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Rules and Regulations of the State of Georgia
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Subject 511-5-10 CANCER STATE AID PROGRAM

Rule 511-5-10-.01 Criteria for Certification as Cancer Treatment Facility

Hospitals, free-standing radiation and physician group practices or medical treatment centers must be certified each state fiscal year by the Department of Public Health to be eligible for reimbursements for active cancer treatment provided to eligible enrolled patients. These categories of medical providers are considered to be "facilities" for the purposes of program participation.

To be eligible for Cancer State Aid (CSA) certification, treatment facilities must complete and submit a signed participation contract or agreement and required documentation, and meet the appropriate requirements as listed by type of facility:

1) Hospitals:
a) The hospital must be licensed by the State of Georgia.
b) The hospital must be accredited by the Joint Commission on Accreditation of Healthcare Organizations or by another Centers for Medicare and Medicaid Services (CMS) accepted accreditation organization.
2) Free-standing radiation therapy centers:

Free-standing radiation therapy centers must be licensed by the State of Georgia and must be in compliance with provisions stated in the annual Cancer State Aid participation agreement.

3) Physician group practices or medical treatment centers that provide cancer treatment services on an out-patient basis:

Physician group practices or medical treatment centers must be in compliance with provisions stated in the annual Cancer State Aid participation agreement.

Rule 511-5-10-.02 Cancer State Aid Program Patient Enrollment

Participating facilities shall assist the patient in completing a Cancer State Aid enrollment application, and shall submit the application, related forms and supporting documentation of eligibility criteria on behalf of the patient to the Cancer State Aid Program, Office of Cancer Screening and Treatment, Health Promotion and Disease Prevention Program, Department of Public Health.

Rule 511-5-10-.03 Eligibility Requirements for Cancer State Aid Patients

1) Eligibility for program enrollment is determined at the time of application by the Cancer State Aid Program of the Department of Public Health.
a) Each patient must apply for program enrollment each state fiscal year.
b) Payment for treatment and evaluation is limited to currently available program funds.
2) State Residency Criteria

Applicants must be Georgia residents at the time of application. A resident is anyone who is living in Georgia voluntarily with the intention of making Georgia his or her permanent home.

3) Legal Residency Criteria

An applicant must be United States citizen; a legal permanent resident; or a qualified alien or nonimmigrant under the federal Immigration and Nationality Act, Title 8 United States Code, and lawfully present in the United States, in which case the applicant must provide the alien number assigned by the United States Department of Homeland Security.

4) Medical Criteria
a) Patients shall have medical documentation of a cancer diagnosis, or symptoms or physical findings that have been medically evaluated, documented, and determined to create a high suspicion of cancer.
b) Patients who are referred with a presumptive diagnosis of cancer will be accepted for only those procedures necessary to establish a cancer diagnosis. Once those procedures are complete, staging of the confirmed cancer diagnosis must be determined and a report submitted to the Cancer State Aid Program.
c) If the diagnosis is found to be non-malignant, the financial obligation of the State ceases and no further medical expenses may be paid with Cancer State Aid funds.
d) Patients who are no longer receiving cancer treatment, and whose care is limited to supportive care only, are ineligible.
5) Financial Criteria

Financial eligibility will be determined by the Cancer State Aid program and is based upon family size, annual income, other assets, and ongoing and outstanding medical expenses.

Rule 511-5-10-.04 Health Insurance

Applicants who have health insurance that covers the cost of cancer treatment are not eligible for Program enrollment.

Rule 511-5-10-.05 Periodic review of eligibility

Interim financial reviews with families shall be conducted when there are significant changes in family circumstances or employment that could affect the patient's eligibility.

Rule 511-5-10-.06 Application Termination

The Cancer State Aid Program shall terminate a patient's enrollment when:

1) The patient no longer meets the criteria for financial and/or medical eligibility.
2) There has been a willful misstatement of fact or material omission on the patient application, including but not limited to facts concerning income or resources.
3) Patient fails to comply with the Program's policies and procedures.
4) Patient becomes eligible for another source of funding.

Rule 511-5-10-.07 Reimbursement of Cost

Based on the guidelines outlined below, reimbursement shall be made for standard diagnostic evaluation, cancer treatment, and facility costs incurred to provide oncology care to enrolled patients.

1) Upon patient enrollment, participating facilities may submit claims for services provided within 90 days prior to the Program's receipt of the patient application.
2) The Program may consider payment of additional outstanding oncology service claims based upon available funds.
3) Payment for medications is based upon current program policies, available funds and facility agreements.
4) No reimbursement will be made to any facility for any services provided prior to the Department's signature date on the Cancer State Aid participation agreement.
5) Cancer State Aid patients shall not be billed for eligible cancer related services provided to the patient during their enrollment period for the fiscal year, up to the established Program maximums or the amount assigned for the patient's care by the Program.
a) It is the responsibility of the facility to submit all claims for payment within 60 days of the date of treatment.
b) Claims received after the 60 day requirement are not eligible for Cancer Sate Aid payment and may not be billed to the patient.
c) At the discretion of the Cancer State Aid Program denied claims may be paid provided funds are available and the Program does not have a waiting list for program enrollment.
6) Hospitals

Participating hospitals must provide the most recent independent certified audit. The audit documents the facility's total expenses and total patient charges. The ratio of these expenses and charges is used to establish the percent of billed charges that will be reimbursed for the current state fiscal year by the Cancer State Aid Program. This number is referred to as the reimbursement percentage.

Hospitals are reimbursed at 100% of the calculated reimbursement percentage up to the allowed Cancer State Aid maximums per enrollment year.

The Cancer State Aid Program shall determine limitations on payment for services based on available funding for the fiscal year in which the patient is approved.

Whenever possible, care should be provided in the most cost effective setting.

Hospice care is not eligible for Cancer State Aid reimbursement.

7) Free-Standing Radiation Therapy Centers
a) Reimbursement of cost shall be made up to the current fiscal year maximum determined by the Program for this provider category, and for procedures as defined in the participation agreement.
8) Physician Group Practices or Medical Treatment Centers
a) Reimbursement shall be made for diagnostic services for suspected cancers, cancer treatment services, and evaluation and management services related to cancer care provided on an outpatient basis only.
b) Reimbursement of cost shall be made up to the current fiscal year maximums determined by the Program for this provider category, and for procedures as defined in the participation agreement.
9) Other or Special Vendors

Pharmacies, home health and medical suppliers must have a current signed and approved Cancer State Aid statement of participation/agreement.

Rule 511-5-10-.08 Refunds of reimbursements for ineligible patients

1) Reimbursements made by Cancer State Aid to participating facilities for a patient later found to be ineligible for Cancer State Aid benefits must be refunded.
2) Such refunds shall be made within 45 days of receipt of written notification of a "request for refund" from the Cancer State Aid Program.
3) CSA may withhold all payments due to a facility or any other medical provider until such refunds are received.

Rule 511-5-10-.09 Reconsideration of eligibility and claims decisions

1) Patients, referring physicians, and other providers who are dissatisfied with the initial determination of the patient's eligibility for the Cancer State Aid Program may request reconsideration.
2) Patients, referring physicians, hospitals, or other providers dissatisfied with a payment limitation or denial may request reconsideration.
3) A request for initial reconsideration must be made in writing to the Program Director - Cancer State Aid Program, Department of Public Health. The request must be submitted within 30 days of the initial denial and should include a complete description and supporting scientific medical or financial information documenting reasons that the initial medical or financial determination was incorrect, or an exception to the payment limitation should be made.
4) Requests for second reconsideration shall be forwarded to the Office of General Counsel, along with any reply that the Program deems appropriate, for an independent and impartial determination of whether the Program's decision was supported by the facts and made in accordance with the law and these regulations.
5) The decision of the Office of General Counsel shall be final.