08
SB507/AP
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
AS
PASSED
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 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 statutory construction;
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)
'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.
(2)
'Department' means the Department of Community Health.
(3)
'EPSDT Program' means the federal Medicaid Early Periodic Screening, Diagnostic,
and Treatment Program contained at 42 U.S.C.A. Sections 1396a and
1396d.
(4)
'Medically necessary services' means 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.
(5)
'Therapy services' means occupational therapy, speech therapy, physical
therapy, or other services provided 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.
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 therapy services 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. Prior approval for therapy
services shall be for a period of up to six months as consistent with the needs
of the individual recipient.
(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 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. 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, shall not be the sole determinant 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 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.