07 LC 33
2041S
The
House Committee on Health and Human Services offers the following
substitute
to HB 549:
to HB 549:
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 a modification to the
state plan for medical assistance regarding the rate of payment to providers of
medical assistance services; 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 subsection (c)
of Code Section 49-4-169 and pursuant to the EPSDT Program to an eligible
Medicaid or PeachCare for Kids beneficiary 21 years of age or younger and which
are prescribed and designated as medically necessary by a physician or other
health care provider working within the scope of his or her legal
authority.
(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.S. Sections 1396a and
1396d.
(4)
'Medically necessary services' means services which are deemed necessary by a
physician or other health care provider to correct or ameliorate defects and
physical and mental illnesses and conditions.
(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 a uniform form to be used by speech, occupational,
and physical therapists and all payers, utilization review agents, or other
entities for the low-income program and the aged, blind, and disabled programs
administered by the department or by any of its vendors, including care
management organizations, responsible for the EPSDT Program to document the
beneficiary´s patient care plan, the medical necessity for basic therapy
services, and prior approval of medically necessary services in addition to
basic therapy services, when required pursuant to this Code section. The form
shall:
(1)
Document that a patient care plan has been established and that basic therapy
services have been ordered and are medically necessary services as solely
determined and prescribed by the physician or other health care provider
authorized to make such determination;
(2)
Record the acknowledgement of the patient care plan and the order for services
by the occupational, speech, physical, or other therapist who will deliver the
services;
(3)
Provide a place for a request for services and a brief explanation of the need
for such services beyond basic therapy services; and
(4)
Be signed by a physician or other health care provider working within the scope
of his or her legal authority.
The
form shall not require documentation of other types of therapy services being
provided to the eligible beneficiary under other programs, including, but not
limited to, services provided by a local school system or those provided
pursuant to an individualized family service plan, nor shall the provision of
therapy services by a local school system or pursuant to an individualized
family service plan be used as the basis for denial of basic therapy services or
additional therapy services prescribed as provided in this Code
section.
(b)
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:
(1)
When required, prior approvals shall be approved or denied and notification of
approval or denial shall be made to the provider requesting prior approval
within ten working days;
(2)
Prior approval for services beyond basic therapy services shall be for a minimum
of six months;
(3)
In addition to any other services which are properly authorized, the beneficiary
shall be entitled to receive and make up any services missed or delayed pending
an appeal of a denial of services during a successive period of up to three
months after the date that an appeal is reversed; and
(4)
The department shall respond to appeals of a denial of prior approval for
services within 30 business days.
(c)
Once designated as basic therapy services, such services shall be provided at a
frequency of 20 units of service per month until such time as the beneficiary is
no longer medically eligible for Medicaid or for such services. In the case of
speech therapists, 20 units per month shall mean ten units of untimed codes and
20 units of timed codes.
(d)
Notwithstanding any other provision of law, the department shall grant prior
approval for requests for services when the recipient is eligible for Medicaid
services and the services requested are medically necessary services.
Prescriptions and prior approval for services shall be for general areas of
treatment or for treatment goals and not for specific treatments or processing
codes for such treatments.
(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.
49-4-169.1.
The
provisions of this article shall apply to children eligible for services under
the PeachCare for Kids Program created pursuant to Article 13 of Chapter 5 of
this title and the Georgia Medical Assistance Act of 1977 created pursuant to
Article 7 of this chapter."
SECTION
2.
Said
chapter is further amended in Code Section 49-4-142, relating to the
establishment of the Department of Community Health, by adding a new subsection
to read as follows:
"(b.1)
The department shall, not later than September 1, 2007, implement a modification
of the state plan for medical assistance or any affected rules or regulations of
the department, which modification shall provide that the rate of payment to
providers shall be sufficient to enlist enough providers so that services are
available to Medicaid or PeachCare for Kids beneficiaries under this title at
least to the extent that services are available to the general public. 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."
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.