08 LC 37
0677S
House
Bill 1234 (COMMITTEE SUBSTITUTE)
By:
Representatives Channell of the
116th,
Cooper of the
41st,
Parrish of the
156th,
Stephens of the
164th,
Hugley of the
133rd,
and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 33 of the Official Code of Georgia Annotated, relating to insurance,
so as to enact the "Medicaid Care Management Organizations Act"; to provide that
care management organizations that contract with the Department of Community
Health to provide health care services for Medicaid and PeachCare for Kids
recipients meet certain requirements; to provide a short title; to provide for
definitions; to provide that care management organizations are subject to
certain laws relating to health maintenance organizations, managed health care
plans, and insurance generally; to provide requirements relating to
reimbursement for emergency health care services; to provide for requirements
relating to critical access hospitals; to provide for coverage for newborn
infants until discharged from the hospital; to provide for bundling of provider
complaints and appeals; to provide for binding arbitration; to provide for
interest payments on denied claims which are reversed; to require care
management organizations to maintain a website for the processing of claims and
to search for health care providers; to provide for standardized processing
times for claims; to prohibit care management organizations from requiring
health care providers to purchase or participate in other plans of the
organization as a condition; to provide for reimbursement for a health care
provider which complies with eligibility verification procedures; to provide for
enforcement by the Commissioner of Insurance; to require that the provisions of
this Act are included in new and renewal agreements with care management
organizations and health care providers; to provide for Hospital Statistical and
Reimbursement Reports from the Department of Community Health; to provide for
applicability; to provide for rules and regulations; to amend Code Section
49-4-153 of the Official Code of Georgia Annotated, relating to administrative
hearings and appeals relative to the Medicaid program, so as to provide that an
administrative law judge can consolidate complaints or claims against a care
management organization; 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.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by adding a new chapter to read as follows:
"CHAPTER
21A
33-21A-1.
This
chapter shall be known and may be cited as the 'Medicaid Care Management
Organizations Act.'
33-21A-2.
As
used in this chapter, the term:
(1)
'Care management organization' means an entity that is organized for the purpose
of providing or arranging health care, which has been granted a certificate of
authority by the Commissioner of Insurance as a health maintenance organization
pursuant to Chapter 21 of this title, and which has entered into a contract with
the Department of Community Health to provide or arrange health care services on
a prepaid, capitated basis to members.
(2)
'Coordination of care' means early identification of members who have or may
have special needs; assessment of a member´s risk factors; development of a
plan of care; referrals and assistance to ensure timely access to providers;
coordination of care actively linking the member to providers, medical services,
and residential, social, and other support services where needed; monitoring;
continuity of care; and follow-up and documentation, all as further described
pursuant to the terms of the contracts between the Department of Community
Health and the care management organizations.
(3)
'CPT Code' means the certain coding reference established by the American
Medical Association and more fully known as 'Current Procedural Terminology,'
which is a generally accepted listing of descriptive terms and identifying codes
for reporting medical services and procedures performed by physicians, which
codes reflect not only the components of the treatment provided but also the
complexity of medical decision making, and which is utilized by the Department
of Community Health as its coding system for purposes of Medicaid and PeachCare
for Kids; provided, however, that nothing in this chapter shall prohibit the
Department of Community Health from adopting and utilizing another system of
coding.
(4)
'Critical access hospital' means a hospital that meets the requirements of the
federal Centers for Medicare and Medicaid Services to be designated as a
critical access hospital and that is recognized by the Department of Community
Health as a critical access hospital for purposes of Medicaid.
(5)
'Emergency health care services' means health care services provided for
treatment of an emergency medical condition, including those health care
services which are coded CPT Code 99283, 99284, or 99285 and may include those
health care services which are coded CPT Code 99281 or 99282, as determined on a
case-by-case basis.
(6)
'Health care provider' or 'provider' means any person, partnership, professional
association, corporation, facility, or institution certified, licensed, or
registered by the State of Georgia that has contracted with a care management
organization to provide health care services to members.
(7)
'Health care services' has the same meaning as in paragraph (5) of Code Section
33-21-1.
(8)
'Health maintenance organization' means an entity which has been issued a
certificate of authority by the Commissioner of Insurance pursuant to Chapter 21
of this title to establish and operate a health maintenance
organization.
(9)
'Hospital Statistical and Reimbursement Report' or 'HS&R report' means a
consolidated report created by the Department of Community Health that includes
data related to an individual hospital, including aggregate statistics and
reimbursement data for all Medicaid recipients who received health care services
at such hospital during a specific fiscal year, including data for Medicaid
recipients for whom the Department of Community Health reimburses directly, data
for all care management organization members, and data regarding services
provided for out-of-network care management organization patients. HS&R
reports are utilized by the Department of Community Health for purposes of the
Indigent Care Trust Fund´s disproportionate share hospital survey and are
also utilized by hospitals to claim payments under Medicare´s
disproportionate share hospital program.
(10)
'Medicaid' means the joint federal and state program of medical assistance
established by Title XIX of the federal Social Security Act, which is
administered in this state by the Department of Community Health pursuant to
Article 7 of Chapter 4 of Title 49.
(11)
'Member' means a Medicaid or PeachCare for Kids recipient who is currently
enrolled in a care management organization plan.
(12)
'PeachCare for Kids' means the State of Georgia´s State Children´s
Health Insurance Program established pursuant to Title XXI of the federal Social
Security Act, which is administered in this state by the Department of Community
Health pursuant to Article 13 of Chapter 5 of Title 49.
(13)
'Post-stabilization services' means covered services related to an emergency
medical condition that are provided after a member is stabilized in order to
maintain the stabilized condition or to improve or resolve the member´s
condition.
(14)
'Prudent layperson standard' means the standard defined in Section 1932(b)(2) of
the federal Social Security Act.
33-21A-3.
A
care management organization shall be required to obtain a certificate of
authority as a health maintenance organization pursuant to Chapter 21 of this
title prior to providing or arranging health care for members pursuant to a
contract with the Department of Community Health. On and after the date of
issuance of its certificate of authority as a health maintenance organization, a
care management organization shall comply with all provisions relating to health
maintenance organizations, including, but not limited to, Chapter 21 of this
title and all regulations established pursuant to such chapter.
33-21A-4.
On
and after the date of issuance of its certificate of authority as a health
maintenance organization, a care management organization shall comply with all
provisions relating to managed health care plans, including, but not limited to,
Chapter 20A of this title, with the exception of Code Section 33-20A-9.1, and
all regulations established pursuant to such chapter, except those established
pursuant to Code Section 33-20A-9.1.
33-21A-5.
On
and after the date of issuance of its certificate of authority as a health
maintenance organization, a care management organization shall comply with all
applicable provisions of Chapter 24 of this title and all applicable regulations
established pursuant to such chapter, including but not limited to Code
Section 33-24-59.5.
33-21A-6.
(a)
In particular, but without limitation, a care management organization shall not:
(1)
Deny or inappropriately reduce payment to a provider of emergency health care
services for any evaluation, diagnostic testing, or treatment provided to a
recipient of medical assistance for an emergency condition; or
(2)
Make payment for emergency health care services contingent on the recipient or
provider of emergency health care services providing any notification, either
before or after receiving emergency health care services.
(b)
Unless the care management organization or the Department of Community Health
has reason to believe that a provider is upcoding or engaging in activity
violating program integrity, each claim for payment submitted by a provider of
emergency health care services to a care management organization which is coded
CPT Code 99283, 99284, or 99285, or subsequent codes representing equivalent
health care services or procedures adopted for use by the Department of
Community Health, and any facility or ambulatory payment classification claim
submitted by a facility for services provided in conjunction with a physician
service which is coded CPT Code 99283, 99284, or 99285 shall be regarded by the
care management organization as treatment of an emergency condition and shall be
paid by the care management organization at the applicable emergency services
rate regardless of any prior authorization requirements. All claims payment
systems used by any care management organization shall be programmed to identify
and pay claims with these CPT Codes as emergency health care services
claims.
(c)
Each claim for payment submitted by a provider of emergency health care services
to a care management organization which is coded CPT Code 99281 or 99282, or
subsequent codes representing equivalent health care services or procedures
adopted for use by the Department of Community Health, shall be evaluated on a
case-by-case basis to determine whether such claim should be regarded by the
care management organization as treatment of an emergency condition. Such
evaluation shall be based on all pertinent documentation, shall be focused on
the patient´s presenting symptoms and not on the final diagnosis, and shall
be made in accordance with the prudent layperson standard. If it is determined
under that standard that the services provided constituted treatment of an
emergency medical condition, then the care management organization shall pay for
the services at the applicable emergency services rate, regardless of any prior
authorization requirements.
(d)
If a provider that has not entered into a contract with a care management
organization provides emergency health care services or post-stabilization
services to that care management organization´s member, the care management
organization shall reimburse the noncontracted provider at a rate equal to the
rate paid by the Department of Community Health for Medicaid claims that it
reimburses directly.
(e)
Any care management organization which violates this Code section shall be
subject to a penalty of $1,000.00 per violation. Such penalty shall be
collected by the Department of Community Health and deposited into the Indigent
Care Trust Fund created pursuant to Code Section 31-8-152. A care management
organization shall not reduce the funding available for health care services for
members as a result of payment of such penalties.
(f)
The provisions of this Code section shall apply to emergency health care
services provided to members by providers, and every care management
organization shall be required to pay for emergency health care services that
meet the prudent layperson standard.
33-21A-6.1.
(a)
Each care management organization shall include, through contract, all critical
access hospitals that are in its service region as providers.
(b)
Each care management organization shall reimburse critical access hospitals a
payment rate based on the most recent available critical access hospital
Medicare cost report to prospectively determine and set forth inpatient and
outpatient rates for each year. The care management organization shall conduct
an annual end-of-year cost report reconciliation process followed by a
corresponding annual settlement transaction to ensure each critical access
hospital is reimbursed all allowable costs, in accordance with the Department of
Community Health´s established Medicaid policies and procedures.
33-21A-7.
(a)
Each care management organization shall pay for health care services provided to
a newborn infant who is born to a mother who is a member currently enrolled with
that care management organization until such time as the newborn is finally
discharged from all inpatient care to a home environment. For a newborn infant
whose mother is enrolled in a Medicaid program under which she receives Medicaid
benefits directly from the Department of Community Health, the Department of
Community Health shall pay for health care services provided to the newborn
until such time as the newborn is finally discharged from all inpatient care to
a home environment.
(b)
In the event a newborn is disenrolled from a care management organization and
re-enrolled into the Medicaid fee-for-service program conducted directly by the
Department of Community Health, the care management organization shall ensure
the coordination of care for that child until the child has been appropriately
discharged from the hospital and placed in an appropriate care
setting.
33-21A-8.
(a)
In reviewing provider complaints or appeals related to denial of claims, a care
management organization shall allow providers to consolidate complaints or
appeals of multiple claims that involve the same or similar payment or coverage
issues, regardless of the number of individual patients or payment claims
included in the bundled complaint or appeal.
(b)
Each care management organization shall allow a provider that has exhausted the
care management organization´s internal appeals process related to a denied
or underpaid claim or group of claims bundled for appeal the option either to
pursue the administrative review process described in subsection (e) of Code
Section 49-4-153 or to select binding arbitration by a private arbitrator who is
certified by a nationally recognized association that provides training and
certification in alternative dispute resolution. If the care management
organization and the provider are unable to agree on an association, the rules
of the American Arbitration Association shall apply. The arbitrator shall have
experience and expertise in the health care field and shall be selected
according to the rules of his or her certifying association. Arbitration
conducted pursuant to this Code section shall be binding on the parties. The
arbitrator shall conduct a hearing and issue a final ruling within 90 days of
being selected, unless the care management organization and the provider
mutually agree to extend this deadline. All costs of arbitration, not including
attorney´s fees, shall be shared equally by the parties.
(c)
For all claims that are initially denied or underpaid by a care management
organization but eventually determined or agreed to have been owed by the care
management organization to a provider of health care services, the care
management organization shall pay, in addition to the amount determined to be
owed, interest of 18 percent per annum, calculated from the date the claim was
submitted. However, denial or underpayment due to omission or error by the
provider shall not require the care management organization to incur this
penalty.
(d)
Each care management organization shall maintain a website that allows providers
to submit, process, edit, rebill, and adjudicate claims electronically. Each
care management organization shall submit payments to providers electronically
and submit remittance advices to providers electronically within one business
day of when payment is made. To the extent that any of these functions involve
covered transactions under 45 C.F.R. Section 162.900, et seq., then those
transactions also shall be conducted in accordance with applicable federal
requirements.
(e)
Each care management organization shall post on its website a searchable list of
all providers with which the care management organization has contracted. At a
minimum, this list shall be searchable by provider name, specialty, and
location. At a minimum, the list shall be updated once each month.
(f)
The Department of Community Health shall require each care management
organization to utilize the same timeframes and deadlines for submission,
processing, payment, denial, adjudication, and appeal of Medicaid claims as the
timeframes and deadlines that the Department of Community Health uses on claims
it pays directly.
(g)
No care management organization shall, as a condition of contracting with a
provider, require that provider to participate or accept other plans or products
offered by the care management organization unrelated to providing care to
members. Any care management organization which violates this prohibition shall
be subject to a penalty of $1,000.00 per violation. Such penalty shall be
collected by the Department of Community Health. A care management organization
shall not reduce the funding available for members as a result of payment of
such penalties.
33-21A-9.
If
a provider complies with the published procedures, whether published
electronically or in print, of the Department of Community Health for verifying
a patient´s eligibility for Medicaid benefits, the Department of Community
Health shall reimburse that provider for all covered health care services the
provider provides to the patient during the 72 hours after obtaining
verification of enrollment if such services are denied, either initially or
after review, by a care management organization or by the Department of
Community Health, because the patient was not enrolled as indicated through the
eligibility verification process. The amount of reimbursement to the provider
shall be equal to the amount to which the provider would have been entitled if
the patient had been enrolled as shown in the eligibility verification process.
After reimbursing the provider, the Department of Community Health may pursue a
cause of action against any person whose conduct or inaction contributed to the
incorrect verification of enrollment, including but not limited to the fiscal
agent of the Department of Community Health or any care management
organization.
33-21A-10.
The
Commissioner of Insurance shall revoke or suspend the health maintenance
organization certificate of authority issued to a care management organization
or in lieu thereof impose a monetary penalty in accordance with Chapter 2 of
this title if the Commissioner determines that such care management organization
no longer meets the applicable requirements for such certificate of authority or
violates any provision of this chapter or other applicable laws. Before
imposing any such sanction, the Commissioner shall provide the care management
organization with notice and opportunity for a hearing on the proposed
sanctions. Nothing in this Code section shall be construed as precluding or
limiting the Commissioner´s authority under other Code sections, including
but not limited to the authority granted in Code Section 33-21-5, or as
precluding any other remedies at law, including but not limited to remedies
available to the Department of Community Health under its contract with a care
management organization or remedies available to the Commissioner of the
Department of Human Resources.
33-21A-11.
(1)
On and after the effective date of this chapter, the Department of Community
Health shall include provisions in all new or renewal agreements with a care
management organization, which require the care management organization to
comply with all provisions of this chapter.
(2)
On and after the effective date of this chapter, a care management organization
shall not include any provisions in new or renewal agreements with providers
entered into pursuant to the contract between the Department of Community Health
and the care management organization, which are inconsistent with the provisions
of this chapter.
33-21A-12.
Upon
request by a hospital provider related to a specific fiscal year, the Department
of Community Health shall, within 30 days of the request, provide that hospital
with an HS&R report for the requested fiscal year.
33-21A-13.
To
the extent any provision in this chapter is inconsistent with applicable federal
law, rule, or regulation, the applicable federal law, rule, or regulation shall
govern.
33-21A-14.
The
Commissioner of Insurance and the Department of Community Health, as
appropriate, shall be authorized to adopt rules and regulations to effect the
implementation of this chapter."
SECTION
2.
Code
Section 49-4-153 of the Official Code of Georgia Annotated, relating to
administrative hearings and appeals relative to the Medicaid program, is amended
by revising paragraph (1) of subsection (e) as follows:
"(1)
A provider of medical assistance may request a hearing on a decision of a care
management organization with respect to a denial or nonpayment of or the
determination of the amount of reimbursement paid or payable to such provider on
a certain item of medical or remedial care of service rendered by such provider
by filing a written request for a hearing in accordance with Code Sections
50-13-13 and 50-13-15 with the Department of Community Health. The Department
of Community Health shall, within 15 business days of receiving the request for
hearing from the provider, transmit a copy of the provider´s request for
hearing to the Office of State Administrative
Hearings,
but shall not be a party to the proceedings. The provider´s request for
hearing shall identify the care management organization with which the provider
has a dispute, the issues under appeal, and specify the relief requested by the
provider. The request for hearing shall be filed no later than 15 business days
after the provider of medical assistance receives the decision of the care
management organization which is the basis for the appeal.
Notwithstanding
any other provision of this title, an administrative law judge appointed
pursuant to paragraph (2) of this subsection shall be authorized to allow
providers of medical assistance to consolidate pending complaints or claims
against a care management organization that are based on the same or similar
payment or coverage issues, as determined by such administrative law judge.
Such consolidation shall include disposition of the same or similar claims
through a single hearing that adjudicates the total amount of such consolidated
claims."
SECTION
3.
This
Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
SECTION
4.
All
laws and parts of laws in conflict with this Act are repealed.