Rule 290-2-26-.07 - Eligibility Criteria and Determination(1) When a woman receives services from a hospital, hospitals, or physicians under the provisions of the law, and claims indigency, the Chief Administrative Officer of the hospital shall determine whether any portion of the cost of services may be paid by the medical assistance program for the needy, or by insurance, or by any other governmental or public agency with a federal, state, or local program, and provide written notification of determination to the Health Care Advisory Officer of the woman's county of residence. Such notification shall include a certification by the Chief Administrative Officer on the Certification and Acknowledgment Form that an appropriate investigation has been made and the results of such determination, the amount to be paid if the determination shows that a portion of the cost of services is available from such sources as identified above, and a request for a determination of indigency on the woman. Such request shall be made on a form entitled "Request for a Determination of Indigency". If the woman receives services in more than one hospital because of transfer, each hospital must submit a request in order to seek reimbursement under this program.(2) The Health Care Advisory Officer of the woman's county of residence shall complete a determination of indigency in accordance with these rules and regulations and notify the hospital, the governing authority of the patient's county of residence, and the patient of the results of the determination not later than 60 days after receipt of the request. Notifications shall be made on a standard form designated by the Department. If the Health Care Advisory Officer fails to respond to a request for determination within the 60 day time limitation, the county of residence of the patient is liable for the payment of cost of care of the woman. The Health Care Advisory Officer shall establish and maintain files showing names of county residents who the Officer has determined to be indigent. These records are required to the end that certification of indigency may be expedited. The Health Care Advisory Officer should develop standards to protect the confidentiality of these records consistent with the "Open Records Act", O.C.G.A. § 50-18-70, et seq. The fact that the patient has obtained prenatal care or any treatment whatsoever relating to the pregnancy will not, in and of itself, preclude such patient from utilizing the benefits of this program, nor will such prenatal care or any treatment whatsoever relating to the pregnancy preclude the delivery from being characterized as an emergency.(3) Eligibility is based on family income and family size. The gross family income is used to determine eligibility and in order to be considered indigent, the family income must be less than 125% of the federal poverty level. Only the income of the patient and legally liable adult family members is considered in making the eligibility determination.(4) The Request for Determination of Indigency Form (Sections A and B) and the Certification and Acknowledgment Form are completed before a patient is discharged from the hospital, and are forwarded by the Hospital Administrative Officer to the Health Care Advisory Office of the patient's county of residence. The Health Care Advisory Officer completes a determination of indigency on the patient, and returns the Request for Determination of Indigency to the Hospital Administrative Officer within 60 days of the date received. The Health Care Advisory Officer also notifies the patient of the outcome of the determination. The county governing authority is notified of only those persons determined to be indigent.(5) In order to do an eligibility determination, the Health Care Advisory Officer must have contact with the patient and complete an Indigency Worksheet. The completed worksheet provides the total family income and family size which are basic to using the Eligibility Determination Scale. The scale is designed to simplify the process of determining whether a patient's family income is less than 125% of the federal poverty level. Individuals whose income is less than 125% of the federal poverty level are eligible for this program. A copy of the Eligibility Determination Scale is attached here to and reflected as "Annex A".(6) In addition to establishing the eligibility of a pregnant woman for the Emergency Medical Services Program, it is the responsibility of the Health Care Advisory Officer to determine the amount of repayment to the county for which the patient, and each other legally responsible person, is liable. This amount can range from a minimum of $100 to a maximum of 65% of the actual cost.Ga. Comp. R. & Regs. R. 290-2-26-.07
O.C.G.A. § 31-8-43.
Original Rule entitled "Eligibility Criteria and Determination" adopted as Emergency Rule 290-2-26-0.5-.07. Filed June 19, 1985; effective June 19, 1985, the date of adoption, to remain in effect for a period of 120 days or until the effective date of a permanent Rule covering the same subject matter superseding this Emergency Rule, as specified by the Agency. (This Emergency Rule expired October 16, 1985.)Amended: Permanent Rule of the same title adopted. Filed October 18, 1985; effective November 7, 1985.