TITLE 49 SOCIAL SERVICES

Section 4. Public Assistance, 49-4-1 through 49-4-193.

ARTICLE 7 MEDICAL ASSISTANCE GENERALLY

49-4-142. Department of Community Health established; adoption, administration, and modification of state plan; drug application fees; personal needs allowance.

The Department of Community Health established under Chapter 2 of Title 31 is authorized to adopt and administer a state plan for medical assistance in accordance with Title XIX of the federal Social Security Act, as amended (Act of July 30, 1965, P.L. 89-97, 79 Stat. 343, as amended), provided such state plan is administered within the appropriations made available to the department. The department is authorized to establish the amount, duration, scope, and terms and conditions of eligibility for and receipt of such medical assistance as it may elect to authorize pursuant to this article. Further, the department is authorized to establish such rules and regulations as may be necessary or desirable in order to execute the state plan and to receive the maximum amount of federal financial participation available in expenditures made pursuant to the state plan; provided, however, that the department shall establish reasonable procedures for notice to interested parties and an opportunity to be heard prior to the adoption, amendment, or repeal of any such rule or regulation. The department is authorized to enter into such reciprocal and cooperative arrangements with other states, persons, and institutions, public and private, as it may deem necessary or desirable in order to execute the state plan.
The department shall, not later than June 1, 1986, implement a modification of the state plan for medical assistance or any affected rules or regulations of the department, which modification will allow supplementation by relatives or other persons for a private room or private sitter or both for a recipient of medical assistance in a nursing home. The modification to the plan or to any affected rules and regulations shall be effective unless and until federal authorities rule that such modification is out of compliance with federal regulations. Such modification of the state plan for medical assistance or rules and regulations:
1. Shall provide that a provider of nursing home services in either a skilled care facility or an intermediate care facility shall be obligated to provide a recipient of medical assistance only semiprivate accommodations which meet the other requirements of appropriate regulations;
2. Shall provide that at no time can more than 10 percent of a skilled care or intermediate care facility's rooms be used for Medicaid recipients for whom a private room supplementation has been made;
3. Shall provide that payments made by relatives or other persons to a provider of medical assistance for the specific stated purpose of paying the additional costs for a private room or private sitter or both for a recipient of medical assistance in a skilled care facility or intermediate care facility shall not be considered as income when determining the amount of patient liability toward vendor payments; provided, however, that the department's entitlement to payments made by legally liable third parties shall not be diminished by this modification of the state plan;
4. Shall provide that no provider of medical assistance shall discriminate against a recipient of medical assistance who does not have a relative or other person who is willing and able to provide supplementation; but the provision of a private room or private sitter to a recipient when supplementation is provided shall not constitute discrimination against other recipients;
5. Shall provide that no recipient who is transferred to or admitted to a private room because of a shortage of beds in semiprivate rooms shall be discharged because the recipient does not have a relative or other person who is willing and able to provide supplementation; and
6. May provide that the rate charged by the provider of medical assistance to the relative or other person providing supplementation for a private room for a recipient shall not exceed the difference between the maximum rate charged by the provider for a private room to or for a private pay patient and the amount which the provider receives or will receive from the department as reimbursement for otherwise providing for the recipient's care in a semiprivate room.
The department is authorized to establish drug application fees which shall be equal to the department's cost of investigating and determining whether a new drug product should be included in the Controlled Medical Assistance Drug List.Such fees shall be adjusted annually and shall be paid by the drug manufacturers at the time of application.
The department shall, upon state appropriations, implement a modification of the state plan for medical assistance or any affected rules or regulations of the department, which modification shall provide that, in determining the amount of a recipient's income that is to be applied to payment for the costs of care in a nursing home, there shall be deducted a personal needs allowance of not less than $70.00 per month which shall include the minimum amount required by 42 U.S.C. Section 1396a(q)(2).

(Ga. L. 1977, p. 384, § 4; Ga. L. 1984, p. 1647, § 1; Ga. L. 1985, p. 517, § 1; Ga. L. 1986, p. 486, § 1; Ga. L. 1990, p. 1808, § 1; Ga. L. 1994, p. 97, § 49; Ga. L. 1999, p. 296, § 18; Ga. L. 2009, p. 453, §§ 1-7, 1-52/HB 228; Ga. L. 2017, p. 219, § 3/HB 206; Ga. L. 2018, p. 1112, § 49/SB 365.)

The 2017 amendment, effective July 1, 2017, added subsection (d).

The 2018 amendment, effective May 8, 2018, part of an Act to revise, modernize, and correct the Code, substituted "provided, however, that the department shall" for "provided, however, the department shall" in the proviso at the end of the third sentence of subsection (a).

Administrative Rules and Regulations.

- Administration and procedures for adoption, amendment, and repeal of rules and for public notice of changes in methods and standards for setting payment rates, Official Compilation of the Rules and Regulations of the State of Georgia, Department of Medical Assistance, Chapter 350-1 et seq.

Indigent Care Trust Fund, Official Compilation of the Rules and Regulations of the State of Georgia, Department of Community Health, Medical Assistance, Chapter 111-3-6.

U.S. Code.

- Title XIX of the federal Social Security Act of 1935, referred to in this Code section, is codified at 42 U.S.C. § 1396 et seq.

JUDICIAL DECISIONS

Exhaustion of administrative remedies required.

- In an action involving a dispute over Medicaid reimbursement rates, the plaintiffs were not excused from the exhaustion of administrative remedies requirement because the plaintiffs were required to raise the plaintiffs' defective notice claims in the administrative review process in the first instance and O.C.G.A. § 49-4-153 governed that administrative review process. Ga. Dep't of Behavioral Health & Developmental Disabilities v. United Cerebral Palsy of Ga., Inc., 298 Ga. 779, 784 S.E.2d 781 (2016).

State's rules restricting reimbursement for abortions inconsistent with Social Security Act.

- Rules promulgated by Georgia's Department of Medical Assistance (now Department of Community Health) restricting reimbursement to Medicaid enrollees for medically necessary abortions are inconsistent with Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., and because the plaintiff classes will suffer irreparable injury for which there is no adequate legal remedy, the defendants, the defendants' agents and employees, must be permanently enjoined from refusing to provide Medicaid reimbursement to the members of the plaintiff classes for the provision of all medically necessary abortions. Doe v. Busbee, 481 F. Supp. 46 (N.D. Ga. 1979).

Restrictive rules amounting to denial or reduction of required service.

- Restrictions on reimbursement for abortions contained in Georgia's rules amount to a denial or reduction of a required service to an otherwise eligible recipient solely because of that eligible recipient's condition, i.e., pregnancy, and furthermore, these restrictions are not based on medical necessity or utilization control procedures nor is any contention made by the defendants that the abortions sought by the plaintiffs were not medically necessary or presented utilization control problems; therefore, under 42 C.F.R. § 440.230(c), the Georgia Department of Medical Assistance (now Department of Community Health) must provide reimbursement for these medically necessary abortions. Doe v. Busbee, 481 F. Supp. 46 (N.D. Ga. 1979).

Plan administrator.

- In O.C.G.A. § 49-4-142(a), the General Assembly has designated the Georgia Department of Community Health as the agency authorized to adopt and administer the plan for medical assistance under the federal Medicaid program. Ga. Dep't of Cmty. Health v. Freels, 258 Ga. App. 446, 576 S.E.2d 2 (2002).

Minimum requirements that state's Medicaid plan must meet.

- As a participating state, Georgia's Medicaid plan must meet certain minimum requirements as set out in Title XIX of the Social Security Act. The following categories of services must be provided: (1) inpatient hospital services; (2) outpatient hospital services; (3) laboratory and x-ray services; (4)(A) skilled nursing facility services; (B) early and periodic screening and diagnosis for persons under 21 years of age; (C) family planning services and supplies; and (5) physicians' services, (whether furnished in the office, patient's home, a hospital, skilled nursing facility or elsewhere). Doe v. Busbee, 471 F. Supp. 1326 (N.D. Ga. 1979).

Effect of renunciation of inheritance on Medicaid benefits.

- While a Medicaid claimant was entitled under O.C.G.A. § 53-1-20 to renounce an inheritance under the will of the claimant's spouse, this did not insulate that choice from the application of Medicaid's eligibility regulations. Thus, the Georgia Department of Community Health properly denied Medicaid vendor benefits to the claimant. Ga. Dep't of Cmty. Health v. Medders, 292 Ga. App. 439, 664 S.E.2d 832 (2008).

Cited in Georgia Hosp. Ass'n v. Department of Medical Assistance, 528 F. Supp. 1348 (N.D. Ga. 1982); Brogdon v. National Healthcare Corp., 103 F. Supp. 2d 1322 (N.D. Ga. 2000); Crittenden v. White, 346 Ga. App. 179, 816 S.E.2d 308 (2018).

OPINIONS OF THE ATTORNEY GENERAL

Limited use of state funds to pay for abortions.

- Statutory language which authorizes the Department of Medical Assistance (now Department of Community Health) "to establish such rules and regulations as may be necessary or desirable in order to . . . receive the maximum amount of federal financial participation as is available in expenditures made pursuant to the state plan . . ." indicates that state funds, like federal funds, should not be used to pay for any abortions except those in cases where the mother's life would be threatened if the fetus were carried to term. 1977 Op. Att'y Gen. No. 77-64.

Coverage for medically necessary abortions, reporting requirements.

- Georgia Department of Medical Assistance (now Department of Community Health) must provide coverage for medically necessary abortions and may impose reasonable reporting or documentation requirements for abortions resulting from rape or incest. 1994 Op. Att'y Gen. No. U94-6.

Limitation on nursing home charges for private rooms.

- Nursing home providers may not charge more than the difference between their usual private and semiprivate room rates to individuals who desire to provide private rooms for medical assistance recipients. 1985 Op. Att'y Gen. No. 85-60.

Department of Medical Assistance (now Department of Community Health) may not forbear collection of overpayments made to providers. 1980 Op. Att'y Gen. No. 80-89.

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