental Health and Substance Abuse  County Health Departments  Community Care for the Elderly  Homelessness Programs 10/15/2015 20

21. Questions and Feedback Contact: Susan HarbinSusan Harbin (850) 922-4300 10/15/2015 21