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Georgia Departmentof Community HealthMedicaid Managed Care UpdatePresentation to: Medical Care Advisory Committee (MCAC)Marvis Butler, Director, CMO Provider ServicesGeorgia Departmentof Community Health0Date: November 13, 2013
Georgia Departmentof Community HealthMissionThe Georgia Department of CommunityH lthHealthWe will provide access to affordable, quality health caret GeorgianstoGiththroughh effectiveff ti planning,lipurchasingh iand oversight.We are dedicated to a healthy Georgia.Georgia Departmentof Community Health1
Georgia FamiliesEffective June 1, 2006, the state of Georgia implemented Georgia Families, amanaged care program through which health care services are delivered tomembers of Medicaid and PeachCare for Kids .A partnership between the Georgia Department of Community Health (DCH)and private Care Management Organizations (CMOs).(CMOs)Georgia Families members continue to receive the same benefits that areofferedff d withi h Medicaid/PeachCaredi id/hCffor Kidsid . Theh hhealthl h planslalsol offerffadditional benefits such as: Expanded access to health care services and providers ; Added member education on accessing care, referrals to specialists,member benefits and wellness education ; More efficient deliveryy of health care services and member careGeorgia Departmentof Community Health2
Administrative Simplification Process UpdateProvider Enrollment andCollaborative Credentialing ProcessEffective March 29,9, 2013,3, new pproviders are able to use the GeorgiagHealth Partnership Web Portal (https://www.mmis.georgia.gov) as asingle source system to complete:g Medicaid and CMO Applicationpp Joint Georgia Electronic process to upload credentialing documentsPhase I - Providers who do not currently have an active and validGeorgia Medicaid number. Includes: Facilities Professional providers Ancillary providersPhase II - Providers who do have a current active and valid GeorgiaMedicaid number, or who are applying for new/additional servicelocations, or who are scheduled for re-credentialing with the CMOs.Georgia Departmentof Community Health3
Administrative Simplification Process UpdateCentralized PA Portal ProcessEff ti JEffectiveJune 1, 2013 Georgia Medicaid Management Information Services (GAMMIS) WebPortal’s functionality was expanded to serve as the ‘centralized’ singlepoint of entry for all Georgia Prior Authorization (PA) requests. Medicaid providers who are participating with a Care ManagementOrganization (CMO) or Fee-for-service (FFS) can access one site tosubmit PA requests for enrolled members.Georgia Departmentof Community Health4
Administrative Simplification Process UpdateCentralized PA Portal ProcessPhaseDateAuthorization Services that should be submitted via the CentralizedPA Portal FunctionalityPhase1A6/1/2013 Newborn Deliveryy Notifications - all OB deliveries that will bePhase1B7/1/2013PhasePh2TBDsubmitted for claims payments to the CMOs.Pregnancy Notification - all pregnant members to ensure highrisk OB members are identified and get appropriate assistance andsupport.Inpatient Hospital Services (inc. In-State Transplants)Hospital Outpatient TherapyAmbulatory Surgery ServicesServicesSihandledh dl d bby CMO third-partythi dt vendorsd(d(dental,t l vision,i iradiology, etc.)Behavioral Health inpatientpor outpatientpPAsGeorgia Departmentof Community Health5
Centralized PA Portal ProcessThe Web submission rate for October 2013 was just under 78%.Review TypeTotalsNewborn ital Admission((Portal)o ta )20,623Hospital Admission(CMO)30,385Hospital Outpatient Therapy (Portal)2,959Hospital Outpatient Therapy (CMO)14,933TOTAL95,521Georgia Departmentof Community Health6
Network Access RequirementsSection 4.8.13 of Georgia Families Contract Geographic Access StandardsTypesUrbanRuralPrimary Care ProvidersTwo (2) withineight (8) milesTwo (2) withinfifteen (15) milesSpecialistsDental ProvidersDental Sub SpecialtyProvidersHospitalsMental Health ProvidersOne (1) within thirty (30)minutes orthirty (30) milesOne withinforty-fivefortyfive (45) minutes orforty-five (45) milesPharmaciesOne (1) twenty-four (24)y seven (7)hours a day,days a week within fifteen(15) minutes or fifteen(15) milesOne (1) twenty-four (24)hours a day,y seven (7) daysya week within fifteen (15)minutes or fifteen (15) milesGeorgia Departmentof Community Health7
CMO PCP Provider AccessBelow the Required 90% BenchmarkR iRegionAAmerigroupiPPeachh StateSW llCWellCareAtlantaBartow, Carroll, NewtonNewtonBartow, NewtonCentralHarris, Heard, Laurens,Macon, Marion, Muscogee,TaylorLaurens, TaylorLaurens, Taylor,TroupEastNo Deficient CountiesJeffersonBurke, ColumbiaNorthGordon, Jackson, Murray,WhitfieldGordon, Habersham,WhitfieldGordon, Habersham,Murray, WhitfieldSoutheastBulloch,, Charlton,,Effingham, McIntosh,Bryan,y , Bulloch,, Charlton,,Effingham, McIntosh,WareBulloch,, Camden,,Effingham,McIntosh, Screven,WareS hSouthwestBerrien,iClinch,Cli h Coffee,C ffColquitt, Lowndes,Seminole, Thomas, TiftCoffee,CffC l i Seminole,Colquitt,S i lThomas, TiftCoffee,CffC l iColquitt,Echols, Lowndes,Seminole, Thomas,TiftGeorgia Departmentof Community Health8
CMO Pediatrician Provider AccessB lBelowtheth RequiredRi d 90%%BBenchmarkhkRegionAmerigroupPeach StateWellCareAtlantaCoweta, NewtonCoweta, NewtonNewtonCentralLaurens, Talbot, TaylorLaurens, Taylor, TelfairLaurens, Talbot,Taylor,l TroupEastNo Deficient CountiesColumbia, Emanuel,JeffersonBurke, ColumbiaNorthGordon, MurrayCatoosa, Gordon,Murray, Walker, WhitfieldGordon, Murray,SoutheastBulloch, Charlton,Effingham, McIntosh,Bryan, Bulloch, Camden,Charlton, Effingham,Glynn, McIntosh, WareBulloch, Camden,Effingham,McIntosh, Screven,WareSouthwestCoffee, Decatur, Grady,Irwin, Lowndes, Mitchell,SeminoleClay, Clinch, Coffee,Colquitt, Lowndes,Seminole, ThomasCalhoun, Coffee,Colquitt, Echols,Lowndes,Seminole ThomasSeminole,Georgia Departmentof Community Health9
CMO Dental Provider AccessBelow the Required 90% BenchmarkRegionAmerigroupPeach StateWellCareAtlantaNo Deficient CountiesNo Deficient CountiesNo Deficient CountiesCentralNo Deficient CountiesNo Deficient CountiesNo Deficient CountiesEastNo Deficient CountiesNo Deficient CountiesBurke, ColumbiaNorthNo Deficient CountiesNo Deficient CountiesNo Deficient CountiesSoutheastNo Deficient CountiesCamden, CharltonNo Deficient CountiesSouthwestEarly, SeminoleNo Deficient CountiesNo Deficient CountiesGeorgia Departmentof Community Health10
TelemedicineTelemedicine allows CMO members in rural and underservedcommunities to receive ggreater access to specialtypy care. The CMOstelemedicine network allows patients in Georgia will have access to acomprehensive telemedicine network. Telemedicine reduces traveldistance All 3 CMOs are contracted with the Georgia Partnership forTelehealth. Network includes:– Nursing homes, school-based clinics, jails, clinics and emergencyrooms.rooms– 175 Specialists & health care providersGeorgia Departmentof Community Health11
CMOs Subcontractor Contact yAmerigroupAAvesisiS iScionI HIn-HouseI HIn-HouseNationalNilImaging Assoc.(NIA)Peach StateHealth maging lCareGeorgia Departmentof Community Health12
Care ManagementgOrganizationsgEffective February 2011 – all three CMOs are statewideAmerigroup1 800 454 37301-800-454-3730Georgia Departmentof Community HealthPeach State Health Plan1 866 874 06331-866-874-0633WellCare of Georgia1 866 300 11411-866-300-114113
DCH Provider ServicesMarvis R. ButlerDirector(404) 463-7495mabutler@dch.ga.govGeorgia FamiliesProvider ‘s Resolution Hotline1-888-943-5743404-651-8363 (Atlanta Area)helpdesk4georgiafamilies@dch.ga.govGeorgia Departmentof Community Health14
DCH Provider Services Marvis R. Butler Director (404) 463-7495 mabutler@dch.ga.gov Georgia Families Provider 's Resolution Hotline 1-888-943-5743 404-651-8363 (Atlanta Area) helpdesk4georgiafamilies@dch.ga.gov 14 Georgia Department of Community Health
