HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 5201 PCB HCAS 21-01 Health Care
SPONSOR(S): Health Care Appropriations Subcommittee, Avila
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
Orig. Comm.: Health Care Appropriations 15 Y, 0 N Nobles Clark
Subcommittee
1) Appropriations Committee 25 Y, 0 N Nobles Pridgeon
SUMMARY ANALYSIS
The bill conforms statutes to the funding decisions related to Health Care included in the House proposed
General Appropriations Act (GAA) for Fiscal Year 2021-2022. The bill:
 Continues the personal needs allowance of residents of Veterans Nursing Homes at $130 per month;
 Reduces the Medicaid nursing home lease bond alternative collection threshold from $25 million to $10
million;
 Requires nursing homes and home offices to report audited financial information to the Agency for
Health Care Administration’s (AHCA) uniform reporting system;
 Defines Florida Nursing Home Uniform Reporting System (FNHURS) and home office;
 Extends postpartum Medicaid eligibility for pregnant women to 12 months;
 Continues the policy of retroactive Medicaid eligibility for non-pregnant adults to the first day of the
month in which an application for Medicaid is submitted;
 Provides a methodology to spread the nursing home rate increase across all providers, even if the
provider is held to the September 2016 rate;
 Holds the County Health Departments’ reimbursement to the level established on July 1, 2011;
 Conforms the Low Income Pool (LIP) program to the other program’s due dates that rely on
Intergovernmental Transfers (IGTs) for funding. Requires that Letters of Agreement for LIP be received
by the AHCA by October 1 and the funds outlined in the Letters of Agreement be received by October
31;
 Requires essential providers to contract with managed care plans to be eligible to receive supplemental
payments, thereby making certain that those who receive supplemental payments treat Medicaid
patients;
 Requires the Florida Healthy Kids Corporation to validate and calculate a refund amount for Title XXI
providers who achieve a Medical Loss Ratio below 85%. These refunds shall be deposited into the
General Revenue Fund, unallocated;
 Provides for technical corrections to statutory cross references in Managed Care Plan Accountability
and Appropriations to First Accredited Medical Schools due to the change in the number of definitions
listed in s. 408.07, F.S.
The bill provides for an effective date of July 1, 2021.
This document does not reflect the intent or official position of the bill sponsor or House of Representatives.
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 FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Current Situation
Veterans Nursing Homes
Once an individual requiring an institutional level of care has established Medicaid eligibility, some of
his or her income is used to pay for Medicaid services. For individuals residing in an institution, most of
their incomes are applied to the cost of that care, with the exception of a small personal needs
allowance used to pay for personal needs that are not covered by Medicaid. A personal needs
allowance is the amount of income a resident may retain for personal expenditures not covered by the
nursing home such as toiletries and haircuts.
Section 296.37, F.S., requires every resident of a state veteran domiciliary or nursing home who
receives a pension, compensation, or gratuity from the United States Government or income from any
other source of more than $130 per month to contribute to his or her maintenance and support while
residing in a home, pursuant to a schedule of payment determined by the home administrator and
department director that shall not exceed the actual cost of operating and maintaining the home.
Chapter 2017-157, Laws of Florida, amended s. 296.37, F.S., to increase the personal needs
allowance to $105 per month from $35 per month. For the past three fiscal years, the General
Appropriations Act implementing legislation increased the personal needs allowance to $130 per
month.1 This provision expires July 1, 2021.
Florida Medicaid Program
The Agency for Health Care Administration (AHCA) is the single state agency responsible for the
administration of the Florida Medicaid program, authorized under Title XIX of the Social Security Act.
This authority includes establishing and maintaining a Medicaid state plan, approved by the Centers for
Medicare and Medicaid Services.
Medicaid is the health care safety net for low-income Floridians. Medicaid is a federal and state
partnership established to provide coverage for health services for eligible persons and financed by
federal and state funds. AHCA delegates certain functions to other state agencies, including the
Department of Children and Families, the Department of Health (DOH), the Agency for Persons with
Disabilities (APD), and the Department of Elderly Affairs (DOEA).
The Florida Medicaid program covers approximately 4.6 million low-income individuals, including
approximately 2.2 million children in Florida. These children make up 55.2% of the Florida Medicaid
population.2 Medicaid is the second largest single program in the state, behind public education,
representing 32.2% of the total FY 2020-21 budget.
A Medicaid state plan is an agreement between a state and the federal government describing how a
state administers its Medicaid program. It establishes groups of individuals covered, services that are
provided, payment methodologies, and other administrative and organizational requirements. In order
to participate in Medicaid, federal law requires states to cover certain population groups (mandatory
eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility
groups). States set individual eligibility criteria within federal minimum standards.
1 Chapters 2016-116, 2018-10, 2019-116, and 2020-114, Laws of Florida.
2 Agency for Health Care Administration, Florida Statewide Medicaid Monthly Enrollment Report, January 2021, available at
https://ahca.myflorida.com/medicaid/Finance/data_analytics/enrollment_report/index.shtml (last accessed March 11, 2021).
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 In Florida, the majority of Medicaid recipients receive their services through a managed care plan
contracted with AHCA under the Statewide Medicaid Managed Care (SMMC) program. The SMMC
program has three components: the Managed Medical Assistance (MMA) program, the Long-Term
Care (LTC) program and the Dental program. Florida's SMMC program benefits are authorized by
federal authority and are specifically required by the Florida Legislature in sections 409.973 and
409.98, F.S.
AHCA contracts with managed care plans on a regional basis to provide services to eligible recipients.
The MMA program, which covers most medical and acute care services for managed care plan
enrollees, was fully implemented in August 2014 and then was re-procured. Current contracts end in
2024.
Nursing Home Lease Bond Alternative
All nursing home facilities currently leasing the property where nursing facility services are provided are
required to submit a Surety Bond annually. As an alternative, a nonrefundable fee may be presented to
the AHCA in the amount equal to 1% of 3 months of Medicaid payments to the facility based on the
preceding 12-month average Medicaid payments to the facility as calculated by the AHCA. These
funds are held in a trust fund as a Medicaid nursing home overpayment account. These fees are used
at the sole discretion of the AHCA to repay nursing home Medicaid overpayments should a facility be
unable to pay the liability but does not release the licensee from any liability for any Medicaid
overpayments. Each year, the AHCA will assess the fund after all overpayments have been repaid
and, if the balance after all other amounts have been subtracted is greater than $25 million, collections
of the fee will be suspended for the subsequent fiscal year.
Nursing Home Uniform Reporting System
Currently, nursing homes, continuing care facilities, and state run hospitals are exempt from the
requirement to submit their actual financial experience for the fiscal year to the AHCA. All other health
care facilities are mandated to do so. In addition, hospitals must submit their actual audited financial
experience and submit the information in the Florida Hospital Uniform Reporting System (FHURS).
The FHURS is a database designed by the AHCA expressly for the reporting of the hospitals’ audited
actual financial experience. The hospitals have had this requirement since 1992 and it has been an aid
to the AHCA to make management decisions and the Legislature to make policy and budgetary
decisions. The hospital financial information has been used to determine revenues for the Public
Medical Assistance Trust Fund, hospital assessments, review certificates of need, licensure condition
compliance, for research, to prepare hospital financial data reports, and to respond to media and
legislative requests.
Medicaid Postpartum Eligibility
Medicaid covers pregnant women for their entire pregnancy and a short while after, but, unless a
woman qualifies for Medicaid under other criteria, the coverage ends 60 days after birth. This program
is particularly important for pregnant women and children. It pays for 56% of Florida’s births and
provides health care coverage for just under half the state’s children. About 700 women die each year
in the United States as a result of pregnancy or delivery complications. In Florida, several initiatives at
the state and provider level have been put into place in recent years to address the issue of maternal
mortality. These efforts have helped reduce the state’s overall maternal mortality rate by 25%, cut the
rate for non-Hispanic Black women nearly in half, and reduced the rate for Hispanic women and the
Black-White disparity gap both by 75% – making Florida a model for the country. Although Florida is
trending in the right direction, more can be done to combat maternal mortality in order to keep mothers
and their babies safe and healthy.
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 Medicaid Retroactive Eligibility
The Social Security Act provides the requirements under which state Medicaid programs must operate.
Federal law directs state Medicaid programs to cover, and provides federal matching funds for, medical
bills up to three months prior to a recipient’s application date.3 The federal Medicaid statute requires
that Medicaid coverage for most eligibility groups include retroactive coverage for a period of 90 days
prior to the date of the application for medical assistance, however, this requirement can be waived
pursuant to federal regulations.
An initial analysis by the AHCA indicated that approximately 39,000 non-pregnant adults were made
retroactively eligible under the 90-day requirement of federal regulations in State Fiscal Year 2015-
2016.4 A more recent AHCA analysis indicates that 11,466 distinct individuals were granted such
retroactive eligibility and utilized services during their retroactive period during State Fiscal Year 2017-
2018.5 In compliance with the federal requirement for 90 days of retroactive eligibility, the Florida
Medicaid State Plan previously provided that “[c]overage is available beginning the first day of the third
month before the date of application if individuals who are aged, blind or disabled, or who are AFDC-
related,6 would have been eligible at any time during that month, had they applied.” These provisions
had been applicable to the Florida Medicaid State Plan since at least October 1, 1991.7
In 2018, the Florida Legislature, via the General Appropriations Act (GAA)8 and the Implementing Bill
accompanying the GAA9, approved a measure to direct the AHCA to seek a waiver from the federal
Centers for Medicare and Medicaid Services (CMS) to eliminate the 90-day retroactive eligibility period
for non-pregnant adults aged 21 and older. For these adults, eligibility would become retroactively
effective on the first day of the month in which their Medicaid application was filed, instead of the first
day of the third month prior to the date of application.
The waiver request that included the retroactive eligibility item was submitted to federal CMS by AHCA
on April 27, 2018, and was approved by federal CMS on November 30, 2018 to be effective February
1, 2019. The waiver included the stipulation that waiver authority ends on June 30, 2019 and that
AHCA must timely submit a letter to CMS by May 17, 2019 if legislative approval is granted to continue
the waiver past June 30, 2019.10 Legislative approval was granted in section 30 of the 2019 General
Appropriations Act Implementing Bill11 and the letter was sent timely to CMS on May 17, 2019. In 2020,
the Legislature again granted approval in section 16 of the 2020 General Appropriations Act
Implementing Bill.12
3 42 U.S.C. s. 1396a.
4 See Agency for Health Care Administration, Florida’s 1115 Managed Medical Assistance (MMA) Prepaid Dental Health Program (PDHP), Low Income
Pool (LIP), and Retroactive Eligibility Amendment Request (March 28, 2018), Power Point presentation, available at:
http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/MMA_PDHP_LIP-
Retro_Elig_amendment_presentation_032818.pdf (last visited March 11, 2021).
5 Agency for Health Care Administration, Senate Bill 192 Analysis (February 27, 2019).
6 Aid to Families with Dependent Children (AFDC) was a federal assistance program in effect from 1935 to 1996 created by the Social Security Act and
administered by the United States Department of Health and Human Services that provided financial assistance to children whose families had low or no
income.
7 See Florida Medicaid State Plan, page 373 of 431, available at
https://ahca.myflorida.com/medicaid/stateplanpdf/Florida_Medicaid_State_Plan_Part_I.pdf (last visited March 11, 2021).
8 See Specific Appropriation 199 of the General Appropriations Act for Fiscal Year 2018-2019, Chapter 2018-9, Laws of Florida, available at
http://laws.flrules.org/2018/9 (last visited March 11, 2021).
9 See section 20 of the Implementing bill for Fiscal Year 2018-2019, Chapter 2018-10, Laws of Florida, available at http://laws.flrules.org/2018/10 (last
visited March 22, 2021).
10 See the November 30, 2018, CMS letter and waiver approval document, including waiver Special Terms and Conditions, available at
https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/fl/fl-mma-ca.pdf (last visited January 9, 2020).
11 See section 30 of the Implementing bill for Fiscal Year 2019-2020, Chapter 2019-116, Laws of Florida, available at http://laws.flrules.org/2019/116
(last visited March 22, 2021).
12 See section 16 of the Implementing bill for Fiscal Year 2020-2021, Chapter 2020-114, Laws of Florida, available at http://laws.flrules.org/2020/114
(last visited March 11, 2021).
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 Nursing Homes Reimbursement
On October 1, 2018, Medicaid nursing homes migrated to the prospective rate reimbursement
methodology. Under the new methodology, nursing home providers were limited to the greater of their
September cost-based rate or their prospective rate. This limitation will end on September 30, 2021.
On October 1, 2021, each facility will be limited to the greater of 95% of their September cost-based
rate or their rebased prospective rate that was calculated using the most recently audited cost report.
This limitation will end on September 30, 2023.13
County Health Departments
Section 19 of the 2019 General Appropriations Act Implementing Bill, Ch. 2019-116, Laws of Florida,
amended s. 409.908(23), F.S., to provide that Nursing Home Medicaid reimbursement would no longer
be held to a rate freeze, but rather be based upon a prospective payment system. This change left only
the county health departments subject to the rate freeze.
Low Income Pool
The terms and conditions of CMS Florida Managed Medical Assistance Waiver Approval Document
created a Low Income Pool (LIP) to be used to provide supplemental payments to providers who
provide services to Medicaid and uninsured patients. This pool constituted a new method for such
supplemental payments, different from the prior program called Upper Payment Limit. The LIP program
also authorized supplemental Medicaid paym