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; and3. 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.Ga. Comp. R. & Regs. R. 82-7-1-.09
O.C.G.A. §§ 37-9-2, 37-9-5, 37-9-6, 37-9-7, 37-9-8, 37-9-9.
Original Rule entitled "Standards for Assessments" adopted. F. Dec. 15, 2021; eff. Jan. 4, 2022.