Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix O

A. General Information

The Indigent Care Trust Fund (ICTF) program provides funds to certain hospitals to cover all or a

portion of the costs of medical services to the medically indigent that, for example, may be

uninsured or have accrued medical bills that Medicaid does not cover. The Department of

Community Health (Department) is authorized by statute to establish rules that support the

purposes for which contributions, deposits and transfers to the ICTF may be made. Chapter 111-

3-6 of the Rules of the Department sets forth those rules, which include a provision for the

issuance of this Manual.

In this Manual, the Department provides the conditions for participation, policies, procedures,

instructions, forms, dispute-resolution procedures, sanction provisions for non-compliance, and

other items for use by each eligible hospital in operating programs consistent with the Rules for

the ICTF program. In addition to this, the Department’s Policies and Procedures for Hospital

Services, the Policies and Procedures outlined in Part I for all Medicaid providers shall also apply

to each participating hospital.

Funds appropriated or transferred to the Department for the ICTF program only may be used for

the following purposes:

i. To expand Medicaid eligibility and services;

ii. For programs to support rural and other health care providers, primarily hospitals, who

serve the medically indigent;

iii. For primary health care programs for medically indigent citizens and children of the state

of Georgia; or

iv. Any combination of the above-stated purposes.

Such funds shall be used to match federal funds or any other funds from a public source or

charitable organization that are made available for these purposes

B. ICTF Program Objectives

The objectives of the ICTF program are designed by the Department to guide each participating

hospital in the appropriate utilization of funds in accordance with the purposes outlined by the

General Assembly. Although this list is not intended to be exhaustive, these program objectives

will assist the hospital in formulating and implementing its program for which ICTF payments

may be allocated:

i. To ensure that quality medical services are made available and accessible to patients

eligible for Medicaid, Medicare or determined to be medically indigent according to

criteria established by the Department.

ii. To support the provision of medical services to medically indigent persons so that they

may receive care without charge or at a reduced rate.

iii. To ensure that medically indigent patients receive care in the setting determined by

current professional standards to be the most appropriate and cost effective for the

treatment of the individual’s medical condition.

iv. To ensure that medically indigent patients are not denied medical care or subjected to the

under-utilization of medical services

v. To reduce significant local health care problems within the hospital’s medical service

area.

vi. To establish and identify an appropriate and regular source of primary care for medically

indigent patients.

vii. To provide services in which evidence of community support and linkage to local health

planning is shown.

C. ICTF-Eligible Hospitals:

Each hospital that is designated as a Disproportionate Share Hospital (DSH) is eligible to

participate in the ICTF program. The hospital must be licensed in Georgia and meet at least one

of the criteria established by the Department for designation as a hospital which serves a

disproportionate number of low-income patients with special needs.

ii. Requirements for Participation in the ICTF Program:

1. Each hospital shall meet the conditions specified by the Department in this

Manual in order to begin and continue participation in the ICTF program.

Requirements for participation in the ICTF program are divided into the

following categories:

a) Contractual Obligations

b) Conditions for Receipt of ICTF Payment Adjustments

c) Free and Reduced-Charge Care

d) Public Notification about the ICTF Program

e) Financial Reporting

f) Hospital’s Resolution Process

g) Compliance

D. Contractual Obligations

i. Letter of Agreement.

Each participating hospital shall execute a Letter of Agreement (or similar form) provided

by the Department, which incorporates the provisions of the Rules, the Manual, and the

applicable policies and procedures of the Department. The Letter of Agreement permits

the Department to assess liquidated damages against the hospital as follows:

1. In an amount established by the Department for each calendar day in which the

hospital fails to comply with the Department’s Rules, Policies and Procedures of

the Department or this Manual.

2. In an amount not greater than the disproportionate share payment for the year in

which the hospital knowingly and willfully makes or causes to be made any false

statement or misrepresentation of material fact with respect to:

a) The use of funds from the Trust Funds by the hospital; or

b) The response of the hospital to any request for information from the

Department related to the Trust Funds, including without limitation the

submission of any report required under the Department’s Rules, Policies

and Procedures or this Manual.

The assessment of liquidated damages against the hospital shall be in addition to every other

remedy available to the Department at law, in equity, by statute or under contract. In its

discretion, the Department may also require the hospital to submit a corrective plan of action, if

applicable, that demonstrates the hospital’s compliance with its contractual obligations.

E. Intergovernmental Deposits and Transfers

ICTF payments to hospitals are dependent, in part, on the availability of funds received from

intergovernmental deposits and transfers. Under Georgia law, hospital authorities and other

governmental or public entities are authorized to make such deposits and transfers to the ICTF.

Each year, the Department provides instructions to participating hospitals and affiliated hospital

authorities regarding the amount of funds needed and the manner by which funds can be

deposited or transferred.

F. Conditions for Deposits and Transfers to the ICTF

All moneys that are deposited or transferred to the Trust Fund are irrevocable, and no limitation

on the use of the moneys is permitted except as set forth by the Department or the Rules. Hospital

authorities, counties, municipalities, or other state or local public or governmental entities may

deposit or transfer moneys to the Trust Fund. To facilitate the deposit or transfer, each entity must

execute a Letter of Intent to deposit or transfer funds as outlined in Section II.A.5.

G. Refunds or Returns of Deposits and Transfers to the ICTF

i. Inappropriate Deposits and Transfers:

Deposits and transfers to the ICTF that are not properly designated or that do not satisfy

the Rules and the contracts, agreements or other instruments with the Department shall

be returned to the depositor or transferor with interest earned after payments are

collected from the appropriate hospital, except that penalties so transferred to the Trust

Fund shall not be refunded.

ii. Hospital Closing:

If a participating hospital closes during the fiscal year in which funds are received,

deposits and transfers shall be returned with interest earned pro rata to such hospital,

unless the hospital has received a DSH payment for that fiscal year.

iii. Failed or Void Appropriations:

Deposits and transfers to the ICTF and interest earned thereon will be refunded to the

entity depositing or transferring if such monies:

1. Have not been appropriated by the end of the fiscal year; or

2. Have been appropriated but have been determined to be:

a) A void appropriation in violation of O.C.G.A. 31-8-156;

b) ineligible for anticipated matching federal funds;

c) Not contractually obligated at the end of the fiscal year for which they

were appropriated;

d) Subject to return based on any Rule of the Department; or

e) Void because the Department violated the terms of a contract,

agreement or other instrument facilitating transfers to the ICTF. The

Department will ensure that any appropriate refunds are made no less

than thirty (30) days from the end of the fiscal year or other time

determined by the Department as applicable.

H. Conditions for Receipt of ICTF Payment Adjustments:

i. As a condition for receipt of ICTF payments, each participating hospital must:

1. continue participation in the Medicaid program;

2. comply with the Department’s Rules and the Department’s Policies and

Procedures, including specifically Part II of the Hospital Services manual

including the Appendix Q;

3. comply with the Department’s requests for reports and verification thereof on

the use of the funds from the ICTF;

4. use the funds from the ICTF to provide health care services to Medicaid

recipients and medically indigent citizens of the state; and

5. meet the following additional conditions, if the hospital is a Disproportionate

Share Hospital:

a) Continue participation in the Medicare program.

b) Make available medical services to Medicaid and Medicare recipients

without discrimination.

c) Provide obstetrical care services if such services are presently provided.

d) Comply with the patient transfer requirements provided in the

Emergency Medical Treatment and Active Labor Act (EMTALA) of

1986, as amended.

e) Ensure that patients are not transferred or denied services based solely

or in significant part on economic reasons.

f) Make arrangements with sufficient numbers of physicians for each

service to assure that Medicaid patients have full access to the facility’s

services without being required to pay physicians for Medicaid covered

services.

g) Make arrangements with physicians to ensure Medicaid and medically

indigent patients are not required to have a physician with staff

privileges as a condition of admission or treatment when such

admission or treatment is determined to be medically necessary and

within the scope of service capability of the hospital.

h) Document which physicians with staff privileges accept and will treat

Medicaid patients in their offices and assist Medicaid patients with

referrals to such physicians. The hospital shall encourage full provider

participation in the Medicaid program.

i) Ensure that preadmission deposits are not required on demand as a

condition of treatment of Medicaid eligible persons or medically

indigent persons.

i. For treatment of medically indigent patients, ensure that inability to pay does not

act to deny or substantially delay receipt of medically necessary services. The

hospital shall provide assistance to medically indigent patients by operating a

program under which patients may receive care without charge or at a reduced

charge, as more specifically set forth in this Manual under Section II.D, Free and

Reduced - Charge Care.

ii. Effectively advise the public of the hospital’s participation in the program, the

availability of services provided, the terms of eligibility for free and reduced

charge services, the application process for free and reduced charge services, and

the person or office to whom complaints or questions about the hospital’s

participation in or operation of the program may be directed. Upon request by the

Department, the hospital shall provide evidence of its compliance with the public

notification requirements of this section. Refer to the subsection in this manual

entitled Public Notification about the ICTF Program.

iii. Submit to the Department a report on the use of ICTF payment adjustments each

calendar year. Such reports shall:

1. Be in a format established by the Department.

Be available to the public for examination; and

2. Include a report of the number of medically indigent persons served

without charge in both inpatient and primary care settings and the dollars

expended for such services. Hospitals shall report dollars expended using

a cost-to-charges ratio of 65 percent. Over a twelve-month period, each

hospital will be expected to report a medical indigence services

expenditure of an amount equal to no less than 100 percent of the

hospital’s total ICTF payment adjustments minus the amount transferred

or deposited to the Trust Fund by or on behalf of the hospital.

The following example describes the amount as the medical indigence services

requirement to be calculated as follows:

($100 - $40) x 100% = $60

$100 =Total DSH payment adjustment

$40 = Amount transferred or deposited to the Trust Fund by or on behalf of

the hospital

$60 =Amount to be reported to the Department as indigence services

expenditures

Failure to provide such reports in the format prescribed and within the time

periods established by the Department, or to demonstrate timely accessibility to

ICTF supported services may result in a withholding or recoupment of ICTF

payment adjustments.

Complete and fulfill the requirements as more specifically set forth in this

Manual under Section II.A, Contractual Obligations.

For the development and provision of new institutional health services or health

care facilities, comply with the rules and requirements of the Certificate of Need

program under the Division of Health Planning of the Department, as set forth

more specifically in O.C.G.A. Sections 31-6-40 et seq., and the annual reporting

requirements under O.C.G.A. Section 31-6-70.

I. Free and Reduced-Charge Care

Each disproportionate share hospital must ensure that, for treatment of medically indigent

patients, the inability to pay does not act to deny or substantially delay receipt of medically

necessary services. The hospital shall provide assistance to medically indigent patients by

operating a program under which such patients may receive care without charge or at a reduced

charge, except that no hospital shall be required to provide services without charge or at a

reduced charge once the hospital’s expenditures meet the medical indigence services requirement

described on page R-7 subsection II.B (e) 12(c) in this Manual

The Department may approve a plan for the operation of a disproportionate share hospital’s

program under Rule 111-3-6-.03(4)(e)10 which contains one or more variances from the manual

for the purpose of allowing a disproportionate share hospital to coordinate its program with an

existing program of care for the medically indigent sponsored by a local government, provided

that the program is operated in a manner consistent with these Rules and further provided that no

patients are rendered ineligible for serviced without charge or at a reduced charge who would

have been eligible if the variance had not been granted. The hospital can mail their request to:

Director of Medical Policy Unit

Division of Medicaid, 19th Floor

2 Martin Luther King Jr. Drive SE, East Tower

Atlanta, Georgia 30303-3159

J. Eligibility Criteria

i. The hospital shall apply standard eligibility criteria for each person requesting free and

reduced charge care that enables the hospital to:

1. Provide services for no charge to persons with incomes below 125 percent of

the federal poverty level; and

2. Provide services for no charge or adopt a sliding fee scale (reduced-charge

services) for persons with incomes between 125 and, at a minimum, 200

percent of the federal poverty level.

ii. General instructions for hospital include:

1. Income:

a) Income is the family unit’s gross income. Use either the average

monthly income for the previous three months or for the previous year,

whichever is more favorable to the applicant. (This is consistent with

Hill-Burton uncompensated care regulations.)

b) For self-employed individuals, the amount of income to be counted is

gross income minus work expenses directly related to producing the

goods or services and without which the goods or services could not be

produced.

c) For money received that may be considered as a non-recurring lump

sum (insurance settlements, accumulated back RSDI payments, etc.),

consider the gross amount received as income in the month received.

d) Temporary Assistance Needy Families (TANF) or Social Security

Insurance (SSI) income received by any family member should be

excluded.

e) Do not count income from any person who is not financially

responsible for the patient. For example, do not count income from one

sibling as available to another sibling for purposes of paying medical

bills. Likewise, do not count income from any child (minor or adult) in

considering eligibility under the ICTF for the child’s parent.

2. Verification of income:

a) You may require reasonable methods of income verification such as

pay stubs, award letters, employer statements, income tax returns, etc.

b) The applicant’s statement of zero income maybe accepted.

3. Sliding fee scale:

a) Outline and publish the sliding scale you intend to apply.

4. Family unit:

a) The family unit consists of individuals living alone; and spouses,

parents and their children under age 21 living in the same household.

b) A family unit may include minor children living with a legal guardian.

The child, legal guardian, and the legal guardian’s family unit living in

the same household may comprise a family unit.

K. Program Requirements:

i. The hospital shall comply with each provision below to implement and maintain its

program for free and reduced charge services:

ii. Designate a point of contact within the facility to receive applications and determine

eligibility for free and reduced-charge services. Consider the out-stationed eligibility

worker assigned to the facility so that individuals also may receive help to apply for

Medicaid if appropriate. You must also establish adequate procedures to safeguard

confidentiality of patient information.

iii. Provide application forms or an application request sheet in the admissions area,

business office, emergency room, and outpatient department so that individuals

receiving services at times when the designated office is closed may apply or indicate

their intention to apply for assistance.

iv. Apply the eligibility criteria included in this manual.

v. Accept applications at any time, including after initiation of a collection effort.

vi. For patients applying for Medicaid or other assistance and those attempting to obtain

any necessary verification of income, make a determination that they are conditionally

eligible for assistance under the ICTF. Adjust the Log of Patient Accounts to reflect the

final determination when it is made.

vii. Make determinations of eligibility within 5 working days from the date of application

information is complete.

viii. Issue written notices to applicants informing them of the results of the determinations.

If an applicant is determined ineligible, include the reasons and the information you

relied upon to make the determination.

ix. Include in the notice information on how to be reconsidered if the patient disagrees with

the initial decision. Appoint someone different from the person who makes initial

determinations of eligibility to reconsider applications.

x. Issue a written final determination of eligibility. Include the Department’s toll-free

number 1-877-261-3117 or local 404-463-5827 to call if the applicant still disagrees

with the determination you have made.

xi. Maintain and make available for inspection by the Department and members of the

public a Log of Patient Accounts, with patient identifying information deleted that is

specific to the free and reduced-charge services available at the hospital under the Trust

Fund program. Refer to Page R-32 for the form entitled “Log of Patient Accounts”.

xii. Maintain written records and documentation of each application and all notices to

applicants for free and reduced-charge services for a minimum period of five (5) years.

All such documentation shall be made available to the Department upon request.

L. Program Limitations:

If the hospital plans to place any limitations on services available under the free and reduced-charge services program, it must obtain written prior approval from the Department for its policy.

Upon approval from the Department, the hospital must include information on any such

limitations on its signs and on written notices for patients and the public. Limitations that are

prohibited and will not be approved by the Department include without limitation:

i. Restricting coverage to emergency services only

ii. Restricting coverage to non-emergency services only

iii. Restricting coverage in a way that could have the effect of discriminating against a

particular group or groups of individuals

iv. Restricting coverage in a way that could have the effect of discriminating against

individuals with particular types of conditions, provided that the needed services are

within the scope of those ordinarily provided by the facility

M. Geographic limitations

i. Variances:

The Department may approve a hospital’s plan containing one or more variances from

this Manual for the purpose of allowing the hospital to coordinate its program with an

existing program of care for the medically indigent sponsored by the local government.

The Department will not approve a variance that permits a program to operate in a

manner inconsistent with the Rules, nor that renders ineligible those persons who would

have been eligible for free or reduced-charge services if the variance had not been

granted. For additional information or to request a variance from a requirement of this

Manual, contact the Department. Any variance granted by the Department must be

approved in writing by the Chief of the Medical Assistance Plans prior to its

implementation and will become part of the Letter of Agreement.

N. Public Notification about the ICTF Program

Each hospital is required to give adequate notification to the public regarding services that are

hospital must provide forms and instructions to assist those who may be eligible to apply for

services. Utilization of the methods listed below is required. The hospital shall provide the

Department, upon request, with other methods of public notification that it utilizes.

i. The Notice shall include the following:

1. The availability of free and reduced-charge services.

2. The patient’s ability to gain admittance without pre-admission deposits.

3. The right not to be transferred solely or insignificant part for economic reasons

4. The availability of services provided.

5. The terms of eligibility for free and reduced-services.

6. The application process for free and reduced- charges services.

7. The person or office to which complaints or questions about the hospital’s

participation in or operation of the program may be directed.

ii. Publish notices in newspapers of general circulation in the area and distribute notices

through other organizations and mechanisms to reach the population in need of free or

reduced-charge services.

iii. Provide similar individual written notices to each patient potentially eligible for free or

reduced charged care under the Trust Fund program. Also, include these notices with

bills to the patient. Include in the notice the Department’s toll-free telephone number 1-

877-261-3117 or local 404-463-5827 for individuals to call if they are unable to resolve

any problems they experience with the Trust Fund program at the facility.

iv. Place easily readable signs in the emergency room, business office and the admissions

area that include the appropriate program information. Refer to page R-23 for a sample

sign entitled “Help Getting Health Care Services and Help with Your Hospital Bills” for

posting in various areas of the facility.

v. Provide notices in English, Spanish and any other languages as appropriate.

vi. Instruct staff to communicate the content of the notices to people who are unable to read

and to assist individuals who have difficulty applying for available services.

vii. The hospital’s business office staff, social workers and others having contact with

patients regarding the payment of bills should receive adequate training about the

hospital’s ICTF program. The staff shall also make appropriate efforts to refer inpatients

and outpatients needing financial assistance to the local county office of the Department

of Family and Children Services (DFCS) for Medicaid eligibility determinations

O. Financial Reporting

The hospital must provide appropriate data to the Department on the use of Trust Funds. The

hospital must institute written policies and procedures by which patients are determined to be

medically indigent. Adoption of and compliance with this manual shall satisfy the requirement to

institute written policies and procedures.

Each participating hospital must submit an annual financial report documenting its expenditures

for services to medically indigent patients. A hospital must use the Hospital Financial Survey

form issued by the Division of Health Planning of the Department to report this information and

must file the report within the time period specified by the Division.

P. Hospital’s Resolution Processes

Free and Reduced-Charge Services. Hospitals in the ICTF program shall inform persons who

have been denied free or reduced-charge services under the hospital’s ICTF program that they

have an opportunity for reconsideration by the hospital. Refer to subsection D in this manual

entitled Free and Reduced- Charge Care. The hospital shall maintain written evidence verifying

that its reconsideration process has been utilized.

i. Each hospital shall implement and maintain a process that includes the following

mechanisms for tracking and documenting requests for reconsideration:

1. Keep an application on file for each person applying for free or reduced-charge

services

2. Issue written notice to the applicant that approves or denies free or reduced-charge services from the hospital within five (5) working days from the date of

application information is complete. Notices that deny free or reduced-charge

services or that only approve reduced-charge services must include a provision

informing the applicant that the request can be reconsidered. The hospital must

appoint someone to reconsider applications other than the personnel issuing the

original notice. Notices must include specific contact information to hospital

personnel. The formats for these notices are included in this manual as follows:

a) Eligible and approved for free services: Page R-26 (no reconsideration

required)

b) Eligible and approved for reduced-charge services: Page R-27

c) Ineligible for free or reduced-charge services: Page R-28

3. Issue written notice to the applicant of the hospital’s final decision after

reconsideration is made by the appropriate hospital personnel. The formats for

final notices are included in this manual as follows:

a) Reconsidered and approved for free services: Page R-30 (no

reconsideration required)

b) Reconsidered and confirmed original denial of eligibility for free or

reduced-charge services: Page R-29

c) Reconsidered and approved for reduced-charge services: Page R-3

ii. All Other Complaints

The hospital shall seek to resolve complaints in a timely manner regarding its

compliance with the Rules, Policies and Procedures of the Department, including this

Manual, or with the maintenance of the hospital’s ICTF program as required by the

Department.

iii. Compliance:

In the event that a hospital fails to comply with the Rules, the Department’s Policies

and Procedures or this Appendix Q, the Department may, in addition to any legal

remedies, assess liquidated damages against the hospital under its Letter of Agreement

in an amount(s) established by the Department for each calendar day in which the

hospital is non-compliant. These liquidated damages are not and shall not be construed

to be penalties and shall be in addition to every other remedy now or hereinafter

enforceable at law, in equity, by statue, under contract.

In the event that a disproportionate share hospital knowingly and willfully makes or

causes to be made any false statement or misrepresentation of material fact with respect

to the hospital’s use of funds from the Trust Fund or in response to any request for

information from the Department related to the Trust Fund, including without limitation

the submission of any report required pursuant to these Rules, the Department may, in

addition to any other legal remedies available, assess liquidated damages against the

disproportionate share payment or the year in which the false statement or

misrepresentation occurred. These liquidated damages are not, and shall not be

construed to be penalties, and shall be in addition to every other remedy now or

hereinafter enforceable at law, inequity, by statue, or under contract.

SAMPLE

[Sample sign to be posted in facility. The signs should be printed in large format (at least 14” by 17”). Signs

should be placed as specified in the required areas in a prominent spot so that patients can easily read it.]

Assistance Information for Health Care Services or your Hospital Bills:

This hospital participates in the Georgia Indigent Care Trust Fund. As our patient, you receive certain benefits

under the Trust Fund.

You have a right to:

The availability of free and reduced-charge services

The ability to gain admittance without pre-admission deposits.

Not be transferred solely or insignificant part for economic reasons

The availability of services provided.

The terms of eligibility for free and reduced services

The application process for free and reduced charges.

*And the person or office to which complaints or questions about the hospital’s participation in or operation of

the program may be directed

Help with your hospital bills:

You may be eligible for financial help with your bills for inpatient and outpatient services at this hospital. Under

the Trust Fund, we offer a certain amount of free and reduced charge care each year. Apply at _

If you have problems:

If you have any concerns about how we operate programs under the Trust Fund rules, please let us try to work

with you to resolve them. However, if you are not satisfied with our handling of your situation, you may call the

Department of Community Health toll-free at, or write to:

SAMPLE

[Sample Individual Notice of Availability for Free or Reduced-Charged Services]

Do you need help with your hospital bill?

If you do not have insurance to cover your hospital bill, and you have low income, you may qualify for help under

Georgia’s Indigent Care Trust Fund.

This hospital participates in the Georgia Indigent Care Trust Fund. We receive special funding to assist qualified

patients with their medical bills. This year we will provide a certain amount of services to patients free or at a

reduced charge.

Apply at (office address and telephone number). We will make a decision on

whether you are eligible within 5 working days. We will give you a written notice of our decision.

The income guidelines are as follows: Free Services:

Family Size

Income/Mo.

1

2

3

4

Each additional

Reduced-Charge Services:

Family Size

Income/Mo.

20%

Income/Mo.

40%

Income/Mo.

60%

1

2

3

4

Each additional

SAMPLE

APPLICATION FOR

FREE AND REDUCED-CHARGE SERVICES

UNDER THE ICTF PROGRAM HOSPITAL

Name of patient:

Date(s) of service:

Amount of charges: $

Name of applicant:

Relationship to patient:

Address:

Telephone:

Lost member of household, birth date, relationship to patient, and income from each source; state whether

income is per week, month, or year:

Name Birth

Date

Relationship Income

(wk/mo/yr)

Income

(wk/mo/yr)

Income

(wk/mo/yr)

TOTAL

INCOME

If income of any member is from self-employment, you may give information on business costs so that we can

determine actual income to be counted. Write details on the back of this sheet.

(Note to applicant: You do not have to report income for a person in the household who is not legally responsible

for the patient’s medical bills and is not counted in the family size. For example, if you have a brother or sister

who lives with you, that person is not responsible for paying your medical bills, and would not have to be

counted or report income.)

Signature of Applicant:

Date:

For Hospital Staff Use:

TOTAL COUNTABLE INCOME:

(Average monthly income for last year or past 3 months, whichever is more favorable.)

Verification of income supplied (if requested)? Yes No

Determination:

Eligible for free services

Conditional?

Pending:

Eligible for discount

Ineligible

Reason:

(%)

Conditional?

Pending:

Date notice mailed:

Staff Signature:

Date:

Reconsideration:

Result:

Date:

NUMBER COUNTED IN HOUSEHOLD:

SAMPLE

[Letter to applicant with income below 125% of poverty who

qualifies for ICTF Funding]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

Thank you for your application for assistance with your hospital bills under the Georgia Indigent Care Trust

Fund. We are pleased to tell you that you are eligible for free services because of your income. We are

therefore writing off a hospital bill of [$] for services received by [name of patient] on

[date(s)]. You should not receive any further bills from us for these services. Please call if you have any

questions.

Sincerely, Name

Title, Telephone

[For hospital without physicians who are on salary at the facility or who have agreed to treat patients

without charge, add the note below.]

Note: If you received services from physicians not employed by this hospital, you may receive bills for

treatment they provided to you unless you have made arrangements with them.

SAMPLE

[Letter to applicant with income between 125% and 200% of poverty who

qualifies for reduced price services]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

Thank you for your application for assistance with your hospital bills under the Georgia Indigent Care

Trust Fund. We are pleased to tell you that you are eligible for reduced charge services because of your

income.

We have determined that your income is [$ per] for your family size of [#], which

qualifies you to pay only [%] of our usual charge. A hospital bill of [$] for services received by [name

of patient] on [date(s)] is being reduced to [$]. We will contact you about arrangements for

payment on this bill. We will send you a detailed bill if you request it.

Please call at if you have any questions. If you disagree with this decision and believe that you should

qualify for a further reduction in your payment, you may ask for another review of your application.

Please contact [person / office / telephone number].

Sincerely,

Name Title,

Telephone

[For hospitals without physicians who are on salary at the facility or who have agreed to treat patients

without charge, add the note below:]

Note. If you received services from physicians not employed by this hospital, you may receive bills for

treatment they provided to you unless you have made arrangements with them.

SAMPLE

[Letter to applicant determined ineligible for free or reduced-charge services]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

Thank you for your application for assistance with your hospital bills under the Georgia Indigent Care

Trust Fund. We are sorry to tell you that we have determined that you are not eligible for free services or a

reduction in our charges based on your income.

We have determined that your income of [$ per] for your family size of [#] is more than the

limit of [amount that is 200% of the federal level for this family size].

If you disagree with this decision and believe that you should qualify for free services or a

reduction in your payment, you may ask for another review of your application. Please contact

[person/office/telephone number].

Sincerely,

Name Title,

Telephone

SAMPLE

[Letter to applicant after reconsideration - no change in decision]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

We have reconsidered our original decision on your application for assistance with your hospital bills

under the Georgia Indigent Care Trust Fund. We are sorry to tell you that we still find that you are not eligible

for free services or a reduction in our charges based on your income.

We have determined that your income of [$ per] for your family size of [#] is more than the

limit of [amount that is 200% of the federal poverty level for this family size].

If you still disagree with this decision and believe you should qualify for free services or a

reduction in your payment, you may contact the Department of Community Health by writing to the

address below or by calling local 404-463-5827 or toll-free 1-877-261-3117

Indigent Care Trust Fund

Medical Policy Unit, Hospital Services

Division of Medicaid

2 Martin Luther King Jr. Drive SE, East Tower

19th Floor

Atlanta, Georgia 30303-3159

You may be eligible for free legal assistance. You may contact your local office of Georgia Legal

Services or Atlanta Legal Aid.

Sincerely,

Name Title,

Telephone

SAMPLE

[Letter to applicant after reconsideration --

Change in decision to free care eligibility]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

We have reconsidered our original decision on your application for assistance with your hospital bills

under the Georgia Indigent Care Trust Fund. We are pleased to tell you that you are eligible for free services

because of your income. We are therefore writing off the hospital bill of [$] for services received by [name of

patient] on [date(s)]. Please call if you have any questions.

Sincerely,

Name Title,

Telephone

[For hospitals without physicians who are on salary at the facility or who have agreed to treat patients

without charge, add the note below:]

Note: If you received services from physicians not employed by this hospital, you may receive bills for

treatment they provided to you unless you have made arrangements with them.

SAMPLE

[Letter to applicant after reconsideration - Change in

decision to reduced charge eligibility]

[Hospital letterhead]

Date

Name of applicant

Address

Patient account number

Dear

We have reconsidered our original decision on your application for assistance with your hospital bills

under the Georgia Indigent Care Trust Fund. We are pleased to tell you that you are eligible for reduced

charges for our hospital services based on your income.

We have determined that your income of [$ per] for your family size of [#] qualifies you to pay

only [%] of our usual charge. A hospital bill of [$] for services received by [name of patient] on

[date(s)] is being reduced to [$]. We will contact you about arrangements for payment on this bill. We

will send you a detailed bill if you request it.

Please call at if you still disagree with this decision and believe that you should qualify for free services

or a further reduction in your payment, you may contact the Department of Community Health by writing to the

address below or by calling local 404-463-5827 or toll-free 1-877-261-3117.

Indigent Care Trust Fund

Medical Policy Unit, Hospital Services

Division of Medicaid

2 Martin Luther King Jr. Drive SE, East Tower

19th Floor

Atlanta, Georgia 30303-3159

You may be eligible for free legal assistance. You may contact your local office of Georgia Legal

Services or Atlanta Legal Aid.

Sincerely,

Name Title,

Telephone

[For hospitals without physicians who are on salary at the facility or who have agreed to treat patients

without charge, add the note below:]

Note: If you received services from physicians not employed at the facility by this hospital, you may

receive bills for treatment they provided to you unless you have made arrangements with them.