08 LC 33
2648S
The
Senate Government Oversight Committee offered the following substitute to HB
1234:
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 requirements for participation by
dentists; to provide for claims to a responsible health organization; 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 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;
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)
'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.
(4)
'Emergency health care services' means health care services that are provided
for a condition of recent onset and sufficient severity, including, but not
limited to, severe pain, that would lead a prudent layperson, possessing an
average knowledge of medicine and health, to believe that his or her condition,
sickness, or injury is of such a nature that failure to obtain immediate medical
care could result in:
(A)
Placing the patient´s health in serious jeopardy;
(B)
Serious impairment to bodily functions; or
(C)
Serious dysfunction of any bodily organ or part.
(5)
'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.
(6)
'Health care services' has the same meaning as in paragraph (5) of Code Section
33-21-1.
(7)
'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.
(8)
'Hospital Statistical and Reimbursement Report' or 'HS&R report' means a
report created by a care management organization, using the same format that is
used by the Department of Community Health in completing HS&R reports, that
includes data related to an individual hospital, including aggregate statistics
and reimbursement data for all Medicaid recipients who are covered by the care
management organization and who received health care services at such hospital
during a specific fiscal year, including data regarding services that were
provided out of network. 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.
(9)
'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.
(10)
'Member' means a Medicaid or PeachCare for Kids recipient who is currently
enrolled in a care management organization plan.
(11)
'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.
(12)
'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.
(13)
'Responsible health organization' means the entity that a health care provider
reasonably identifies to be responsible for providing or arranging health care
services for a patient who is a Medicaid or PeachCare for Kids recipient after
the provider has properly conducted an eligibility verification in accordance
with the procedures of the Department of Community Health.
33-21A-3.
(a)
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 and all provisions relating to managed health care
plans, with the exception of Code Section 33-20A-9.1.
(b)
The Commissioner of Insurance shall not have the authority to approve,
disapprove, or set rates paid by the Department of Community Health to a care
management organization or paid by a care management organization to a health
care provider.
(c)
The Commissioner of Insurance shall not have the authority to approve,
disapprove, or modify any plan offered by a care management organization or any
contract between a care management organization and the Department of Community
Health.
(d)
Nothing in this chapter shall be interpreted as altering the authority of the
commissioner of community health.
33-21A-4.
(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)
In processing claims for emergency health care services, a care management
organization shall consider, at the time that a claim is submitted, at least the
following criteria:
(1)
The age of the patient;
(2)
The time and day of the week the patient presented for services;
(3)
The severity and nature of the presenting symptons;
(4)
The patient´s initial and final diagnosis; and
(5)
Any other criteria prescribed by the Department of Community Health, including
criteria specific to patients under 18 years of age.
A
care management organization shall configure or program its automated claims
processing system to consider at least the conditions and criteria described in
this subsection for claims presented for emergency health care services. The
Department of Community Health may develop and publish a list of additional
standards to be used by care management organizations to maximize the
identification and accurate payment of claims for emergency health care
services.
(c)
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 for such emergency
health care services and post-stabilization services at a rate equal to the rate
paid by the Department of Community Health for Medicaid claims that it
reimburses directly.
33-21A-5.
(a)
A critical access hospital must provide notice to a care management organization
and the Department of Community Health of any alleged breaches in its contract
by such care management organization.
(b)
If a critical access hospital satisfies the requirement of subsection (a) of
this Code section, and if the Department of Community Health concludes, after
notice and hearing, that a care management organization has substantively and
repeatedly breached a term of its contract with a critical access hospital, the
department is authorized to require the care management organization to pay
damages to the critical access hospital in an amount not to exceed three times
the amount owed. Notwithstanding the foregoing, nothing in this Code section
shall be interpreted to limit the authority of the Department of Community
Health to establish additional penalties or fines against a care management
organization for failure to comply with the contract between a care management
organization and the Department of Community Health.
33-21A-6.
(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 subject to approval by
the federal Centers for Medicare and Medicaid Services. 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-7.
(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 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A care management organization shall pay all interest
required to be paid under this provision or Code Section 33-24-59.5
automatically and simultaneously whenever payment is made for the claim giving
rise to the interest payment. All interest payments shall be accurately
identified on the associated remittance advice submitted by the care management
organization to the provider. A care management organization shall not be
responsible for the penalty described in this subsection if the health care
provider submits a claim containing a material omission or inaccuracy in any of
the data elements required for a complete standard health care claim form as
prescribed under 45 C.F.R. Part 162 for electronic claims, a CMS Form 1500 for
nonelectronic claims, or any claim prescribed by the Department of Community
Health.
(d)
Each care management organization shall maintain a website that allows providers
to submit, process, edit, rebill, and adjudicate claims electronically. To the
extent a provider has the capability, 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.
(h)
No health care provider shall, as a condition of contracting with a care
management organization, require that a care management organization contract
with or not contract with another health care provider. Any health care
provider which violates this subsection shall be subject to a penalty of
$1,000.00 per violation. Such penalty shall be collected by the Department of
Community Health. A health care provider shall not terminate an agreement with
a care management organization as a result of payment of such
penalties.
33-21A-8.
(a)
Except as provided in subsection (b) of this Code section, no care management
organization or agent of such care management organization shall deny any
dentist from participating in the Medicaid and PeachCare for Kids dental program
administered by such care management organization if:
(1)
Such dentist has obtained a license to practice in this state and is an enrolled
provider who has met all of the requirements of the Department of Community
Health for participation in the Medicaid and PeachCare for Kids program;
and
(2)(A)
The licensed dentist will provide dental services to members pursuant to a state
or federally funded educational loan forgiveness program that requires such
services; provided, however, each care management organization shall be required
to offer dentists wishing to participate through such loan forgiveness programs
the same contract terms offered to other dentists in the service region who
participate in the care management organization´s Medicaid and PeachCare
for Kids dental programs;
(B)
The geographic area in which the dentist intends to practice has been designated
as having a dental professional shortage as determined by the Department of
Community Health, which may be based on the designation of the Health Resources
and Services Administration of the United States Department of Health and Human
Services; or
(C)
Such care management organization fails to establish to the satisfaction of the
Department of Community Health that a sufficient number of general dentists and
specialists have contracted with the care management organization to provide
covered dental services to members in the geographic region.
(b)
A care management organization may decline to contract with a dentist who meets
the requirements of subsection (a) of this Code section if such dentist has had
his or her license to practice dentistry sanctioned in any manner or fails to
meet the credentialing criteria established by the care management organization.
Any dentist denied on this basis shall be entitled to a hearing before an
administrative law judge as set forth in subsection (e) of Code Section
49-4-153.
(c)
The Department of Community Health shall also provide a means for dentists to
request an annual hearing to determine whether a condition described in
subparagraph (B) or (C) of paragraph (2) of subsection (a) of this Code section
exists. The department may compel the attendance of care management
organizations or agents of care management organizations to attend such
hearings. The department may request additional information as a result of the
hearing, and it shall consider matters raised in the hearing when deciding
whether a condition described in subparagraph (A) or (B) of paragraph (2) of
subsection (a) of this Code section exists.
33-21A-9.
(a)
If a provider submits a claim to a responsible health organization for services
rendered within 72 hours after the provider verifies the eligibility of the
patient with that responsible health organization, the responsible health
organization shall reimburse the provider in an amount 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 resolving the
provider´s claim, if the responsible health organization made payment for a
patient for whom it was not responsible, then the responsible health
organization may pursue a cause of action against any person who was responsible
for payment of the services at the time they were provided but may not recover
any payment made to the provider.
(b)
If a provider verifies the eligibility of a patient as set forth in subsection
(a) of this Code section, and if a provider determines that a person other than
the responsible health organization to which it has submitted a claim is
responsible for Medicaid or PeachCare for Kids coverage of the patient at the
time the service was rendered, the provider may submit the claim to the person
that is responsible for Medicaid or PeachCare for Kids coverage and that person
shall reimburse all medically necessary services, without application of any
penalty for failure to file claims in a timely manner, for failure to obtain
prior authorization, or for the provider not being a participating provider in
the person´s network, and the amount of reimbursement shall be that
person´s applicable rate for the service if the provider is under contract
with that person or the rate paid by the Department of Community Health for the
same type of claim that it pays directly if the provider is not under contract
with that person.
33-21A-10.
(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-11.
Upon
request by a hospital provider related to a specific fiscal year, a care
management organization shall, within 30 days of the request, provide that
hospital with an HS&R report for the requested fiscal year. Any care
management organization which violates this Code section by not providing the
requested report within 30 days shall be subject to a penalty of $1,000.00 per
day, starting on the thirty-first day after the request and continuing until the
report is provided. It is the intent of the General Assembly that such penalty
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.
33-21A-12.
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."
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 dentist
acting pursuant to subsection (b) of Code Section 33-21A-8 or
a provider of medical assistance may
request a hearing on a decision of a care management organization with respect
to the
provisions set forth in subsection (b) of Code Section 33-21A-8 or 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 a
provider 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.