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Subject 290-2-26 EMERGENCY MEDICAL SERVICES TO PREGNANT WOMEN

Rule 290-2-26-.01 Definitions

Unless a different meaning is required by the context, the following terms as used in these rules and regulations shall have the meaning hereafter respectively ascribed to them:

(a) "Cost of Care" means the cost of services rendered by a hospital for care required to be provided under the provisions of the law and rules and regulations, and for services rendered by a physician in connection there with, at the lesser of the actual charges or the reimbursement rate currently in effect for the hospital and physician under the medical assistance program for the needy [Title XIX of the Social Security Act ( 42 U.S.C.A. Section 1396, et seq.), as amended], but shall not include any portion of such cost which is paid by the indigent patient, by the spouse or a relative of the indigent patient, by the father of the child, by insurance, or by any governmental or other public agency pursuant to any federal, state, or local program paying cost of health care for indigent patients, other than the program established by the Act.
(b) "Department" means the Georgia Department of Human Resources.
(c) "Health Care Advisory Officer" means the person designated by the governing authority of a county to make determinations of indigency for residents of the county.
(d) "Hospital" means a hospital which is permitted to operate by the Department of Human Resources pursuant to O.C.G.A. § 31-7-1, et seq.
(e) "Indigency" means the inability of a patient or other person to pay the entire cost of care determined in accordance with O.C.G.A. § 31-8-43(a).
(f) "Statewide Standards for Determining Indigency" means those standards adopted by the Commissioner of the Department of Human Resources to determine levels of indigency for the purposes of the law.
(g) "Patient" means a pregnant woman who receives services under the law.
(h) "Family" means the adult patient (or married minor patient), the patient's spouse, and any dependent children who reside together, or the (unmarried) minor patient, the patient's parent(s) and any dependent children of the patient or parent(s) who reside together.
(i) "Active labor" means regular, progressive uterine contractions producing cervical thinning and dilation, as determined by a licensed physician.
(j) "Resident of the County" means a person who is domiciled in the county, as defined in O.C.G.A. Chapter 19-2, subject to verification as specified in the Indigency Worksheet Instructions.

Rule 290-2-26-.02 Emergency Services Procedures

Any hospital which operates an emergency service (room) where necessary emergency services to pregnant women are usually and customarily provided shall provide the appropriate, necessary emergency services to any pregnant woman who is a Georgia resident and presents herself in active labor at the hospital. Such services include initial care provided in the emergency room, intrapartum and postpartum care provided in the hospital's obstetrical department, and pediatric examination for the newborn infant. Such services shall be provided within the scope of generally accepted practice based upon the information furnished the hospital by the pregnant woman, including such information as the pregnant woman reveals concerning her prenatal care, diet, allergies, previous births, general health information, and other such information as the pregnant woman may furnish the hospital.

Rule 290-2-26-.03 Procedures for Determining Cost of Care

(1) Payments received by the hospital or physician from the patient, the patient's spouse, family member, father of the patient's child, insurance, or any other third party payor other than the county, shall constitute payment to the hospital or physician and shall be excluded from the definition of cost of care.
(2) When a hospital provides care to a woman who is not a resident of the same county,"cost of care" is the actual charges for care rendered or the Medicaid reimbursement rate for the same care in the hospital in the woman's county of residence, whichever is less. If the woman's county of residence has more than one hospital, the rate is the average Medicaid rate of all the hospital's in the woman's county of residence or actual charges, whichever is less.

Rule 290-2-26-.04 Procedures for Transfer When Another Level of Care is Required

If in the medical judgment of the physician responsible for the emergency service, the woman requires a level of obstetrical care that the hospital is unable to provide, then the hospital and physician shall:

(a) Provide, within the capabilities of the hospital, such services as the circumstances require. Such services shall be provided within the scope of generally accepted practice based upon the information furnished the hospital by the pregnant woman, including such information as the pregnant woman reveals concerning her prenatal care, diet, allergies, previous births, general health information, and other such information as the pregnant woman may furnish the hospital.
(b) Contact a receiving hospital and an attending physician which provide a level of obstetrical care that the woman requires, and notify such hospital and physician that the patient is in transit. Such transfer shall be from the emergency room to the obstetrical department of the receiving hospital.
(c) Arrange suitable transportation for the woman, if necessary, and send the receiving hospital any available information on the woman's medical history and condition. However, transportation to the receiving hospital shall not be authorized until the physician considers the patient sufficiently stabilized for transport.

Rule 290-2-26-.05 Appointment of Health Care Advisory Officer

The governing authority of each county, by resolution, is responsible for designating a person to be known as the Health Care Advisory Officer. The governing authority may change the person designated as the Health Care Advisory Officer, and any such change shall be made by resolution of the governing authority, a copy of which shall be mailed to the Commissioner of the Department or his designee within 15 days after its adoption. If the county fails or refuses to appoint a Health Care Advisory Officer, the governing authority of the county shall be deemed to be such officer.

Rule 290-2-26-.06 Duties of County of Residence

It is the duty of the governing authority of the county to pay the hospital and physician for the billed amount of the cost of care of any patient determined to be indigent under the standards set forth herein. If the billed amount is not paid within 120 days after the mailing of a request for a determination of indigency, the county will be charged interest on the billed amount at the rate specified in O.C.G.A. § 48-2-40 for unpaid taxes.

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.

Rule 290-2-26-.08 Violations

Any violations of the law or rules and regulations by the hospital should be referred to the Office of Regulatory Services of the Department of Human Resources for enforcement proceedings.

ANNEX A INDIGENCY STANDARDS TOTAL ANNUAL GROSS INCOME

 

%POVERTY LEVEL

 

100%

105%

110%

115%

120%

125%

[GREATER THAN]125%

 

PAY CATEGORY

FAMILY SIZE

EARNINGS PERIOD

Pay $100

Pay 25%

Pay 35%

Pay 45%

Pay 55%

Pay 65%

Pay 100%

1

ANNUAL MONTHLY WEEKLY

$5,250.00 [LESS THAN] $437.50 $100.96

$5,512.50 [LESS THAN] $459.38 $106.01

$5,775.00 [LESS THAN] $481.25 $111.06

$6,037.50 [LESS THAN] $503.13 $116.11

$6,300.00 [LESS THAN] $525.00 $121.15

$6,562.50 [LESS THAN] $546.88 $126.20

$6,562.50 [GREATER THAN] $546.88 $126.20

2

ANNUAL MONTHLY WEEKLY

$7,050.00 [LESS THAN] $587.50 $135.58

$7,402.50 [LESS THAN] $616.88 $142.36

$7,755.00 [LESS THAN] $646.25 $149.13

$8,107.50 [LESS THAN] $675.63 $155.91

$8,460.00 [LESS THAN] $705.00 $162.69

$8,812.50 [LESS THAN] $734.38 $169.47

$8,812.50 [GREATER THAN] $734.38 $169.47

3

ANNUAL MONTHLY WEEKLY

$8,850.00 [LESS THAN] $737.50 $170.19

$9,292.50 [LESS THAN] $774.38 $178.70

$9,735.00 [LESS THAN] $811.25 $187.21

$10,177.50 [LESS THAN] $848.13 $195.72

$10,620.00 [LESS THAN] $885.00 $204.23

$11,062.50 [LESS THAN] $921.88 $212.74

$11,062.50 [GREATER THAN] $921.88 $212.74

4

ANNUAL MONTHLY WEEKLY

$10,650.00 [LESS THAN] $887.50 $204.81

$11,182.50 [LESS THAN] $931.88 $215.05

$11,715.00 [LESS THAN] $976.25 $225.29

$12,247.50 [LESS THAN] $1,020.63 $235.53

$12,780.00 [LESS THAN] $1,065.00 $245.77

$13,312.50 [LESS THAN] $1,109.38 $256.01

$13,312.50 [GREATER THAN] $1,109.38 $256.01

5

ANNUAL MONTHLY WEEKLY

$12,450.00 [LESS THAN] $1,037.50 $239.42

$13,072.50 [LESS THAN] $1,089.38 $251.39

$13,695.00 [LESS THAN] $1,141.25 $263.37

$14,317.50 [LESS THAN] $1,193.13 $275.34

$14,940.00 [LESS THAN] $1,245.00 $287.31

$15,562.50 [LESS THAN] $1,296.88 $299.28

$15,562.50 [GREATER THAN] $1,296.88 $299.28

6

ANNUAL MONTHLY WEEKLY

$14,250.00 [LESS THAN] $1,187.50 $274.04

$14,962.50 [LESS THAN] $1,246.88 $287.74

$15,675.00 [LESS THAN] $1,306.25 $301.44

$16,387.50 [LESS THAN] $1,365.63 $315.14

$17,100.00 [LESS THAN] $1,425.00 $328.85

$17,812.50 [LESS THAN] $1,484.38 $342.55

$17,812.50 [GREATER THAN] $1,484.38 $342.55

7

ANNUAL MONTHLY WEEKLY

$16,050.00 [LESS THAN] $1,337.50 $308.65

$16,852.50 [LESS THAN] $1,404.38 $324.09

$17,655.00 [LESS THAN] $1,471.25 $339.52

$18,457.50 [LESS THAN] $1,538.13 $354.95

$19,260.00 [LESS THAN] $1,605.00 $370.38

$20,062.50 [LESS THAN] $1,671.88 $385.82

$20,062.50 [GREATER THAN] $1,671.88 $385.82

8

ANNUAL MONTHLY WEEKLY

$17,850.00 [LESS THAN] $1,487.50 $343.27

$18,742.50 [LESS THAN] $1,561.88 $360.43

$19,635.00 [LESS THAN] $1,636.25 $377.60

$20,527.50 [LESS THAN] $1,710.63 $394.76

$21,420.00 [LESS THAN] $1,785.00 $411.92

$22,312.50 [LESS THAN] $1,859.38 $429.09

$22,312.50 [GREATER THAN] $1,859.38 $429.09

9

ANNUAL MONTHLY WEEKLY

$19,650.00 [LESS THAN] $1,637.50 $377.88

$20,632.50 [LESS THAN] $1,719.38 $396.78

$21,615.00 [LESS THAN] $1,801.25 $415.67

$22,597.50 [LESS THAN] $1,883.13 $434.57

$23,580.00 [LESS THAN] $1,965.00 $453.46

$24,562.50 [LESS THAN] $2,046.88 $472.36

$24,562.50 [GREATER THAN] $2.046.88 $472.36

10

ANNUAL MONTHLY WEEKLY

$21,450.00 [LESS THAN] $1,787.50 $412.50

$22,522.50 [LESS THAN] $1,876.88 $433.13

$23,595.00 [LESS THAN] $1,966.25 $453.75

$24,667.50 [LESS THAN] $2,055.63 $474.38

$25,740.00 [LESS THAN] $2,145.00 $495.00

$26,812.50 [LESS THAN] $2,234.38 $515.63

$26,812.50 [GREATER THAN] $2,234.38 $515.63

For Families Exceeding 10 Members, Add $1800 To The Annual Income For Each Additional Family Member

LEGEND:

[LESS THAN] = LESS THAN

BASED ON ANNUAL REVISION GE POVERTY INCOME GUIDELINES

 

[GREATER THAN] = MORE THAN OR EQUAL TO

published 3/8/85 FEDERAL REGISTER, VOL. 50, NO. 46.