- As of July 1, 2011, there were 1,548,090 beneficiaries enrolled in Georgia’s Medicaid program. Of these, 1,413,643 were enrolled in managed care. Managed care organizations (called Care Management Organizations in Georgia, or CMOs) are responsible for providing physical health, mental health, and substance abuse benefits to most Medicaid enrollees, including children.
- A Home and Community-Based Services waiver, the Georgia Pediatric Program, provides services to medically frail children whose needs cross systems.
Last updated February 2014.
The Georgia Code (at § 49-4-169.1) defines medically necessary services for children as “services or treatments that are prescribed by a physician or other licensed practitioner, and which, pursuant to the EPSDT Program, diagnose or correct or ameliorate defects, physical and mental illnesses, and health conditions, whether or not such services are in the state plan.”
It further specifies that “’Correct or ameliorate’ means to improve or maintain a child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, prevent the development of additional health problems, or improve or maintain a child’s overall health, even if treatment or services will not cure the recipient’s overall health.”
|Initiatives to Improve Access
Managed care organizations (MCOs) are required to provide primary care providers with a monthly list of Health Check eligible children who are not in compliance with the state’s periodicity schedule; the MCO or provider must then contact the child’s family to schedule an appointment.
MCOs are eligible for performance incentive payments based on the percentage of Health Check well-child visits and screens achieved above a minimum 80% threshold.
|Reporting & Data Collection||
Managed care organizations (MCOs) must select certain care elements to monitor in physician profiles; one possible element is preventive care, which includes Medicaid well-child visits.
MCO contracts also require the MCO to submit an EPSDT report that, at a minimum, lists:
MCOs must establish internal tracking systems registering compliance with the state’s Health Check requirements. These systems must track:
External Quality Review reports track several performance measures related to Health Check Services, including children’s access to primary care providers, well-child visits, and others.
Georgia requires that primary care providers performance developmental screenings for children at 9 months, 18 months, and 30 months. Providers must use standardized tools, though the Health Check handbook does not recommend particular screening tools.
Autism screenings are required at 18 months and 24 months and the state recommends the MCHAT screening tool
Alcohol and drug use assessments are required at all adolescent well visits, but standardized screening instruments are only required when a parent raises a concern.
CHIPRA Quality Demonstration
Georgia partnered with Maryland and Wyoming on a CMS CHIPRA Quality Demonstration Grant to implement a project called “Care Management Entities for Children With Serious Behavioral Health Needs.”
The grant will support the development of a Care Management Entity provider model to improve the service delivery to Medicaid and CHIP enrolled children with serious behavioral health disorders. Stated goals are to:
|Support to Providers and Families||
Georgia’s managed care plans are required to create Medicaid provider manuals that describe the Medicaid benefit for children and adolescents. Some have created dedicated Health Check provider handbooks to inform providers of the benefit.
Managed care plans also have Health Check websites to inform beneficiaries about the benefit.
||Primary care providers can bill (using code D1206) for applying fluoride varnish to a Medicaid-enrolled child.|