Fla. Admin. Code R. 59H-1.008

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59H-1.008 - Determination of a Qualified Indigent Patient

(1) The county of residence has the primary responsibility for determining eligibility for individuals applying for coverage, using the eligibility determination procedures described in this section. The Agency shall conduct eligibility determinations only when the county demonstrates to the Agency that staff are not available. The county shall notify the Agency of its intent to determine eligibility. The participating hospital may elect to provide some of the eligibility documentation to the certifying agency.

(2) The governing board of the county shall designate a person or county agency to be responsible for the administration of the Act. The name, title, address, and phone number of the person or county agency, which shall determine eligibility and certify county of residence under the Act shall be provided to the Agency on an annual basis, and when modified. The county is reponsible for informing the Agency of any changes in this information within 30 calendar days of such change. The Agency shall provide such information to the participating hospitals and regional referral hospitals on an annual and modified basis.

(3) Hospitals shall screen applicants to determine the availability and adequacy of third party insurance and potential eligibility for Medicaid or other State or Federal governmental programs. Participating hospitals are responsible for initiating the eligibility determination procedures and assisting the applicant in completing the application. The hospital has 30 calendar days from the date of admission or emergency treatment to notify the certifying agency by certified mail of an individual who may qualify or the hospital forfeits its right to reimbursement. The postage date shall be used to determine such deadline.

(4) Notification shall consist of an application signed by the applicant or the applicant's designated representative.

(5) In those situations where the applicant is comatose or is physically incapacitated to the extent that an application cannot be completed, and there is no designated representative to complete the application, the hospital may serve as designated representative.

(6) The hospital shall include with the application any documentation available that would assist the certifying agency in determining eligibility or residency, and shall include hospital bills applicable to the applicant's meeting the applicant's share of cost. Lack of documentation will not preclude submission of the application nor constitute a reason to delay the submission of the application within proscribed time limits.

(7) The certifying agency has 60 days following receipt of an application from the hospital to determine eligibility. When the applicant provides all required information or verification, the certifying agency determines eligibility for the HCRA program. If for any reason eligibility cannot be determined within 60 days, the hospital shall be notified, in writing, of the reason for the delay. If the due date falls on a weekend or holiday, the deadline is the next business day.

(8) If the certifying agency determines at any time during the application process, including interviews, that the applicant must provide additional information or verification, the certifying agency must give the applicant written notice to provide the requested information, allowing at least 10 calendar days from request or the interview, whichever is later. If the due date falls on a weekend or holiday, the deadline is the next business day.

(9) The certifying agency shall use gross family income to determine if the family unit's income is less than or equal to 100 percent of the poverty guidelines or less than or equal to 150 percent of the poverty guidelines for residents of spend-down provision eligible counties. Verification of earnings shall be requested for the 4-week period prior to the date of determination pursuant to Section 154.308(4), F.S. The certifying agency shall require additional income verification for the preceding 12-month period if the income received for the 4-weeks prior to determination is not representative of the family unit's gross income.

(10) If the family unit's monthly gross income is more than 100 percent of the poverty guidelines and the applicant is a resident of a spend-down provision eligible county, the certifying agency shall use monthly gross family income to determine if the family unit's income is between 100 percent and 150 percent of the poverty guidelines. Verification of earnings shall be for the one month period prior to the applicant's date of determination. The certifying agency shall require additional income verification for the preceding 12-month period if the income received for the month prior to the date of determination is not representative of the family unit's annual gross income.

(11) Verification of income, except as provided in subsection 59H-1.0035(41), F.A.C., may be a written or oral statement that certifies the applicant's income includes:

(a) A statement from a state or federal agency which attests to the patient's financial status;

(b) A statement from the employer;

(c) Pay stubs for 4 weeks if available or if needed, information for the preceding 12 month period; or

(d) A statement from the source providing unearned income to the applicant or family unit.

(12) The certifying agency shall determine if the applicant's assets exceed the standards of the asset limits specified in subsection 59H-1.0035(7), F.A.C. The certifying agency shall verify assets but such verification must be completed within 30 days of receipt of the application. If verification is not requested and received within 30 days of receipt of the application, the assets will be accepted as stated in the application unless the certifying agency documents by independent means that assets exceed the limit.

(13) The following shall not be included as assets in the eligibility determination:

(a) One homestead;

(b) Household furnishings;

(c) One automobile in operating condition;

(d) Clothing;

(e) Tools used in employment;

(f) Cemetery plots, crypts, vaults, mausoleums, and urns;

(g) Produce and animals raised for home consumption; and,

(h) The income and assets of roomers and boarders. The applicant must verify the 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 payment and that the payment is for a room or a room and meals and that the person is not the spouse or partner of the landlord.

(14) The certifying agency may conduct phone or face-to-face interviews with applicants to complete the eligibility review process. The certifying agency may determine eligibility based on documentation submitted by the hospital or applicant without a phone or face-to-face interview, if adequate information is provided to verify income, assets and spend-down provision eligibility.

(15) If the applicant is a resident of a spend-down provision eligible county and the applicant's gross family income is between 100 percent and 150 percent of the poverty guidelines, the certifying agency shall determine the applicant's share of cost for the spend-down provision as defined in subsection 59H-1.0035(37), F.A.C. The applicant's share of cost is the difference between the applicant's monthly gross family income and 100 percent of the poverty guidelines.

(16) For out-of-county hospital reimbursement, the applicant must have out-of-county hospital bills that exceed the applicant's share of cost, as defined in subsection 59H-1.0035(35), F.A.C., to be eligible. Allowable out-of-county hospital bills are the out-of-county hospital bill for the date(s) of service indicated on the application and all other hospital bills for related services, which would have otherwise qualified for payment under this part, that had been provided during the four weeks prior to the date(s) of service indicated on the application. Follow-up care which occurs within 4-weeks from the date of discharge of a related reimbursed incident shall not require an additional share of cost.

(17) For in-county hospital reimbursement, the applicant must live in a county that uses up to 1/2 of its designated HCRA funds for in-county hospital reimbursement and have in-county hospital bills that exceed the applicant's share of cost, as defined in subsection 59H-1.0035(35), F.A.C., to be eligible. Allowable in-county hospital bills are the in-county hospital bill for the date(s) of service indicated on the application and all other hospital bills for related services, which would have otherwise qualified for payment under this part, that had been provided during the four weeks prior to the date(s) of service indicated on the application. Follow-up care which occurs within 4 weeks from the date of discharge of a related reimbursed incident shall not require an additional share of cost.

(18) To determine if the applicant has met the applicant's share of cost, the certifying agency shall first determine the amount of reimbursement for which the hospital would have been eligible if no share of cost was involved. To determine the amount of reimbursement for inpatient hospital care, the certifying agency shall multiply the number of approved days by 100 percent of the Medicaid per diem rate or other negotiated rate. The certifying agency shall determine the amount of reimbursement for any outpatient services provided, for which the hospital would have been eligible if no share of cost was involved, based on the Medicaid rate, or other negotiated rate, for each covered service. If the applicant's share of cost is less than the determined amount of reimbursement, then the applicant has met his share of cost and is eligible for reimbursement through the spend-down provision, within the limitations specified in Rule 59H-1.0045, F.A.C.

(19) The certifying agency shall notify the applicant and the hospital of the disposition of the application using the Notification of Eligibility within 10 calendar days of the disposition. If the eligibility criteria are met, the applicant is approved for benefits through the HCRA program. A copy of the Notification of Eligibility shall be included with the request for payment submitted by the hospital.

(20) Eligibility shall be retroactive to the date of admission or treatment, as indicated on the application.

(21) The eligibility determination may be done prior to admission for applicants who expect to be hospitalized for non-emergency or elective services.

(22) The certifying agency shall establish a case record for each individual applying for assistance under the Act. The case record shall contain the application, any documentation or evidence used in the determination of eligibility and a copy of any notices issued to the applicant or hospital making the referral.

(23) The certifying agency shall retain all case records for a period of 3 years from the date of the last action taken.

Fla. Admin. Code Ann. R. 59H-1.008

Rulemaking Authority 154.3105 FS. Law Implemented 154.306, 154.308, 154.316 FS.

New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.008, Amended 6-7-00, 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-26.008, Amended 6-7-00, 8-25-16.