HB 1393: Hospitals; allow rural hospitals to join together to allow further purchasing power with third-party payors but retain their independence

The Senate Committee on Health and Human Services offered the following substitute to HB 1393:

A BILL TO BE ENTITLED

AN ACT

To amend Title 31 of the Official Code of Georgia Annotated, relating to health, so as to provide for government efficiency and improved regulation of healthcare facilities and hospital authorities in order to maximize the provision of quality and affordable healthcare services throughout the state; to eliminate certificate of need requirements for all healthcare facilities except certain skilled nursing facilities and related services; to provide for the certificate of need program for skilled nursing facilities; to authorize the Department of Community Health to administer such program; to provide for rules promulgation; to provide for new institutional health services; to provide for exemptions; to provide for resolution of prior applications; to provide for applications; to provide for indigent care requirements; to provide for scope and term of validity of certificate; to provide for qualifications for issuances of certification; to require applicants to pay certain outstanding debts; to provide for letters of intent; to provide for acceptance or rejection of applications; to provide for the recreation of the Certificate of Need Appeal Panel; to provide for appeal procedure and judicial review; to provide for discretionary and automatic revocation; to provide for participation as a Medicaid provider; to provide for the Department of Community Health to submit annual reports; to provide for exemptions for the certificate of need program; to provide for resolution of matters under review no longer applicable; to allow rural hospital authorities to engage in coordinated healthcare planning and delivery; to provide for legislative declarations, findings, and intentions; to provide for corporate restructuring; to provide for strategic alliances; to provide for shared staffing; to provide for joint purchasing arrangements and shared services agreements; to provide for shared information; to provide for integrated networks; to provide for collaborative activities; to provide for limited immunity to antitrust liability; to provide for notice; to provide for review by the Attorney General; to provide for aggrieved parties; to provide for appeals; to provide for guidance; to provide for review of conduct; to amend other provisions in various titles of the Official Code of Georgia Annotated, so as to make conforming changes; to provide for definitions; to provide for narrow construction; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

PART I

Certificate of need program

SECTION 1-1.

Title 31 of the Official Code of Georgia Annotated, relating to health, is amended by repealing Chapter 6, relating to state health planning and development, and enacting a new Chapter 6 to read as follows:

"CHAPTER 6

ARTICLE 1

31-6-1.

As used in this chapter, the term:

(1) 'Application' means a written request for a certificate of need made to the department, containing such documentation and information as the department may require.

(2) 'Bed capacity' means space used exclusively for inpatient care, including space designed or remodeled for inpatient beds even when not used for such purposes. The number of beds to be counted in any patient room shall be the maximum number for which adequate square footage is provided as established by rules of the department, except that single beds in single rooms shall be counted even if the room contains inadequate square footage.

(3) 'Board' means the Board of Community Health established under Chapter 2 of this title.

(4) 'Certificate of need' means an official finding by the department, evidenced by certification issued pursuant to an application, that the action proposed in the application satisfies and complies with the criteria contained in this chapter and rules promulgated pursuant hereto.

(5) 'Certificate of Need Appeal Panel' or 'appeal panel' means the panel of independent hearing officers created pursuant to Code Section 31-6-46 to conduct appeal hearings.

(6) 'Clinical health services' means diagnostic, treatment, or rehabilitative services provided in a skilled nursing facility and includes inpatient nursing care, whether intermediate, skilled, or extended care.

(7) 'Commissioner' means the commissioner of community health established under Chapter 2 of this title.

(8) 'Department' means the Department of Community Health established under Chapter 2 of this title.

(9) 'Develop,' with reference to a project, means constructing, remodeling, installing, or proceeding with a project, or any part of a project, or a capital expenditure project, the cost estimate for which exceeds $10 million. Notwithstanding the provisions of this paragraph, the expenditure or commitment or incurring an obligation for the expenditure of funds to develop certificate of need applications, studies, reports, schematics, preliminary plans and specifications, or working drawings or to acquire, develop, or prepare sites shall not be considered to be the developing of a project.

(10) 'New institutional health service' shall have the same meaning as described in subsection (a) of Code Section 31-6-40.

(11) 'Offer' means that a skilled nursing facility is open for the acceptance of patients or performance of services and has qualified personnel, equipment, and supplies necessary to provide specified clinical health services.

(12) 'Person' means any individual, trust or estate, partnership, limited liability company or partnership, corporation (including associations, joint-stock companies, and insurance companies), state, political subdivision, hospital authority, or instrumentality (including a municipal corporation) of a state as defined in the laws of this state. This term shall include all related parties, including individuals, business corporations, general partnerships, limited partnerships, limited liability companies, limited liability partnerships, joint ventures, nonprofit corporations, or any other for profit or not for profit entity that owns or controls, is owned or controlled by, or operates under common ownership or control with a person.

(13) 'Project' means a proposal to take an action for which a certificate of need is required under this chapter. A project or proposed project may refer to the proposal from its earliest planning stages up through the point at which the new institutional health service is offered.

(14) 'Skilled nursing facility' means a public or private institution or a distinct part of an institution which is primarily engaged in providing inpatient skilled nursing care and related services for patients who require medical or nursing care or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

(15) 'State health plan' means a comprehensive program based on recommendations by the Health Strategies Council and the board, approved by the Governor, and implemented by the State of Georgia for the purpose of providing adequate healthcare services and facilities throughout the state.

ARTICLE 2

31-6-20.

(a) The department is authorized to administer the certificate of need program established under this chapter and, within the appropriations made available to the department by the General Assembly of Georgia and consistently with the laws of the State of Georgia, a state health plan adopted by the board. The department shall review and update the state health plan at least every five years to ensure the plan meets the evolving needs of the state. The department shall provide, by rule, for procedures to administer its functions unless otherwise provided by the board.

(b) The functions of the department shall be:

(1) To conduct the health planning activities of the state and to implement those parts of the state health plan which relate to the government of the state;

(2) To prepare and revise a draft state health plan;

(3) To adopt, promulgate, and implement rules and regulations sufficient to administer the provisions of this chapter including the certificate of need program;

(4) To define, by rule, the form, content, schedules, and procedures for submission of applications for certificates of need, other determinations, and periodic reports;

(5) To establish time periods and procedures consistent with this chapter to hold hearings and to obtain the viewpoints of interested persons prior to issuance or denial of a certificate of need;

(6) To provide, by rule, for such fees as may be necessary to cover the costs of hearing officers, preparing the record for appeals before such hearing officers and the Certificate of Need Appeal Panel of the decisions of the department, and other related administrative costs, which costs may include reasonable sharing between the department and the parties to appeal hearings;

(7) To establish, by rule, service-specific need methodologies and criteria for new skilled nursing facilities. In developing such need methodologies, the department shall, at a minimum, consider the demographic characteristics of the population, the health status of the population, service use patterns, standards and trends, financial and geographic accessibility, and market economics;

(8) To provide, by rule, for a reasonable and equitable fee schedule for certificate of need applications;

(9) To grant, deny, or revoke a certificate of need as applied for or as amended; and

(10) To perform powers and functions delegated by the Governor, which delegation may include the powers to carry out the duties and powers which have been delegated to the department under Section 1122 of the federal Social Security Act of 1935, as amended.

(c) The commissioner shall have the power to establish and abolish technical advisory committees as he or she deems necessary, in consultation with the board, to inform effective strategy development and execution.

31-6-21.

(a) Rules of the department shall be adopted, promulgated, and implemented as provided in this Code section and in Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' except that the department shall not be required to comply with subsections (c) through (g) of Code Section 50-13-4.

(b) The department shall transmit three copies of the notice provided for in paragraph (1) of subsection (a) of Code Section 50-13-4 to the legislative counsel. The copies shall be transmitted at least 30 days prior to the department's intended action. Within five days after receipt of the copies, if possible, the legislative counsel shall furnish the presiding officer of each house with a copy of the notice and mail a copy of the notice to each member of the Senate Health and Human Services Committee and each member of the House Committee on Health and Human Services. Each such rule promulgated pursuant to subsection (a) of this Code section and any part thereof shall be subject to the making of an objection by either such committee within 30 days of transmission of the rule to the members of such committee. Any rule or part thereof to which no objection is made by both such committees may become adopted by the department at the end of such 30 day period. The department may not adopt any such rule or part thereof which has been changed since having been submitted to such committees unless:

(1) That change is to correct only typographical errors;

(2) That change is approved in writing by both committees and that approval expressly exempts that change from being subject to the public notice and hearing requirements of subsection (a) of Code Section 50-13-4;

(3) That change is approved in writing by both committees and is again subject to the public notice and hearing requirements of subsection (a) of Code Section 50-13-4; or

(4) That change is again subject to the public notice and hearing requirements of subsection (a) of Code Section 50-13-4 and the change is submitted and again subject to committee objection as provided in this subsection.

Nothing in this subsection shall prohibit the department from adopting any rule or part thereof without adopting all of the rules submitted to the committees if the rule or part so adopted has not been changed since having been submitted to the committees and objection thereto was not made by both committees.

(c) Any rule or part thereof to which an objection is made by both committees within the 30 day objection period under subsection (b) of this Code section shall not be adopted by the department and shall be invalid if so adopted. A rule or part thereof thus prohibited from being adopted shall be deemed to have been withdrawn by the department unless the department, within the first 15 days of the next regular session of the General Assembly, transmits written notification to each member of the objecting committee or committees that the department does not intend to withdraw that rule or part thereof but intends to adopt the specified rule or part effective the day following adjournment sine die of that regular session. A resolution objecting to such intended adoption may be introduced in either house of the General Assembly after the fifteenth day but before the thirtieth day of the session in which occurs the notification of intent not to withdraw a rule or part thereof. In the event the resolution is adopted by the house of the General Assembly in which the resolution was introduced, it shall be immediately transmitted to the other house of the General Assembly. It shall be the duty of the presiding officer of the other house to have that house, within five days after receipt of the resolution, consider the resolution for purposes of objecting to the intended adoption of the rule or part thereof. Upon such resolution being adopted by two-thirds of the vote of each house of the General Assembly, the rule or part thereof objected to in that resolution shall be disapproved and not adopted by the department. If the resolution is adopted by a majority but by less than two-thirds of the vote of each such house, the resolution shall be submitted to the Governor for his or her approval or veto. In the event of a veto, or if no resolution is introduced objecting to the rule, or if the resolution introduced is not approved by at least a majority of the vote of each such house, the rule shall automatically become adopted the day following adjournment sine die of that regular session. In the event of the Governor's approval of the resolution, the rule shall be disapproved and not adopted by the department.

(d) Any rule or part thereof which is objected to by only one committee under subsection (b) of this Code section and which is adopted by the department may be considered by the house of the General Assembly whose committee objected to its adoption by the introduction of a resolution for the purpose of overriding the rule at any time within the first 30 days of the next regular session of the General Assembly. It shall be the duty of the department in adopting a proposed rule over such objection to notify the chairpersons of the Senate Health and Human Services Committee and the House Committee on Health and Human Services within ten days after the adoption of the rule. In the event the resolution is adopted by such house of the General Assembly, it shall be immediately transmitted to the other house of the General Assembly. It shall be the duty of the presiding officer of the other house of the General Assembly to have such house, within five days after the receipt of the resolution, consider the resolution for the purpose of overriding the rule. In the event the resolution is adopted by two-thirds of the votes of each house of the General Assembly, the rule shall be void on the day after the adoption of the resolution by the second house of the General Assembly. In the event the resolution is ratified by a majority but by less than two-thirds of the votes of either house, the resolution shall be submitted to the Governor for his or her approval or veto. In the event of a veto, the rule shall remain in effect. In the event of the Governor's approval, the rule shall be void on the day after the date of approval.

(e) Except for emergency rules, no rule or part thereof adopted by the department after July 1, 2026, shall be valid unless adopted in compliance with subsections (b), (c), and (d) of this Code section and subsection (a) of Code Section 50-13-4.

(f) Emergency rules shall not be subject to the requirements of subsection (b), (c), or (d) of this Code section but shall be subject to the requirements of subsection (b) of Code Section 50-13-4. Upon the first expiration of any department emergency rules, when those emergency rules are intended to cover matters which had been dealt with by the department's nonemergency rules but such nonemergency rules have been objected to by both legislative committees under this Code section, the emergency rules concerning those matters may not again be adopted except for one 120 day period. No emergency rule or part thereof which is adopted by the department shall be valid unless adopted in compliance with this subsection.

(g) Any proceeding to contest any rule on the ground of noncompliance with this Code section must be commenced within two years from the effective date of the rule.

(h) As used in this Code section, the term 'rules' means rules and regulations.

(i) The state health plan or the rules establishing considerations, standards, or similar criteria for the grant or denial of a certificate of need pursuant to Code Section 31-6-43 shall not apply to any application for a certificate of need as to which, prior to the effective date of such plan or rules, respectively, the evidence has been closed following a full evidentiary hearing before a hearing officer.

ARTICLE 3

31-6-40.

(a) On and after July 1, 2026, any new institutional health service shall be required to obtain a certificate of need pursuant to this chapter. New institutional health services include:

(1) The construction, development, or other establishment of a new, expanded, or relocated skilled nursing facility, except as otherwise provided in Code Section 31-6-52;

(2) Any increase in the bed capacity of a skilled nursing facility; and

(3) Clinical health services which are offered in or through a skilled nursing facility, which were not offered on a regular basis in or through such skilled nursing facility within the 12 month period prior to the time such services would be offered.

(b) Any person proposing to develop or offer a new institutional health service shall, before commencing such activity, submit a letter of intent and an application to the department and obtain a certificate of need in the manner provided in this chapter unless such activity is excluded from the scope of this chapter.

(c) Any person that had a valid exemption granted or approved by the former Health Planning Agency prior to July 1, 2008, or the department prior to July 1, 2026, shall not be required to obtain a certificate of need in order to continue to offer those previously offered services.

(d) Any pending application with the department as of the day prior to the effective date of this Act that relates to a facility or services other than a skilled nursing facility shall be deemed withdrawn by operation of law as of the effective date of this Act.

31-6-41.

(a) Any person who acquires a skilled nursing facility by stock or asset purchase, merger, consolidation, or other lawful means shall notify the department of such acquisition, the date thereof, and the name and address of the acquiring person. Such notification shall be made in writing to the department within 45 days following the acquisition and the acquiring person may be fined by the department in the amount of $500.00 for each day that such notification is late. Such fine shall be paid into the state treasury.

(b) The department may limit the time periods during which it will accept applications for skilled nursing facilities to only such times after the department has determined there is an unmet need for such facilities. The department shall make a determination as to whether or not there is an unmet need for such facility at least every six months and shall notify those requesting such notification of that determination.

(c) The department may require that any applicant for a certificate of need agree to provide a specified amount of clinical health services to indigent patients as a condition for the grant of a certificate of need. A grantee or successor in interest of a certificate of need or an authorization to operate under this chapter which violates such an agreement or violates any conditions imposed by the department relating to such services, whether made before or after July 1, 2008, shall be liable to the department for a monetary penalty in the amount of the difference between the amount of services so agreed to be provided and the amount actually provided and may be subject to revocation of its certificate of need, in whole or in part, by the department pursuant to Code Section 31-6-48. Any penalty so recovered shall be paid into the state treasury.

(d) Penalties authorized under this Code section shall be subject to the same notices and hearing for the levy of fines under Code Section 31-6-48.

31-6-42.

(a) A certificate of need shall be valid only for the defined scope, location, cost, service area, and person named in an application, as it may be amended, and as such scope, location, service area, cost, and person are approved by the department, unless such certificate of need owned by an existing skilled nursing facility is transferred to a person who acquires such existing facility. In such case, the certificate of need shall be valid for the person who acquires such a facility and for the scope, location, cost, and service area approved by the department. However, in reviewing an application to relocate all or a portion of an existing skilled nursing facility, the department may allow such facility to divide into two or more such facilities if the department determines that the proposed division is financially feasible and would be consistent with quality patient care.

(b) A certificate of need shall be valid and effective for a period of 12 months after it is issued, or such greater period of time as may be specified by the department at the time the certificate of need is issued. Within the effective period after the grant of a certificate of need, the applicant of a proposed project shall fulfill reasonable performance and scheduling requirements specified by the department, by rule, to assure reasonable progress toward timely completion of a project.

(c) By rule, the department may provide for extension of the effective period of a certificate of need when an applicant, by petition, makes a good faith showing that the conditions to be specified according to subsection (b) of this Code section will be performed within the extended period and that the reasons for the extension are beyond the control of the applicant.

31-6-43.

(a) The written findings of fact and decision, with respect to the department's grant or denial of a certificate of need, shall be based on the applicable considerations specified in this Code section and reasonable rules promulgated by the department interpretive thereof. The department shall issue a certificate of need to each applicant whose application is consistent with the following considerations and such rules deemed applicable to a project, except as specified in subsection (f) of Code Section 31-6-45:

(1) The proposed new institutional health service is reasonably consistent with the relevant general goals and objectives of the state health plan;

(2) The population residing in the area served, or to be served, by the new institutional health service has a need for such services;

(3) Existing alternatives for providing services in the same service area as the new institutional health service proposed are neither currently available, implemented, similarly utilized, nor capable of providing a less costly alternative, or no certificate of need to provide such alternative services has been issued by the department and is currently valid;

(4) The project can be adequately financed and is, in the immediate and long term, financially feasible;

(5) The effects of new skilled nursing facility service on payors for health services, including governmental payers, are not unreasonable;

(6) The costs and methods of a proposed construction project, including the costs and methods of energy provision and conservation, are reasonable and adequate for quality healthcare;

(7) The new institutional health service proposed is reasonably financially and physically accessible to the residents of the proposed service area;

(8) The proposed new institutional health service has a positive relationship to the existing healthcare delivery system in the service area;

(9) The proposed new institutional health service encourages more efficient utilization of the skilled nursing facility proposing such service;

(10) The proposed new institutional health service provides, or would provide, a substantial portion of its services to individuals not residing in its defined service area or the adjacent service area;

(11) The proposed new institutional health service conducts biomedical or behavioral research projects or new service development which is designed to meet a national, regional, or state-wide need;

(12) The proposed new institutional health service meets the clinical needs of health professional training programs which request assistance;

(13) The proposed new institutional health service fosters improvements or innovations in the financing or delivery of health services, promotes healthcare quality assurance or cost effectiveness, or fosters competition that is shown to result in lower patient costs without a loss of the quality of care;

(14) The proposed new institutional health service meets the department's minimum quality standards, including, but not limited to, standards relating to accreditation, minimum volumes, quality improvements, assurance practices, and utilization review procedures; and

(15) The proposed new institutional health service can obtain the necessary resources, including healthcare personnel and management personnel.

(b) For the purposes of the considerations contained in this Code section and in the department's applicable rules, relevant data which were unavailable or omitted when the state health plan or rules were prepared or revised may be considered in the evaluation of a project.

(c) The department shall specify in its written findings of fact and decision which of the considerations contained in this Code section and the department's rules are applicable to an application and its reasoning as to and evidentiary support for its evaluation of each such applicable consideration and rule.

31-6-44.

No applicant for a new certificate of need, a modification to an existing certificate of need, or a conversion of a certificate of need that has any outstanding amounts owed to the state including fines, penalties, fees, or other payments for noncompliance with any requirements contained in Code Section 31-6-41, 31-6-50, 31-7-280, or 31-8-179.2 shall be eligible to receive a new certificate of need or a modification to an existing certificate of need unless such applicant pays such outstanding amounts to the state. Any such fines, penalties, fees, or other payments for noncompliance shall be subject to the same notices and hearing for the levy of fines under Code Section 31-6-48.

31-6-45.

(a) At least 25 days prior to submitting an application for a certificate of need for clinical health services, a person shall submit a letter of intent to the department. The department shall provide by rule a process for submitting letters of intent and a mechanism by which applications may be filed to compete with and be reviewed comparatively with proposals described in submitted letters of intent.

(b) Each application for a certificate of need shall be received by the department, and the department shall declare the application complete for review, shall accept and date the application, and shall notify the applicant of the timetable for its review. The department shall also notify a newspaper of general circulation in the county in which the project shall be developed that the application is complete for review. The department shall also notify the appropriate regional commission and the chief elected official of the county and municipal governments, if any, in whose boundaries the proposed project will be located that the application is complete for review. If the application does not comply with the rules governing the preparation and submission of applications, the department shall notify the applicant in writing and provide a list of all deficiencies. The applicant shall be afforded an opportunity to correct such deficiencies, and upon such correction, the application shall then be declared complete for review within ten days of the correction of such deficiencies, and notice given to a newspaper of general circulation in the county in which the project shall be developed that the application has been so declared. The department shall also notify the appropriate regional commission and the chief elected official of the county and municipal governments, if any, in whose boundaries the proposed project will be located that the application is complete for review or when in the determination of the department a significant amendment is filed.

(c) The department shall specify by rule the time within which an applicant may amend its application. The department may request an applicant to make amendments. The department decision shall be made on an application as amended, if at all, by the applicant. (d)(1) There shall be a time limit of 120 days for review of a project, beginning on the day the department receives the application. The department may adopt rules for determining when it is not practicable to complete a review in 120 days and may extend the review period upon written notice to the applicant but only for an extended period of not longer than an additional 30 days. The department shall adopt rules governing the submission of additional information by the applicant and for opposing an application; provided, however, that such rules shall provide that any party permitted to oppose an application shall submit a notice of opposition no later than 30 days of receipt by the department of such application.

(2) No party may oppose an application for a certificate of need for a proposed project unless:

(A) Such party offers substantially similar services as proposed within a 35 mile radius of the proposed project or has a service area that overlaps the applicant's proposed service area; or

(B) Such party has submitted a competing application in the same batching cycle and is proposing to establish the same type of facility proposed or offers substantially similar services as proposed and has a service area that overlaps the applicant's proposed service area.

(e) To allow the opportunity for comparative review of applications, the department may provide by rule for applications for a certificate of need to be submitted on a timetable or batching cycle basis no less often than two times per calendar year for each clinical health service. Applications for services, facilities, or expenditures for which there is no specified batching cycle may be filed at any time.

(f) The department may order the joinder of an application which is determined to be complete by the department for comparative review with one or more subsequently filed applications declared complete for review during the same batching cycle when:

(1) The first and subsequent applications involve similar clinical health service projects in the same service area or overlapping service areas; and

(2) The subsequent applications are filed and are declared complete for review within 30 days of the date the first application was declared complete for review. Following joinder of the first application with subsequent applications, none of the subsequent applications so joined may be considered as a first application for the purposes of future joinder. The department shall notify the applicant to whose application a joinder is ordered and all other applicants previously joined to such application of the fact of each joinder pursuant to this subsection. In the event one or more applications have been joined pursuant to this subsection, the time limits for department action for all of the applicants shall run from the latest date that any one of the joined applications was declared complete for review. In the event of the consideration of one or more applications joined pursuant to this subsection, the department may award no certificate of need or one or more certificates of need to the applicant or applicants, if any, which are consistent with the considerations contained in Code Section 31-6-43, the department's applicable rules, and the award of which will best satisfy the purposes of this chapter.

(g) The department shall review the application and all written information submitted by the applicant in support of the application and all information submitted in opposition to the application to determine the extent to which the proposed project is consistent with the applicable considerations stated in Code Section 31-6-43 and in the department's applicable rules. During the course of the review, the department staff may request additional information from the applicant as deemed appropriate. Pursuant to rules adopted by the department, a public hearing on applications covered by those regulations may be held prior to the date of the department's decision thereon. Such rules shall provide that when good cause has been shown, a public hearing shall be held by the department. Any interested person may submit information to the department concerning an application, and an applicant shall be entitled to notice of and to respond to any such submission.

(h) The department shall within 30 days of receipt of the application provide the applicant an opportunity to meet with the department to discuss such application and to provide the applicant an opportunity to submit additional information. Such additional information shall be submitted within the time limits adopted by the department. The department shall also provide an opportunity for any party that is permitted to oppose an application pursuant to paragraph (2) of subsection (d) of this Code section to meet with the department and to provide additional information to the department. In order for any such opposing party to have standing to appeal an adverse decision pursuant to Code Section 31-6-46, such party must attend and participate in an opposition meeting.

(i) Unless extended by the department for an additional period of up to 30 days pursuant to subsection (d) of this Code section, the department shall, no later than 120 days after an application is determined to be complete for review, or, in the event of joined applications, 120 days after the last application is declared complete for review, provide written notification to an applicant of the department's decision to issue or to deny issuance of a certificate of need for the proposed project. Such notice shall contain the department's written findings of fact and decision as to each applicable consideration or rule and a detailed statement of the reasons and evidentiary support for issuing or denying a certificate of need for the action proposed by each applicant. The department shall also mail such notification to the appropriate regional commission and the chief elected official of the county and municipal governments, if any, in whose boundaries the proposed project will be located. In the event such decision is to issue a certificate of need, the certificate of need shall be effective on the day of the decision unless the decision is appealed to the Certificate of Need Appeal Panel in accordance with this chapter. Within seven days of the decision, the department shall publish notice of its decision to grant or deny an application in the same manner as it publishes notice of the filing of an application.

(j) Should the department fail to provide written notification of the decision within the time limitations set forth in this Code section, an application shall be deemed to have been approved as of the one hundred twenty first day following notice from the department that an application, or the last of any applications joined pursuant to subsection (f) of this Code section, is declared complete for review.

(k) Notwithstanding other provisions of this article, when the Governor has declared a state of emergency in a region of the state, existing healthcare facilities in the affected region may seek emergency approval from the department to offer services that may otherwise require a certificate of need. The department shall give special expedited consideration to such requests and may authorize such requests for good cause. Once the state of emergency has been lifted, any services offered by an affected skilled nursing facility under this subsection shall cease to be offered until such time as the skilled nursing facility that received the emergency authorization has requested and received a certificate of need. As used in this subsection, the term 'good cause' means that authorization of the request shall directly resolve a situation posing an immediate threat to the health and safety of the public. The department shall establish, by rule, procedures whereby requirements for the process of review and issuance of a certificate of need may be modified and expedited as a result of emergency situations.

31-6-46.

(a) There is recreated the Certificate of Need Appeal Panel, which shall be an agency separate and apart from the department and shall consist of a panel of independent hearing officers. The purpose of the appeal panel shall be to serve as a panel of independent hearing officers to review the department's initial decision to grant or deny a certificate of need application. The Certificate of Need Appeal Panel in existence on June 30, 2026, shall be reconstituted and each member of such appeal panel shall be reconstituted as a member of such reconstituted appeal panel, effective July 1, 2026.

(b) The appeal panel shall be composed of five members appointed by the Governor for a term of up to four years each. The Governor shall appoint to the appeal panel attorneys who practice law in this state and who are familiar with the healthcare industry but who do not have a financial interest in or represent or have any compensation arrangement with any skilled nursing facility. Each member of the appeal panel shall be an active member of the State Bar of Georgia in good standing, and each attorney shall have maintained such active status for the five years immediately preceding such person's appointment. The Governor shall name from among such members a chairperson and a vice chairperson of the appeal panel. The vice chairperson shall have the same authority as the chairperson; provided, however, that the vice chairperson shall not exercise such authority unless expressly delegated by the chairperson or in the event the chairperson becomes incapacitated, as determined by the Governor. Vacancies on the appeal panel caused by resignation, death, or any other cause shall be filled for the unexpired term in the same manner as the original appointment. No person required to register with the Secretary of State as a lobbyist or registered agent shall be eligible for appointment by the Governor to the appeal panel.

(c) The appeal panel shall promulgate reasonable rules for its operation and rules of procedure for the conduct of initial administrative appeal hearings held by the appointed hearing officers, including an appropriate fee schedule for filing such appeals. Members of the appeal panel shall serve as hearing officers for appeals that are assigned to them on a random basis by the chairperson of the appeal panel. The members of the appeal panel shall receive no salary but shall be reimbursed for their expenses in attending meetings and for transportation costs as authorized by Code Section 45-7-21, which provides for compensation and allowances of certain state officials; provided, however, that the chairperson and vice chairperson of the appeal panel shall also be compensated for their services rendered to the appeal panel outside of attendance at an appeal panel meeting, such as for time spent assigning hearing officers, the amount of which compensation shall be determined according to regulations of the Department of Administrative Services. Appeal panel members shall receive compensation for the administration of the cases assigned to them, including prehearing, hearing, and posthearing work, in an amount determined to be appropriate and reasonable by the Department of Administrative Services. Such compensation to the members of the appeal panel shall be made by the Department of Administrative Services.

(d) Any party that is permitted to oppose an application pursuant to paragraph (2) of subsection (d) of Code Section 31-6-45 that has notified the department prior to its decision that such party is opposed to the application before the department shall have the right to an initial administrative appeal hearing before an appeal panel hearing officer or to intervene in such hearing. Such request for hearing or intervention shall be filed with the chairperson of the appeal panel within 30 days of the date of the decision made pursuant to Code Section 31-6-45. In the event an appeal is filed by a party that is permitted to oppose an application pursuant to paragraph (2) of subsection (d) of Code Section 31-6-45, the appeal shall be accompanied by payment of such fee as is established by the appeal panel. In the event an appeal is requested, the chairperson of the appeal panel shall appoint a hearing officer for each such hearing within 30 days after the date the appeal is received. Within 14 days after the appointment of the hearing officer, such hearing officer shall confer with the parties and set the date or dates for the hearing, provided that no hearing shall be scheduled less than 60 days nor more than 120 days after the filing of the request for a hearing, unless the applicant consents or, in the case of competing applicants, all applicants consent to an extension of this time period to a specified date. Unless the applicant consents or, in the case of competing applicants, all applicants consent to an extension of said 120 day period, any hearing officer who regularly fails to commence a hearing within the required time period shall not be eligible for continued service as a hearing officer for the purposes of this Code section. The hearing officer shall have the authority to dispose of all motions made by any party before the issuance of the hearing officer's decision and shall make such rulings as may be required for the conduct of the hearing.

(e) In fulfilling the functions and duties of this chapter, the hearing officer shall act, and the hearing shall be conducted as a full evidentiary hearing, in accordance with Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' relating to contested cases, except as otherwise specified in this Code section. Subject to the provisions of Article 4 of Chapter 18 of Title 50, all files, working papers, studies, notes, and other writings or information used by the department in making its decision shall be public records and available to the parties, and the hearing officer may permit each party to exercise such reasonable rights of prehearing discovery of such information used by the parties as will expedite the hearing.

(f) In addition to evidence submitted to the department, a party may present any additional relevant evidence to the appeal panel hearing officer reviewing the decision of the department if the evidence was not reasonably available to the party presenting the evidence at the time of the department's review. The burden of proof as to whether the evidence was reasonably available shall be on the party attempting to introduce the new evidence. The issue for the decision by the hearing officer shall be whether, and the hearing officer shall order the issuance of a certificate of need if, in the hearing officer's judgment, the application is consistent with the considerations as set forth in Code Section 31-6-43 and the department's rules, as the hearing officer deems such considerations and rules applicable to the review of the project. The appeal hearing conducted by the appeal panel hearing officer shall be a de novo review of the decision of the department. The hearing officer shall also consider:

(1) Whether the department committed prejudicial procedural error in its consideration of the application;

(2) Whether the appeal lacks substantial justification; and

(3) Whether such appeal was undertaken primarily for the purpose of delay or harassment.

The burden of proof shall be on the appellant. Appellants or applicants shall proceed first with their cases before the hearing officer in the order determined by the hearing officer, and the department, if a party, shall proceed last. In the event of a consolidated hearing on applications which were joined for comparative review pursuant to subsection (f) of Code Section 31-6-45, the hearing officer shall have the same powers specified for the department in subsection (f) of Code Section 31-6-45 to order the issuance of no certificate of need or one or more certificates of need.

(g) All evidence shall be presented at the initial administrative appeal hearing conducted by the appointed hearing officer. A party or intervenor may present any relevant evidence on all issues raised by the hearing officer or any party to the hearing or revealed during discovery and shall not be limited to evidence or information presented to the department prior to its decision, except that an applicant may not present a new need study or analysis responsive to the general need consideration or service-specific need formula as provided in the applicable rules that is substantially different from any such study or analysis submitted to the department prior to its decision and that could have reasonably been available for submission. The hearing officer may consider the latest data available, including updates of studies previously submitted, in deciding whether an application is consistent with the applicable considerations or rules. The hearing officer shall consider the applicable considerations and rules in effect on the date the appeal is filed, even if the provisions of those considerations or rules were changed after the department's decision. The hearing officer may remand a matter to the department if the hearing officer determines that it would be beneficial for the department to consider new data, studies, or analyses that were not available before the decision or changes to the provisions of the applicable considerations or rules made after the department's decision. The hearing officer shall establish the time deadlines for completion of the remand and shall retain jurisdiction of the matter throughout the completion of the remand.

(h) After the issuance of a decision by the department pursuant to Code Section 31-6-43, no party to an appeal hearing, nor any person on behalf of such party, including the department, shall make any ex parte contact with the appeal panel hearing officer appointed to conduct the appeal hearing or any other member of the appeal panel in regard to a decision under appeal.

(i) Within 30 days after the conclusion of the hearing, the hearing officer shall make written findings of fact and conclusions of law as to each consideration as set forth in Code Section 31-6-43 and the department's rules, including a detailed statement of the reasons for the decision of the hearing officer. If any party has alleged that an appeal lacks substantial justification or was undertaken primarily for the purpose of delay or harassment, the decision of the hearing officer shall make findings of fact addressing the merits of the allegation. The hearing officer shall file such decision with the chairperson of the appeal panel who shall serve such decision upon all parties, and shall transmit the administrative record to the department.

(j) The decision of the appeal panel hearing officer shall constitute the final decision of the department. Such final decision shall be the final department decision for purposes of Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act.' The appeals process provided by this Code section shall be the administrative remedy only for decisions made by the department pursuant to Code Section 31-6-45 which involve the approval or denial of applications for certificates of need.

(k) All matters of the appeal panel that relate to facilities other than skilled nursing facilities that are pending as of the day prior to the effective date of this Act shall be dismissed without prejudice by operation of law as of the effective date of this Act.

31-6-47.

(a) Any party to the initial administrative appeal hearing conducted by the appointed appeal panel hearing officer, excluding the department, may seek judicial review of the final decision in accordance with the method set forth in Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' except as otherwise modified by this Code section; provided, however, that in conducting such review, the court may reverse or modify the final decision only if substantial rights of the appellant have been prejudiced because the procedures followed by the department or the hearing officer or the administrative findings, inferences, and conclusions contained in the final decision are:

(1) In violation of constitutional or statutory provisions;

(2) In excess of the statutory authority of the department;

(3) Made upon unlawful procedures;

(4) Affected by other error of law;

(5) Not supported by substantial evidence, which shall mean that the record does not contain such relevant evidence as a reasonable mind might accept as adequate to support such findings, inferences, conclusions, or decisions, which such evidentiary standard shall be in excess of the 'any evidence' standard contained in other statutory provisions; or

(6) Arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.

(b) In the event a party seeks judicial review, the proceedings for such review shall be governed by Chapter 3 of Title 5 except as provided otherwise in this Code section. If a party seeks judicial review, the department shall, within 30 days after being served with a copy of the petition for review filed in the superior court, transmit certified copies of all documents and papers in its file together with a transcript of the testimony taken and its findings of fact and decision to the clerk of the superior court to which the case has been appealed. The case so appealed may then be brought by either party upon ten days' written notice to the other before the superior court for a hearing upon such record, subject to an assignment of the case for hearing by the court; provided, however, that, if the court does not hear the case within 120 days of the date of docketing in the superior court, the decision of the department shall be considered affirmed by operation of law unless a hearing originally scheduled to be heard within the 120 days has been continued to a date certain by order of the court. In the event a hearing is held later than 90 days after the date of docketing in the superior court because same has been continued to a date certain by order of the court, the decision of the department shall be considered affirmed by operation of law if no order of the court disposing of the issues on appeal has been entered within 30 days after the date of the continued hearing. If a case is heard within 120 days from the date of docketing in the superior court, the decision of the department shall be considered affirmed by operation of law if no order of the court disposing of the issues on appeal has been entered within 30 days of the date of the hearing.

(c) A party responding to an appeal to the superior court shall be entitled to reasonable attorney's fees and costs if such party is the prevailing party of such appeal as decided by final order; provided, however, that the department shall not be required to pay attorney's fees or costs. This subsection shall not apply to the portion of attorney's fees accrued on behalf of a party responding to or bringing a challenge to the department's authority to enact a rule or regulation or the department's jurisdiction or another challenge that could not have been raised in the administrative proceeding.

31-6-48.

(a) The department may revoke a certificate of need, in whole or in part, after notice to the holder of the certificate and a fair hearing pursuant to Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' for the following reasons:

(1) Failure to comply with the provisions of Code Section 31-6-42;

(2) The intentional provision of false information to the department by an applicant in that applicant's application;

(3) Repeated failure to pay any fines or moneys due to the department;

(4) Failure to maintain minimum quality of care standards that may be established by the department; or

(5) Failure to participate as a provider of medical assistance for Medicaid purposes pursuant to Code Section 31-6-50 or any other applicable Code section. The department may not, however, revoke a certificate of need if the applicant changes the defined location of the project within the same county to a location less than three miles from the location specified in the certificate of need for financial reasons or other reasons beyond its control, including, but not limited to, failure to obtain any required approval from zoning or other governmental agencies or entities, provided that such change in location is otherwise consistent with the considerations and rules applied in the evaluation of the project.

(b) The department may revoke a certificate of need, in whole or in part, after notice to the holder of the certificate and a fair hearing pursuant to Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' if the services or units of services for which the certificate of need was issued are not implemented in a timely manner, as established by the department in its rules.

(c) Any skilled nursing facility offering a new institutional health service without having obtained a certificate of need and which has not been previously licensed as a skilled nursing facility shall be denied a license to operate.

(d) In the event that a new institutional health service is knowingly offered or developed without having obtained a certificate of need as required by this chapter, or the certificate of need for such service is revoked according to the provisions of this Code section, a facility or applicant may be fined an amount of $5,000.00 per day up to 30 days, $10,000.00 per day from 31 days through 60 days, and $25,000.00 per day after 60 days for each day that the violation of this chapter has existed and knowingly and willingly continues; provided, however, that the expenditure or commitment of or incurring an obligation for the expenditure of funds to take or perform actions not subject to this chapter or to acquire, develop, or prepare a skilled nursing facility site for which a certificate of need application is denied shall not be a violation of this chapter and shall not be subject to such a fine. The commissioner shall determine, after notice and a hearing, whether the fines provided in this Code section shall be levied.

(e) In addition, for purposes of this Code section, the State of Georgia, acting by and through the department, or any other interested person, shall have standing in any court of competent jurisdiction to maintain an action for injunctive relief to enforce the provisions of this chapter.

(f) The department shall have the authority to make public or private investigations or examinations inside or outside of this state to determine whether all provisions of this Code section or any other law, rule, regulation, or formal order relating to the provisions of Code Section 31-6-40 has been violated. Such investigations may be initiated at any time in the discretion of the department and may continue during the pendency of any action initiated by the department pursuant to subsection (a) of this Code section. For the purpose of conducting any investigation or inspection pursuant to this subsection, the department shall have the authority, upon providing reasonable notice, to require the production of any books, records, papers, or other information related to any certificate of need issue.

31-6-49.

(a) A skilled nursing facility which has a certificate of need or is otherwise authorized to operate pursuant to this chapter shall have such certificate of need or authority to operate automatically revoked by operation of law without any action by the department when that facility's permit to operate pursuant to Code Section 31-7-4 is finally revoked by order of the department. For purposes of this subsection, the date of such final revocation shall be as follows:

(1) When there is no appeal of the order pursuant to Chapter 5 of this title, the one hundred and eightieth day after the date upon which expires the time for appealing the revocation order without such an appeal being filed; or

(2) When there is an appeal of the order pursuant to Chapter 5 of this title, the date upon which expires the time to appeal the last administrative or judicial order affirming or approving the revocation or revocation order without such appeal being filed.

(b) The services which had been authorized to be offered by a skilled nursing facility for which a certificate of need has been revoked pursuant to subsection (a) of this Code section may continue to be offered in the service area in which that facility was located under such conditions as specified by the department notwithstanding that some or all of such services could not otherwise be offered as new institutional health services.

31-6-50.

(a) 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.

(b) Any proposed or existing skilled nursing facility which obtains a certificate of need on or after July 1, 2026, 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 31-6-48; provided, however, that this Code section shall not apply if:

(1) Such facility's participation as a provider of medical assistance is terminated by the state or federal government; or

(2) Such facility establishes good cause for terminating its participation as a provider of medical assistance. As used in this Code section, the term 'good cause' means:

(A) 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;

(B) 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

(C) 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.

(c) 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.

(d) 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 31-6-48.

31-6-51.

The department shall prepare and submit an annual report to the board and to the Senate Health and Human Services Committee and the House Committee on Health and Human Services about its operations and decisions for the preceding 12 month period, not later than 30 days prior to each convening of the General Assembly in regular session. Either committee may request any additional reports or information, including decisions, from the department at any time, including a period in which the General Assembly is not in regular session. The annual report shall include information and updates relating to the state health plan and the certificate of need program and an annual analysis of proactive and prospective approaches to need methodologies and access to skilled nursing facility services. The annual report shall include information for Georgia's congressional delegation which highlights issues regarding federal laws and regulations influencing Medicaid and Medicare, insurance and related tax laws, and long-term healthcare.

31-6-52.

(a) Notwithstanding the other provisions of this chapter, this chapter shall not apply to:

(1) Institutions operated exclusively by the federal government or by any of its agencies;

(2) Religious, nonmedical healthcare institutions as defined in 42 U.S.C. Section 1395x(ss)(1), listed and certified by a national accrediting organization;

(3) Site acquisitions for skilled nursing facilities or preparation or development costs for such sites prior to the decision to file a certificate of need application;

(4) Expenditures related to adequate preparation and development of an application for a certificate of need;

(5) The commitment of funds conditioned upon the obtaining of a certificate of need;

(6) Expenditures for the restructuring or acquisition of existing skilled nursing facilities by stock or asset purchase, merger, consolidation, or other lawful means;

(7) An expenditure for the minor or major repair of a skilled nursing facility;

(8) Capital expenditures otherwise covered by this chapter required solely to eliminate or prevent safety hazards as defined by federal, state, or local fire, building, environmental, occupational health, or life safety codes or regulations, to comply with licensing requirements of the department, or to comply with accreditation standards of a nationally recognized healthcare accreditation body;

(9) Cost overruns whose percentage of the cost of a project is equal to or less than the cumulative annual rate of increase in the composite construction index, published by the United States Bureau of the Census of the Department of Commerce, calculated from the date of approval of the project;

(10) Transfers from one skilled nursing facility to another such facility of major medical equipment previously approved under or exempted from certificate of need review, except where such transfer results in the institution of a new clinical health service for which a certificate of need is required in the facility acquiring such equipment, provided that such transfers are recorded at net book value of the medical equipment as recorded on the books of the transferring facility;

(11) New institutional health services provided by or on behalf of skilled nursing facilities in circumstances defined by the department pursuant to federal law;

(12) Expenditures for nonclinical projects, including parking lots, parking decks, and other parking facilities; computer systems, software, and other information technology; administrative office space; conference rooms; education facilities; lobbies; common spaces; clinical staff lounges and sleep areas; waiting rooms; bathrooms; cafeterias; hallways; engineering facilities; mechanical systems; roofs; grounds; signage; family meeting or lounge areas; other nonclinical physical plant renovations or upgrades that do not result in new or expanded clinical health services;

(13) Facilities operated by, on behalf of, or under contract with the Department of Corrections or the Department of Juvenile Justice for the sole and exclusive purpose of providing healthcare services in a secure environment to prisoners within a penal institution, penitentiary, prison, detention center, or other secure correctional institution, including correctional institutions operated by private entities in this state which house inmates under the Department of Corrections or the Department of Juvenile Justice;

(14) The relocation of any skilled nursing facility within the same county; or

(15) The renovation, remodeling, refurbishment, or upgrading of a skilled nursing facility, so long as the project does not result in the offering of any new or expanded clinical health services.

(b) By rule, the department shall establish a procedure for expediting or waiving reviews of certain projects, the nonreview of which it deems compatible with the purposes of this chapter, in addition to expenditures exempted from review by this Code section.

31-6-53.

The review and appeal considerations and procedures set forth in Code Sections 31-6-43 through 31-6-46, respectively, shall apply to and govern the review of capital expenditures under the Section 1122 program of the federal Social Security Act of 1935, as amended, including, but not limited to, any application for approval under Section 1122 which is under consideration by the department or on appeal before the Certificate of Need Appeal Panel."

PART II

Conforming changes

SECTION 2-1.

Title 16 of the Official Code of Georgia Annotated, relating to crimes and offenses, is amended by revising paragraph (8) of Code Section 16-11-62, relating to eavesdropping, surveillance, or intercepting communication which invades privacy of another and divulging private message, as follows:

"(8) Any person to intentionally and in a clandestine manner place, or direct someone else to place, a global positioning system monitoring device, or any other electronic monitoring device, on a motor vehicle owned or leased by another person without the consent of such person when such person has a protective order pursuant to Code Section 17-17-16, 19-13-4, or 19-13A-4, or a protective order from another jurisdiction, against the person who places, or directs another to place, the global positioning system monitoring device or other electronic device. Nothing in this paragraph shall be construed to limit electronic monitoring as provided in Code Sections 31-7-12, or

31-7-12.1, and 31-6-2; or "

SECTION 2-2.

Title 31 of the Official Code of Georgia Annotated, relating to health, is amended in Chapter 2, relating to Department of Community Health, by revising paragraph (12) of subsection (d) of Code Section 31-2-4, relating to powers, duties, functions, and responsibilities, divisions, directors, and contracts for health benefits, as follows: "(12) Shall request federal approval for and facilitate the application of certificates of need for licensure of facilities capable of providing long-term care services, with Medicaid as the primary funding source, to inmates who are eligible for such services and funding upon his or her release from a public institution, as such term is defined in Code Section 49-4-31."

SECTION 2-3.

Said title is further amended in said chapter by replacing "Code Section 31-6-21.1" with "Code Section 31-6-21" wherever the former term occurs in:

(1) Code Section 31-2-5, relating to transfer of personnel, functions, rights, duties, regulations, agreements, and property; and

(2) Code Section 31-2-7, relating to rules and regulations, variances, waivers, and exemptions.

SECTION 2-4.

Said title is further amended in Chapter 7, relating to regulation and construction of hospitals and other health care facilities, by revising paragraph (4) of and adding a new paragraph to Code Section 31-7-1, relating to definitions, to read as follows: "(4) 'Institution' means:

(A) Any building, facility, or place in which are provided two or more beds and other facilities and services that are used for persons received for examination, diagnosis, treatment, surgery, maternity care, nursing care, assisted living care, or personal care for periods continuing for 24 hours or longer and which is classified by the department, as provided for in this chapter, as either a hospital, nursing home, assisted living community, intermediate care facility, or personal care home;

(B) Any health facility wherein abortion procedures under subsections (b) and (c) of Code Section 16-12-141 are performed or are to be performed;

(C) Any building or facility, not under the operation or control of a hospital, which is primarily devoted to the provision of surgical treatment to patients not requiring hospitalization and which is classified by the department as an ambulatory surgical treatment center;

(D) Any fixed or mobile specimen collection center or health testing facility where specimens are taken from the human body for delivery to and examination in a licensed clinical laboratory or where certain measurements such as height and weight determination, limited audio and visual tests, and electrocardiograms are made, excluding public health services operated by the state, its counties, or municipalities;

(E) Any building or facility where human births occur on a regular and ongoing basis and which is classified by the department as a birthing center;

(F) Any building or facility which is devoted to the provision of treatment and rehabilitative care for periods continuing for 24 hours or longer for persons who have traumatic brain injury, as defined in Code Section 37-3-1; or

(G) Any freestanding imaging center where magnetic resonance imaging, computed tomography (CT) scanning, positron emission tomography (PET) scanning, positron emission tomography/computed tomography, and other advanced imaging services as defined by the department by rule, but not including X-rays, fluoroscopy, or ultrasound services, are conducted in a location or setting not affiliated or attached to a hospital or in the offices of an individual private physician or single group practice of physicians and conducted exclusively for patients of that physician or group practice.

(4.1) 'Intermediate care facility' means an institution which provides, on a regular basis, health related care and services to individuals who do not require the degree of care and treatment which a hospital or skilled nursing facility is designed to provide but who, because of their mental or physical condition, require health related care and services beyond the provision of room and board."

SECTION 2-5.

Said title is further amended in said chapter by revising subsection (a) of Code Section 31-7-3, relating to requirements for permits to operate institutions, as follows: "(a) Any person or persons responsible for the operation of any institution skilled nursing facility, or who may hereafter propose to establish and operate an institution a skilled nursing facility and to provide specified clinical services, shall submit an application to the department for a permit to operate the institution skilled nursing facility and provide such services, such application to be made on forms prescribed by the department. No institution skilled nursing facility shall be operated in this state without such a permit, which shall be displayed in a conspicuous place on the premises. No clinical services shall be provided by an institution a skilled nursing facility except as approved by the department in accordance with the rules and regulations established pursuant to Code Section 31-7-2.1. Failure or refusal to file an application for a permit shall constitute a violation of this chapter and shall be dealt with as provided for in Article 1 of Chapter 5 of this title. Following inspection and classification of the institution skilled nursing facility for which a permit is applied for, the department may issue or refuse to issue a permit or a provisional permit. Permits issued shall remain in force and effect until revoked or suspended; provisional permits issued shall remain in force and effect for such limited period of time as may be specified by the department. Upon conclusion of the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) Study, the department shall consider and analyze the data and conclusions of the study and promulgate rules pursuant to Code Section 31-7-2.1 to regulate the quality of care for therapeutic cardiac catheterization. All hospitals that participated in the study and are exempt from obtaining a certificate of need based on paragraph (22) of subsection (a) of Code Section 31-6-47 shall apply for a permit to continue providing therapeutic cardiac catheterization services once the department promulgates the rules required by this Code section."

SECTION 2-6.

Said title is further amended in said chapter by revising paragraph (24) of Code Section 31-7-75, relating to functions and powers, as follows: "(24) To provide management, consulting, and operating services including, but not limited to, administrative, operational, personnel, and maintenance services to another hospital authority, hospital, health care facility, as said term is defined in Chapter 6 of this title, healthcare facility, person, firm, corporation, or any other entity or any group or groups of the foregoing; to enter into contracts alone or in conjunction with others to provide such services without regard to the location of the parties to such transactions; to receive management, consulting, and operating services including, but not limited to, administrative, operational, personnel, and maintenance services from another such hospital authority, hospital, health care facility, person, firm, corporation, or any other entity or any group or groups of the foregoing; and to enter into contracts alone or in conjunction with others to receive such services without regard to the location of the parties to such transactions;"

SECTION 2-7.

Said title is further amended in said chapter by revising paragraph (1) of subsection (e) of Code Section 31-7-94.1, relating to rural hospital organization assistance, legislative findings, grant eligibility, and rules and regulations, as follows: "(1) Infrastructure development, including, without being limited to, health information technology, facility renovation, or equipment acquisition; provided, however, that the amount granted to any qualified hospital may not exceed the expenditure thresholds that would constitute a new institutional health service requiring a certificate of need under Chapter 6 of this title and the grant award may be conditioned upon obtaining local matching funds;"

SECTION 2-8.

Said title is further amended in said chapter by revising subsection (i) of Code Section 31-7-116, relating to issuance of bonds and bond anticipation notes, obligations of authority, and limitations and conditions, as follows:

"(i) No bonds or bond anticipation notes except refunding bonds shall be issued by an authority under this article unless its board of directors shall adopt a resolution finding that the project for which such bonds or notes are to be issued will promote the objectives stated in subsection (b) of Code Section 31-7-111 and will increase or maintain employment in the territorial area of such authority. Nothing contained in this Code section shall be construed as permitting any authority created under this article or any qualified sponsor to finance, construct, or operate any project without obtaining any certificate of need or other approval, permit, or license which, under the laws of this state, is required in connection therewith."

1000 SECTION 2-9.

1001 Said title is further amended in said chapter by repealing and reserving Code 1002 Section 31-7-155, relating to certificates of need for new service or extending service area 1003 and exemption from certificate.

1004 SECTION 2-10.

1005 Said title is further amended in said chapter by repealing Code Section 31-7-179, relating to 1006 certificate of need not required.

1007 SECTION 2-11.

1008 Said title is further amended in said chapter by revising Code Section 31-7-307, relating to 1009 certificate of need not required of licensees and operation of licensee as home health agency 1010 not authorized, as follows:

1011 "31-7-307.

1012 (a) A certificate of need issued pursuant to Chapter 6 of this title is not required for any 1013 person, business entity, corporation, or association, whether operated for profit or not for 1014 profit, which is operating as a private home care provider as long as such operation does 1015 not also constitute such person, entity, or organization operating as a home health agency 1016 or personal care home under this chapter.

1017 (b) A license issued under this article shall not entitle the licensee to operate as a home 1018 health agency, as defined in Code Section 31-7-150, under medicare Medicare or Medicaid 1019 guidelines."

1020 SECTION 2-12.

1021 Said title is further amended in Chapter 8, relating to care and protection of indigent and 1022 elderly patients, by revising Code Section 31-8-181, relating to individuals and hospitals 1023 excluded from application of article, as follows:

1024 "31-8-181.

1025 This article shall not apply to the following:

1026 (1) An individual licensed to practice medicine under the provisions of Chapter 34 of 1027 Title 43, and persons employed by such an individual, provided that any nursing home, 1028 personal care home as defined by Code Section 31-6-2 31-7-12, hospice as defined by 1029 Code Section 31-7-172, respite care service as defined by Code Section 49-6-72, adult 1030 day program, or home health agency owned, operated, managed, or controlled by a 1031 person licensed to practice medicine under the provisions of Chapter 34 of Title 43 shall 1032 be subject to the provisions of this article; or

1033 (2) A hospital. However, to the extent that a hospital's nursing home, personal care 1034 home as defined by Code Section 31-6-2 31-7-12, hospice as defined by Code 1035 Section 31-7-172, respite care service as defined by Code Section 49-6-72, adult day 1036 program, or home health agency holds itself out as providing care, treatment, or 1037 therapeutic activities for persons with Alzheimer's disease or Alzheimer's related 1038 dementia as part of a specialty unit, such nursing home, personal care home, hospice, 1039 respite care service, adult day program, or home health agency shall be subject to the 1040 provisions of this article."

1041 SECTION 2-13.

1042 Said title is further amended in said chapter by revising Code Section 31-8-153.1, relating 1043 to irrevocable transfer of funds to trust fund and provision for indigent patients, as follows: 1044 "31-8-153.1.

1045 After June 30, 1993, any hospital authority, county, municipality, or other state or local 1046 public or governmental entity is authorized to transfer moneys to the trust fund. Transfer 1047 of funds under the control of a hospital authority, county, municipality, or other state or 1048 local public or governmental entity shall be a valid public purpose for which those funds 1049 may be expended. The department is authorized to transfer to the trust fund moneys paid 1050 to the state by a health care healthcare facility as a monetary penalty for the violation of an 1051 agreement to provide a specified amount of clinical health services to indigent patients 1052 uncompensated indigent or charity care pursuant to a certificate of need license held by 1053 such facility. Such transfers shall be irrevocable and shall be used only for the purposes 1054 contained in Code Section 31-8-154."

1055 SECTION 2-14.

1056 Said title is further amended in Chapter 11, relating to emergency medical services, by 1057 revising paragraph (3) of Code Section 31-11-100, relating to Georgia Trauma Care Network 1058 Commission, as follows:

1059 "(3) 'Trauma center' means a facility designated by the Department of Public Health as 1060 a Level I, II, III, or IV or burn trauma center. However, a burn trauma center shall not 1061 be considered or treated as a trauma center for purposes of certificate of need 1062 requirements under state law or regulations, including exceptions to need and adverse 1063 impact standards allowed by the department for trauma centers or for purposes of 1064 identifying safety net hospitals."

1065 SECTION 2-15.

1066 Said title is further amended in Chapter 54, relating to hospital peace officers, by revising 1067 paragraph (1) of Code Section 31-54-1, relating to definitions, as follows: 1068 "(1) 'Hospital' shall have the same meaning as provided in Code Section 31-6-2 means 1069 a facility that is permitted to operate as a hospital pursuant to Article 1 of Chapter 7 of 1070 this title."

1071 SECTION 2-16.

1072 Title 33 of the Official Code of Georgia Annotated, relating to insurance, is amended in 1073 Chapter 45, relating to continuing care providers and facilities, by revising subparagraph (A) 1074 of paragraph (1) of Code Section 33-45-1, relating to definitions, as follows: 1075 "(A) Lodging that is not:

1076 (i) In a skilled nursing facility, as such term is defined in Code Section 31-6-2 1077 31-6-1;

1078 (ii) An intermediate care facility, as such term is defined in Code Section 31-6-2 1079 31-7-1;

1080 (iii) An assisted living community, as such term is defined in Code 1081 Section 31-7-12.2; or

1082 (iv) A personal care home, as such term is defined in Code Section 31-7-12;" 1083 SECTION 2-17.

1084 Said title is further amended in said chapter by revising subsections (b) and (d) of Code 1085 Section 33-45-3, relating to certificate of authority required for operation of life plan 1086 communities, as follows:

1087 "(b) Nothing in this chapter shall be construed so as to modify or limit in any way: 1088 (1) Provisions of Article 3 of Chapter 6 of Title 31 and any rules and regulations 1089 promulgated by the Department of Community Health pursuant to such article relating 1090 to certificates of need for life plan communities or home health agencies, as such terms 1091 are defined in Code Section 31-6-2; or

1092 (2) Provisions provisions of Chapter 7 of Title 31 relating to licensure or permit 1093 requirements and any rules and regulations promulgated by the Department of 1094 Community Health pursuant to such chapter, including, without limitation, licensure or 1095 permit requirements for nursing home care, assisted living care, personal care home 1096 services, home health services, and private home care services." 1097 "(d) A provider of continuing care at home may contract with a licensed home health 1098 agency to provide home health services to a resident. In order to provide home health 1099 services directly, a provider of continuing care at home shall obtain a certificate of need for 1100 a home health agency, as such term is defined in Code Section 31-6-2, pursuant to the same 1101 criteria and rules as are applicable to freestanding home health agencies that are not 1102 components of life plan communities."

1103 SECTION 2-18.

1104 Said title is further amended in said chapter by revising Code Section 33-45-7.1, relating to 1105 provider authorized to offer continuing care when resident purchases resident owned living 1106 unit, as follows:

1107 "33-45-7.1.

1108 A provider which has obtained a certificate of authority pursuant to Code Section 33-45-5 1109 and the written approval of the Commissioner is authorized to offer, as a part of the 1110 continuing care agreement, continuing care at home or continuing care in which the 1111 resident purchases a resident owned living unit, subject to the provisions of Chapters 6 and 1112 Chapter 7 of Title 31 and rules and regulations promulgated by the Department of 1113 Community Health pursuant to such chapters chapter relating to certificate of need and 1114 licensure requirements."

1115 SECTION 2-19.

1116 Title 37 of the Official Code of Georgia Annotated, relating to mental health, is amended by 1117 revising subsection (j) of Code Section 37-1-29, relating to crisis stabilization units, as 1118 follows:

1119 "(j) Any program certified as a crisis stabilization unit pursuant to this Code section shall 1120 be exempt from the requirements to obtain a certificate of need pursuant to Article 3 of 1121 Chapter 6 of Title 31. Reserved."

1122 SECTION 2-20.

1123 Title 43 of the Official Code of Georgia Annotated, relating to profession and businesses, is 1124 amended in Chapter 26, relating to nurses, by revising subparagraph (c)(4)(C) and the 1125 undesignated text at the end of paragraph (4) of subsection (c) of Code Section 43-26-7, 1126 relating to requirements for licensure as registered professional nurse and requirements for 1127 nontraditional nursing education program, as follows:

1128 "(C) If the applicant entered a nontraditional nursing education program as anything 1129 other than a licensed practical nurse whose academic education as a licensed practical 1130 nurse included clinical training in pediatrics, obstetrics and gynecology, 1131 medical-surgical, and mental illness, have graduated from such program and practiced 1132 nursing as a registered professional nurse in a health care healthcare facility for at least 1133 two years in the five years preceding the date of the application, and such practice is 1134 documented by the applicant and approved by the board; provided, however, that for 1135 an applicant who does not meet the experience requirement of this subparagraph, the 1136 board shall require the applicant to complete a postgraduate preceptorship of at least 1137 480 hours but not more than 640 hours, as determined by the board, arranged by the 1138 applicant under the oversight of a registered professional nurse where such applicant 1139 is transitioned into the role of a registered professional nurse. The preceptorship shall 1140 have prior approval of the board, and successful completion of the preceptorship shall 1141 be verified in writing by the preceptor.

1142 For purposes of this paragraph, the term 'health care 'healthcare facility' means an acute 1143 care inpatient facility, a long-term acute care facility, an ambulatory surgical center or 1144 obstetrical facility as defined in Code Section 31-6-2, and a skilled nursing facility, so 1145 long as such skilled nursing facility has 100 beds or more and provides health care 1146 healthcare to patients with similar health care healthcare needs as those patients in a 1147 long-term acute care facility;"

1148 SECTION 2-21.

1149 Title 50 of the Official Code of Georgia Annotated, relating to state government, is amended 1150 in Chapter 26, relating to housing and finance authority, by revising subsection (c) of Code 1151 Section 50-26-19, relating to financing, acquisition, construction, and equipping of health 1152 care facilities, as follows:

1153 "(c) The authority may not finance a project for any participating provider unless the 1154 Department of Community Health, or any successor thereof, has issued a certificate of need 1155 or comparable certification of approval to the participating provider for the project to be 1156 financed by the authority if the acquisition of such project by the participating provider 1157 would require a certificate of need or comparable certification of approval under Chapter 6 1158 of Title 31."

1159 SECTION 2-22.

1160 Title 51 of the Official Code of Georgia Annotated, relating to torts, is amended in 1161 Chapter 16, relating to COVID-19 pandemic business safety, by revising paragraph (5) of 1162 Code Section 51-16-1, relating to definitions, as follows: 1163 "(5) 'Healthcare facility' shall have the same meaning as 'healthcare facility' as provided 1164 for in paragraph (17) of Code Section 31-6-2 means hospitals; destination cancer 1165 hospitals; other special care units, including but not limited to podiatric facilities; skilled 1166 nursing facilities; intermediate care facilities; personal care homes; ambulatory surgical 1167 centers or obstetrical facilities; freestanding emergency departments or facilities not 1168 located on a hospital's primary campus; health maintenance organizations; home health 1169 agencies; and diagnostic, treatment, or rehabilitation centers and all related parties;. Such 1170 term shall have the same meaning as 'institution' as provided for in subparagraphs (A) and 1171 (C) through (G) of paragraph (4) and paragraph (5) of Code Section 31-7-1 and all related 1172 parties; as 'end stage renal disease facility' as provided for in paragraph (6) of Code 1173 Section 31-44-1 and all related parties; and shall mean the recipient of a contract as 1174 authorized in paragraph (5) of Code Section 37-1-20 and any clinical laboratory certified 1175 under the Clinical Laboratory Improvement Amendments in Section 353 of the Public 1176 Health Service Act, 42 U.S.C. Section 263a. Such term shall not be construed to include 1177 premises."

1178 PART III

1179 Rural hospital authorities and coordinated healthcare planning 1180 SECTION 3-1.

1181 Title 31 is further amended in Article 4 of Chapter 7, relating to county and municipal 1182 hospital authorities, by revising paragraph (2) of Code Section 31-7-71, relating to 1183 definitions, as follows:

1184 "(2) 'Authority' or 'hospital authority' means any public corporation created by this 1185 article. Such term shall include rural hospital authority as defined in Code 1186 Section 31-7-100."

1187 SECTION 3-2.

1188 Said chapter is further amended in said article by revising subsection (e) of Code 1189 Section 31-7-72.1, relating to merger of hospital authorities, as follows: 1190 "(e) It is declared by the General Assembly of Georgia that in the exercise of the power 1191 specifically granted to them by this Code section, hospital authorities are acting pursuant 1192 to state policy and shall be immune from antitrust liability to the same degree and extent 1193 as enjoyed by the State of Georgia; provided, however, that any rural hospital authority 1194 exercising powers as authorized pursuant to Article 4A of this chapter shall be immune 1195 from antitrust liability as provided therein."

1196 SECTION 3-3.

1197 Said chapter is further amended by adding a new article to read as follows: 1198 "ARTICLE 4A

1199 31-7-100.

1200 (a) It is the intent of the General Assembly to deem rural hospital authorities immune from 1201 federal antitrust laws when acting as expressly authorized by this article and Article 4 of 1202 this chapter. The express intent of the General Assembly is to avoid weakening antitrust 1203 provisions applicable to: any group of hospitals that includes any hospital that is not a rural 1204 hospital authority; any hospital authority that is not a rural hospital authority; or any group 1205 of four or more rural hospital authorities.

1206 (b) The General Assembly finds that:

1207 (1) Rural hospital authorities are unique and have different interests from nonrural 1208 hospital authorities or healthcare systems that include nonrural hospitals and nonrural 1209 hospital authorities;

1210 (2) Rural hospital authorities perform essential public and governmental functions on 1211 behalf of this state and the counties and municipalities that activate them by providing 1212 healthcare services to the indigent sick, expanding access to healthcare, promoting public 1213 health, supporting medical education and research, sustaining rural healthcare providers, 1214 and maintaining healthcare infrastructure in communities throughout this state; 1215 (3) In today's healthcare marketplace, any difference between the levels of charity care 1216 and care provided to the indigent sick by hospitals is not a consequence of being a 1217 hospital authority or a hospital's tax status;

1218 (4) Hospitals of every kind, regardless of whether public or private or whether they pay 1219 taxes, provide critical services, including those identified in paragraph (2) of this 1220 subsection;

1221 (5) Healthcare delivery in rural counties that have a rural hospital authority, as well as 1222 rural counties without a hospital but adjacent to a county with a rural hospital authority, 1223 can be significantly enhanced through coordinated planning, joint operations, and 1224 collaborative arrangements among rural hospital authorities. Accordingly, rural hospital 1225 authorities may find it necessary to achieve efficiency, reduce costs, improve quality, 1226 expand access to services, attract and retain healthcare professionals, maintain financial 1227 viability of essential healthcare facilities, and respond effectively to public health 1228 emergencies and evolving community health needs; and 1229 (6) The nature and scope of the powers conferred on rural hospital authorities operating 1230 in rural counties pursuant to this article and Article 4 of this chapter may compel such an 1231 authority, in the course of exercising its powers or by virtue of such exercise of powers, 1232 to engage in activities itself or in collaboration with other rural hospital authorities, public 1233 or private healthcare entities operating exclusively in rural counties, regardless of such 1234 entities' tax status, and persons operating exclusively in rural counties, that may be 1235 characterized as anticompetitive or may result in the acquisition or maintenance of market 1236 power within the meaning of federal antitrust laws or may have the effect of displacing 1237 competition in the provision of hospital, physician, or other healthcare related services. 1238 (c) Based on the findings provided in subsection (b) of this Code section, the General 1239 Assembly hereby declares, as expressions of the public policy of this state with respect to 1240 the displacement of competition in the field of healthcare in only those rural counties with 1241 a rural hospital authority or with no hospital but adjacent to a rural county with a rural 1242 hospital authority:

1243 (1) The powers granted to rural hospital authorities under this article are conferred for 1244 the purpose of carrying out the state's public health mission in rural counties. The 1245 exercise of such powers in accordance with this article constitutes implementation of the 1246 express policy of this state, and such powers constitute a clearly articulated and 1247 affirmatively expressed state policy to displace competition with regulation or monopoly 1248 public service in the field of healthcare delivery in rural counties where a rural hospital 1249 authority is the only hospital and in rural counties without a hospital adjacent to a rural 1250 county with a rural hospital authority; and

1251 (2) The potential anticompetitive effects of conduct of a rural hospital authority as 1252 authorized by this article are a foreseeable result of the powers granted herein, and such 1253 potential anticompetitive effects are consistent with the state's policy of promoting 1254 coordinated healthcare delivery through rural hospital authorities in counties without a 1255 hospital or where the rural hospital authority is the only hospital. 1256 (d) The provisions of this Code section shall be narrowly construed. 1257 31-7-101.

1258 As used in this article, the term:

1259 (1) 'Healthcare system' means a group of hospitals that are affiliated, share common 1260 direct or indirect ownership, or do business under a common name. Such term also 1261 means any physician group that is affiliated with such a group of hospitals. 1262 (2) 'Hospital authority' shall have the same meaning as set forth in Code Section 31-7-71. 1263 (3) 'Project' shall have the same meaning as set forth in Code Section 31-7-71. 1264 (4) 'Restructured rural hospital authority' means an entity that leases its operating assets 1265 from a hospital authority organized and created by resolution that includes at least one 1266 member of such hospital authority on the restructured governing board and operates a 1267 project in a rural county.

1268 (5) 'Rural county' means any county in this state having a population of less than 50,000 1269 according to the United States decennial census of 2020 or any future such census. 1270 (6) 'Rural hospital authority' means a hospital authority or a restructured rural hospital 1271 authority that is located in a rural county or that is part of a rural hospital authority that 1272 operates only in rural counties. Such authority shall not be affiliated with more than two 1273 other rural hospital authorities. Such authority shall not be affiliated directly or indirectly 1274 with any hospital authority that operates directly or indirectly in a nonrural county, that 1275 operates directly or indirectly more than two other hospitals of any kind located in a 1276 nonrural county, or is part of a healthcare system that includes two or more other 1277 affiliated hospitals of any kind located in a nonrural county. 1278 (7) 'Rural physician practice' means a group of physicians or physician practices that 1279 perform medical care and treatment exclusively in a rural county or rural counties and are 1280 not affiliated with any hospital, hospital authority, or healthcare system that is not a rural 1281 hospital authority.

1282 31-7-102.

1283 (a) Rural hospital authorities may engage in conduct authorized pursuant to Article 4 of 1284 this chapter and this article.

1285 (b) Based on the legislative findings and expression of public policy set forth in Code 1286 Section 31-7-100, rural hospital authorities may engage in coordinated healthcare planning 1287 and delivery for the provision of healthcare services in rural counties, including but not 1288 limited to:

1289 (1) Mergers, acquisitions, consolidations, and affiliations with no more than two other 1290 rural hospital authorities or rural physician practices per corporate restructuring; 1291 (2) Joint ventures, partnerships, and collaborative arrangements with no more than two 1292 other rural hospital authorities or rural physician practices per strategic alliance; 1293 (3) Coordinated or joint negotiations with other rural hospital authorities or rural 1294 physician practices and third-party payors, health insurers, and managed care 1295 organizations, whether such negotiations result in separate or combined agreements, 1296 provided that each such agreement is with no more than two other rural hospital 1297 authorities;

1298 (4) Joint purchasing arrangements and shared services agreements with no more than two 1299 rural hospital authorities or rural physician practices per arrangement or agreement; 1300 (5) Shared staffing to promote flexible staffing among rural hospital authorities or rural 1301 physician practices;

1302 (6) Coordinated decisions among no more than two rural hospital authorities regarding 1303 the allocation, expansion, reduction, or discontinuation of healthcare services and service 1304 lines in rural counties;

1305 (7) Agreements between no more than two rural hospital authorities regarding pricing, 1306 reimbursement rates, or the terms of contracts with third-party payors and other third 1307 parties;

1308 (8) Information sharing with public or private entities and individuals; and 1309 (9) The creation or operation of or participation in delivery system networks, clinically 1310 integrated networks, and accountable care organizations in a rural county or rural 1311 counties for use of rural hospital authorities and rural physician practices. 1312 31-7-103.

1313 (a) Rural hospital authorities exercising any power granted under Article 4 of this chapter 1314 or this article, including, but not limited to, the power to merge with other rural hospital 1315 authorities, to consolidate operations, to affiliate with other rural hospital authorities or 1316 rural physician practices, to coordinate healthcare planning and delivery with other rural 1317 hospital authorities or rural physician practices, and to engage in the collaborative activities 1318 described in Code Sections 31-7-75 and 31-7-102 with other rural hospital authorities or 1319 rural physician practices, shall be immune from antitrust liability under any federal laws 1320 to the same degree and extent as enjoyed by the state. 1321 (b) Without limiting the provisions of subsection (a) of this Code section, rural hospital 1322 authorities exercising powers pursuant to Article 4 of this chapter or this article shall be 1323 immune from liability under federal antitrust laws, including without limitation the federal 1324 Sherman Act, 15 U.S.C. Section 1, et seq., the federal Clayton Act, 15 U.S.C. Section 12, 1325 et seq., and the Federal Trade Commission Act, 15 U.S.C. Section 41, et seq., as well as 1326 any state law counterpart thereto or any other state or federal law prohibiting or regulating 1327 anticompetitive conduct, monopolization, restraints of trade, or unfair methods of 1328 competition; provided, however, such immunity shall not extend to any prohibition in the 1329 Constitution of Georgia.

1330 (c) Each rural hospital authority exercising powers granted under Article 4 of this chapter 1331 or this article:

1332 (1) Acts as an agency or instrumentality of the county or municipality that activated it 1333 and as a public body corporate and politic. For purposes of any federal antitrust law, 1334 including the application of the state action doctrine as developed in federal antitrust 1335 jurisprudence, each rural hospital authority shall be deemed a political subdivision of this 1336 state; and

1337 (2) Shall not be subject to active state supervision in order to enjoy immunity from the 1338 application of any federal antitrust laws when the rural hospital authority collaborates 1339 with any other rural hospital authority or rural physician practice. To the extent that any 1340 court or regulatory body determines that active state supervision is required for any 1341 person or entity to assert immunity under this subsection, the General Assembly hereby 1342 designates the governing body of the rural county or municipality that activated the rural 1343 hospital authority or, if activated by multiple governing bodies, the governing bodies 1344 acting jointly as the state actor responsible for supervising the conduct of the rural 1345 hospital authority, and such governing body or bodies are hereby authorized and directed 1346 to review, approve, and supervise agreements and collaborative arrangements entered into 1347 between any rural hospital authorities and rural physician practices pursuant to this 1348 article.

1349 31-7-104.

1350 (a) The immunity from antitrust liability under any federal laws established pursuant to 1351 Code Section 31-7-103 extends only to the following persons: 1352 (1) A rural hospital authority or group of no more than three rural hospital authorities 1353 exercising powers granted under Article 4 of this chapter or this article, with or without 1354 a rural physician practice;

1355 (2) Any surviving, resulting, or successor rural hospital authority that continues to satisfy 1356 the definition of a rural hospital authority following a merger, acquisition, consolidation, 1357 or other combination authorized under this article;

1358 (3) Any members of the board of a rural hospital authority and any officers, employees, 1359 or agents of a rural hospital authority acting within the scope of the rural hospital 1360 authority only;

1361 (4) Any rural hospital authority, rural physician practice, or other person who 1362 collaborates with a rural hospital authority in a manner expressly authorized by this 1363 article; and

1364 (5) Any entity controlled by or under common control with a rural hospital authority, 1365 including without limitation any nonprofit subsidiary, affiliate, joint venture, or other 1366 entity in which a rural hospital authority has an ownership or membership interest. 1367 (b) The immunity from antitrust liability under any federal laws established pursuant to 1368 Code Section 31-7-103 and as limited pursuant to subsection (a) of this Code section shall 1369 apply to:

1370 (1) Any action, suit, or proceeding brought by the Federal Trade Commission, the United 1371 States Department of Justice, or any other federal agency or instrumentality under federal 1372 antitrust laws only;

1373 (2) Any action, suit, or proceeding brought by this state, the Attorney General, or any 1374 other state agency or instrumentality for antitrust laws only; 1375 (3) Any action, suit, or proceeding brought by any county, municipality, or other political 1376 subdivision of this state for antitrust laws only;

1377 (4) Any private action, suit, or proceeding, including without limitation any action for 1378 damages, injunctive relief, or other remedy under federal or state antitrust laws; and 1379 (5) Any investigation, inquiry, civil investigative demand, subpoena, or other 1380 compulsory process issued in connection with any antitrust law. 1381 (c) The provisions of this Code section shall be narrowly construed. 1382 31-7-105.

1383 (a) Nothing in this article shall be construed as:

1384 (1) Extending sovereign immunity to any hospital authority; 1385 (2) Applying to any hospital, hospital authority, or restructured hospital authority located 1386 in any nonrural county;

1387 (3) Applying to any group of hospitals of any kind when any hospital in the group is not 1388 a rural hospital authority;

1389 (4) Applying to any physician practice that is affiliated with any hospital or group of 1390 hospitals that is not a rural hospital authority;

1391 (5) Applying to mergers, acquisitions, or other any other collaboration between a rural 1392 hospital authority and hospital of any kind that is not a rural hospital authority or between 1393 a rural hospital authority and a healthcare system that includes any hospital that is not a 1394 rural hospital authority; or

1395 (6) Applying to a merger, acquisition, consolidation, or other combination between more 1396 than three rural hospital authorities.

1397 (b) Nothing in this article shall be construed to authorize conduct that would violate any 1398 other applicable state or federal law, rule, or regulation, other than the antitrust laws 1399 addressed herein.

1400 (c) No immunity granted by this article shall apply any action arising under the 1401 Constitution of the United States or the Constitution of Georgia, arising out of common 1402 law, or based on a statute other than federal antitrust law. 1403 (d) Any ambiguity in the scope or application of this Code section shall be resolved 1404 against the grant of immunity.

1405 31-7-106.

1406 (a) No rural hospital authority shall be able to assert the immunity to antitrust laws 1407 provided in this article prior to satisfaction of the notice and review requirements as 1408 follows:

1409 (1) The rural hospital authority shall provide written notice to the Governor, the Attorney 1410 General, the President of the Senate, the Speaker of the House of Representatives, and 1411 the chairpersons of the House Committees on Judiciary and Health and the Senate 1412 Judiciary and Health and Human Services Committees of its intent to assert the immunity 1413 to antitrust laws provided in this article;

1414 (2) Upon receiving such notice from a rural hospital authority, the Attorney General shall 1415 post the notice on his or her official website and shall have not more than 180 days to 1416 conduct a review to determine whether the rural hospital authority satisfies the statutory 1417 criteria provided in this article;

1418 (3) During the review process, the rural hospital authority shall provide any requested 1419 documents to the Attorney General within a reasonable amount of time, not to exceed 1420 15 calendar days. If the rural hospital authority fails to provide any such requested 1421 documents within such time, the Attorney General shall deny the rural hospital authority's 1422 request to assert the immunity to antitrust laws provided in this article. If a rural hospital 1423 authority claims that the request of the Attorney General is unlawful, it may seek a 1424 remedy in the Superior Court of Fulton County;

1425 (4) The immunity to antitrust laws provided in this article to rural hospital authorities 1426 shall not be effective until the Attorney General determines that the rural hospital 1427 authority satisfies all the statutory criteria provided in this article and indicates the same 1428 by written notice published on the Attorney General's website; 1429 (5) If the Attorney General determines that the rural hospital authority satisfies all the 1430 statutory criteria provided in this article for such rural hospital authority to assert the 1431 immunity to antitrust laws provided in this article, such rural hospital authority shall have 1432 ten days to notify in writing the United States Attorney General and the Chair of the 1433 Federal Trade Commission of such determination. Any failure to comply with this 1434 paragraph by the rural hospital authority will deprive such rural hospital authority the 1435 ability to assert the immunity to antitrust laws provided in this article; 1436 (6) Any hospital or healthcare provider located in an adjacent county to or within 35 1437 miles of the rural hospital authority that seeks to assert the immunity to antitrust laws 1438 provided in this article may submit its objection to the Attorney General no later than 30 1439 days after the notice is published pursuant to paragraph (2) of this subsection. The 1440 Attorney General shall consider such objection before making the determination required 1441 by paragraph (5) of this subsection;

1442 (7) Any person aggrieved by the Attorney General's determination under this subsection 1443 may seek judicial review as set forth in Chapter 3 of Title 5, provided that such person 1444 submitted objections to the Attorney General as set forth in paragraph (6) of this 1445 subsection; and

1446 (8) The immunity to antitrust laws provided in this article to rural hospital authorities 1447 shall not be effective for any action filed before the Attorney General determines that the 1448 rural hospital authority satisfies the statutory criteria provided in this article. If the 1449 Attorney General's determination is reversed by final order on judicial review, the grant 1450 of such immunity shall be deemed null and void.

1451 (b) Notwithstanding any provision contained in Article 4 of Chapter 8 of Title 13, a rural 1452 hospital authority that has successfully asserted the immunity to antitrust laws provided by 1453 this article shall be ineligible to enter into a restrictive covenant in contract with any 1454 physician, nurse, or other healthcare provider licensed under a provision of Title 43. 1455 (c) Any rural hospital authority that has asserted the immunity to antitrust law provided in 1456 this article and satisfied statutory criteria as determined by the Attorney General shall be 1457 deemed to be a private state actor pursuant to 42 U.S.C. Section 1983; provided, however, 1458 that such determination shall not establish that all actions of such rural hospital authority 1459 are made under color of state law.

1460 (d) Any rural hospital authority that has asserted the immunity to antitrust law provided in 1461 this article shall, no later than June 30 of each year, provide a sworn statement to the 1462 Attorney General that it continues to meet the definition of a rural hospital authority. The 1463 failure to timely provide such notice shall render such immunity to antitrust law no longer 1464 valid as a matter of law. Any rural hospital authority that ceases to qualify for the 1465 immunity to antitrust law provided in this article may seek to assert such immunity once 1466 it qualifies or requalifies pursuant to review and determination by the Attorney General 1467 pursuant to this Code Section.

1468 (e) A rural hospital authority that has asserted the immunity provided in this article may 1469 request guidance from the Attorney General about whether a proposed transaction would 1470 deprive the rural hospital authority of such immunity. The Attorney General shall have 90 1471 days to respond to the request, but the Attorney General's response shall not be binding. 1472 (f) The Attorney General shall have the authority to ensure compliance with any and all 1473 notices and obligations which are required to be made pursuant to this Code section. No 1474 provision of this Code section shall derogate the common law or statutory authority of the 1475 Attorney General.

1476 (g) The Department of Community Health, in consultation with the Attorney General, shall 1477 annually and as necessary review conduct of rural hospital authorities to confirm 1478 compliance with the provisions of this article; ensure that any displacement of competition 1479 does not impair the public's access to quality and affordable healthcare services and the 1480 state's duty to provide indigent care; and take necessary action against rural hospital 1481 authorities."

1482 PART IV

1483 Effective date and repealer

1484 SECTION 4-1.

1485 This Act shall become effective upon its approval by the Governor or upon its becoming law 1486 without such approval.

1487 SECTION 4-2.

1488 All laws and parts of laws in conflict with this Act are repealed.