(a) Notwithstanding the other provisions of this chapter, this chapter shall not apply to: (1) Infirmaries operated by educational institutions for the sole and exclusive benefit of students, faculty members, officers, or employees thereof; (2) Infirmaries or facilities operated by businesses for the sole and exclusive benefit of officers or employees thereof, provided that such infirmaries or facilities make no provision for overnight stay by persons receiving their services; (3) Institutions operated exclusively by the federal government or by any of its agencies; (4) Offices of private physicians or dentists whether for individual or group practice, except as otherwise provided in paragraph (3) or (7) of subsection (a) of Code Section 31-6-40 ; (5) Religious, nonmedical health care institutions as defined in 42 U.S.C. Section 1395x(ss)(1) , listed and certified by a national accrediting organization; (6) Site acquisitions for health care facilities or preparation or development costs for such sites prior to the decision to file a certificate of need application; (7) Expenditures related to adequate preparation and development of an application for a certificate of need; (8) The commitment of funds conditioned upon the obtaining of a certificate of need; (9) Expenditures for the restructuring or acquisition of existing health care facilities by stock or asset purchase, merger, consolidation, or other lawful means; (9.1) The purchase of a closing hospital or of a hospital that has been closed for no more than 24 months by a hospital in a contiguous county to repurpose the facility as a micro-hospital; (10) The acquisition, replacement, or repair of diagnostic, therapeutic, or other imaging equipment by any existing health care facility that is not owned by a group practice of physicians or a hospital and that provides diagnostic imaging services so long as it does not result in the offering of any new clinical health services; (10.1) An expenditure for the minor or major repair of a health care facility or a facility that is exempt from the requirements of this chapter, parts thereof, or services provided therein; (11) 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 health care accreditation body; (12) 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; (13) Transfers from one health care 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; (14) New institutional health services provided by or on behalf of health maintenance organizations or related health care facilities in circumstances defined by the department pursuant to federal law; (15) Increases in the bed capacity of a hospital up to ten beds or 20 percent of capacity, whichever is greater, in any consecutive three-year period, in a hospital that has maintained an overall occupancy rate greater than 60 percent for the previous 12 month period; (16) Expenditures for nonclinical projects, including parking lots, parking decks, and other parking facilities; computer systems, software, and other information technology; medical office buildings; 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, and state mental health facilities; (17) Life plan communities, provided that the skilled nursing component of the facility is for the exclusive use of residents of the life plan community and that a written exemption is obtained from the department; provided, however, that new sheltered nursing home beds may be used on a limited basis by persons who are not residents of the life plan community for a period up to five years after the date of issuance of the initial nursing home license, but such beds shall not be eligible for Medicaid reimbursement. For the first year, the life plan community sheltered nursing facility may utilize not more than 50 percent of its licensed beds for patients who are not residents of the life plan community. In the second year of operation, the life plan community shall allow not more than 40 percent of its licensed beds for new patients who are not residents of the life plan community. In the third year of operation, the life plan community shall allow not more than 30 percent of its licensed beds for new patients who are not residents of the life plan community. In the fourth year of operation, the life plan community shall allow not more than 20 percent of its licensed beds for new patients who are not residents of the life plan community. In the fifth year of operation, the life plan community shall allow not more than 10 percent of its licensed beds for new patients who are not residents of the life plan community. At no time during the first five years shall the life plan community sheltered nursing facility occupy more than 50 percent of its licensed beds with patients who are not residents under contract with the life plan community. At the end of the five-year period, the life plan community sheltered nursing facility shall be utilized exclusively by residents of the life plan community, and at no time shall a resident of a life plan community be denied access to the sheltered nursing facility. At no time shall any existing patient be forced to leave the life plan community to comply with this paragraph. The department is authorized to promulgate rules and regulations regarding the use and definition of the term "sheltered nursing facility" in a manner consistent with this Code section. Agreements to provide continuing care include agreements to provide care for any duration, including agreements that are terminable by either party; (18) Any single specialty ambulatory surgical center that: (A) (i) Has capital expenditures associated with the construction, development, or other establishment of the clinical health service which do not exceed $2.5 million; or (ii) Is the only single specialty ambulatory surgical center in the county owned by the group practice and has two or fewer operating rooms; provided, however, that a center exempt pursuant to this division shall be required to obtain a certificate of need in order to add any additional operating rooms; (B) Has a hospital affiliation agreement with a hospital within a reasonable distance from the facility or the medical staff at the center has admitting privileges or other acceptable documented arrangements with such hospital to ensure the necessary backup for the center for medical complications. The center shall have the capability to transfer a patient immediately to a hospital within a reasonable distance from the facility with adequate emergency room services. Hospitals shall not unreasonably deny a transfer agreement or affiliation agreement with the center; (C) (i) Provides care to Medicaid beneficiaries and, if the facility provides medical care and treatment to children, to PeachCare for Kids beneficiaries and provides uncompensated indigent and charity care in an amount equal to or greater than 2 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department which shall be reviewed by the department every 12 months; or (ii) If the center is not a participant in Medicaid or the PeachCare for Kids Program, provides uncompensated care to Medicaid beneficiaries and, if the facility provides medical care and treatment to children, to PeachCare for Kids beneficiaries, uncompensated indigent and charity care, or both in an amount equal to or greater than 4 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department which shall be reviewed by the department every 12 months; provided, however, that single specialty ambulatory surgical centers owned by physicians in the practice of ophthalmology shall not be required to comply with this subparagraph; and (D) Provides annual reports in the same manner and in accordance with Code Section 31-6-70 . Noncompliance with any condition of this paragraph shall result in a monetary penalty in the amount of the difference between the services which the center is required to provide and the amount actually provided and may be subject to revocation of its exemption status by the department for repeated failure to pay any fines or moneys due to the department or for repeated failure to produce data as required by Code Section 31-6-70 after notice to the exemption holder and a fair hearing pursuant to Chapter 13 of Title 50, the "Georgia Administrative Procedure Act." The dollar amount specified in this paragraph shall be adjusted annually by an amount calculated by multiplying such dollar amount (as adjusted for the preceding year) by the annual percentage of change in the composite index of construction material prices, or its successor or appropriate replacement index, if any, published by the United States Department of Commerce for the preceding calendar year, commencing on July 1, 2009, and on each anniversary thereafter of publication of the index. The department shall immediately institute rule-making procedures to adopt such adjusted dollar amounts. In calculating the dollar amounts of a proposed project for purposes of this paragraph, the costs of all items subject to review by this chapter and items not subject to review by this chapter associated with and simultaneously developed or proposed with the project shall be counted, except for the expenditure or commitment of 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 sites; (19) Any joint venture ambulatory surgical center that: (A) Has capital expenditures associated with the construction, development, or other establishment of the clinical health service which do not exceed $5 million; (B) (i) Provides care to Medicaid beneficiaries and, if the facility provides medical care and treatment to children, to PeachCare for Kids beneficiaries and provides uncompensated indigent and charity care in an amount equal to or greater than 2 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department which shall be reviewed by the department every 12 months; or (ii) If the center is not a participant in Medicaid or the PeachCare for Kids Program, provides uncompensated care to Medicaid beneficiaries and, if the facility provides medical care and treatment to children, to PeachCare for Kids beneficiaries, uncompensated indigent and charity care, or both in an amount equal to or greater than 4 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department which shall be reviewed by the department every 12 months; and (C) Provides annual reports in the same manner and in accordance with Code Section 31-6-70 . Noncompliance with any condition of this paragraph shall result in a monetary penalty in the amount of the difference between the services which the center is required to provide and the amount actually provided and may be subject to revocation of its exemption status by the department for repeated failure to pay any fines or moneys due to the department or for repeated failure to produce data as required by Code Section 31-6-70 after notice to the exemption holder and a fair hearing pursuant to Chapter 13 of Title 50, the "Georgia Administrative Procedure Act." The dollar amount specified in this paragraph shall be adjusted annually by an amount calculated by multiplying such dollar amount (as adjusted for the preceding year) by the annual percentage of change in the composite index of construction material prices, or its successor or appropriate replacement index, if any, published by the United States Department of Commerce for the preceding calendar year, commencing on July 1, 2009, and on each anniversary thereafter of publication of the index. The department shall immediately institute rule-making procedures to adopt such adjusted dollar amounts. In calculating the dollar amounts of a proposed project for purposes of this paragraph, the costs of all items subject to review by this chapter and items not subject to review by this chapter associated with and simultaneously developed or proposed with the project shall be counted, except for the expenditure or commitment of 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 sites; (20) Expansion of services by an imaging center based on a population needs methodology taking into consideration whether the population residing in the area served by the imaging center has a need for expanded services, as determined by the department in accordance with its rules and regulations, if such imaging center: (A) Was in existence and operational in this state on January 1, 2008; (B) Is owned by a hospital or by a physician or a group of physicians comprising at least 80 percent ownership who are currently board certified in radiology; (C) Provides three or more diagnostic and other imaging services; (D) Accepts all patients regardless of ability to pay; and (E) Provides uncompensated indigent and charity care in an amount equal to or greater than the amount of such care provided by the geographically closest general acute care hospital; provided, however, that this paragraph shall not apply to an imaging center in a rural county; (21) Diagnostic cardiac catheterization in a hospital setting on patients 15 years of age and older; (22) Therapeutic cardiac catheterization in hospitals selected by the department prior to July 1, 2008, to participate in the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) Study and therapeutic cardiac catheterization in hospitals that, as determined by the department on an annual basis, meet the criteria to participate in the C-PORT Study but have not been selected for participation; provided, however, that if the criteria requires a transfer agreement with another hospital, no hospital shall unreasonably deny a transfer agreement with another hospital; (23) Infirmaries or 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 health care 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; (24) The relocation of any skilled nursing facility, intermediate care facility, or micro-hospital within the same county, any other health care facility in a rural county within the same county, and any other health care facility in an urban county within a five-mile radius of the existing facility so long as the facility does not propose to offer any new or expanded clinical health services at the new location; (25) Facilities which are 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 ; (26) Capital expenditures for a project otherwise requiring a certificate of need if those expenditures are for a project to remodel, renovate, replace, or any combination thereof, a medical-surgical hospital and: (A) That hospital: (i) Has a bed capacity of not more than 50 beds; (ii) Is located in a county in which no other medical-surgical hospital is located; (iii) Has at any time been designated as a disproportionate share hospital by the department; and (iv) Has at least 45 percent of its patient revenues derived from medicare, Medicaid, or any combination thereof, for the immediately preceding three years; and (B) That project: (i) Does not result in any of the following: (I) The offering of any new clinical health services; (II) Any increase in bed capacity; (III) Any redistribution of existing beds among existing clinical health services; or (IV) Any increase in capacity of existing clinical health services; (ii) Has at least 80 percent of its capital expenditures financed by the proceeds of a special purpose county sales and use tax imposed pursuant to Article 3 of Chapter 8 of Title 48; and (iii) Is located within a five-mile radius of and within the same county as the hospital's existing facility; (27) The renovation, remodeling, refurbishment, or upgrading of a health care facility, so long as the project does not result in any of the following: (A) The offering of any new or expanded clinical health services; (B) Any increase in inpatient bed capacity; or (C) Any redistribution of existing beds among existing clinical health services; (28) The acquisition of diagnostic, therapeutic, or other imaging equipment by or on behalf of: (A) A hospital; or (B) An individual private physician or single group practice of physicians exclusively for use on patients of such private physician or single group practice of physicians and such private physician or member of such single group practice of physicians is physically present at the practice location where the diagnostic or other imaging equipment is located at least 75 percent of the time that the equipment is in use; (29) Any capital expenditures by a hospital at such hospital's primary campus for: (A) The expansion or addition of the following clinical health services: operating rooms, other than dedicated outpatient operating rooms; medical-surgical services; gynecology; procedure rooms; intensive care; pharmaceutical services; pediatrics; cardiac care or other general hospital services; provided, however, that such expenditure does not include the expansion or addition of inpatient beds or the conversion of one type of inpatient bed to another type of inpatient bed; or (B) The movement of clinical health services from one location on the hospital's primary campus to another location on such hospital's primary campus; (30) New or expanded psychiatric or substance abuse inpatient programs or state funded beds that serve Medicaid and uninsured patients that: (A) Are open 365 days per year, seven days per week, and 24 hours per day; (B) Provide uncompensated indigent and charity care in an amount equal to or greater than 3 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department by rule which shall be at least 3 percent and which shall be reviewed by the department every 12 months; (C) Participate as providers of medical assistance for Medicaid purposes; (D) Have hospital affiliation agreements with acute care hospitals within a reasonable distance from the programs or state funded beds or the medical staffs at the programs or state funded beds have admitting privileges or other acceptable documented arrangements with such hospitals to ensure the necessary backup for the programs or state funded beds for medical complications. The programs or state funded beds shall have the capability to transfer a patient immediately to a hospital within a reasonable distance from the programs or state funded beds with adequate emergency room services. Acute care hospitals shall not unreasonably deny a transfer agreement or affiliation agreement with the programs or state funded beds; and (E) Provide annual reports in the same manner and in accordance with Code Section 31-6-70 ; (31) The offering of new or expanded basic perinatal services by a hospital in a rural county provided that: (A) Such services are available 365 days per year, seven days per week, and 24 hours per day; (B) The hospital participates as a provider of medical assistance for Medicaid purposes; (C) The hospital has a hospital affiliation agreement with an acute care hospital with at least Level III perinatal services within a reasonable distance from the hospital providing the perinatal services or the medical staff at the hospital providing the perinatal services has admitting privileges or other acceptable documented arrangements with such acute care hospital to ensure the necessary backup for the hospital providing the perinatal services for medical complications. The hospital providing the perinatal services shall have the capability to transfer a patient immediately to the acute care hospital within a reasonable distance from the hospital providing the perinatal services with adequate emergency room services. Acute care hospitals shall not unreasonably deny a transfer agreement or affiliation agreement with the hospital providing the perinatal services. This subparagraph shall not apply if the hospital providing the basic perinatal services is itself an acute care hospital with at least Level III perinatal services; and (D) Provides annual reports in the same manner and in accordance with Code Section 31-6-70 ; (31.1) Any new or expanded building or facility where human births occur on a regular and ongoing basis and which is classified as a birthing center by the department for purposes of Chapter 7 of this title, provided that: (A) Services are available 365 days per year, seven days per week, and 24 hours per day; (B) The birthing center participates as a provider of medical assistance for Medicaid purposes; (C) The birthing center has a hospital affiliation agreement with an acute care hospital with at least Level III perinatal services within a reasonable distance from the birthing center or the medical staff at the birthing center has admitting privileges or other acceptable documented arrangements with such acute care hospital to ensure the necessary backup for the birthing center for medical complications. The birthing center shall have the capability to transfer a patient immediately to the acute care hospital within a reasonable distance from the birthing center. Acute care hospitals shall not unreasonably deny a transfer agreement or affiliation agreement with the birthing center; (D) The birthing center: (i) Provides basic perinatal services, as defined by the department, which shall include but not be limited to a combination of such services as determined by the department; (ii) Meets the standards for certification established by the American Association of Birth Centers, or equivalent or higher standards as determined by the department; (iii) Schedules routine visits and visits with other appropriate providers, as necessary, and tracks patients to verify that services have been received; (iv) Prior to 20 weeks gestation, certifies that a patient has been deemed to be a low risk patient, as defined by the department for purposes of this paragraph; (v) Admits and provides services only to patients certified as low risk; and (vi) Refers patients to other appropriate providers if, at any point between the 20 weeks gestation certification and antepartum, the birthing center determines that a patient no longer qualifies as a low risk patient for any reason; and (E) The birthing center provides annual reports in the same manner and in accordance with Code Section 31-6-70 ; (32) A new general acute care hospital in a rural county that: (A) (i) Attains status as a teaching hospital within 36 months of opening, and maintains such status thereafter; or (ii) Obtains verification as a Level I, II, III, or IV trauma center from the American College of Surgeons within 36 months of opening, and maintains such verification thereafter; (B) Provides emergency, inpatient, and outpatient psychiatric and behavioral health services; (C) Has an emergency department that is open 365 days per year, seven days per week, and 24 hours per day; (D) Provides uncompensated indigent and charity care in an amount equal to or greater than 3 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department by rule which shall be no less than 3 percent and which shall be reviewed by the department every 12 months; (E) Participates as a provider of medical assistance for Medicaid purposes; and (F) Provides annual reports in the same manner and in accordance with Code Section 31-6-70 ; (33) A new acute care hospital where a short-stay general hospital in a rural county has been closed for more than 12 months and a new replacement hospital has not opened that: (A) Is located in the same rural county where the short-stay general hospital was closed; (B) Has no more than the number of licensed beds that were previously licensed in the closed hospital; (C) Has an emergency department that is open 365 days per year, seven days per week, and 24 hours per day; (D) Provides all required clinical health services as generally offered by a short-stay general hospital to meet licensure requirements; and (E) Provides uncompensated indigent and charity care in an amount equal to or greater than 3 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department by rule which shall be no less than 3 percent and which shall be reviewed by the department every 12 months. Such new acute care hospital may provide basic perinatal services; (34) (A) A new short-stay general hospital to address the underserved population previously served by a short-stay general hospital that was closed within the 48 months preceding the filing of a request for a letter of determination that: (i) Is located within a county with a population of more than 1 million according to the United States decennial census of 2020 or any future such census; (ii) Is located within five miles of and in the same county as the main campus of a medical school that is accredited by the Liaison Committee on Medical Education to confer Doctor of Medicine (M.D.) degrees; (iii) Has in place at the time of filing of a request for a letter of determination a written agreement to serve as a teaching hospital for students of the medical school described in division (ii) of this subparagraph; (iv) Has a maximum number of short-stay general hospital beds not greater than 50 percent of the maximum number of short-stay general hospital beds for which the closed short-stay general hospital had previously been licensed at any time during the 12 months prior to its closure; (v) Has an emergency department that is open 365 days per year, seven days per week, and 24 hours per day; and (vi) Provides uncompensated indigent and charity care in an amount equal to or greater than 3 percent of its adjusted gross revenue, and on and after January 1, 2026, in an amount equal to or greater than the minimum amount established by the department by rule which shall be no less than 3 percent and which shall be reviewed by the department every 12 months; (B) An exemption for a new short-stay general hospital under this paragraph shall include an exemption for all clinical services and equipment generally utilized at an acute care short-stay general hospital and required for licensure, including, but not limited to, an emergency department; Level II perinatal/neonatal services, including labor, delivery, recovery, and Level II neonatal intermediate care services; diagnostic imaging services; and surgical services; and (C) For a period of ten years following the issuance of its original license, a new short-stay general hospital approved for an exemption pursuant to this paragraph shall be entitled to one or more determinations from the department to add additional short-stay general hospital beds, so long as the total licensed capacity of such hospital does not exceed the maximum number of short-stay general hospital beds for which the closed short-stay general hospital had previously been licensed at any time during the 12 months prior to its closure; and (35) Transfer of existing beds from one general acute care hospital's primary campus to another general acute care hospital's primary campus within the same hospital system within a 15 mile radius of the original campus, provided that all of the following are satisfied: (A) Both hospitals involved in the transfer are general acute care hospitals and neither is a specialty hospital; (B) Both hospitals involved in the transfer are under common ownership or control; (C) The transferring hospital may not, for a period of 12 months after the transfer is effective, seek to expand the bed type which was transferred; and (D) The transferring hospital is open and operational at the time of transfer and shall not close within 12 months after the transfer is effective. (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.