08 LC 33
2414ER
Senate
Bill 507
By:
Senators Moody of the 56th, Carter of the 13th, Johnson of the 1st, Brown of the
26th, Butler of the 55th and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating
to public assistance, so as to establish requirements for basic therapy services
for children with disabilities detected under screening activities required by
federal law; to provide for legislative findings; to provide for definitions; to
assure similar treatments and services for categorically needy and medically
fragile children; to provide certain requirements relating to administrative
prior approval for services and appeals; 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:
SECTION
1.
Chapter
4 of Title 49 of the Official Code of Georgia Annotated, relating to public
assistance, is amended by adding a new article to read as follows:
"ARTICLE
7C
49-4-169.
The
General Assembly finds that changes in the approval process of certain health
care programs have made it difficult for children with disabilities who are
eligible for medical assistance pursuant to Article 7 of this chapter to
receive the services to which they are entitled with the frequency and within
the time periods which are appropriate. Separate administration of the
categorically needy and the medically fragile programs should not result in any
variation in the amount, duration, and scope of services. Redundant paperwork
requirements have hampered service approvals and delivery and reduced the number
of providers serving children. It is the intent of this article to ensure that
children with disabilities receive the medically necessary therapy services to
which they are entitled under the Medicaid Early Periodic Screening, Diagnostic,
and Treatment Program and that categorically needy and medically fragile
children have available to them the same scope, duration, and amount of
services. It is also the intent of this article to simplify the process and
paperwork by which occupational, speech, and physical therapy services are
applied for and received by eligible recipients.
49-4-169.1.
As
used in this article, the term:
(1)
'Basic therapy services' means occupational therapy, speech therapy, physical
therapy, or other services provided in the frequency specified in paragraph (2)
of subsection (a) of Code Section 49-4-169.3, without prior approval, pursuant
to the EPSDT Program to an eligible Medicaid beneficiary 21 years of age or
younger and which are recommended as medically necessary by a
physician.
(2)
'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.
(3)
'Department' means the Department of Community Health.
(4)
'EPSDT Program' means the federal Medicaid Early Periodic Screening, Diagnostic,
and Treatment Program contained at 42 U.S.C.A. Sections 1396a and
1396d.
(5)
'Medically necessary services' means services which are deemed necessary and
ordered by a physician pursuant to the EPSDT Program to diagnose or to correct
or ameliorate defects, physical and mental illnesses, and health conditions,
whether or not such services are covered under the state plan.
(6)
'Prior approval' means the process by which medically necessary services
provided at a frequency or interval above the minimum levels specified in Code
Section 49-4-169.3 for basic therapy services are authorized by the Department
of Community Health, its utilization review vendors, or its care management
organizations.
49-4-169.2.
All
persons who are 21 years of age or younger who are eligible for services under
the EPSDT Program shall receive basic therapy services without prior approval in
accordance with the provisions of this article, whether they are categorically
needy children enrolled in the low income Medicaid program or medically fragile
children enrolled in the aged, blind, and disabled Medicaid
program.
49-4-169.3.
(a)
The department shall develop and implement for itself, the care management
organizations with which it enters into contracts, and its utilization review
vendors consistent requirements, paperwork, and procedures for utilization
review and prior approval of physical occupational, or speech language
pathologist services prescribed for children. The following procedures and
criteria shall be used by the department, its utilization review vendors, and
its care management organizations for the processing of requests for prior
approval of such services:
(1)
Prior approval for services beyond basic therapy services, when permitted under
this article, shall be for a minimum of six months; provided, however, that to
the extent permitted under federal law and regulations, the department, care
management organizations with which it contracts, and its utilization review
vendors shall grant such prior approval for six months for beneficiaries with
congenital or chronic conditions and up to six months, as determined by a
beneficiary´s medical condition and needs, for a beneficiary with acute
conditions. In no event shall this distinction as to chronic, congenital, or
acute conditions result in variations as to scope, duration, or amount of
services available to all Medicaid eligible children either within or across
children categorically eligible for Medicaid or who are medically fragile;
and
(2)
Basic therapy services, if ordered by a physician, shall be permitted by the
department, the care management organizations with which it contracts, and its
utilization review vendors without prior approval at a frequency of 16 units of
service per month until such time as the beneficiary is no longer eligible for
Medicaid or such services are no longer medically necessary. The prescribing
physician shall reconfirm in writing the medical necessity of such services at
least once every six months. In the case of speech therapists, 16 units per
month shall mean eight units of untimed codes and 16 units of timed codes. The
physician prescribing services shall only prescribe such services as are
medically necessary, and nothing in this paragraph shall require such physician
to order or prescribe basic therapy services at the 16 unit frequency specified
in this paragraph.
(b)
The department, its utilization review vendors, or the care management
organizations with which it contracts shall give notice to affected Medicaid
recipients of the following information in cases where prior approval is
denied:
(1)
The medical procedure or service for which such entity is refusing to grant
prior approval;
(2)
Any additional information needed from the recipient´s medical provider
which could change the decision of such entity; and
(3)
The specific reason used by the entity to determine that the procedure is not
medically necessary to the Medicaid recipient, including facts pertinent to the
individual case.
(c)
Notwithstanding any other provision of law, the department, its utilization
review vendors, or its care management organizations shall grant prior approval
for requests for services in excess of basic therapy services when the recipient
is eligible for Medicaid services and the services prescribed are medically
necessary.
(d)
In cases where prior approval is required under this article, it shall be
decided with reasonable promptness, not to exceed 15 business days, and may not
be denied until it has been evaluated under the EPSDT Program.
(e)
Prescriptions and prior approval for services shall be for general areas of
treatment, treatment goals, or ranges of specific treatments or processing
codes and shall not be restricted to specific treatments or processing codes
for such treatments. Clinical coverage criteria or guidelines, including
restrictions such as location of service and prohibitions on multiple services
on the same day or at the same time, may not be used by the department, its
utilization vendors, or its care management organizations to limit the EPSDT
standards or its medically necessary definition in this article. Any such
restrictions shall be waived under the EPSDT Program or this article if the
prescribed services are medically necessary.
(f)
Nothing in this article shall be construed to prohibit the department, its
utilization review vendors, or its care management organizations from performing
utilization reviews of the diagnosis or treatment of a child receiving speech,
occupational, or physical therapy services pursuant to the EPSDT Program, the
amount, duration, or scope or the actual performance or delivery of such
services by providers, so long as such utilization review does not unreasonably
deny or unreasonably delay the provision of medically necessary services to the
recipient.
(g)
Nothing in this article shall be deemed to prohibit or restrict the department,
its utilization review vendors, or its care management organizations from
denying claims or prosecuting or pursuing beneficiaries or providers who submit
false or fraudulent prescriptions, forms required to implement this article, or
claims for services or whose eligibility as a beneficiary or a participating
provider has been based on intentionally false information."
SECTION
2.
This
Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.