This chapter implements Georgia's Patient Cost of Care Act for state hospitals under the control of the Department of Behavioral Health and Developmental Disabilities (DBHDD) and any facilities operated by those state hospitals. It establishes standards and procedures for determining, assessing, billing, and collecting patient cost-of-care charges from individuals served and other liable parties (e.g., spouses, parents of minors, insurers). Operators must develop procedures for income/asset investigation, periodic reassessment, administrative hearings, and collection actions in compliance with O.C.G.A. Title 37, Chapter 9.
View official sourceSubject 82-7-1 PATIENT COST OF CARE
Rule 82-7-1-.01 Legal Authority
The legal authority for this chapter, unless otherwise noted,
is the Patient Cost of Care Act, O.C.G.A. Title 37,
Chapter-9.
Rule 82-7-1-.02 Applicability
This chapter applies to any state hospital under the control
of the department and any facility that provides services to individuals that
is controlled by a state hospital.
Rule 82-7-1-.03 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
Behavioral Health and Developmental Disabilities establishes standards for
determining assessments for patient cost of care, determines liability thereof,
makes investigations thereof, establishes billing and collection procedures,
and provides for hearings, among other requirements.
Rule 82-7-1-.04 Definitions
(1)
Unless a different meaning is required by
the context, the following terms as used in these regulations shall have the
meanings hereinafter set forth:
(a)
"Assessment" means a determination by the Department of the amount payable by
the persons liable for cost of care for services rendered to an individual;
such amount shall be either the full cost of care or, if applicable, the amount
payable toward cost of care, determined in accordance with the requirements of
O.C.G.A §
37-9-5
. There shall be a
rebuttable presumption that the full cost of care be imposed. This presumption
shall prevail until testimony, documentation, or evidence is provided pursuant
to other provisions of O.C.G.A Title 37, Chapter 9.
(b)
"Commissioner" means the Commissioner of
the Georgia Department of Behavioral Health and Developmental Disabilities, or
the Commissioner's designee.
(c)
"Cost of care" means the costs incurred for the support, care, and treatment of
each individual, or the per patient average of such costs as determined by the
Department on the basis of the estimated current operating costs of the
hospital or an identifiable part or section thereof providing such
services.
(d)
"Department" means
the Georgia Department of Behavioral Health and Developmental Disabilities and
includes its duly authorized agents and designees.
(e)
"Hospital Chief Financial Officer" means
that person appointed by DBHDD's Chief Financial Officer or their designee to
manage the administration of the Patient Cost of Care Program.
(f)
"Income," except for individuals who are
residents of other states, means that amount determined by adding to the gross
income as now or hereafter defined in Georgia income tax laws, minus deductions
and personal exemptions as authorized by such income tax laws, in addition to
the items listed in this paragraph, if such items are not already included in
gross income as defined above. For an individual who is a resident of another
state, "income" means the same as above except no deductions will be made for
any deductions or personal exemptions as authorized by Georgia income tax laws.
The following items are to be added, respectively:
1.
Any amounts received by or on behalf of
the person liable for cost of care from accident insurance or workers'
compensation for total or partial incapacity to work, plus the amount of any
damages received by or on behalf of the person liable for cost of care, whether
by suit or agreement, on account of such injuries or sickness;
2.
The net income from property acquired by
gift, bequest, devise, or descent;
3.
Interest upon obligations of the United
States government or of this state or of a political subdivision
thereof;
4.
The net income from
individual holdings of stock in banks and trust companies incorporated under
the banking laws of this state or of the United States;
5.
Retirement income, social security
benefits, veterans' benefits, and any other benefits that could be applied for
the support of the individual served;
6.
The net income from any other assets,
including but not limited to personal property, real property, mixed property,
and any other property or estate wherever located and in whatever form,
inclusive of any assets sold or transferred within a period of ninety (90) days
prior to the date services were first rendered to the individual by a
hospital.
(g)
"Individual" (formerly referred to as client, consumer, and/or patient) means
any person who is admitted to or who receives services from a state hospital,
including any person who is admitted to or receives services from a facility
operated by a state hospital.
(h)
"Persons liable for cost of care" means:
1.
The individual served or their estate;
2.
The individual's spouse;
3.
The parent or parents of any individual
under eighteen (18) years of age who is served;
4.
Any fiduciary or representative payee
holding assets for the individual or on their behalf, including, in such
person's representative capacity, the guardian, trustee, executor, or
administrator of any trust, estate, inheritance, or fund in which an individual
has a legal or beneficial interest;
5.
Any person, if not otherwise liable,
listed as the insured member of a contract, plan, or benefit to the extent that
such contract, plan, or benefit provides payment of hospitalization, medical
expenses, and other health care services for the individual as a covered
beneficiary or dependent;
6.
A
stepparent or any other person residing with and providing support of an
individual under eighteen (18) years of age who has not been legally adopted by
such stepparent or other person, with maximum liability limited to the amount
such stepparent or other individual is authorized by Georgia income tax laws to
claim as a standard deduction and personal exemption for the individual
receiving services; provided, however, that this limitation shall not apply to
liability pursuant to other provisions of this chapter regarding hospital,
health, and other medical insurance, program, or plan benefits or subrogation
rights.
(i)
"State
hospital" means any state hospital which now or hereafter comes under the
control of the Department and any facility operated in conjunction therewith.
This includes facilities operated by state hospitals that are not located on
state hospital grounds and that also provide care or services to
individuals.
Rule 82-7-1-.05 Authority to Develop Procedures
The Commissioner hereby is empowered to delegate authority to
implement these regulations, including authority to determine assessments based
on the standards prescribed in these Cost of Care regulations to the DBHDD
Chief Financial Officer. Each determination of assessment shall be made
pursuant to procedures developed under the direction of the Commissioner in
accordance with these regulations and the Patient Cost of Care
Act.
Rule 82-7-1-.06 Care of Individuals Not Related to Payment
Care rendered to all individuals in state hospitals and
programs shall be of the same nature and quality without regard to whether the
payment of any sum or sums is made for the cost of care.
Rule 82-7-1-.07 Responsibility for Cost of Care
(1)
Each individual receiving services from a
state hospital shall be legally responsible for and shall pay to the Department
of Behavioral Health and Developmental Disabilities, the cost of their care
received from a state hospital. Payments for cost of care shall be payable
following the receipt of services in accordance with standards and procedures
established by the Department. In the event the Department is unable to collect
the assessment from the individual served, or in the event the individual's
assessment is less than the full cost of care for such individual, all other
persons liable for the cost of care for such individual shall pay to the
Department their respective assessments as provided by O.C.G.A §
37-9-5
.
(2)
The Department shall develop procedures
by which it shall determine all persons who are liable for the cost of care of
an individual and by which it shall notify such persons of their joint and
several liability and of their assessment. Such notice shall offer opportunity
for any person so notified to be heard to show cause, if there be any, why such
person should not be liable for payment of the assessment, as provided by
O.C.G.A §
37-9-5
.
Rule 82-7-1-.08 Requirements for Procedures to Determine and Allocate Cost of Care
(1)
The Department shall establish:
(a)
A method for determining cost of
care;
(b)
A method for assessing
the portion of cost of care owed by each individual;
(c)
A method for determining other persons
liable for cost of care for each individual;
(d)
A method for notifying each individual
(including any representative of that individual designated in accordance with
GA COMP. R. & REGS §
82-5-1.07(2)
) and/or
persons liable for cost of care of the responsibility for assisting the
Department in assessing cost of care, the assessment of the individual's cost
of care, and the right to contest and appeal the assessment of the cost of care
for which that person is liable.
(2)
The Department's procedures shall meet
the following requirements:
(a)
The
procedures shall comply with the Patient Cost of Care Act, O.C.G.A. Title 37,
Chapter 9.
(b)
The procedures shall
ensure each individual receives appropriate care and treatment regardless of
any issue related to cost of care.
(c)
The procedures shall ensure that each
assessment of an individual's responsibility for cost of care will be based
upon:
1.
a determination that each individual
has exhausted his or her eligibility and receipt of benefits under all other
existing or future private, public, local, state, or federal programs or plans
and;
2.
upon a process by which the
Department assesses and recovers the cost of an individual's care from the
individual and from or any other persons or entities who may be liable for such
patient's cost of care if such patient is eligible for benefits under any other
program or plan.
Rule 82-7-1-.09 Standards for Assessments
(1)
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.
(2)
The Department hereby
establishes the assessment for cost of care for any individual covered by a
contract of insurance or other third-party reimbursement contract or
entitlement as:
(a)
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; provided,
however, that 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 shall be determined by application of the
standards prescribed in paragraphs (3) and (4), below; further provided,
however, that:
1.
amounts payable toward any
remaining balance for an individual eligible under 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;
2.
amounts payable toward any remaining
balance for 93an individual eligible under 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
3.
amounts payable toward any remaining
balance for a person eligible under 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; or,
(b)
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.
(3)
The Department shall develop a
standard scale for determining assessments for cost of care for all individuals
and other persons liable for cost of care, except as provided in paragraph (2)
above, or further provided in paragraph (3) below, derived by application of
the following factors:
(a)
for all
individuals except as provided in paragraphs (b) or (c) below:
1.
poverty income guidelines published by the
federal government, effective upon issuance by the Department; but effective
not later than sixty (60) days following the publication date of the revised
guidelines in the Federal Register;
2.
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 individual and other
responsible parties for each individual served;
3.
a graduated range of income levels in
excess of the sum of (3)(a)1. and (3)(a)2. above;
4.
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 individual
served;
5.
a base and graduated
percentage charge associated with each income level;
6.
a charge in conjunction with the initial
and any subsequent annual assessment associated with assets that are not exempt
from Medicaid or Social Security calculations equal to five percent (5%) of
accumulated non-exempt assets; except, effective January 1, 1993, for
individuals hospitalized six (6) continuous months and having assets
accumulated from government benefit payments, a charge associated with assets
will be made as provided in paragraph (c) below;
(b)
for individuals remaining in inpatient
care in State Hospitals longer than three (3) continuous months but fewer than
six (6) continuous months, who receive monthly benefits or funds:
1.
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 (3)(a)1.-5.;
2.
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 individuals in state operated hospitals or
state operated facilities, in accordance with 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 in
conjunction with the initial and any subsequent annual assessment associated
with assets that are not exempt from Medicaid or Social Security calculations
equal to five percent (5%) of accumulated non-exempt assets; except, effective
January 1, 1993, for individuals hospitalized for six (6) continuous months and
having assets accumulated from government benefit payments, a charge associated
with assets will be made as provided in paragraph (c) below.
(c)
for patients
hospitalized six (6) or more continuous months and remaining in inpatient
status, who have accumulated assets from government benefit payments, effective
January 1, 1993:
1.
a charge for full cost of
care against the individual's accumulated assets which are in excess of allowed
limits as those for establishing eligibility for institutionalization benefits
under the State Medical Assistance Plan and which are not otherwise exempt and
counted as resources of the individual under the State Medical Assistance
Plan.
(4)
The
Department prescribes the same standard scale referenced in Paragraph (3),
above, for a stepparent or other person residing with and providing support of
an individual under eighteen (18) years of age who has not been legally adopted
by such stepparent or other person; except, after application of the factors in
paragraphs (3)(b)-(c) to derive 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
individual.
1.
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 individual is eligible; or to any subrogation
rights as provided by law.
2.
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 82-7-1-.10 Reassessments/Redeterminations
(1)
The Department shall reexamine the
individual's assessment periodically and adjust such assessment as hereinafter
provided in accordance with changes in the ability to pay of the person liable
for cost of care and in a manner that complies with the Patient Cost of Care
Act. If the Department determines that the economic circumstances of a person
liable for cost of care have improved to an extent justifying an increase in
the assessment, any such increase shall apply only to cost of care for services
rendered for the individual after the effective date of the increase in
assessment. No such increase shall cause the assessment to exceed the total
cost of care. The Department may not increase an assessment without affording
the person liable for cost of care an opportunity for a hearing on the increase
in the assessment. A person liable for cost of care may apply to the Department
for a change in the assessment when the person's economic circumstances have
changed sufficiently to adversely affect their future ability to pay. If an
assessment for services previously rendered for an individual is being paid in
accordance with a scheduled plan of payments approved by the Department, then a
reduction in assessment because of a change in the economic circumstances
affecting the ability to pay of the person liable for cost of care may apply to
that portion of the assessment which remains unpaid as of the date of the
reduction, as well as to the assessment for cost of services rendered after the
date of the reduction. However, no such reduction shall require the refund of
any payments made on an assessment prior to the date of the reduction. After
investigation and hearing, the Department shall act upon the application made
by the person liable for cost of care. Any redetermination of the assessment
pursuant to this subsection shall be subject to the requirements of O.C.G.A
§
37-9-6
. Notwithstanding any
reexamination or corresponding adjustment of an assessment which might be
afforded, each assessment shall be valid for a period of twelve (12) months
from the date of the initial assessment or any reassessment thereafter. No
reduction, increase, or opportunity for hearing shall be allowed after the
assessment period.
(2)
All
assessments determined under the provisions of the Patient Cost of Care Act,
and in accordance with the standards prescribed in Rule
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 their personal or
representative capacity;
(b)
On
discovery by the Department of error, omission, or false statements which were
relied upon by the Hospital Chief Financial 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.
(3)
Except as determined under the provisions
of paragraph (2) above, no redetermination shall increase the assessment for
cost of care for services received prior to such redetermination. Such
redetermination may decrease assessments for care previously received if a
change in economic or other circumstances so dictates. 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.
(4)
The Department may accept payment for
full cost of care if any person liable for cost of care offers such payment in
lieu of declaring financial circumstances and having an assessment determined
by hearing.
(5)
The Department
shall adopt and comply with procedures to inform adequately individuals served
and other persons liable for the cost of care of their right to hearings and of
their right to request reassessments.
Rule 82-7-1-.11 Investigation of Income and Assets of Persons Liable for Cost of Care
(1)
As provided in O.C.G.A. §
37-9-7
, the Department, through
its duly authorized agents, has the authority to investigate or otherwise
determine the income and assets of the individual served or their estate and,
when necessary, the income and assets of all other persons liable for the cost
of care of such individual to determine ability to pay cost of care.
Furthermore, all persons liable for cost of care must provide signed consent
forms to authorize an investigation to determine the income and assets of such
persons to determine ability to pay cost of care. The Department shall further
have the authority to contract with any person, firm, or corporation it finds
necessary to provide the information appropriate for carrying out its duties
under this chapter.
(2)
The
Department requires declarations to be filed by the individual served or other
persons liable for cost of care necessary to determine the assessments required
by this regulation and shall prescribe the form and content thereof. All such
declarations are to be regarded as essential to carrying out the public policy
of this state; any person who knowingly falsifies such declarations may be
referred to law enforcement. If an individual served or other person liable for
cost of care fails to provide information required by such declarations or
provide signature of consent for the Department to conduct an investigation
authorized by subsection (1) of this section, that failure shall create a
rebuttable presumption that the individual or other persons liable for cost of
care consent to and agree with the assessment of the full cost of care, and the
declaration shall contain on its face, conspicuously and in clear language, a
statement to that effect.
(3)
As
provided in O.C.G.A. §
37-9-7
, the Department, through
its duly authorized agents, has access to Georgia income tax records for the
purpose of obtaining necessary information to enforce this regulation. Upon the
request of the Department or its duly authorized agents, the state revenue
commissioner and their agents or employees shall disclose such income tax
information contained in any report or return required under Georgia law as may
be necessary to enforce the provisions of this chapter. Any tax information
secured from the federal government by the Department of Revenue, pursuant to
express provisions of §
6103
of the Internal
Revenue Code, may not be disclosed by the Department of Revenue pursuant to
this subsection. Any person receiving any tax information or tax returns under
the authority of this subsection shall be considered either an officer or
employee as those terms are used in O.C.G.A §
48-7-60(a)
;
accordingly, any person receiving any tax information or returns under the
authority of this subsection shall be subject to O.C.G.A §
48-7-61
.
(4)
Any evidence, records, or other
information obtained by the Department or its duly authorized agents pursuant
to the authority of this section is confidential and shall be used by the
Department or its agents only for the purposes of enforcing this regulation and
shall not be released for any purpose other than a hearing provided for by this
regulation.
(5)
Persons with no
other documentation or evidence may sign an affidavit attesting to their
indigent financial status.
(6)
In
addition to the use of income for determining assessments for the payment of
cost of care, any other assets of a person liable for cost of care, except as
provided in this regulation, shall be considered in determining an assessment
and is liable to be assessed for the payment thereof. Such assets include any
tangible or intangible property or any combination thereof and also include the
net proceeds derived from the disposition of any such property, including any
disposition of any such property which took place ninety (90) days or less
prior to the date services were first rendered to the individual by a hospital.
When the income of a person liable for cost of care is sufficient to determine
that an assessment should be made for the total cost of care, it shall not be
necessary for the Department to investigate and determine the other assets of
such person; but such investigation and determination may be made by the
Department if necessary to collect the assessment from the person liable for
cost of care.
(7)
The following
assets of a person liable for cost of care shall be exempt from subsection (6)
of this section:
(a)
Real property which
qualifies for a homestead exemption from ad valorem taxation; and
(b)
Any other real property which constitutes
the principal residence of the person liable for cost of care, but which does
not qualify for a homestead exemption under this subsection.
(8)
Notwithstanding any other
provisions of this section, as of January 1, 1993, following six (6) months of
continuous inpatient hospitalization, the Department is expressly authorized to
levy an assessment for the full cost of care against the assets of all
individuals having assets accumulated from government benefit payments in
excess of amounts allowed by the eligibility resource limit for
institutionalized residents established by Title XIX of the Social Security Act
of 1935, as amended, and regulations promulgated pursuant thereto, until said
assets are reduced to a level which would establish resource eligibility under
such program for the individual served; provided, however, that the assets
listed in § shall be exempt from such
assessment if said assets would also be an excluded resource under eligibility
criteria of Title XIX of the federal Social Security Act. Following April 13,
1992, the Department shall provide notice regarding the provisions of this
subsection to individuals and family members or other appropriate persons who
may be affected by the provisions of this subsection.
(9)
Nothing in this regulation shall be
construed to supersede the provisions of the Revised Georgia Trust Code of
2010, O.C.G.A Title 53, Chapter 12.
Rule 82-7-1-.12 Sources of Payment of Cost of Care
(1)
Notwithstanding any other provisions of
law, the Department is not required to expend public funds for the purpose of
providing support, care, and treatment covered under this regulation to any
individual until such individual has exhausted the individual's eligibility and
receipt of benefits under all other existing or future private, public, local,
state, or federal programs or plans.
(2)
Before the Department expends public
funds for an individual's cost of care, the Department may assess and recover
the cost of an individual's care from the individual served or other persons
liable for such individual's cost of care if such individual is eligible for
benefits under any other program or plan.
Rule 82-7-1-.13 Administrative Hearing Procedures
(1)
Hearings shall be conducted by the Office
of State Administrative Hearings ("OSAH") after referral of any request for a
hearing to OSAH.
(2)
On request of
a party affected by an assessment for cost of care to challenge the assessment,
the Hospital receiving such a request will forward the request to the
department's legal office so that an OSAH Form 1 may be filed.
(3)
DBHDD Legal Services may attempt to
resolve the issue with the person requesting a hearing prior to forwarding an
OSAH Form 1 to OSAH. The department shall develop policies and procedures that
set forth the manner such a request is handled. If the matter is not resolved
informally, the department's legal office will file the OSAH Form 1 with
OSAH.
Rule 82-7-1-.14 Actions for Collection
The Department shall bill persons liable for cost of care for
the amount due on their assessments in the same manner as other debts and
accounts. No bill shall be payable unless it contains the dates of service for
which the costs billed therein were incurred. The Department is authorized to
maintain in the name of the Department and the State of Georgia any action at
law or equity in any court of this state or any other state which may be
necessary to collect such sums.
Rule 82-7-1-.15 Severability
If any rule, sentence, clause or phrase of any of the rules
and regulations in this Chapter may be construed by any court of competent
jurisdiction to be invalid, illegal, unconstitutional, or otherwise
unenforceable, such determination or adjudication shall in no manner affect the
remaining rules or portions thereof. The remaining rules or portions thereof
shall remain in full force and effect as if such rule or portions thereof so
determined, declared or adjudicated invalid or unconstitutional were not
originally part of these rules.
Rule 82-7-1-.01 Legal Authority
Rule 82-7-1-.02 Applicability
Rule 82-7-1-.03 Organization and Purpose
Rule 82-7-1-.04 Definitions
Rule 82-7-1-.05 Authority to Develop Procedures
Rule 82-7-1-.06 Care of Individuals Not Related to Payment
Rule 82-7-1-.07 Responsibility for Cost of Care
Rule 82-7-1-.08 Requirements for Procedures to Determine and Allocate Cost of Care
Rule 82-7-1-.09 Standards for Assessments
Rule 82-7-1-.10 Reassessments/Redeterminations
Rule 82-7-1-.11 Investigation of Income and Assets of Persons Liable for Cost of Care
Rule 82-7-1-.12 Sources of Payment of Cost of Care
Rule 82-7-1-.13 Administrative Hearing Procedures
Rule 82-7-1-.14 Actions for Collection
Rule 82-7-1-.15 Severability