Participation as Medicaid Provider Requirement; Termination by Health Care Facility of Participation as Provider of Medical Assistance; Monetary Penalty

  1. Law
  2. Georgia Code
  3. Health
  4. State Health Planning and Development
  5. Certificate of Need Program
  6. Participation as Medicaid Provider Requirement; Termination by Health Care Facility of Participation as Provider of Medical Assistance; Monetary Penalty

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  1. The department may require that any applicant for a certificate of need agree to participate as a provider of medical assistance for Medicaid purposes pursuant to Article 7 of Chapter 4 of Title 49.
  2. Any proposed or existing health care facility which obtains a certificate of need on or after April 6, 1992, based in part upon assurances that it will participate as a provider of medical assistance, as defined in paragraph (6) of Code Section 49-4-141, and which terminates its participation as a provider of medical assistance or violates any conditions imposed by the department relating to such participation, shall be subject to a monetary penalty in the amount of the difference between the Medicaid covered services which the facility agreed to provide in its certificate of need application and the amount actually provided and may be subject to revocation of its certificate of need by the department pursuant to Code Section 31-6-45; provided, however, that this Code section shall not apply if:
    1. The proposed or existing health care facility's certificate of need application was approved by the Health Planning Agency prior to April 6, 1992, and the Health Planning Agency's approval of such application was under appeal on or after April 6, 1992, and the Health Planning Agency's approval of such application is ultimately affirmed;
    2. Such facility's participation as a provider of medical assistance is terminated by the state or federal government; or
    3. Such facility establishes good cause for terminating its participation as a provider of medical assistance. For purposes of this Code section, "good cause" shall mean:
      1. Changes in the adequacy of medical assistance payments, as defined in paragraph (5) of Code Section 49-4-141, provided that at least 10 percent of the facility's utilization during the preceding 12 month period was attributable to services to recipients of medical assistance, as defined in paragraph (7) of Code Section 49-4-141. Medical assistance payments to a facility shall be presumed adequate unless the revenues received by the facility from all sources are less than the total costs set forth in the cost report for the preceding full 12 month period filed by such facility pursuant to the state plan as defined in paragraph (8) of Code Section 49-4-141 which are allowed under the state plan for purposes of determining such facility's reimbursement rate for medical assistance and the aggregate amount of such facility's medical assistance payments (including any amounts received by the facility from recipients of medical assistance) during the preceding full 12 month cost reporting period is less than 85 percent of such facility's Medicaid costs for such period. Medicaid costs shall be determined by multiplying the allowable costs set forth in the cost report, less any audit adjustments, by the percentage of the facility's utilization during the cost reporting period which was attributable to recipients of medical assistance;
      2. Changes in the overall ability of the facility to cover its costs if such changes are of such a degree as to seriously threaten the continued viability of the facility; or
      3. Changes in the state plan, statutes, or rules and regulations governing providers of medical assistance which impose substantial new obligations upon the facility which are not reimbursed by Medicaid and which adversely affect the financial viability of the facility in a substantial manner.
  3. A facility seeking to terminate its enrollment as a provider of medical assistance shall submit a written request to the department documenting good cause for termination. The department shall grant or deny the facility's request within 30 days. If the department denies the facility's request, the facility shall be entitled to a hearing conducted in the same manner as an evidentiary hearing conducted by the department pursuant to the provisions of Code Section 49-4-153 within 30 days of the department's decision.
  4. The imposition of the monetary penalty provided in this Code section shall commence upon the date that said facility has terminated its participation as a provider of medical assistance, as determined by the commissioner. The monetary penalty shall be levied and collected by the department on an annual basis for every year in which the facility fails to participate as a provider of medical assistance. Penalties authorized under this Code section shall be subject to the same notices and hearings as provided for levy of fines under Code Section 31-6-45.

(Code 1981, §31-6-45.2, enacted by Ga. L. 1992, p. 1068, § 2; Ga. L. 1999, p. 296, §§ 22, 24; Ga. L. 2008, p. 12, § 1-1/SB 433.)

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1992, "April 6, 1992" was substituted for "the effective date of this Code section" in the introductory language of subsection (a) (now subsection (b)) and in paragraph (a)(1) (now paragraph (b)(1)), and "government" was substituted for "governments" in paragraph (a)(2) (now paragraph (b)(2)).

Pursuant to Code Section 28-9-5, in 1999, "Health Planning Agency" was substituted for "department" and "Health Planning Agency's" was substituted for "department's" in paragraph (a)(1) (now paragraph (b)(1)) and "commissioner" was substituted for "executive director" in the first sentence of subsection (c) (now subsection (d)).

Editor's notes.

- Ga. L. 2008, p. 12, § 3-1/SB 433, not codified by the General Assembly, provides that the amendment to this Code section shall only apply to applications submitted on or after July 1, 2008.

Law reviews.

- For note on 1992 enactment of this Code section, see 9 Ga. St. U. L. Rev. 265 (1992).


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