Section 144-150-1.05 - DETERMINATION OF QUALIFICATIONA.Application(1) Each hospital shall provide an opportunity for each person seeking free care to make application on forms provided by the hospital.(2) A hospital may require an applicant to furnish any information that is reasonably necessary to substantiate the applicant's income or the fact that the individual is not covered by insurance or eligible for coverage by state or federal programs of medical assistance.B.Determination(1) Upon receipt of an application, a hospital shall determine that an individual seeking free care qualifies for such care if:(a) the individual meets the income guidelines specified in Section 1.02;(b) the individual is not covered by any insurance nor eligible for coverage by state or federal programs of medical assistance; and,(c) services received were medically necessary.(2) If the hospital determines that the individual seeking free care meets the income guidelines but is covered by insurance or by state or federal programs of medical assistance, it shall determine that any amount remaining due after payment by the insurer or medical assistance program will be considered free care.(3) A hospital may allow the determination of qualification for outpatient free care services to remain valid for up to six months following the date of determination. If a hospital adopts the policy of allowing qualification for outpatient free care services to remain valid for six months, such policy shall apply to all individuals determined qualified for outpatient free care services. A determination of qualification for inpatient free care services shall be made with each admission.
C.Deferral of Determination(1) Under the conditions specified in paragraphs (2) and (3) below, a determination of qualifications for free care may be deferred up to 60 days, for the purpose of requiring the applicant to obtain the present evidence of ineligibility for medical assistance programs or to verify that the services in question are not covered by insurance.(2) If an applicant for free care, who meets the income guidelines in section 1.02 and who is not covered under any state or federal program of medical assistance, meets any of the following criteria, qualification for free care shall be deferred: (d) an individual is a member of a family in which a child is deprived of parental support or care due to one of the following causes, and the individual's income is less than the guidelines in section 1.02: (ii) continued absence of the parent(s) from the home due to incarceration in a penal institute, confinement in a general, chronic or specialized medical institution, deportation to a foreign country, divorce, desertion or mutual separation of parents, or unwed parenthood;(iii) disability of a parent; or(iv) unemployment of a parent who is the principal wage earner;(3) If an individual does not meet any of the criteria specified in (2) above, but the hospital is unable to determine the coverage of the individual and has a reasonable basis for believing that the individual may be covered by insurance or eligible for federal or state medical assistance programs, it may defer the determination concerning free care.D.Content of Favorable Determination. A determination that an applicant qualifies for free care must indicate: (1) That the hospital will provide care at no charge;(2) The date on which the services were requested;(3) The date on which the determination was made; and(4) The date on which services were or will be first provided to the applicant.E.Reasons for DenialEach hospital shall provide each applicant who requests free care and is denied it, in whole or in part, a written and dated statement of the reasons for the denial when the denial is made. When the reason for denial is failure to provide required information during a period of deferral under subsection 1.05(C), the applicant shall be informed that she or he may reapply for free care, if the required information can be furnished. Additionally, the notice must state that the patient has a right to a hearing; how to obtain a hearing; and name and telephone number of the person who should be contacted, should the provider/patient have questions regarding the notice.
F.Reasons for Deferral(1) When an application for free care under paragraph 1.05 (C) (2) is deferred, the applicant shall be notified as follows: A free care determination has not yet been made. There is reason to believe that you [the applicant] may be eligible for coverage by state or federal medical assistance programs. If you can show that you are not eligible for coverage by these programs within 60 days of the date of this notice by obtaining a letter or other statement from __________ [insert name of state or federal agency to which applicant has been referred], then you will be considered qualified for free care. Even if you are eligible for coverage, free care will be available for any portions of the bills that medical assistance programs (or any insurance that you have) will not pay.
(2) When an application is deferred under paragraph 1.05 (C) (3), the applicant shall be notified of the reason for deferral, including the basis for the hospital's belief that coverage or eligibility may exist and the nature of the evidence that should be provided to complete the determination. The notice shall be in substantially the form specified in paragraph (1) above and shall include the last sentence of that form.10- 144 C.M.R. ch. 150, § 1.05