07 HB 549/AP
House
Bill 549 (AS PASSED HOUSE AND SENATE)
By:
Representative Burkhalter of the
50th
A
BILL TO BE ENTITLED
AN ACT
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 basic therapy services
for children with disabilities; to provide for legislative findings; to provide
for definitions; to provide certain requirements relating to administrative
prior approval for services and appeals; 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
7B
49-4-166.
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 and
Article 13 of Chapter 5 of this title to receive the services to which they are
entitled with the frequency and within the time periods which are appropriate.
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. 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.
49-4-167.
As
used in this article, the term:
(1)
'Basic therapy services' means occupational therapy, speech therapy, physical
therapy, or other services provided in the frequency specified in paragraph (2)
of subsection (a) of Code Section 49-4-169 and 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.
(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 those services provided under the EPSDT
Program such as screening services, vision services, dental services, hearing
services, and such other necessary health care, diagnostic services, treatment
and equipment, and other measures to treat defects and physical and mental
illnesses and conditions discovered by such screening services. Such services
shall be based upon generally accepted medical practices in light of conditions
at the time of treatment which are:
(A)
Appropriate and consistent with the diagnosis of the treating physician and the
omission of which could adversely affect the recipient´s medical condition
or the provision of which would correct or ameliorate the beneficiary´s
medical condition;
(B)
Compatible with the standards of acceptable medical practice in the United
States;
(C)
Provided in a safe, appropriate, and cost-effective setting, given the nature of
the diagnosis and the severity of the symptoms;
(D)
Not provided solely for the convenience of the recipient or the convenience of
the health care provider or hospital;
(E)
Not primarily custodial care unless custodial care is a covered service or
benefit under the recipient´s evidence of coverage; and
(F)
Services for which there are no other effective and more conservative or
substantially less costly treatments, services, and settings
available.
(5)
'Prior approval' means the process by which medically necessary services
provided at a frequency or interval above the minimum levels specified in Code
Section 49-4-169 for basic therapy services are authorized by the Department of
Community Health.
49-4-168.
All
persons who are 21 years of age or younger who are eligible for services under
the EPSDT Program shall receive basic therapy services without prior approval in
accordance with the provisions of this article.
49-4-169.
(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 of physical, occupational, or speech language pathologist services
prescribed for children under the EPSDT Program. The following procedures and
criteria shall be used by the department or an entity performing services for
the department for the processing of requests for prior approval of such
services:
(1)
Prior approval for services beyond basic therapy services, when required under
this article, shall be for a minimum of six months; provided, however, that to
the extent allowable under federal law and regulations, the department, care
management organizations with which it contracts, and its utilization review
vendors shall grant prior approval for six months for treatment or services
beyond basic therapy services for a minimum of six months for beneficiaries with
congenital or chronic conditions and up to six months for beneficiaries with
acute conditions; and
(2)
Basic therapy services shall be permitted at a frequency of 16 units of service
per month until such time as the beneficiary is no longer medically eligible for
Medicaid or such services are no longer medically necessary. The prescribing
physician shall reconfirm in writing the medical necessity of such services at
least once every six months. In the case of speech therapists, 16 units per
month shall mean eight units of untimed codes and 16 units of timed codes. The
physician prescribing services shall only prescribe such services as are
medically necessary, and nothing in this paragraph shall require such physician
to order or prescribe basic therapy services at the 16 unit frequency specified
in this paragraph.
(b)
Notwithstanding any other provision of law, the department shall grant prior
approval for requests for services in excess of basic therapy services when the
recipient is eligible for Medicaid services and the services requested are
medically necessary services.
(c)
Prescriptions and prior approval for services shall be for general areas of
treatment, treatment goals, or ranges of specific treatments or processing codes
and shall not be restricted to specific treatments or processing codes for such
treatments.
(d)
Nothing in this article shall be construed to prohibit the department or its
vendors and contractors from performing utilization reviews of the diagnosis of
a child receiving speech, occupational, or physical therapy services pursuant to
the EPSDT Program, the amount, duration, or scope, or the actual performance or
delivery of such services by properly licensed therapists, so long as such
utilization review does not unreasonably deny or unreasonably delay the
provision of medically necessary services to the recipient.
(e)
Nothing in this article shall be deemed to prohibit or restrict the department
from denying claims or prosecuting or pursuing beneficiaries or providers who
submit false or fraudulent prescriptions, forms specified in 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.