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Georgia Departmentof ofCommunityHealth:AnnualReportFY Y 2013Table of ContentsIntroduction. 3DCH At-a-Glance. 4Division Highlights. 5Accomplishments. 6Medicaid.7-10State Health Benefit Plan . 11-13Healthcare Facility Regulation. 14Health Information Technology. 15Communications. 16Financial Management. 17Office of General Counsel. 18Information Technology. 19Office of Inspector General. 20Legislative & External Affairs. 21Operations. 22Attached Agencies. 23Appendix. 242
Georgia Department of Community Health: Annual Report FY 2013IntroductionThe Big Health Care PictureIn Fiscal Year 2012 (FY 12), the federal government passed the PatientProtection and Affordable Care Act (ACA), and the Supreme Courtupheld its legality. The Governor and lawmakers had to decide how orwhether they were going to implement the act. During FY 13, Georgia’sgovernor made the decision not to expand Medicaid and to use theresources of the Federal Health Exchange to direct Medicaid-eligiblecitizens to its programs and services instead. However, DCH’s Medicaidenrollment was expected to increase, because of daily coverage of ACAin the media.In addition, DCH’s Medicaid Division planned for the procurementand implementation of an Integrated Eligibility System (IES) and theHealthcare Facility Regulation Division planned and developed a systemfor electronically capturing and disseminating healthcare facility Plans ofCorrection. Health IT launched Georgia ConnectedCare, an innovativeGaHIN technology solution that offered health care providers the abilityto securely find a patient’s complete health record directly through theirrespective EHR system. DCH’s offices continued to support the mission,vision and goals of the Department.The DCH Annual Report for FY 13 describes the Department, givespertinent figures and chronicles the greatest accomplishments of thedivisions and offices.3
Georgia Department of Community Health: Annual Report FY 2013DCH At-a-GlanceDCH OrganizationIn FY 13, DCH was composed of four divisions, seven support offices and twoattached agencies.Georgia Department of Community HealthBoard of Community HealthExecutive AssistantDCH BoardDCH is governed by the Board of Community Health.The board is composed of nine people who havepolicymaking authority for the Department. The board isappointed by the Governor and confirmed by the StateSenate. The board meets monthly. The members servingat the end of FY 13 were: Norm Boyd, ChairmanGovernorGeorgia Board forPhysician WorkforceGeorgia CompositeMedical BoardCommissionerGeorgia Drugs andNarcoticsAgencyHealthcare FacilityRegulationMedical AssistancePlansOffice of HealthInformation TechnologyState Health BenefitPlan William H. Wallace Jr., Vice Chair Jamie Pennington, Secretary Clay Cox Donna MosesJack Chapman, MD Kiera L. Von Besser Richard Jackson Mimi Collins4Information TechnologyFinancialManagementGeorgia State Boardof PharmacyGeneral CounselCommunications andLegislative AffairsGeorgia Board ofDentistryDCH MissionWe are dedicated to A Healthy Georgia.Executive OfficesInspector GeneralProgramsAdmin OfficesAttached Agencies
Georgia Department of Community Health: Annual Report FY 2013AccomplishmentsFY 2013 Department of Community Health ExpendituresLow-Income Medicaid26.5%State Health Benefit Plan Payments22.4%Aged, Blind, & Disabled Medicaid41.0%Healthcare Facility Regulation0.1%Healthcare Access & Improvement0.2%Indigent Care Trust Fund3.5%PeachCare for Kids2.9%Administration0.6%Medical Education & Licensing0.4%5Systems Support1.0%Medicaid & PeachCare for KidsProgram Support1.3%
AccomplishmentsGeorgia Department of Community Health: Annual Report FY 2013FY 2013 Table of Members and ExpendituresMedicaidMeasuresMedicaid: Aged, Blind,and Disabled (ABD)Medicaid: Low-IncomeMedicaid (LIM)Medicaid: TotalAverage Members*PeachCare for Kids 468,4131,119,6611,588,074218,139Number of Providers**67,08383,17190,03939,173Number of Claims Paid25,606,88923,106,63648,713,5253,505,804 4,668,342,097 590,374,651 5,258,716,748 24,291,812 30,598,925 2,758,455,678 2,789,054,603 368,905,318 4,698,941,022 3,348,830,329 8,047,771,351 393,197,130 836 249 422 150Net Fee for Service Payments to ProvidersCapitation Payments to Care Management Organizations (CMOs)Total Payments***Total Payment Per Member Per MonthSource: Truven Health Analytics Advantage Suite based on incurred dates July 2012 through June 2013*Average Members is calculated by summing all 12 months of enrollment and dividing that sum by 12 months**A unique count of providers is used for the Total Medicaid count***Total Payments is the sum of Net Fee for Service Payments to Providers and Capitation Payments to Care Management Organizations (CMOs)Georgia Children* Served by the Department of Community Health in FY 2013Total Georgia Children**Georgia Children Served bythe Department of CommunityHealth***Percent of Georgia ChildrenServed by the Department ofCommunity HealthMedicaid & PeachCare for Kids 2,848,3271,203,72242.26%State Health Benefit .01%Health Plan*Georgia Children includes children aged 0-19**Total Georgia Children based on estimated 2012 population figures from www.census.gov***Georgia Children Served by the Department of Community Health reflects average enrollment6
Georgia Department of Community Health: Annual Report FY 2013Primary Role of DivisionIn FY 13, the Department of Community Health (DCH) served as thesingle agency for the administration of the Medicaid program underTitle XIX of the Social Security Act, providing health care for children,pregnant women and people who were aged, blind or disabled (ABD).DCH’s Medicaid Division oversaw the Georgia Medicaid programs andPeachCare for Kids (Georgia’s Children’s Health Insurance Program{CHIP} population). Medicaid and PeachCare for Kids membersreceived services through either managed care (Georgia Families) orfee-for-service arrangements.The Medicaid Division provides management oversight of theMedicaid and PeachCare for Kids programs by: Developing and implementing policies related to allowable servicesand service delivery Overseeing member eligibility and enrollment into Medicaid and PeachCare for Kids , as well as enrollment into the three GeorgiaFamilies care management organizations (CMOs)Overseeing the seven waiver programs offeringhome-and-community-based alternatives over long-term institutionalcare Medicaid Waivers ChartCollecting data and reporting the performance metrics for boththe fee-for-service population and members in Georgia Families.Georgia uses the Healthcare Effectiveness Data and Information Set(HEDIS) as a tool to measure performance on important dimensionsof care and service.Developing and implementing new programs in Medicaid andPeachCare for Kids promoting continuity of care, care coordinationand enhanced health outcomes.Controlling expenditures and overseeing all categories of service,including capitation payments, pharmacy, inpatient hospital, outpatienthospital, nursing and long term care facility, and transportation. Addressing member needs through Medicaid and PeachCare for Kidsprovider relations and resolution services. Evaluating opportunities to improve efficiency and effectiveness inMedicaid operations and implementing changes that streamlineprocesses for providers and Medicaid and PeachCare for Kids members.7 Major Programs and/or InitiativesMedicaidBeyond the primary role of managing Medicaid, the division developed new and innovative programsthat enhanced the effectiveness and efficiency of healthcare services offered. The latest programsenhancements are Medicaid Redesign. The Medicaid Redesign began in FY 2011 and focuses onimproving the health of Medicaid members, while also controlling the ever-increasing expenditurelevels of providing Medicaid services in Georgia. In FY 2013, Medicaid planned and implemented thefollowing: Plans to improve the health outcomes of 27,000 children, youth and young adults in fostercare, children and youth receiving adoption assistance plus select youth in the juvenile justicesystem. To accomplish this, DCH will transition these children and youth into a new Medicaid managed care program called Georgia Families 360 in March 2014. By focusing on the total well-being ofthe child, Georgia Families 360 will address both their physical health and behavioral needs througha holistic approach. The program will be administered by a single Care Management Organization(CMO), Amerigroup, and will provide: Medical homes – with a consistent primary care provider Dental homes – for routine and other dental services Care coordination teams – to ensure appropriate, consistent and effective ongoing health care,regardless of where the member lives in Georgia. Personal health care plans – individualized detailed recommendations for ongoing care for physical andbehavioral health issues Electronic health records – electronic health records to ensure coordinated care between providers Ombudsman staff to support members and families Monitoring and management of psychotropic medication Procurement activities for the Medical Coordination Program for the oversight of the ABDpopulation. As part of the continuing focus of enhancing care while achieving long-term sustainablesavings for the state, DCH began planning the care coordination of the most costly and vulnerableMedicaid members. DCH’s goals for this voluntary program include providing: Person-centered Medical Coordination for all eligible members Intensive Medical Coordination services for targeted high-risk, affected populations A Medical Home to coordinate and manage care for participants receiving Intensive MedicalCoordination services Care Coordinators who will assist eligible members in obtaining needed medical and behavioralhealth services. Initiating procurement for the Medical Coordination Program for the oversight of the ABDcontinued on page 8
MedicaidGeorgia Department of Community Health: Annual Report FY 2013Table of Historical PeachCare for Kids Average Membersand Total Payments by Fiscal Yearpopulation. As part of the continuing focus of enhancing care while achieving longterm sustainable savings for the state, DCH began planning the care coordination of themost costly and vulnerable Medicaid members. DCH’s goals for this voluntary programincluded providing: Person-centered Medical Coordination for all eligible members Intensive Medical Coordination services for targeted high-risk, affected populations A Medical Home to coordinate and manage care for participants receiving Intensive Care Coordinators who would assist eligible members in obtaining needed medicaland behavioral health servicesFiscal YearAverageMembersTotal Payments*PaymentPer MemberPercent Change inPayment Per Member20008,503 50,730,000 5,966N/A200114,028 115,931,116 8,26438.5%2002154,406 170,916,516 1,107-86.6%2003180,953 212,319,603 1,1736.0%2004200,562 262,676,747 1,31011.6%2005208,185 273,274,876 1,3130.2%2006238,330 310,331,108 1,302-0.8% Re-procurement planning for the CMO contracts. DCH first implemented GeorgiaFamilies, the Medicaid managed care program, for Low Income Medicaid (LIM) andPeachCare for Kids members in FY 2005. The current contracts will expire at the endof FY 2015. The new CMO contracts will be implemented in CY 2016 with changes tothe Georgia Families program, such as a value-based purchasing component to ensurethat the CMOs meet pre-defined performance metrics.2007273,659 432,157,786 1,57921.3%2008249,681 345,678,006 1,384-12.3%2009205,548 304,985,696 1,4847.2%2010202,527 302,383,388 1,4930.6%2011199,532 317,510,000 1,5916.6%2012205,330 340,344,900 1,6584.2% Planning for the procurement and implementation of an Integrated EligibilitySystem (IES). Along with other state agencies in FY 13, DCH worked to develop arobust IES, projected to be operational in FY 14. As the lead agency, DCH workedclosely with the Department of Human Services (DHS), the Department of PublicHealth (DPH) and others to develop an integrated eligibility solution. A single pointof entry was created to serve those applying for Medicaid, Food Stamps (SNAP),Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Program forWomen, Infants, and Children (WIC) benefits and more.2013218,139 393,197,130 1,8038.7% Implementing of ICD-10 was a large scale project for Medicaid. With a deadline ofOctober 1, 2015, DCH ensured that the Georgia Medicaid Management InformationSystem (GAMMIS) will be ready with more than 150,000 medical codes.8Source: Truven Health Analytics Advantage Suite based on incurred dates July 1999 through June 2013*Total Payments include Net Fee for Service Payments to Providers and Capitation Payments to Care ManagementOrganizations (CMOs)
MedicaidGeorgia Department of Community Health: Annual Report FY 2013PeachCare for Kids In February 2013, electronic transfer of Medicaid files to the PeachCare for Kids eligibilitysystem was implemented using grant funding from CMS. In the past, Medicaid referred electronicapplications when children appeared to be eligible for the PeachCare for Kids program, butparents still had to reapply with PeachCare for Kids . In most cases, parents had to provide thesame information and verification they already submitted to Medicaid. Electronic verificationincludes verification codes, pay frequencies and household demographics that do not need tobe re-verified. The electronic verification process not only ensured that PeachCare for Kids staffwere able to obtain the information needed to make a program eligibility determination, but alsoguaranteed that children were referred to the program, ensuring income information consistency.FY 2013 PeachCare for Kids Payment Distribution by Service Type500Capitation Payments93.9%PeachCare For Kids Average Members and Total Payments by Fiscal Year 500 432 393400 310300 263 273 305200201 302 300274250238 212 340 318208206203200205218 200 171181154 116Source: Truven Health Analytics Advantage Suite based on incurred dates July 2012 through June 2013100 100 51902000142001200220032004200520062007Average Members20082009201020112012Total Payments*Source: Truven Health Analytics Advantage Suite*Total Payments include Net Fee for Service Payments to Providers and Capitation Payments to Care Management Organizations (CMOs)92013 0Total Payments (in Millions)Hospital Services1.8%Mental Health Services0.3%Physician Services0.8%Maternal & ChildAll Other ServicesHealth Services0.2%0.8%Other Practitioner Services Pharmacy Services0.9%1.3%Average Members (in Thousands) 346 400
MedicaidGeorgia Department of Community Health: Annual Report FY 2013FY 2013 Medicaid Payment Distributionby ServiceFY 2013 TypeMedicaid Payment Distribution by Service TypeTable of Historical Medicaid Membersand Payments by Fiscal YearFiscal YearMembersAverage19961,013,386All Other Services2.8%Total PaymentsPayment PerMember 3,125,050,131 3,084% Change inPayment PerMemberN/A1997999,337 3,162,117,909 3,1642.6%1998977,061 3,043,018,566 3,114-1.6%1999965,229 3,226,445,622 3,3437.3%2000947,054 3,482,779,560 3,67710.0%2001996,901 3,822,786,433 3,8354.3%20021,268,225 4,461,972,245 3,518-8.3%20031,260,795 4,885,865,204 3,87510.1%20041,326,909 6,039,465,103 4,55217.5%20051,376,730 6,311,890,515 4,5850.7%20061,390,497 6,280,193,139 4,517-1.5%20071,283,940 6,155,158,918 4,7946.1%20081,268,661 6,371,942,440 5,0234.8%20091,353,191 6,703,774,787 4,954-1.4%20101,447,865 6,954,116,861 4,803-3.0%20111,496,881 7,464,027,216 4,9863.8%20121,540,666 7,813,851,582 5,0721.7%20131,588,074 8,047,771,351 5,068-0.1%Source: Truven Health Analytics Advantage Suite based on incurred dates July 1995 through June 2013*Table includes data for both the Medicaid ABD and Medicaid LIM programs**Total Payments include Net Fee for Service Payments to Providers and Capitation Payments to Care Management Organizations(CMOs)10Capitation Payments34.4%Nursing Facility Services14.9%Hospital Services19.8%Waiver Program Services11.6%Pharmacy Services6.4%Emergency Transportation0.4%Maternal & Child Health Services0.7%Mental Health ServicesEquipment & Devices2.8%0.9%Other Practitioner Services1.1%Physician Services4.2%Source: Truven Health Analytics Advantage Suite based on incurred dates July 2012 through June 2013
Georgia Department of Community Health: Annual Report FY 2013State HealthBenefit PlanOverviewThe Georgia Department of Community Health (DCH) served asthe State’s administrator of health insurance coverage for stateemployees, teachers, school system employees and retirees whocontinued coverage (including annuitants and former employees onextended coverage) and covered dependents. This health coverage isknown as the State Health Benefit Plan (SHBP).SHBP is composed of three plans: the State Employees Plan, theTeachers Plan and the Public Schools Employees Plan. SHBPcovered 635,896 lives as of June 2013.SHBP is a self-insured, self-funded plan that pays benefits out ofthe premiums contributed from members (through monthly payrolldeductions) and from monthly contributions from the employers thatoffer the SHBP (e.g., state agencies and public school systems).SHBP also offers fully insured Medicare Advantage options forformer employees who are continuing coverage and are enrolled ata minimum in Medicare Part B. Employer contributions and memberpremiums are used to purchase Medicare Advantage insurance.In FY 13, SHBP offered eligible active employees, annuitants underage 65 and eligible former employees the choice of a Wellness orStandard Plan through these self-insured plan options: 1) HealthReimbursement Arrangement (HRA); 2) High Deductible Health Plan(HDHP); and 3) Health Maintenance Organization (HMO) Plans.Georgia’s SHBP Wellness Plan Options, when combined, became thelargest in the nation.11Structure of SHBPWithin the Division, there were six primary operating units: Plan Management developed the Benefit Plan and designed the Plan documents, which containedthe terms and conditions of the SHBP. The unit was responsible for the negotiation of vendorcontracts and compliance. Medical Management provided oversight of the vendors’ performance of services for clinicalprograms including, but not limited to: utilization management, case management, diseasemanagement, behavioral health, wellness and pharmacy management and the overall quality ofthese services. Communications provided information to employers and members of the Plan’s benefits, eligibility,policies and procedures. Employer Services assisted participating employers with information and training about Plancoverage and billing. Member Services assisted members with all eligibility mat
DCH At-a-Glance Board of Community Health Governor Georgia Department of Community Health Executive Assistant Commissioner Georgia Board for Physician Workforce Georgia Composite . Georgia Children* Served by the Department of Community Health in FY 2013 Accomplishments. Georgia Department of Community
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