Ga. Medicaid Part II Policies & Procedures for Hospital Services § 901

The Hospital Program provides reimbursement for medical services rendered in an inpatient or

outpatient hospital setting. Covered services for eligible program members are those primarily for

treatment indicated in the management of acute illness, injury, or impairment, or for maternity care.

Federal regulations require that the Division establish reimbursement limitations to ensure

medical necessity of services and utilization control.

In accordance with Federal regulations, non-covered medically necessary services provided to

children less than twenty-one (21) years of age may be reimbursable if prior approved by the Division.

All services provided to members twenty-one years (21) of age and older are subject to the

reimbursement limitations described in this manual regardless of the diagnosis, type of illness or

condition.

Coverage is provided for preventive, diagnostic, therapeutic, rehabilitative or palliative items or

services furnished under the direction of a doctor or by an institution which is licensed or formally

approved as a hospital by an officially designated state standard- setting authority and is qualified to

participate under Title XVIII (Medicare) of the Social Security Act, or is determined currently to meet

the requirements for such participation, and which is enrolled in the Medicaid program.

In compliance with Section 1902 (a) (57) of the Social Security Act hospitals must:

901.1. Provide written information to patients regarding their rights under state law to make

decisions concerning their medical care, including the right to accept or refuse medical or

surgical treatment and the right to formulate advance directives.

901.2. Provide written information to individuals regarding the institutions or program’s written

policies respecting the implementation of the right to formulate advance directives

901.3. Document in the patient’s medical record whether or not an advance directive has been

executed.

901.4. Comply with all requirements of State law respecting advance directives

901.5. Provide (individually or with others) education for staff and the community on issues

concerning advance directives.

901.6. Not condition the provision of care or otherwise discriminate against an individual who has

executed an advance directive.

901.7. An “inpatient” is defined as a patient who has been admitted to a participating hospital on

recommendation of a licensed doctor and is receiving room, board, and professional services

in the hospital on a continuous twenty-four hour a day basis. A length of stay less than

twenty-four hours may be considered inpatient if the service can only be provided on an

inpatient basis. (See Section 904.7) Transfers between units within the hospital are not

considered new admissions

901.8. An “outpatient” is a patient who is receiving professional services at a participating hospital.

(See Section 903.6 regarding observation services.) Free standing (satellite) clinics, which

are not operated as part of a hospital, are considered doctors’ offices. Services provided in

these clinics and other away- from-hospital settings are not covered in the Hospital Program.