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Subject 290-4-5 ADMINISTRATION OF PATIENT COST OF CARE

Rule 290-4-5-.01 Legal Authority

The legal Authority for this chapter, unless otherwise noted, is "The Patient Cost of Care Act", Georgia Laws 1979, pp. 834-843.

Rule 290-4-5-.02 Organization and Purpose

The purpose of these rules is to effect the requirements of "The Patient Cost of Care Act," which mandates that the Georgia Department of Human Resources establish standards for determining assessments for patient cost of care, determine liability therefore, make investigations thereof, establish billing and collection procedures, provide for hearings and other requirements.

Rule 290-4-5-.03 Definitions

The terms "Department," "State Hospital","Patient","Persons Liable for Cost of Care","Cost of Care," "Income," and "Assessment" as used in these rules shall carry the same meanings as ascribed to such terms in "The Patient Cost of Care Act". Unless a different meaning is required by the context, the following terms as used in these rules shall mean:

(a) "Commissioner" means the Commissioner of the Georgia Department of Human Resources;
(b) "Hospital Hearing Officer" means that person or persons appointed by the Commissioner or his designee to hold hearings at each State Hospital on matters relating to the administration of the Patient Cost of Care Program;
(c) "Hospital Patient Accounts Officer" means that person appointed by the Superintendent of each State Hospital or his designee to manage the administration of the Patient Cost of Care Program;
(d) "Hearing Officer for Final Appeals" means that person appointed by the Commissioner to review, on request, the decisions of the Hospital Hearing Officer and to make a final decision on behalf of the Department on appeal of any such decision.

Rule 290-4-5-.04 Delegation of Authority

The Commissioner hereby delegates authority for the determination of assessments, based on the standards prescribed herein, to each State Hospital Superintendent and his appointed designee, the Hospital Patient Accounts Officer; and the authority for review of such determinations, on request, to the Hospital Hearing Officers and the Hearing Officer for Final Appeals, respectively. Authority delegated to the Hospital Hearing Officers shall not impair the authority of the Hospital Patient Accounts Officer to perform his functions under pertinent sections of the aforesaid Act, nor preclude participation by members of the Hospital Patient Accounts Office staff in the hearing process or in administration of the determination of the Hospital Hearing Officer.

Rule 290-4-5-.05 Standards for Assessments

Standards for determining assessments are based on the income, assets, insurance and other third party coverage or entitlements, and other circumstances of persons liable for cost of care.

(a) The Department hereby establishes the assessment for cost of care for any patient covered by a contract of insurance or other third party reimbursement contract or entitlement as:
1. the total amount payable under such contract or entitlement up to the total cost of care, or that portion of cost of care payable under such contract or entitlement;
2. if benefits payable under such contract or entitlement are less than the total cost of care, the amounts payable by all persons liable for cost of care toward any remaining balance as determined by application of the standards prescribed in paragraphs (b), (c), and (d) below; provided, however, that amount payable toward any remaining balance for a patient eligible under (a) any insurance contract, plan or benefit shall be determined in accordance with any provisions for payment stipulated by the insurance contract, plan or benefit as a requirement for participation in the insurance, plan or benefit; for a patient eligible under (b) the Medical Assistance Program (Title XIX of the Social Security Act) shall be determined in accordance with the provisions of the Georgia State Plan for Medical Assistance; and for a person eligible under (c) the Medicare Program (Title XVIII of the Social Security Act) shall be determined in accordance with the regulations and policies of the Social Security Administration;
3. the total amount payable under such contract or entitlement which exceeds total cost of care if paid in accordance with the provisions or regulations of such contract or entitlement.
(b) The Department hereby prescribes a standard scale for determining assessments for cost of care for all patients and other persons liable for cost of care, except as provided in paragraph (a) above, or further provided in paragraphs (c) or (d) below, derived by application of the factors of:
1. for all patients except as provided in paragraph 2. or 3. below:
(i) poverty income guidelines published by the federal government, effective upon issuance by the Department; but effective not later than sixty days following the publication date of the revised guidelines in the federal register;
(ii) total of deductions and personal exemptions allowable under Georgia Income Tax laws and regulations; except (1) no deductions or personal exemptions will be allowed to persons residing in another state, and (2) no deductions or personal exemptions will be allowed more than once in calculating assessments of the patient and other responsible parties for any one patient;
(iii) a graduated range of income levels in excess of the sum of(i) and (ii) above;
(iv) the number of dependents as defined by Georgia Income Tax Laws and regulations, except that no dependent is to be reflected more than once in calculating assessment(s) for any one patient;
(v) a base and graduated percentage charge associated with each income level;
(vi) a charge associated with assets equal to 5 per cent; except, effective January 1, 1993, for individuals hospitalized six continuous months and having assets accumulated from government benefit payments, a charge associated with assets will be made as provided in paragraph 3. below.
2. for patients remaining as inpatients in State Hospitals longer than three months, who receive monthly benefits or funds:
(i) on earned income and other income which is not paid or otherwise available to be paid on a regular monthly basis, the same factors as (b)1. (i) through (b)1. (v);
(ii) on benefits or other funds paid or available to be paid on a regular monthly basis, even though actual payments may occur at a different interval of time:
(I) total of benefits and funds received or available to be received on a monthly basis;
(II) a deduction equal to the amount of the personal needs allowance allowed institutionalized individuals by the State Medical Assistance Plan;
(III) any other deduction that the Department clearly defines by published policy prior to allowing such deduction.
(IV) a charge associated with assets equal to 5 per cent; except, effective January 1, 1993, for individuals hospitalized for six continuous months and having assets accumulated from government benefit payments, a charge associated with assets will be made as provided in paragraph 3. below.
3. for patients hospitalized six continuous months and remaining inpatients, who have accumulated assets from government benefit payments, effective January 1, 1993:
(i) a charge for full cost of care against the patient's accumulated assets which are in excess of allowed limits as those for establishing eligibility for institutionalization benefits under Title XIX of the State Medical Assistance Plan and which are not otherwise exempt and counted as resources of the patient under the State Medical Assistance Plan.
(c) The Department further prescribes a lower standard scale derived by the application of the above factors plus an additional factor of limited number of days allowable for care for mentally retarded respite care admissions under Code Section 37-4-21 or any other respite program allowed by law or duly adopted department regulations.
(d) The Department prescribes the same standard scale outlined in paragraphs (a), (b) and (c) for a stepparent or other person residing with and providing support of a patient under 18 years of age who has not been legally adopted by such individual; except, after application of the factors in paragraphs (b) and (c) to derive at an assessment for such individual, liability will be capped at the total amount such individual is authorized by Georgia income tax laws to claim as a standard deduction and personal exemption for the patient. This provision of limited liability does not apply to hospital, health, and other medical insurance, program, or plan benefits payable toward cost of care, any benefits or funds or other entitlements for which the patient is eligible or to any subrogation rights as provided by law.

Note: The resultant standard scale shall be published in a uniform table and is hereby incorporated into these rules, and by reference, made a part thereof. Copies of the standard scale shall be available on request at each Hospital Patient Accounts Office.

Rule 290-4-5-.06 Reassessments/Redeterminations

(1) All assessments as determined under the provisions of "The Patient Cost of Care Act" and in accordance with the standards prescribed in Rule 290-4-5-.05 above shall be subject to redetermination under any of the following circumstances:
(a) On request of any person who has been notified of liability for payment of cost of care in either his personal or representative capacity;
(b) On discovery by the Department of error, omission or false statements which were relied upon by the Hospital Patient Accounts Officer in determining assessments for cost of care;
(c) On discovery by the Department of changes in economic circumstances of any person liable for cost of care assessments; and
(d) At the end of a period not to exceed twelve (12) months from the date an assessment was originally made.
(2) Except as determined under the provisions of paragraph (b) above, no such redetermination shall operate to increase the assessment for cost of care for services received previous to such redetermination. Such redetermination may operate to decrease assessments for care previously received if the change in economic or other circumstances so dictate. However, no such reduction shall require the refund of any payments made on an assessment prior to the date of the reduction of the assessment.

Rule 290-4-5-.07 Administrative Hearing Procedures

(1) On request of a party affected by an assessment for cost of care, the Hospital Hearing Officer will initiate the following actions:
(a) Obtain pertinent records from the Hospital Patient Accounts Office in order to create a legally sufficient file in order to hear the matter.
(b) Issue to the indicated party or parties a NOTICE for the hearing. The NOTICE for the hearing shall include:
1. the time of the hearing;
2. the place of the hearing, giving the street address, floor and designated room.
3. the purpose of the hearing and a brief statement of the facts alleged in clear and intelligible language so that the parties may be fully apprised thereof and be able to prepare therefore;
4. a statement of the legal authority under which the hearing is to be held;
5. a statement that the respondent has the right to subpoena witnesses and present relevant evidence through the Department as well as a statement that the parties have the right to be represented by legal counsel or any other representative and present evidence on all the issues involved.
(c) In these cases and within the discretion of the Hospital Hearing Officer, an informal disposition may be made by the Hospital Hearing Officer and the affected party by stipulation, agreed settlement or consent order.
(d) In considering the place for the conduct of the hearing, due regard shall be given to the convenience and necessity of the parties and the representatives. The hearing will be informally held in a manner which will be conducive to an agreeable settlement of the issue.
(e) The hearing shall be opened promptly at the time fixed in the NOTICE of hearing. A brief summary of the law involved, the purpose of the hearing and the issues involved will be entered into a recording device (which may be later transcribed if there is a need for a formal transcript) at the inception of the hearing.
(f) The order or proof in the conduct of such a hearing should be somewhat flexible in order to consider all of the issues. Generally, the following procedure will be adhered to:
1. the Hospital Hearing Officer will introduce into the record the notice of assessment and other pertinent documents and will question any departmental witnesses if this should be necessary;
2. the respondent (that is, the party or parties to whom the assessment is directed) should then be heard;
3. each party shall be given reasonable and adequate time to complete hist presentation. The hearing is not considered complete until both sides have had opportunity to introduce relevant evidence or testimony;
4. the rules of evidence as applied in civil cases in the Superior Courts of Georgia shall be followed; however, when necessary to ascertain facts not reasonably susceptible of proof thereunder, the strict rules of evidence or technical procedures shall not apply. The Hospital Hearing Officer shall conduct the hearing on a middle course between rigid formal technical procedures and informality;
5. a record shall be preserved which will include the recording of the hearing together with all documentary evidence and pertinent data.
(g) The hearing shall be for the purposes of determining the accuracy and reliability of information utilized in making the assessment and whether the assessment was, in all important respects, made in accordance with the provisions of "The Patient Cost of Care Act" and the standards adopted pursuant thereto.
(h) Upon the conclusion of the hearing, he Hospital Hearing Officer shall make a succinct finding of fact an will supply the respondent as well as the Department with a copy of his decision within fifteen days after such hearing. This period may be extended in exceptional cases should the complexity of the hearing require such an extension. If the matter is so extended, the Hospital Hearing Officer will include the reasons for such an extension in his final order.
(2) In the event the responsible party(ies) is adversely affected by a decision of the Hospital Hearing Officer, he may have a review thereof by appeal to the Hearing Officer for Final Appeals at the State level. Such an appeal must be made within thirty days after rendition of the final order by the Hospital Hearing Officer. The Hospital Hearing Officer will supply the dissatisfied party(ies) with the address of the Hearing Officer for Final Appeals and will forward the record and pertinent documents upon being notified by the adversely affected party(ies). Such a request for an appeal must be made in writing thirty days after the rendition of a final order and shall be directed to the Hospital Hearing Officer first hearing the case.
(a) In the event of an appeal to the Hearing Officer for Final Appeals, the petition or letter of the aggrieved party(ies) shall state the reasons why and in what respect such party is aggrieved and the grounds to be relied upon as a basis for the relief demanded. This petition or letter will form a part of the record to be transmitted to the Hearing Officer for Final Appeals.
(b) The Hospital Patient Accounts Officer, upon request, shall assist the aggrieved party in the preparation of a formal request for a hearing by furnishing such pertinent information as may be available and by insuring the request is directed to the Hearing Officer for Final Appeals within the specified time period.