Senate Bill 507
In enacting SB 507, the General Assembly found that Georgia’s Medicaid-eligible children are not receiving the health care services to which they are entitled under the early periodic screening and diagnostic testing (EPSDT) provisions of the federal Medicaid Act. The Medicaid Act’s ESPDT provisions are designed to assure that all Medicaid-eligible children receive comprehensive and preventative health care to the fullest extent of possible Medicaid coverage. The “EPS” of EPSDT refers to “early and periodic screening” and the “DT” refers to vision, hearing, dental, and “other necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.” Children who are eligible for Medicaid are entitled to receive all classes of medical assistance authorized by the Medicaid Act whenever such a service or treatment is necessary to “correct or ameliorate” physical or mental illnesses or conditions identified by EPSDT providers during screenings. Under EPSDT, states do not have discretion to refuse to provide any such services to Medicaid-eligible children even though the state may not provide the prescribed services to any adults or specify them as part of the state Medicaid plan.
Prior to SB 507, the policies and procedures of the Department of Community Health (DCH), the state’s Medicaid agency, its Medicaid managed care contractors (CMOs), and its utilization review contractor have not differentiated between adults and children when determining whether services would be provided to Medicaid-eligible children. SB 507 requires that DCH and its contractors apply a single definition of medical necessity to services prescribed for children who are eligible for Medicaid. SB 507 also requires DCH and its contractors to streamline and expedite the process for approving therapy services and then spells out what information is to be included in the denial notice when DCH or its contractors have not approved the services that have been prescribed for the child.
Under SB 507, a treatment or service is to be considered medically necessary for Medicaid-eligible children if it is “prescribed by a physician or other practitioner to diagnose, correct or ameliorate defects, physical or mental illnesses, and health conditions, whether or not such services are in the state plan.” SB 507 further defines the key terms “correct or ameliorate” to mean “to improve or maintain a child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, prevent the development of additional health problems, or improve or maintain a child’s overall health, even if treatment or services will not cure the recipient’s overall health.”
Senate Bill 507 requires DCH to simplify any prior approval processes that are in use and requires any prior approval determinations to be made within 15 business days of the request for services. Under SB 507, DCH and its contractors are not permitted to make coverage decisions based solely upon criteria such as clinical guidelines and must waive any service restrictions when the service is prescribed by a practitioner to correct or ameliorate a condition, illness or defect of a Medicaid-eligible child.
In the event that DCH or its contractors denies a request for services for a Medicaid-eligible child, SB 507 requires that the denial notification include: 1) the exact treatment/services being denied; 2) any additional information needed from the child’s medical provider that could change the entity’s decision; and 3) the specific reason, including the facts relevant to the individual case, that the entity used to determine that the service is not medically necessary for that Medicaid-eligible child.
The EPSDT provisions of the Medicaid Act have existed in their current form since 1989. Nevertheless, as the General Assembly has found, the policies and procedures of DCH and its contractors have been impediments to children receiving the healthcare to which they are entitled under EPSDT. A lawsuit currently pending in federal court in Atlanta was filed to prevent DCH from applying its policies to reduce nursing services prescribed by the doctor of a Medicaid-eligible girl who is considered to be medically fragile. The child contends that DCH’s policies and procedures violate her right to receive health care services in accordance with EPSDT and that federal courts around the country and even the Georgia Court of Appeals have ruled consistently that state Medicaid agencies such as Georgia are required to provide health care services to Medicaid-eligible children in the manner stated in EPSDT provisions of the Medicaid Act. Recently, the judge in that case, after reviewing the existing law, issued an injunction to prevent DCH from denying an increase in nursing services that her doctor had prescribed for her, observing, “[i]t is quite surprising how broad the statute is and how little discretion the state agencies have in restricting Medicaid services to children.”
For additional information, contact:
Georgia Advocacy Office
150 E. Ponce de Leon Ave.
Decatur, GA 30030
(404) 885-1234 or (800) 537-2329 (voice and TTY)
(404) 378-0031 (fax)