Subject 290-4-5 ADMINISTRATION OF PATIENT COST OF CARE
The legal Authority for this chapter, unless otherwise noted, is "The Patient Cost of Care Act", Georgia Laws 1979, pp. 834-843.
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.
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.|
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.
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:
|(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:
|(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.|
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.
|(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:
|(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.|
|(1)|| On request of a party affected by an
assessment for cost of care, the Hospital Hearing Officer will initiate the
|(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.