Summary of Georgia’s Medicaid Care Management Organization (CMO) Law August 19, 2008 Robert D. Stone, Esq. Alston & Bird LLP 1201 West Peachtree Street Atlanta, Georgia

©Alston + Bird LLP Introduction & Background Brief History of Medicaid Managed Care in Georgia Basic Structure Provider Complaints Myers & Stauffer Report Development of CMO Bill

©Alston + Bird LLP Major Provisions General Effective Date [INSERT] Definition of CMO Every CMO must be an HMO Under Contract with DCH “Subject to” provisions HMO Law Managed Health Care Plans Role of Insurance Commissioner No authority to modify CMO contracts But - retains oversight of CMOs as HMOs and because CMO Law is part of Title 33 – Insurance Code

©Alston + Bird LLP Specific Payment/Coverage Provisions Payment of Emergency Services Specific criteria must be considered Out of network coverage rate equal to DCH rate Coverage of Newborns Coverage by Mother’s plan until discharged home Verification of Eligibility Procedures Services provided with 72 hours of verification

©Alston + Bird LLP Provider Enrollment –Dentists CMO may not deny participation to a licensed dentist who meets general enrollment requirements and who: Will provide services pursuant to a federally funded educational loan forgiveness program In area designated as “dental professional shortage area” CMO has opportunity to show it has sufficient coverage

©Alston + Bird LLP Information Technology Websites CMOs required to maintain websites with current, searchable list of providers Electronic Payments & Claim Adjudication CMOs required to maintain capability for electronic payment and claims adjudication Remittance advices must be provided within one business day of payment

©Alston + Bird LLP Additional Provisions Standardization of Timeframes Same timeframes as DCH for submissions, processing, payment and appeal Prohibition on Leveraging Contracts CMOs prohibited from requiring a provider to enter separate contract to enroll as Medicaid provider Providers prohibited from requiring CMO from entering into separate contract with a different provider Hospital Statistical & Reimbursement Reports (HS&R) CMOs must provide within 30 days of request

©Alston + Bird LLP Complaints and Appeals Special Remedies for Critical Access Hospitals A finding that CMO “substantively & repeatedly breached” contract may result in treble damages Arbitration Option Provider has option to seeks ALJ review or binding arbitration Costs of arbitration (except attorney’s fees) shared equally

©Alston + Bird LLP Complaints and Appeals Interest Applied to Underpayments Improperly denied or underpaid claims are subject to interest at 20% per annum Interest calculated from 15 days after claim submitted No interest if claim was inaccurate or had material omission Consolidation of Claims/Appeals Claims must involve “same or similar payment or coverage issues”

Summary of Georgia Medicaid Care Management Organization Law Georgia Hospital Association T Webinar August 19, 2008 Robert D. Stone, Esq. Alston & Bird LLP 1201 West Peachtree Street Atlanta, Georgia /