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Florida Medicaid Billing Rules

Florida Medicaid implemented by the Florida Agency for Health Care Administration (AHCA), provides health care services to low income residents. Florida laws and regulations outlines Florida Medicaid billing rules for reimbursement and administration of the program including mental health, school based therapy services and prescription medication.

  1. Mental Health

    • Florida Medicaid reimburses community mental health service providers based on a fee schedule determined by the AHCA. Similarly, the state reimburses in-home, non-clinical mental health services based on a fee schedule determined by AHCA. Pediatric extended care center services are also reimbursed on a fee for service basis established by the AHCA. The reimbursable services include nursing services, personal care, medical equipment as well as emergency supplies and drugs. Florida Medicaid reimburses state and non-profit organizations based on the actual cost of goods and services provided.

    School Based Therapy Services

    • Florida Medicaid reimburses school therapy service providers based on the reasonable cost of services provided but reimburses school based psychology services at varying rates depending on the professional level of the service provider. The law requires school districts to certify on a quarterly basis that they utilized public funds to provide speech, occupational or physical therapy or psychology services during that period. Florida Medicaid requires school districts to certify and support the expenditure of local funds for school based therapy services.

    Prescription Medication

    • Florida Medicaid reimburses generic pharmaceuticals based on the Medicare program’s federal upper limit, which is the maximum amount the Medicare program will reimburse for a pharmaceutical, plus a dispensing fee. If the Medicare program has not established an upper limit fee for a pharmaceutical, Florida Medicaid reimburses on a provider’s estimated purchase cost of the drug plus a dispensing fee. Florida Medicaid reimburses brand name pharmaceuticals based on the state’s maximum allowable cost plus a dispensing fee.

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