Georgia Medicaid Changes Cut Coverage for Low-Income Children Cost-cutting changes to Georgia Medicaid regulations that took effect between June 1 and Sept. 1 are putting low-income children and those with disabilities at risk. The state effort to save money has demanded extensive documentation from speech-language pathologists, yet has resulted in abnormally high denial rates. As a part of ... Policy Analysis
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Policy Analysis  |   October 01, 2006
Georgia Medicaid Changes Cut Coverage for Low-Income Children
Author Notes
  • Mark Kander, ASHA’s director of health care regulatory analysis, can be contacted at mkander@asha.org.
    Mark Kander, ASHA’s director of health care regulatory analysis, can be contacted at mkander@asha.org.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2006
Georgia Medicaid Changes Cut Coverage for Low-Income Children
The ASHA Leader, October 2006, Vol. 11, 1-26. doi:10.1044/leader.PA.11142006.1
The ASHA Leader, October 2006, Vol. 11, 1-26. doi:10.1044/leader.PA.11142006.1
Cost-cutting changes to Georgia Medicaid regulations that took effect between June 1 and Sept. 1 are putting low-income children and those with disabilities at risk. The state effort to save money has demanded extensive documentation from speech-language pathologists, yet has resulted in abnormally high denial rates.
As a part of this implementation, the state contracted with care management organizations (CMOs) to manage treatment for low-income children, effective June 1: All regions in the state were phased in by Sept. 1. Children who are blind or who have other disabilities were exempted from the CMO process, but the state has implemented a prior authorization process for them.
“The additional paperwork process for the blind and disabled Medicaid, combined with the CMO implementation for the low-income Medicaid further exacerbates the amount of extra administrative work required by providers,” said Jennifer McCullough, health care chair of the Georgia Speech-Language Hearing Association (GSHA).
To make matters worse, criteria that are being implemented by some of the CMOs’ medical management departments is similar to those used by commercial insurance companies in spite of federal Medicaid mandates and is causing needy children to be denied services. The CMOs will only approve treatment that is not considered a duplication of service in the schools.
“We are concerned that many of these denials are not meeting the federal Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) guidelines,” said Donna Davidson, president of Easter Seals North Georgia, and GHSA’s legislative chair.
If a child is eligible for services in the schools, then the private SLP must obtain a copy of their individualized education plan (IEP) and fax it to the CMO. Some CMOs also state that 3-year-olds are eligible for services through the school system and should first seek care there. McCullough noted this complication requires SLPs to obtain a letter saying a child-who is not attending the school-is not eligible for services.
According to Georgia’s Department of Community Health (DCH), the prior authorization process was created to detect fraudulent activities throughout the state. The process requires SLPs to predict what codes they will bill over a three-month time span and request in advance services totaling more than eight units per month. It means that SLPs must submit PAs for children who require speech-language treatment two times per week. DCH has contracted an outside company to review the paperwork being faxed to the state every three months to adhere to these guidelines.
SLPs face both delays and denials as they attempt to continue treatment plans. In addition even for children authorized for treatment, the providers face multiple delays for reimbursement. These problems come just one and one-half years after the speech and language treatment code (Current Procedural Terminology© 92507) reimbursement was cut in half. The drastic changes in the Georgia Medicaid program have caused some practices to close their doors, McCullough said.
Advocating for Children
ASHA has written to the Centers for Medicare and Medicaid Services regional administrator and to the Georgia Medicaid director. In the letter, ASHA President Alex Johnson noted that the EPSDT program under Medicaid requires the state to offer comprehensive health services to Medicaid-eligible children through age 20.
Johnson said it appears that numerous Georgia state-contracted CMO policies and practices contradict state Medicaid compliance with federal standards. “We believe that any short-term savings gained by the state of Georgia by allowing this low level of coverage will result in long-term costs to the state by children who do not perform well in school because of communication deficits,” he said.
GSHA representatives and parent advocates met with the governor’s staff in early September to discuss the problem. Members of the governor’s staff received ASHA’s letter and indicated that they would contact departments implementing these changes to discuss GSHA’s concerns. GSHA representatives and Georgia physical and occupational therapy representatives have met often with the DCH departments. A Healthcare for Kids Rally is planned Nov. 4 at the Georgia state Capitol.
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October 2006
Volume 11, Issue 14