Fla. Admin. Code R. 59H-1.0035
Current through Reg. 50, No. 235-239, December 10, 2024
Section 59H-1.0035 - DefinitionsThe following words and phrases shall have the following meanings for the purpose of this rule chapter.
(1) Act: The Florida Health Care Responsibility Act (HCRA or Program).(2) Adequate Third Party Insurance: Coverage of the hospitalization by a third party insurer that would be equal to or greater than either: 80 percent of the amount the hospital would receive if reimbursed at the hospital's outpatient or inpatient reimbursement rate allowed for Florida Medicaid or the reimbursement rate negotiated by the county with the affected hospitals, if that negotiated rate is greater than 80 percent of the hospital's outpatient or inpatient reimbursement rate allowed for Florida Medicaid.(3) Agency: As defined in Section 154.304(1), F.S., (AHCA).(4) Applicant: Any person who applies, through written application, for medical assistance under the Act.(5) Application: The Health Care Assistance Application, AHCA Form 5220-0001, used to apply for coverage for hospital services under the Act. The application must include at least the individual's name, date of birth, living address, mailing address, citizenship and signature to initiate the process. Only one hospital visit per applicant shall be submitted on a single application. Interested parties may obtain copies of the application from the HCRA Handbook.(6) Assets: Those items defined as assets in 20 CFR 416 for determining eligibility for Supplemental Security Income (SSI), except as otherwise provided in Rule 59H-1.008, F.A.C., shall be used in determining eligibility under the Act.(7) Asset Limits: The overall amount of countable assets an applicant may retain and still remain eligible. This amount shall be the same as used in the Medicaid medically needy program as defined in Rule 65A-1.716, F.A.C.(8) Certified Resident: A United States citizen or lawfully admitted alien who has been certified by a Florida county or the Agency as being a resident of that county at the time hospital care was rendered.(9) Certifying Agency: The person or office designated by the county of residence responsible for determining patient eligibility and certifying the county of residency under the Act. The Agency will make this determination on behalf of the county of residence only if it is unable to do so for circumstances beyond its control. Such determinations made by the Agency may not be disputed by the county of residence.(10) Charity Care Obligation: As defined in Section 154.304(4), F.S.(11) Claim: The universal hospital billing form, UB 04/CMS-1450. Only one original claim form may be used for each eligible individual. All information must be in black type with no written modifications. The claim shall be completed pursuant to subsection 59H-1.0065(1) F.A.C. A copy of the form is provided in the HCRA Handbook.(12) County fiscal year: October 1 of a given year through September 30 of the subsequent calendar year.(13) County of Residence: (a) A specific county within the State of Florida where an individual establishes or maintains a living arrangement, outside of a medical facility, and which the individual, or someone responsible for the individual, considers to be the individual home with the intent to remain a resident of that county. A visit to another county for any purpose does not make a person a resident of that county, nor does a temporary living arrangement prior to admission in a medical facility. The length of time a person physically resides in a county is not a factor in determining residency. If the applicant or a member of the applicant's family unit maintains a primary residence in another county with the intent to return to that county, then the county of residence is the county in which the primary residence is located.(b) A student attending school away from home is considered a resident of the county in which the student's parents reside if the student is claimed as a dependent for Federal Income Tax purposes. In those situations where one parent resides in-state and one parent resides out-of-state, the county where a parent resides in-state is the county of residence, even if the in-state parent is not claiming the student as a dependent for tax purposes.(14) Designated Representative: An individual who has personal knowledge of the applicant's circumstances and is authorized to act responsibly on behalf of an applicant by providing information, verification and documentation required by the certifying agency to determine eligibility.(15) Eligible Individual: An applicant who is a certified resident of a Florida county, has met the Act's criteria in regards to income, assets, and other eligibility requirements, who has received covered hospital services from a participating hospital, and who is either a qualified indigent patient or a spend-down provision eligible patient.(16) Emergency Medical Condition: As defined in Section 409.901(10), F.S.(17) Emergency Services and Care: As defined in Section 409.901(11), F.S.(18) Family Unit: One or more persons residing together in the same household whose needs, income and assets are included in the household budget, excluding roomers and boarders. Members may include the applicant, legal spouse, partner, dependent children, stepchildren, adopted children and blood relatives under 21 years of age, unrelated minor children for whom the applicant, the applicant's spouse, or partner has legal guardianship or custody, legal guardian or parents of minor children, minor siblings, and partner's children under the age of 21. (a) A boarder is a person for whom payment is made for room and meals and who is not the spouse or partner of the landlord.(b) A roomer is a person for whom a payment is made for a room and who is not the spouse or partner of the landlord.(c) An applicant who is a roomer or boarder must verify the applicant's status as a roomer or boarder by providing a written statement from the landlord stating that the applicant is a roomer or boarder, the amount of the cash payment, that the cash payment is for a room or a room and meals, and that the applicant is not the spouse or partner of the landlord.(d) An applicant who wishes to exclude a person from the applicant's family unit based on the fact that the person is a roomer or boarder must verify that person's status as a roomer or boarder by providing a written statement from the person stating that the applicant is a roomer or boarder, the amount of the cash payment, that the cash payment is for a room or a room and meals, and that the person is not the spouse or partner of the landlord.(19) Gross Family Income: The sum of gross income a family unit receives or is entitled to receive at the time of eligibility determination, as defined under Section 154.308(4), F.S. Income shall include the following: (d) Unemployment compensation;(e) Worker's compensation;(h) Pensions or annuities;(j) Interest on savings or bonds;(k) Income from estates or trusts;(l) Net rental income or royalties;(m) Net income from self-employment; and,(n) Contributions from any source, including any amount contributed toward the support of any individuals and not otherwise excluded under the HCRA guidelines.(20) HCRA Handbook: The Florida Health Care Responsibility Act (Act, HCRA, or Program), Handbook, February 2016, and herein incorporated by reference, for the purpose of providing detailed and uniform policies and procedures to the hospitals, counties and others in complying with the applicable statutes and administrative rules. Copies of the HCRA Handbook may be obtained at https://www.flrules.org/Gateway/reference.asp?No=Ref-07331 and from the Agency's HCRA website at http://www.ahca.myflorida.com/MCHQ/Central_Services/Financial_Ana_Unit/HCRA/index.shtml. The following forms are included in the HCRA Handbook and are incorporated by reference: Health Care Assistance Application, AHCA Form 5220-0001, February 2016; Monthly Caseload and Appeals Report, AHCA Form 3160-0017, February 2016; Notification of Eligibility, AHCA Form 5220-0002, February 2016; and Quarterly Financial Report, AHCA Form 3160-0018, February 2016; and the UB 04/CMS-1450 Claim.(21) Homestead: House, trailer, boat or motor vehicle in which the family unit resides and which is owned by the applicant or a member of the applicant's family unit. Only one homestead shall be excluded as an asset. The composition and value of real property shall be determined by the county property appraiser. If the family unit leaves the homestead and establishes residence elsewhere, the homestead becomes an asset regardless of how it is considered for tax purposes. If a member of the family unit continues to reside in the homestead, it will not be considered an asset. If, in the case of a single person family unit, the individual is absent because of a physical or mental illness, and the individual intends to return, the homestead will not be considered as an asset.(22) Hospital: As defined in Section 154.304(7), F.S.(23) Inpatient: A patient of a hospital who: (1) receives professional services in the hospital for a 24-hour period or longer; or(2) is expected by the hospital to receive professional services in the hospital for a 24-hour period or longer even though it later develops that the patient dies, is discharged or is transferred to another facility and does not actually stay in the hospital for 24 hours.(24) Maximum County Financial Responsibility: That amount obtained by multiplying total county population, as defined in Section 154.306(3), F.S., by $4 per capita using the most recent official state population estimate for the total county population published by the Florida Legislature's Office of Economic and Demographic Research.(25) Medicaid Program: As defined in Section 409.901(16), F.S.(26) Monthly Caseload and Appeals Report: The form, Monthly Caseload and Appeals Report, AHCA Form 3160-0017, used by the counties on a monthly basis and submitted by the 15th of the month following the end of the reported month to the Agency to document and report each county's caseload activity on applications and appeals. Copies of the report form may be obtained from the HCRA Handbook.(27) Notification of Eligibility: The form, Notification of Eligibility, AHCA Form 5220-0002, used by the Certifying Agency to notify hospitals of the eligibility determination of an application. Copies of the notification form may be obtained from the HCRA Handbook.(28) Outpatient: A patient of a hospital who receives professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the hospital past midnight, meaning that a hospital stay may occur over the course of two calendar days and still be less than a 24-hour period. Only one day's services are billable on one outpatient claim.(29) Participating Hospital: As defined in Section 154.304(8), F.S.(30) Poverty Guidelines: The federal poverty measure published annually in the Federal Register by the U.S. Department of Health & Human Services (formally known as the Federal Poverty Level, or FPL).(31) Public Institution: Institution over which a governmental unit exercises administrative control, such as a correctional institution or holding facility for individuals who are prisoners, have been arrested or detained pending dispositions of charges, or are held under court order as material witnesses or juveniles.(32) Qualified Indigent Patient: As defined in Section 154.304(9), F.S.(33) Quarterly Financial Report: The form, Quarterly Financial Report, AHCA Form 3160-0018, used by the counties on a quarterly basis and submitted within 30 calendar days following the end of the reported quarter to the Agency to document and report each county's expenditures and claim activity. Copies of the report form may be obtained from the HCRA Handbook.(34) Regional Referral Hospital: As defined in Section 154.304(10), F.S.(35) Share of Cost: The difference between the spend-down provision applicant's monthly gross family income and the amount of income equal to 100 percent of the poverty guidelines specified for the size of the applicant's family unit.(36) Spend-down Provision: The provision through which an applicant who meets the following criteria becomes eligible by meeting a share of cost requirement. Such an applicant must: (a) Be a resident of a spend-down provision eligible county as defined in subsection 59H-1.0035(37), F.A.C.;(b) Meet the definition of a qualified indigent patient as defined in subsection 59H-1.0035(32), F.A.C., excluding the income requirement;(c) Have a gross family unit income, for the 12 months preceding the determination, between 100 percent and 150 percent of the poverty guidelines; and,(d) Have incurred hospital bills which would have otherwise qualified for payment under this section and which exceed the applicant's share of cost.(37) Spend-down Provision Eligible County: A Florida county which was not at its 10 mill cap on ad valorem taxes as of October 1, 1991, as determined by the Florida Department of Revenue.(38) State Fiscal Year: July 1 of a given year through June 30 of the subsequent calendar year.(39) Teaching Hospital: As defined in Section 408.07(45), F.S.(40) Uncompensated Charity Care: Defined in the Florida Hospital Uniform Reporting System (FHURS) as charity/uncompensated care - other and charity/uncompensated care - Hill-Burton as reported on work sheet C-3a of the hospitals' prior year report.(41) Verification: Confirmation of the accuracy of the information on an application used by the Certifying Agency to determine the applicant's eligibility through sources other than the self-declaratory statement of the individual originally supplying the information. Verification can be secured by telephone, in written form, or by face-to-face contact. Verification does not require a written document to confirm an applicant's statement. In the event an employer will not verify the wages paid, the self-declaratory statement provided by the applicant must be accepted as accurate, except in those circumstances where there is substantial evidence to indicate that actual wages are in excess of those stated in the application.Fla. Admin. Code Ann. R. 59H-1.0035
Rulemaking Authority 154.3105 FS. Law Implemented 154.304, 154.306, 154.308, 154.309 FS.
New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0035, Amended 6-7-00, 12-17-01, Amended by Florida Register Volume 42, Number 154, August 9, 2016 effective 8/25/2016.New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0035, Amended 6-7-00, 12-17-01, 8-25-16.