Georgia

In Georgia:
  • 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.
As of 2012, 1,279,084 individuals were eligible for Georgia’s Health Check program (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Georgia achieved an EPSDT screening ratio of 67% and a participation ratio of 54%. 594,658 children received dental services of any kind, with 558,401 receiving preventive dental services.

Last updated February 2014.

 
Medical Necessity
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:

  • Number of live births,
  • Number of initial newborn visits within 24 hours of birth, and
  • Number of members that received an initial health visit and screening within 90 calendar days of enrollment

MCOs must establish internal tracking systems registering compliance with the state’s Health Check requirements. These systems must track:

  • Initial newborn Health Check visit occurring in the hospital;
  • Periodic and preventive/well child screens and visits as prescribed by the periodicity schedule;
  • Diagnostic and treatment services, including Referrals;
  • Immunizations, lead, tuberculosis and dental services; and
  • A reminder/notification system.
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.
Behavioral Health
Screening
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:
  • improve access to appropriate services;
  • employ health information technology to support data-driven, clinical decision-making;
  • reduce the unnecessary use of restrictive and costly services;
  • improve clinical and functional outcomes for children and youth with serious behavioral health needs; and
  • build resiliency in youth and families, strengthening their involvement both in their own care and in the design and implementation of the behavioral health care delivery system.
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.

Care Coordination
 
Oral Health
Primary care providers can bill (using code D1206) for applying fluoride varnish to a Medicaid-enrolled child.