07 LC
33 2114S
The
Senate Rules Committee offered the following substitute to HB 340:
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 49 of the Official Code of Georgia Annotated, relating to social
services, so as to provide certain eligibility requirements for Medicaid; to
provide for consideration of requiring copayments from Medicaid recipients; to
revise eligibility requirements for the PeachCare for Kids Program; to provide
for basic dental coverage under PeachCare; to provide for optional comprehensive
dental and vision coverage; to provide for certain copayments and premium
amounts; to provide for a policy for increased utilization of generic drugs by
participants in the program; to establish the PeachCare Extended Program; to
provide for eligibility, payment, enrollment, and other criteria of the extended
program; 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
49 of the Official Code of Georgia Annotated, relating to social services, is
amended by revising Code Section 49-4-142, relating to the state plan for
medical assistance, as follows:
"49-4-142.
(a)
The Department of Community Health established under Chapter 5A of Title 31 is
authorized to adopt and administer a state plan for medical assistance in
accordance with Title XIX of the federal Social Security Act, as amended (Act of
July 30, 1965, P.L. 89-97, 79 Stat. 343, as amended), provided such state plan
is administered within the appropriations made available to the department. The
department is authorized to establish the amount, duration, scope, and terms and
conditions of eligibility for and receipt of such medical assistance as it may
elect to authorize pursuant to this
article;
provided, however, that children from birth through 18 years of age in families
with family incomes below 125 percent of the federal poverty level shall be
eligible for the program. Further, the
department is authorized to establish such rules and regulations as may be
necessary or desirable in order to execute the state plan and to receive the
maximum amount of federal financial participation available in expenditures made
pursuant to the state plan; provided, however,
that
the department shall establish reasonable procedures for notice to interested
parties and an opportunity to be heard prior to the adoption, amendment, or
repeal of any such rule or regulation. The department is authorized to enter
into such reciprocal and cooperative arrangements with other states, persons,
and institutions, public and private, as it may deem necessary or desirable in
order to execute the state plan.
(b)
The department shall, not later than June 1, 1986, implement a modification of
the state plan for medical assistance or any affected rules or regulations of
the department, which modification will allow supplementation by relatives or
other persons for a private room or private sitter or both for a recipient of
medical assistance in a nursing home. The Department of Human Resources shall
likewise modify any affected rules and regulations of the Department of Human
Resources. The modification to the plan or to any affected rules and regulations
shall be effective unless and until federal authorities rule that such
modification is out of compliance with federal regulations. Such modification of
the state plan for medical assistance or rules and regulations:
(1)
Shall provide that a provider of nursing home services in either a skilled care
facility or an intermediate care facility shall be obligated to provide a
recipient of medical assistance only semiprivate accommodations which meet the
other requirements of appropriate regulations;
(2)
Shall provide that at no time can more than 10 percent of a skilled care or
intermediate care facility´s rooms be used for Medicaid recipients for whom
a private room supplementation has been made;
(3)
Shall provide that payments made by relatives or other persons to a provider of
medical assistance for the specific stated purpose of paying the additional
costs for a private room or private sitter or both for a recipient of medical
assistance in a skilled care facility or intermediate care facility shall not be
considered as income when determining the amount of patient liability toward
vendor payments; provided, however, that the department´s entitlement to
payments made by legally liable third parties shall not be diminished by this
modification of the state plan;
(4)
Shall provide that no provider of medical assistance shall discriminate against
a recipient of medical assistance who does not have a relative or other person
who is willing and able to provide supplementation; but the provision of a
private room or private sitter to a recipient when supplementation is provided
shall not constitute discrimination against other recipients;
(5)
Shall provide that no recipient who is transferred to or admitted to a private
room because of a shortage of beds in semiprivate rooms shall be discharged
because the recipient does not have a relative or other person who is willing
and able to provide supplementation; and
(6)
May provide that the rate charged by the provider of medical assistance to the
relative or other person providing supplementation for a private room for a
recipient shall not exceed the difference between the maximum rate charged by
the provider for a private room to or for a private pay patient and the amount
which the provider receives or will receive from the department as reimbursement
for otherwise providing for the recipient´s care in a semiprivate
room.
(c)
The department is authorized to establish drug application fees which shall be
equal to the department´s cost of investigating and determining whether a
new drug product should be included in the Controlled Medical Assistance Drug
List. Such fees shall be adjusted annually and shall be paid by the drug
manufacturers at the time of application.
(d)
The department shall give all due consideration to requiring copayments from
recipients of medical assistance under this article in accordance with
provisions of Title XIX of the federal Social Security Act of 1935, as amended,
and regulations promulgated pursuant
thereto."
SECTION
2.
Said
title is further amended by revising Code Section 49-5-273, relating to the
creation of PeachCare for Kids Program, as follows:
"49-5-273.
(a)
There is created the PeachCare for Kids Program to provide health care benefits
for children in families with income
below
235
between 125
and 200 percent of the federal poverty
level. Children from birth through 18 years of age in families with family
incomes
below
235
between 125
and 200 percent of the federal poverty
level and who are not eligible for medical assistance under Medicaid shall be
eligible for the program, to be administered by the department pursuant to
federal law and subject to availability of funding.
(b)
No entitlement to benefits for the children covered under the program or this
article shall be created by the program, nor shall this article or any rules or
regulations adopted pursuant to this article be interpreted to entitle any
person to receive any health services or insurance available under this program.
The program shall be established subject to the availability of funds
specifically appropriated by the General Assembly for this purpose and federal
matching funds as set forth in federal law. The department shall operate the
program consistent with administrative efficiency and the best interests of
children.
(c)(1)
The program shall offer substantially the same health care services available to
children under Georgia´s Medicaid plan, but coverage for such services
shall not be provided by an expansion of eligibility for medical assistance
under Medicaid. However, the program shall exclude nonemergency transportation
and targeted case management services. The department shall utilize appropriate
medical management and utilization control procedures necessary to manage care
effectively and shall prospectively limit enrollment in the program and modify
the health care services benefits when the department has reason to believe the
cost of such enrollment or services may exceed the availability of funding.
(2)
The program shall include vision and basic dental coverage, including
examinations, x-rays, preventive care, and restorative care; provided, however,
that comprehensive dental coverage shall be available to participants at a rate
negotiated between the department and the care management organization providing
health care services pursuant to this Code section, but not to exceed $15.00 per
participant per month. The comprehensive dental coverage shall be offered 60
days after the effective date of this Act.
(d)
The department may require copayments for services consistent with federal law;
provided, however, that no copayment shall be charged for preventive services
and no copayments
or
premiums shall be charged for any child
under six years of age.
The department
and the care management organization providing health care services pursuant to
this Code section shall be authorized to charge a copayment of $25.00 per visit
for emergency room visits. Preventive
services include but are not limited to medically necessary maintenance
medication and monitoring for chronic conditions such as asthma and
diabetes.
(e)
The department shall require payment of premiums for participation in the
program at a
rate of 1.5 percent of a participant´s family
income.
The
premiums shall not exceed the amounts permitted under Section 1916(b)(1) of the
Social Security Act or federal law.
(f)
The department may provide for presumptive eligibility for all applicant
children as allowed by federal law and in a manner consistent with the
provisions of this article.
(g)
The department shall provide for outreach for the purpose of enrolling children
in the program. Applications shall be accepted by mail or in person. All
necessary and appropriate steps shall be taken to achieve administrative cost
efficiency, reduce administrative barriers to application for and receipt of
services under the program, verify eligibility for the program and enforce
eligibility standards, and ensure that enrollment in the program does not
substitute for coverage under a group health insurance plan.
(h)
Any health care provider who is enrolled in the Medicaid program shall be deemed
to be enrolled in the program.
(i)
The department shall file a Title XXI plan to carry out the program with the
United States Department of Health and Human Services Centers for Medicare and
Medicaid Services. The department shall have the authority and flexibility to
make such decisions as are necessary to secure approval of that plan consistent
with this article. The department shall provide a copy of the plan to the
General Assembly. The department shall operate this program consistent with
federal law.
(j)
The department shall publish an annual report, a copy of which shall be provided
to the Governor, setting forth the number of participants in the program, the
health services provided, the amount of money paid to providers, and other
pertinent information with respect to the administration of the program. The
department shall not be required to distribute copies of the annual report to
the members of the General Assembly but shall notify the members of the
availability of the report in the manner which it deems to be most effective and
efficient.
(k)
All state agencies shall cooperate with the department and its designated agents
by providing requested information to assist in the administration of the
program.
(l)
The department, through the Department of Administrative Services or any other
appropriate entity, may contract for any or all of the following: the collection
of premiums, processing of applications, verification of eligibility, outreach,
data services, and evaluation, if such contracting achieves administrative or
service cost efficiency. The department, and other state agencies as
appropriate, shall provide necessary information to any entity which has
contracted with the department for services related to the administration of the
program upon request. For purposes of compliance with Code Section 34-8-125, a
request by any entity which has contracted with the department for services
related to the administration of the program shall be deemed to be a request by
a responsible official of the department and considered to be a request by the
department.
(m)
Nothing in this article shall be interpreted in a manner so as to preclude the
department from contracting with licensed health maintenance organizations (HMO)
or provider sponsored health care corporations (PSHCC) for coverage of program
services and eligible children; provided, however, that such contracts shall
require payment of premiums and copayments in a manner consistent with this
article. The department may require enrollment in a health maintenance
organization (HMO) or provider sponsored health care corporation (PSHCC) as a
condition of receiving coverage under the program.
(n)
The department shall develop a policy for increased utilization of generic drugs
by participants in the program and negotiate a reduced patient premium rate with
the care management organization providing health care services pursuant to this
Code section based on such policy. The requirements under this subsection shall
be completed no later than four months after the effective date of this
Act.
(n)(o)
The Department of Education and local boards of education shall cooperate with
and provide assistance to the department and its designated agents for the
purposes of identifying and enrolling eligible children in the
program.
(p)
Children in families with income between 200 and 235 percent of the federal
poverty level who were enrolled in the program on April 16, 2007, shall remain
enrolled in the program so long as eligibility requirements continue to be
met."
SECTION
3.
Said
title is further amended by adding a new Code section to read as
follows:
"49-5-274.
(a)
There is created the PeachCare Extended Program to provide health care benefits
for children in families with income between 200 and 250 percent of the federal
poverty level. Children from birth through 18 years of age in families with
family incomes between 200 and 250 percent of the federal poverty level and who
are not eligible for medical assistance under Medicaid shall be eligible for the
extended program, to be administered by the department pursuant to federal law
and subject to availability of funding.
(b)
Eligible recipients may purchase coverage under the extended program from the
care management organization managing the PeachCare for Kids Program. The cost
of such coverage shall not exceed 5 percent of the recipient´s family
income.
(c)
No entitlement to benefits for the children covered under the extended program
shall be created by such program, nor shall this article or any rules or
regulations adopted pursuant to this article be interpreted to entitle any
person to receive any health services or insurance available under this extended
program. No state or federal funds shall be used for the extended program. The
department shall operate the extended program consistent with administrative
efficiency and the best interests of children.
(d)
The extended program shall offer substantially the same health care services
available to children under Georgia´s Medicaid plan and under the PeachCare
for Kids Program, but coverage for such services shall not be provided by an
expansion of eligibility for medical assistance under Medicaid.
(e)
The department may require copayments for services consistent with federal law;
provided, however, that no copayment shall be charged for preventive services
and no copayments shall be charged for any child under six years of age.
Preventive services include but are not limited to medically necessary
maintenance medication and monitoring for chronic conditions such as asthma and
diabetes.
(f)
The department may provide for presumptive eligibility for all applicant
children as allowed by federal law and in a manner consistent with the
provisions of this article.
(g)
The department shall provide for outreach for the purpose of enrolling children
in the extended program. Applications shall be accepted by mail or in person.
All necessary and appropriate steps shall be taken to achieve administrative
cost efficiency, reduce administrative barriers to application for and receipt
of services under the extended program, verify eligibility for the extended
program and enforce eligibility standards, and ensure that enrollment in the
extended program does not substitute for coverage under a group health insurance
plan.
(h)
Any health care provider who is enrolled in the Medicaid program shall be deemed
to be enrolled in the extended program.
(i)
The department shall file a Title XXI plan to carry out the extended program
with the United States Department of Health and Human Services Centers for
Medicare and Medicaid Services. The department shall have the authority and
flexibility to make such decisions as are necessary to secure approval of that
plan consistent with this article. The department shall provide a copy of the
plan to the General Assembly. The department shall operate this extended
program consistent with federal law.
(j)
The department shall publish an annual report, a copy of which shall be provided
to the Governor, setting forth the number of participants in the extended
program, the health services provided, the amount of money paid to providers,
and other pertinent information with respect to the administration of the
extended program. The department shall not be required to distribute copies of
the annual report to the members of the General Assembly but shall notify the
members of the availability of the report in the manner which it deems to be
most effective and efficient.
(k)
All state agencies shall cooperate with the department and its designated agents
by providing requested information to assist in the administration of the
extended program.
(l)
The department, through the Department of Administrative Services or any other
appropriate entity, may contract for any or all of the following: the collection
of premiums, processing of applications, verification of eligibility, outreach,
data services, and evaluation, if such contracting achieves administrative or
service cost efficiency. The department, and other state agencies as
appropriate, shall provide necessary information to any entity which has
contracted with the department for services related to the administration of the
extended program upon request. For purposes of compliance with Code Section
34-8-125, a request by any entity which has contracted with the department for
services related to the administration of the extended program shall be deemed
to be a request by a responsible official of the department and considered to be
a request by the department.
(m)
Nothing in this article shall be interpreted in a manner so as to preclude the
department from contracting with licensed health maintenance organizations (HMO)
or provider sponsored health care corporations (PSHCC) for coverage of program
services and eligible children; provided, however, that such contracts shall
require payment of premiums and copayments in a manner consistent with this
article. The department may require enrollment in a health maintenance
organization (HMO) or provider sponsored health care corporation (PSHCC) as a
condition of receiving coverage under the extended program.
(n)
The Department of Education and local boards of education shall cooperate with
and provide assistance to the department and its designated agents for the
purposes of identifying and enrolling eligible children in the extended
program."
SECTION
4.
This
Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
SECTION
5.
All
laws and parts of laws in conflict with this Act are repealed.