Item C21
BOARD OF COUNTY COMMISSIONERS ~
AGENDA ITEM SUMlVlARY Louis LaTorre, Direc tor
Social Services
Meeting Date: September 19,2001
Division: Communit\-. Services
Bulk Item: Yes L- No
Department: Social Services
AGENDA ITEM WORDING: Approval of Health Care Responsibility Act (HCRA) In-County Hospital
Reimbursement
ITEM BACKGROUND: Since the recent discussions concerning the Trauma District, the issue was
raised as to whether HCRA funds could be used for In-County Hospital Reimbursement. See
attached documentation.
PREVIOUS RELEVANT BOCC ACTION: Continued from August 15, 2001 BOCC Meeting.
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATION: Staff (Social Services Director and County Legal Department, Suzanne
Hutton), reviewed the obligation of HCRA funds for In-County Hospital Reimbursements. Staff strongly
recommends that it is in the best interest of the County that funds that are currently allocated for HCRA be
utilized for use of out-of-County HCRA cases. It is in the best interests of the County and in-county
hospitals using these funds for medical cases that cannot be handled in Monroe County.
TOTAL COST: $(One-halfof$353.840 Legal Obligation) BUDGETED: Yes x.. No _ (Only $100,000)
COST TO COUNTY: $176.920.00
REVENUE PRODUCING: YES
NOL-
AMT. PER MONTH
APPROVED BY: County Atty.
E. Malloch, Division Director/Community Services
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION:
Included: K-- To Follow:
Not Required: _
DISPOSITION:
Agenda Item #: ~
'0. O~~T.y ~o~~~E
(305) 294-460(1
Social Services Department
5100 College Road, Wing III
Key West, FL 33040
(305) 292-4573
(305) 292-4517 FAX
(-.." .---.--
BOARD OF COUNTY COMMISSIONERS
Dixie Spehar, District I
MAYOR George Neugent, District 2
Charles "Sonny" McCoy, District 3
Mayor Pro Tern Nora Williams, District 4
Murray E. Nelson, District 5
MEMORANDUM
.J'
TO:
County Commissioners
James L. Roberts, County A~nistrator
Louis LaTorre, Director~ ~
Social Services 1:~
FROM:
DATE:
August 31, 2001
RE: HCRA Items on Agenda
In reference to the items on the Agenda pertaining to HCRA,
please be advised OT the Tollo~ng.
HCRA Agenda Item:
Health Care Responsibility Act (HCRA) In-County Hospital
Reimbursement. Please see the attached Recap of the Policy
and Procedure for In-County Hospital Reimbursements
pertaining to HCRA.
As you are aware, in Monroe County there are three hospitals
that are qualified under the rules for this in-county
hospital reimbursement. But before they can qualify they
must provide the proper documentation to the State that they
meet the 2% charity care obligation, and other conditions
pertaining to the requirements of this Act. Currently, the
County has a legal obligation based on the population at
$4.00 a head, for a total of $353,840, which is obligated
for HCRA. Currently the County only budgets $100,000 a year
for this expense. Under the rules of this program, the
County would have to obligate, budget or fund one half of
this $353,840 for the purpose of in-county reimbursement.
This would allow all three of these hospitals to use those
dollars as needed. Currently, the County does not budget
this amount of dollars as stated previously. The
legislative intent of HCRA as far back as 1977, was to fund
in-patient care out of county for those clients that had
medical conditions that were unable to be handled by the
Page Two
three facilities in-county, which cases would be referred to
an out-of-county HCRA hospital.
If one-half of the money was earmarked for in-patient care,
among the three hospitals, these funds could easily be spent
by anyone of the three hospitals in the County. Which
would only leave the remaining $177,000 for in-patient out-
of-county cases, which staff feels is not sufficient funds
remaining to handle the patient liability regarding the
approximately 40 cases a year that are HCRA eligible.
.'"
Staff strongly feels that there is a greater need to have
dollars obligated to take care of those in-patient cases
needing specialized medical attention that is not available
in any of the three facilities in Monroe County.
So, staff recommends that it is in everyone's best interest
to stay out of the option to govern In-County HCRA
Reimbursement due to the following reasons:
(1) The intent of HCRA is to provide Health Care
Services to those county residents who are eligible
for these medical services out-of-county Hospital
(HCRA), due to the fact that these medical needs
are not available in Monroe County.
(2) If HCRA funds are split into two funding sources:
~ (In-County) $177,000
~ (Out-County) $177,000
(A) They will create insufficient funds to
provide services to the county hospital for
those clients that need to be transferred to
an out-of-county (HCRA) Hospital due to the
fact the local hospital cannot provide the
medical services needed to their clients.
(B) Also, by splitting the funds, both funding
services would be depleted, of which the HCRA
obligation ceases. What happens the hospital will
not be able to refer those serious medical (HCRA)
cases to out-of-county hospitals due to insuffi-
cient funds.
CC: James E. Malloch, Director
Community Services
Hutton-Suzanne
From:
Sent:
To:
Subject:
Hutton-Suzanne
Monday, August 13, 2001 4:39 PM
Malloch-Jim
HCRA: Items 1-02 & 3,8/15 SOCC meeting
Please be advised that my concurrence with Mr, LaTorre's recommendatIons was based primarily on experience with
litigation Involving Baptist Hospital -2 cases from the 80's, each of which incurred over $300,000 in medical costs, for
which we were responsible under HCRA - and administrative hearings due to a State agency erroneously
categorizing people as Monroe County residents,
One of those cases (Weldy) was the result of a traffic accident and the other (Schmelz) involved someone booked
Into the County Jail who attempted suicide Notwithstanding the language that someone eligible under HCRA "not
live In a public Institution," someone temporarily residing in the County Jail pending a bail hearing may still qua)Jty as
eligible under HCRA. .
Acceptance of the proposal that we decrease our population number in the maximum liability equation by inmates,
military, etc. could prove only to decrease the maximum liability without deleting those persons from our requirement
to pay their hospital bills That reduction in maximum liability cannot be a lot. If you eliminate 5,000 to 10,000 people
from the equation, we could save $20,000 to $40,000 in maximum liability.
Unfortunately, you increase the likelihood of that maximum being actually consumed because of the number of
people being classified as Monroe County residents which we could not contest. I would estImate from my
experience with the Agency for Health Care Administration, that about 15% of the people in nursing homes are
erroneously classified as Monroe County residents If that same level of mlsclassification carries over to out-of-
county hospital care, the amounts involved could be significant. Therefore, I concurred that the item in 1-03 was not
in the best interest of the County.
As for item 1 D-2, my concern was that the HCRA money for out-of-county care not be depleted because the medical
facilities in this County make it much more likely that a County resident will end up in an out-of-County hospital for
treatment at exorbitant amounts than that out-of-County residents will need similar accomodation in local hospitals
It seemed a matter of fairness and acceptance of responsibility for our indigent residents who end up or need to go
elsewhere. Further, there are many people who qualify as County residents who work in construction, restaurants,
accomodations. and other service industries who have no insurance but, at least at the beginning of their hospital
stay, would not qualify for Medicaid and therefore would be eligible for HeRA Just because we may not have had to
pay as much as our maximum liability for out-of-county care in most years, just 1 incident, perhaps a traffic accident,
may incur out-ot-county costs which far exceed that amount for one or more of our residents.
Finally, your e-mail prompted me to look more closely at the statutes. Subsection (3) at F ,S. 154306 was actually
interpreted in 1981 to require a County to pay the full hospital costs for out-of-County emergency care. ShandS v
Jacksonville, 398 So. 2d 907 (F 1st DCA 1981). That subsection does not refer to the maximum liability for
participating and regional referral hospitals,
, hope these comments will be of some use to you, Please call if you have questions
Page 1
Effecti\e Date: hnuary 28. 2000
RECAP OF POLICY AND PROCEDURE FOR
IN-COUNTY HOSPITAL REIMBURSEMENTS
All current policies :md procedures governing out-of-county HCRA reimbursement will be
utilized to govern in-county HCRA reimbursement. All participating hospitals must meet the 2%
charity care obligation unless there is no other hospital(s) within the county to provide ~ndigent
care or if no other hospital(s) within the county meets the 2% charity care obligation. Under
those Clrcumstances. the county must provide the Agency with a written statement that no
hospital within the county meets the 2% requirement.
In all cases, there must be a written agreement between the county and the in-county hospital
accepting the HCRA or other negotiated reimbursement standards. A copy of the letter from the
county to the hospital and a copy of the letter from the hospital to the county accept.ing the
HCRA standards, or a copy of a signed contract, must be filed with the Agency. Upon receipt of
the aforementioned letters or contract, the Agency will provide the in-county designated
hospital(s) with the necessary forms and a copy of the HCRA Handbook. There is no limit to the
number of HCRA qualified in-county hospitals that a county may elect to contract with.
The county is then responsible for completing the In-County information on the Monthly
Case load and Appeals Reports and the Quarterly Financial Reports.
The applicant must be a resident of the county where the hospital is located and services were
provided and the county must have elected to reimburse its in-county hospitals. All in-county
HCRA applicants must meet the same HCRA eligibility requirements used for out-of-county
eligibility determination. If the county has established less restrictive requirements, the applicant
would be required to meet the county's requirements on file with the Agency. The HCRA would
not apply to persons active with a county medical assistance plan if the treating hospital is a
participating facility under the county's medical assistance plan. The HCRA is the payor of last
resort.
The maximum amount of HCRA funds that a county can allocate for in-county reimbursement is
up to \12 of its total HCRA funds, i.e., if a county must designate $500,000 for the fiscal year, it
can only use a maximum of $250,000 for in-county hospital reimbursements. No county has the
statutory authority to use out-of-county designated funds to supplement its in-county
reimbursement amount above the aforementioned one half. Should a county exceed its
designated in-county reimbursement limit, the additional funds must be provided through other
funding sources from the county's budget and the amount exceeded shall not reduce the out-of-
countJ obligation.
All counties must notify the Agency of its decision to provide in-county reimbursement starting
with the county fiscal year 1999-2000. Any changes to its decision must be filed with the
Agency along with copies of notifications to the affected in-county hospitals no later than 45
days following the start of the new county fiscal year in which the change takes effect (on or
around November 14).
All HCRA funds, whether in-county or out-of-county, are only to be used to reimburse hospitals
for qualified indigent emergency or pre-approved non-emergency care. Please refer to the
current HCRA Handbook, page 3-8 for services and care NOT covered by HCRA.
Page 1 of 1
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HISTORY: -::--:e ::eal:h Ca:::-e Responsibility Act (HCR.ZI.} was first enacted
:::-evised by :~e ~988 Legislature to place the financial obligation for
r.ospitals :0::- e::1e::-ge"cy in-patient and out-patient services provided
county i"d~gen: patlen:s on the counties in which the patients :::-eside.
in 1977 and
rel.mDu::-sing
to out-of-
;he 1991 Legisla:ure a~ended the Act to increase the number of eligible applicants
:h:::-ough the c:::-eation 0: a spend-do'~ program and to increase hospital :::-ei~~ursement
rates. Both of these ~easures pe:::-tained ONLY to counties that were not at their 10
mill cap on ad valorem taxes as of October 1, 1991. Such counties are refe:::-::-ed to
as spend-down provision eligible counties.
The 1998 Leolslature further
county eligible hospitals up
indigent residents.
amended the P-.ct to allow counties
to one-half of the total HCR.ZI. funds
to rei]J1bu:::-se in-
for non-11edicaid
COVERED SERVICES: The Act covers emergency services provided on either an
inpatient or outpatient basis. The county may choose to cover elective and non-
emergency services if such services are not available at a county funded hospital
within the patient's county. The county may choose to cover services for in-county
indigent care beginning July 1, 1998 for services at participating hospitals within
the patient's county.
HOSPITAL ELIGIBILITY CRITERIA: To receive reimbursement, a hospital must meet
minimum standards. Teaching hospitals that meet the two-percent ove:::-all charity
care obligation also are eligible for HCRA. Non-teaching hospitals must first be
certified by the Agency for Health Care Administration, Bureau of Certificate of
Need/Financial .:malysis as having met a two-percent charity care obligation and
then have either:
.
Demonstrated to
least 2.5% of
residents; or
Bureau of Certificate of
its overall charity care
Need/Financial
was provided
Analysis that at
to out-of-county
. Have an agreement with the patient's county of residence to provide
emergency care to that county's indigent population.
APPLICANT ELIGIBILITY CRITERIA:
To be eligible, an applicant must:
. Have received services covered by HeRA. at a HeR..:; eligible out-af-county
hospital;
.
Have received
hospital if the
indigent care;
services covered by HCRA at a HCRA eligible in-county
county uses up to one-half of its HCR.ZI. funds for in-county
. Be certified by the county or the Agency as being a county resident;
. Have at a maximum, if a resident of a county, which was at its 10 mill cap on
ad valorem taxes, a gross income of 100% of the federal poverty level;
. Have at a maxi~um, if a resident of a spend-down provision eligible county,
a gross income of 150% of the federal poverty level, provided the applicant
"spends dovm" to 100% of the federal poverty level;
.
Not be eligible for any other federally or state
reimbursement program (such as Medicaid or Medicare)
funded hospital
. Not live in a public institution;
HCRA Su=ry Page 2 of 2
Revised February 15. 2000
. Have assets less than the ~edicaid medically needy levels;
. Have no o~ inadequate private lnsu~ance; and
. Be a ~.S. citizen or lawfully admitted alien.
APPLICATION PROCESSING RESPONSIBILITIES FOR THE HOSPITAL: The hospita~ provlding
eme~gency serv~ces to the indigent lS ~esponsible fo~ submitting an application
(..:..HC.; Form 5220-0001) by certi::..ed mail to the indigent applicant:'s councy of
residence '....ichin 30 days 0: the date that the emergency inpatient: or oucpacie;lc
services we~e p~ovided.
APPLICATIONS PROCESSING RESPONSIBILITIES FOR THE COUNTY: The county of residence
is responsible for determining residency and eligibility. If the county is ~nable
to determine residency, the Agency will determine residency for the county. The
county has the right of refusal in determining HC~; eligibility. If th~ county so
chooses. the eligibility function will be performed by the Agency for Healch Care
Administration office in Tallahassee.
The county must notify the hospital and the patient regarding eligibility within 60
days of receipt of the completed application by using the Notification of
Eligibility (AHCA Form 5220-0002). If the certifying agency cannot determine
eligibility within the 60 days, a written explanation must be provided to the
hospital.
HOSPITAL/COUNTY REIMBURSEMENT PROCEDURES: Upon receipt of the notice that the
patient is eligible, the hospital has six (6) months to submit its claim to the
county of residence. The county has 90 days to reimburse the hospital. If payment
is not received, the hospital may certify to the State Comptroller the amount owed
by the county. The Comptroller will then pay the hospital (within 45 days of
receipt of the claim) from any revenue sharing or tax-sharing funds due the county.
except as otherwise provided by the state constitution.
The hospi tal must refund the county or the State Comptroller for any payments
received from third party payers or from any federal or state programs.
HOSPITAL REIMBURSEMENT: Counties are obligated to pay up to 45 days of out-of-
county hospital services per eligible HCRA applicant per county fiscal year. The
maximum amount that a county is obligated to spend through HCRA for any county
fiscal year is $4 per capita. The out-of-county amount may be lessened to one-half
if the funds are used to pay for in-county hospital services for qualified non-
Medicaid indigent residents.
For oatlents who are residents of counties, which were at their 10 mill cap on ad
valorem taxes at October 1, 1991. counties must reimburse hospitals at 80% of their
t-1edic.aid per diem rates, unless another reimbursement rate is negotiated. For
patients who are residents of spend-down provision eligible counties, counties must
reimburse hospi tals at 100% of their Medicaid ~ates, unless another reimbursement
rate has been negotiated. HCRA reimbursement for covered services is considered
payment in full and the hospital cannot charge the recipient for any remaining
balance.
AGENCY RESPONSIBILITIES: The Agency provides technical assistance to counties and
participating hospitals, which include providing the following information: each
county's maximlL"t\ fiscal obligation. a HCRA handbOOK. and lists of all eligible
hospi cals. soend-down provis ion el igible counties. ~edicaid per diem rates (sent
each January and July), and county and hospital contacts.
HeRA Summary Pag~ 2 of 2
Revis~d F~bruary 15. :WOO