““Beyond Here Be Monsters”Beyond Here Be Monsters”Navigating the Unfamiliar Navigating the Unfamiliar

Waters of Georgia’s Changes in Waters of Georgia’s Changes in Mental Health AVLFMental Health AVLFDecember 10, 2007December 10, 2007

Tom C. RawlingsTom C. RawlingsDirector, Office of the Child Director, Office of the Child

AdvocateAdvocateState of GeorgiaState of Georgia(478) 757-2661(478) 757-2661

First Stop: Georgia Crisis & Access First Stop: Georgia Crisis & Access LineLine

Run by Behavioral Health LinkRun by Behavioral Health Link 24/7 SPOE24/7 SPOE Can provide referral to core provider Can provide referral to core provider

or to crisis intervention services.or to crisis intervention services.

Where does the child fit?Where does the child fit? Care Care

Management Management OrganizationOrganization Low-income Low-income

MedicaidMedicaid Right from the Right from the

Start MedicaidStart Medicaid Peachcare for Peachcare for

KidsKids

MHDDADMHDDAD Parental Parental

Custody w/ no Custody w/ no insurance, insurance, exhausted exhausted insurance, or insurance, or otherwise otherwise ineligible for ineligible for CMO or FFS CMO or FFS Medicaid Medicaid

Fee-for-Fee-for-Service Service MedicaidMedicaid Foster Foster

CareCare SSISSI WaiversWaivers Adoption Adoption

Assistance Assistance MedicaidMedicaid

THE MEDICAID ELIGIBILITY MANUAL IS AVAILABLE AT :

http://www.odis.dhr.state.ga.us/3000_fam/3480_medicaid/MAN3480.doc

Where does the child fit?Where does the child fit? Care Management OrganizationsCare Management Organizations These Are Direct Contracts between DCH and These Are Direct Contracts between DCH and

the Health Plan. MHDDAD is NOT really the Health Plan. MHDDAD is NOT really involved.involved.

Capitated fee scheduleCapitated fee schedule Low-income Medicaid, Right from the Start Low-income Medicaid, Right from the Start

Medicaid, Peachcare for KidsMedicaid, Peachcare for Kids How do I get one?How do I get one?

Normally assignedNormally assigned (888) 423-6765 (GA-ENROLL) 7am-7pm MF; (888) 423-6765 (GA-ENROLL) 7am-7pm MF;

8:30am-12pm Sat.8:30am-12pm Sat. www.georgia-families.comwww.georgia-families.com FAQs at:FAQs at:

http://dch.georgia.gov/00/channel_title/0,2094,31446711_43369236http://dch.georgia.gov/00/channel_title/0,2094,31446711_43369236,00.html,00.html

Care Management OrgsCare Management Orgs

Peach State Health PlanPeach State Health Plan CBH run by CenpaticoCBH run by Cenpatico Full contact information in your Full contact information in your

handoutshandouts Provider manual at:Provider manual at:

http://http://www.cenpaticoga.comwww.cenpaticoga.com/provider/manual/provider/manual

Care Management OrgsCare Management Orgs Wellcare of GeorgiaWellcare of Georgia

www.georgia.wellcare.comwww.georgia.wellcare.com Default Plan?Default Plan? CBH administered by MagellanCBH administered by Magellan Clinical guidelines for behavioral health, Clinical guidelines for behavioral health,

including medical necessity guidelines:including medical necessity guidelines: http://www.magellanprovider.com/MHS/MGL/providing_cahttp://www.magellanprovider.com/MHS/MGL/providing_ca

re/clinical_guidelines/MNC.aspre/clinical_guidelines/MNC.asp

Provider manual:Provider manual: https://www.magellanprovider.com/MHS/MGL/about/handhttps://www.magellanprovider.com/MHS/MGL/about/hand

books/provider_handbook.pdfbooks/provider_handbook.pdf Customer Service: 800 231-1821. But it’s only Customer Service: 800 231-1821. But it’s only

available to consumers 7am-7pm M-F!available to consumers 7am-7pm M-F!

Care Management OrgsCare Management Orgs AmerigroupAmerigroup

800-660-4441, 24/7800-660-4441, 24/7 ““If you’re planning to hurt yourself or If you’re planning to hurt yourself or

someone else, press 9.”someone else, press 9.” Provider ManualProvider Manual https://www1.amerigroupcorp.com/providers/_documents/ga/https://www1.amerigroupcorp.com/providers/_documents/ga/

ga_provider_manual.pdfga_provider_manual.pdf

Care Management Care Management OrganizationsOrganizations Contracts with DCHContracts with DCH

The Contractor shall at a minimum provide The Contractor shall at a minimum provide Medically Necessary services and Benefits as Medically Necessary services and Benefits as outlined below, and pursuant to the Georgia outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia Medicaid State Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manual. Such Medically Policies and Procedures Manual. Such Medically Necessary services shall be furnished in an Necessary services shall be furnished in an amount, duration, and scope that is no less than amount, duration, and scope that is no less than the amount, duration, and scope for the same the amount, duration, and scope for the same services furnished to recipients under Fee-for-services furnished to recipients under Fee-for-Service Medicaid. The Contractor may not Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration arbitrarily deny or reduce the amount, duration or scope of a required service solely because of or scope of a required service solely because of the diagnosis, type of illness or Condition.the diagnosis, type of illness or Condition.

Care Management Care Management OrganizationsOrganizations

Contracts with DCHContracts with DCH In the event a Member requires In the event a Member requires

Medicaid-covered services ordered by a Medicaid-covered services ordered by a State or federal court, the Contractor State or federal court, the Contractor shall fully comply with all court orders shall fully comply with all court orders while maintaining appropriate Utilization while maintaining appropriate Utilization Management practices.Management practices.

Fee-For-Service MedicaidFee-For-Service Medicaid Foster Care, SSI, WaiversFoster Care, SSI, Waivers A Partnership of Sorts Between A Partnership of Sorts Between

MHDDAD and APS.MHDDAD and APS. www.apsero.comwww.apsero.com APS provides for these children the sort of APS provides for these children the sort of

external review that CMOs provide, except external review that CMOs provide, except that APS doesn’t “have a dog in the fight.”that APS doesn’t “have a dog in the fight.”

Obtain a core provider (there are over Obtain a core provider (there are over 100) through GCAL100) through GCAL

MHDDAD $$$MHDDAD $$$ Parental Custody w/ no insurance, Parental Custody w/ no insurance,

exhausted insurance, or otherwise exhausted insurance, or otherwise ineligible for CMO or FFS Medicaidineligible for CMO or FFS Medicaid

Access a core provider through GCALAccess a core provider through GCAL

What’s Available in the What’s Available in the Community?Community?

Supposedly, every service that’s available Supposedly, every service that’s available through Medicaid should be available through through Medicaid should be available through FFS, CMOS, or MHDDAD care.FFS, CMOS, or MHDDAD care.

Take a look at the Medicaid Provider Manuals:Take a look at the Medicaid Provider Manuals: www.ghp.georgia.govwww.ghp.georgia.gov, under “Provider Information”, under “Provider Information”

APS Special criteria:APS Special criteria: Intensive Family InterventionIntensive Family Intervention

http://www.apsero.com/Downloads/LOC%20Orientation%20http://www.apsero.com/Downloads/LOC%20Orientation%20-%20Jan%2019%202007.pdf-%20Jan%2019%202007.pdf

Community Support-IndividualCommunity Support-Individual http://www.apsero.com/Downloads/CSI%20for%20LOC%20Phttp://www.apsero.com/Downloads/CSI%20for%20LOC%20P

roviders.pdfroviders.pdf

If CMOs aren’t following APS criteria, ask them, “why If CMOs aren’t following APS criteria, ask them, “why not”not”

Medical NecessityMedical Necessity Early and Periodic Screening, Diagnosis, Early and Periodic Screening, Diagnosis,

and Treatment Provisions of Medicaid Law and Treatment Provisions of Medicaid Law (EPSDT), 42 USC 1396d(EPSDT), 42 USC 1396d

States must provide to persons under 21 States must provide to persons under 21 “such other necessary health care, “such other necessary health care, diagnostic services, treatment, and other diagnostic services, treatment, and other measures . . . to correct or ameliorate measures . . . to correct or ameliorate defects and physical and mental illnesses defects and physical and mental illnesses and conditions discovered by the screening and conditions discovered by the screening services, whether or not such services are services, whether or not such services are covered under the State plan.”covered under the State plan.”

Medical Necessity under EPSDTMedical Necessity under EPSDT ““While there is no federal definition of preventive While there is no federal definition of preventive

medical necessity, federal amount, duration and medical necessity, federal amount, duration and scope rules require that coverage limits must be scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit sufficient to ensure that the purpose of a benefit can be reasonably achieved.... Since the purpose can be reasonably achieved.... Since the purpose of EPSDT is to prevent the onset of worsening of of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of disability and illness and children, the standard of coverage is necessarily broad... the standard of coverage is necessarily broad... the standard of medical necessity used by a state must be one medical necessity used by a state must be one that ensures a sufficient level of coverage to not that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury merely treat an already-existing illness or injury but also, to prevent the development or worsening but also, to prevent the development or worsening of conditions, illnesses, and disabilities." of conditions, illnesses, and disabilities."

Rosenbaum and SonoskyRosenbaum and Sonosky

Medical NecessityMedical Necessity

““Necessary” = medically necessaryNecessary” = medically necessary Generally defined as a decision by a Generally defined as a decision by a

health care professional/provider health care professional/provider that a person’s condition requires a that a person’s condition requires a service/course of treatment to service/course of treatment to address or improve a conditionaddress or improve a condition From Alison Barkoff, Staff Attorney, From Alison Barkoff, Staff Attorney,

Bazelon Center for Mental Health LawBazelon Center for Mental Health Law

What does “correct or What does “correct or ameliorate” mean when a ameliorate” mean when a problem is found during a problem is found during a

screening?screening?““Correct” means to Correct” means to

resolve a health resolve a health problem or problem or condition.condition.

““Ameliorate” means Ameliorate” means to lessen the to lessen the burdens of the burdens of the problem.problem.

From Alison Barkoff, Staff Attorney, Bazelon Center for Mental Health LawFrom Alison Barkoff, Staff Attorney, Bazelon Center for Mental Health Law

Medical Necessity under CMOsMedical Necessity under CMOs Contract with DCH:Contract with DCH: Based upon generally accepted medical practices in Based upon generally accepted medical practices in

light of Conditions at the time of treatment, Medically light of Conditions at the time of treatment, Medically Necessary services are those that are:Necessary services are those that are: Appropriate and consistent with the diagnosis of the treating Appropriate and consistent with the diagnosis of the treating

Provider and the omission of which could adversely affect the Provider and the omission of which could adversely affect the eligible Member’s medical Condition;eligible Member’s medical Condition;

Compatible with the standards of acceptable medical practice Compatible with the standards of acceptable medical practice in the community;in the community;

Provided in a safe, appropriate, and cost-effective setting given Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;the nature of the diagnosis and the severity of the symptoms;

Not provided solely for the convenience of the Member or the Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; andconvenience of the Health Care Provider or hospital; and

Not primarily custodial care unless custodial care is a covered Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.service or benefit under the Members evidence of coverage.

There must be no other effective and more conservative or There must be no other effective and more conservative or substantially less costly treatment, service and setting substantially less costly treatment, service and setting available.available.

Medically Necessary?Medically Necessary? ““EPSDT cannot be simply EPSDT cannot be simply

relinquished to the MCOs, as the relinquished to the MCOs, as the State remains ultimately bound by State remains ultimately bound by the EPSDT regulations.”the EPSDT regulations.” John B. v. Menke, 176 F. Supp. 2d 786, John B. v. Menke, 176 F. Supp. 2d 786,

801 (D. Tenn. 2001)801 (D. Tenn. 2001)

Reasonably Effective?Reasonably Effective?

States also must ensure that the States also must ensure that the EPSDT services provided are EPSDT services provided are reasonably effective. Thus, the State reasonably effective. Thus, the State Medicaid Manual states at several Medicaid Manual states at several points that EPSDT services must be points that EPSDT services must be sufficient "to achieve their purpose." sufficient "to achieve their purpose." Katie A. v. Los Angeles County, 481 F.3d Katie A. v. Los Angeles County, 481 F.3d

1150, 1159 (9th Cir. 2007)1150, 1159 (9th Cir. 2007)

RE: RE: [Name of child][Name of child]DOB:DOB:

Dear _____________,Dear _____________,

I have assessed the above-named child. I am a [physician, nurse, I have assessed the above-named child. I am a [physician, nurse, psychologist, clinical social worker, occupational therapist, etc.] licensed to psychologist, clinical social worker, occupational therapist, etc.] licensed to practice in the State of Georgia. I have determined based upon my training practice in the State of Georgia. I have determined based upon my training and experience that this child requires [list the treatments, procedures, and experience that this child requires [list the treatments, procedures, therapies or tests you believe the child needs based upon your assessment]. therapies or tests you believe the child needs based upon your assessment]. I am making this request pursuant to the Early and Periodic Screening, I am making this request pursuant to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions of the Medicaid Act, 42 U.S.C.A. Diagnosis and Treatment (EPSDT) provisions of the Medicaid Act, 42 U.S.C.A. § 1396d(r).§ 1396d(r). [Describe the child’s medical history, and current diagnoses and treatments. [Describe the child’s medical history, and current diagnoses and treatments. Describe the treatment that you are requesting/prescribing and a description Describe the treatment that you are requesting/prescribing and a description of how this treatment will “correct or ameliorate” any physical or mental of how this treatment will “correct or ameliorate” any physical or mental illness or condition of the child.] illness or condition of the child.] If you deny this request, please provide prompt written notice to this office If you deny this request, please provide prompt written notice to this office [and the child’s parent or legal guardian] of the reason for the denial and the [and the child’s parent or legal guardian] of the reason for the denial and the process by which your decision may be appealed. process by which your decision may be appealed.

Sincerely,Sincerely,

Sample EPSDT Letter (thanks to Josh Sample EPSDT Letter (thanks to Josh Norris, www.thegao.org)Norris, www.thegao.org)

I Need Residential Care!I Need Residential Care!

1.1. CMO processCMO process

2.2. DFCS processDFCS process

3.3. Parental Custody non-CMO processParental Custody non-CMO process

““Unbundling”Unbundling”

Under the old Level of Care System, DFCS Under the old Level of Care System, DFCS or MATCH or whomever would purchase a or MATCH or whomever would purchase a bundle of residential therapeutic services bundle of residential therapeutic services from a provider.from a provider.

Now, the Medicaid officials require that the Now, the Medicaid officials require that the placement and the therapy be paid placement and the therapy be paid separately.separately.

Essentially, what now happens is that:Essentially, what now happens is that:1.1. The “Custodian” pays for Room, Board, and The “Custodian” pays for Room, Board, and

Watchful Oversight; and Watchful Oversight; and 2.2. The “Therapist” provides what is essentially The “Therapist” provides what is essentially

outpatient therapy in a residential settingoutpatient therapy in a residential setting

““Unbundling”Unbundling”

Look at the RBWO “descriptions”Look at the RBWO “descriptions” https://www.kidstarga.com/forms/docs/https://www.kidstarga.com/forms/docs/

RBWOChartProviderRequirementsandChilRBWOChartProviderRequirementsandChildCharacteristics.pdf dCharacteristics.pdf

These descriptions have to be aligned These descriptions have to be aligned with appropriate therapy, as with appropriate therapy, as determined by CMOs, or APS, etc.determined by CMOs, or APS, etc. What happens if there’s a disagreement?What happens if there’s a disagreement?

ORS licensesResidential

provider

DHR tells residential Provider how to

Implement unbundling

Core Provider determines child needs care

APS HealthcareDetermines

Needed Therapy

DFCS/DJJDetermine level

Of RBWO

ResidentialProvider

Takes child

DFCS second-guesses APS

DFCS second-guesses ORS

APS disagrees with DFCS

DCH tells DHR that CMSIs requiring unbundling

Residential Care: DFCS/DJJ Residential Care: DFCS/DJJ CustodyCustody

Case manager works with core Case manager works with core provider to determine child’s provider to determine child’s residential care needs.residential care needs.

In consultation with DFCS Provider In consultation with DFCS Provider Relations Unit, case manager selects a Relations Unit, case manager selects a facility to provide room, board, and facility to provide room, board, and watchful oversight:watchful oversight: Watchful OversightWatchful Oversight Maximum Watchful OversightMaximum Watchful Oversight

Core provider and residential facility Core provider and residential facility work with APS to determine work with APS to determine behavioral health needs.behavioral health needs.

Residential Care: Parental Residential Care: Parental CustodyCustody

Family and Core Provider work with Family and Core Provider work with MHDDAD and APS to obtain RBWO MHDDAD and APS to obtain RBWO and behavioral health services.and behavioral health services.

These should be coordinated through These should be coordinated through a local multidisciplinary team, but a local multidisciplinary team, but word on the street says these aren’t word on the street says these aren’t functioning as well as they did under functioning as well as they did under Level of CareLevel of Care

MHDDAD Regional C & A Program MHDDAD Regional C & A Program

SpecialistsSpecialists

Region One MHDDAD OFFICERegion One MHDDAD OFFICE1305 Redmond Circle, Bldg 4011305 Redmond Circle, Bldg 401Rome, Georgia 30165Rome, Georgia 30165Nora Hall (706) 802 – 5272 Nora Hall (706) 802 – 5272

nohall@dhr.state.ga.us nohall@dhr.state.ga.us

Vicki Harrison (706) 802 – 5272 Vicki Harrison (706) 802 – 5272 vmharrison@dhr.state.ga.usvmharrison@dhr.state.ga.us

Region Two MHDDAD OfficeRegion Two MHDDAD Office3405 Mike Padgett Hwy, Bldg 33405 Mike Padgett Hwy, Bldg 3Augusta, Georgia 30906Augusta, Georgia 30906Kimberly Dempsey (706) 792 – Kimberly Dempsey (706) 792 –

7663 7663 kadempse@dhr.state.ga.uskadempse@dhr.state.ga.us

Felita “Michelle” Broadwater (706) Felita “Michelle” Broadwater (706) 792 – 7662 792 – 7662 fmbroadw@dhr.state.ga.usfmbroadw@dhr.state.ga.us

Region Three MHDDAD OfficeRegion Three MHDDAD Office100 Crescent Centre Parkway, 100 Crescent Centre Parkway,

Suite 900Suite 900Tucker, Georgia 30084Tucker, Georgia 30084Shelia Kirksey (770) 414 – 3052 Shelia Kirksey (770) 414 – 3052

sdkirksey@dhr.state.ga.us sdkirksey@dhr.state.ga.usKelly Waterman (770) 414 – Kelly Waterman (770) 414 –

3052 3052 kwaterman@dhr.state.ga.uskwaterman@dhr.state.ga.us

Region Four MHDDAD OfficeRegion Four MHDDAD OfficeP.O. Box 1378P.O. Box 1378Thomasville, Georgia 31799-1378Thomasville, Georgia 31799-1378Jacquelyn Ezell (229) 225 – 5099 Jacquelyn Ezell (229) 225 – 5099

jxezell@dhr.state.ga.usjxezell@dhr.state.ga.usGeorgia Brown (229) 225 – 5099 Georgia Brown (229) 225 – 5099

gepbrown@dhr.state.ga.usgepbrown@dhr.state.ga.us

MHDDAD Regional C & A MHDDAD Regional C & A

Program SpecialistsProgram Specialists Region Five MHDDAD Region Five MHDDAD

OfficeOffice

1915 Eisenhower Drive, 1915 Eisenhower Drive, Bldg. 2Bldg. 2

Savannah, Georgia Savannah, Georgia 3140631406

Laura Ryan (912) 303 – Laura Ryan (912) 303 – 1670 1670 laryan@dhr.state.ga.ularyan@dhr.state.ga.us s

Residential Care: CMO ProcessResidential Care: CMO Process

Have to request authorization through Have to request authorization through provider.provider.

Magellan Example:Magellan Example: Parents contact Magellan.Parents contact Magellan. Magellan requests records from current Magellan requests records from current

mental health provider – takes 14 days.mental health provider – takes 14 days. Have a treatment team meeting involving Have a treatment team meeting involving

core provider, school officials, etc.core provider, school officials, etc. Then it’s determined at that point that Then it’s determined at that point that

child needs level of care, and find that child needs level of care, and find that facility that’s closest.facility that’s closest.

Residential Care: CMO ProcessResidential Care: CMO Process

That’s all fine and dandy, but who That’s all fine and dandy, but who pays RBWO when you’ve got a CMO pays RBWO when you’ve got a CMO kid without other State involvement?kid without other State involvement?

CMO: In or Out?CMO: In or Out? CMO contracts exclude:CMO contracts exclude:

Children with severe emotional Children with severe emotional disturbance whose care is coordinated disturbance whose care is coordinated under the Multi-Agency Team for Children under the Multi-Agency Team for Children (MATCH) program;(MATCH) program;

Children less than nineteen (19) years of Children less than nineteen (19) years of age who are receiving foster care or other age who are receiving foster care or other adoption assistance under Title IV-E of the adoption assistance under Title IV-E of the Social Security Act;Social Security Act;

Children less than nineteen (19) years of Children less than nineteen (19) years of age who are in foster care or other out-of-age who are in foster care or other out-of-home placement;home placement;

CMO: In or Out?CMO: In or Out? Unanswered Questions:Unanswered Questions:

What happens when a child goes from What happens when a child goes from his home, where he has CMO Medicaid, his home, where he has CMO Medicaid, to foster care?to foster care?

For example, what if a child is in an For example, what if a child is in an institution for 30 days?institution for 30 days?

What happens when he goes from a What happens when he goes from a residential DFCS or “MATCH” placement residential DFCS or “MATCH” placement back into the community where he’d be back into the community where he’d be in a CMO?in a CMO?

Residential Care OverviewResidential Care Overview

Take a look at this Powerpoint by Take a look at this Powerpoint by Roslyn Williams:Roslyn Williams: http://www.apsero.com/webx?http://www.apsero.com/webx?

293@953.kR91abfUd2w.0@.ee7df76 293@953.kR91abfUd2w.0@.ee7df76

Individuals with Disabilities Individuals with Disabilities Education Act (IDEA)Education Act (IDEA)

Source of school-supplied Behavioral Health Source of school-supplied Behavioral Health Services, including positive behavioral Services, including positive behavioral interventions required by IDEA 2004.interventions required by IDEA 2004.

May be a source of residential treatment in May be a source of residential treatment in limited circumstances.limited circumstances.

May be able to use school-determined MH May be able to use school-determined MH needs as a basis for obtaining Medicaid-needs as a basis for obtaining Medicaid-paid care.paid care.

Good general resource: “Teaming Up: Good general resource: “Teaming Up: Using IDEA and Medicaid. . . . “Using IDEA and Medicaid. . . . “

IDEA & CMOsIDEA & CMOs

For Members up to and including age three For Members up to and including age three (3), the Contractor shall be responsible for (3), the Contractor shall be responsible for Medically Necessary IDEA services provided Medically Necessary IDEA services provided pursuant to an Individualized Family Service pursuant to an Individualized Family Service Plan (IFSP) or Individualized Service Plan (IFSP) or Individualized Service Plan(IEP).Plan(IEP).

For Members age four (4) and older, the For Members age four (4) and older, the Contractor shall not be responsible for Contractor shall not be responsible for Medically Necessary IDEA services provided Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services pursuant to an IEP or IFSP. Such services shall remain in FFS Medicaid.shall remain in FFS Medicaid.

Getting into a PRTFGetting into a PRTF PRTFs are the old “level 6” facilities, PRTFs are the old “level 6” facilities,

now classified as “psychiatric now classified as “psychiatric residential treatment facilities,” for residential treatment facilities,” for the most ill children.the most ill children. Coastal HarborCoastal Harbor Devereux Georgia Treatment NetworkDevereux Georgia Treatment Network HillsideHillside Inner HarbourInner Harbour Laurel HeightsLaurel Heights Macon Behavioral Health.Macon Behavioral Health.

PRTFsPRTFs

When DFCS’ Treatment Services Unit When DFCS’ Treatment Services Unit did most placements, children often did most placements, children often stayed in PRTFs for years.stayed in PRTFs for years. No incentive to move them;No incentive to move them; No place for them to go.No place for them to go.

With APS and now CMOs doing With APS and now CMOs doing external review, these will be very external review, these will be very short-term placements.short-term placements.

Processes for PRTFsProcesses for PRTFs

For DFCS and non-CMO parental For DFCS and non-CMO parental custody children, similar process as custody children, similar process as with residential placement.with residential placement. See HandoutsSee Handouts

Good overview Powerpoint by APS Good overview Powerpoint by APS folks:folks: http://www.apsero.com/webx?http://www.apsero.com/webx?

293@953.kR91abfUd2w.3@.ee7e689293@953.kR91abfUd2w.3@.ee7e689

CMO Processes for PRTFsCMO Processes for PRTFs

Good Question!Good Question! According to one CMO exec., they’re still According to one CMO exec., they’re still

figuring it out.figuring it out. Apparently, the DCH contract did not Apparently, the DCH contract did not

specify any procedures for CMOs’ use of specify any procedures for CMOs’ use of PRTFs. That was added as of July 1 for new PRTFs. That was added as of July 1 for new entries, September 1 for existing clients.entries, September 1 for existing clients.

At GRN, they’ve had 10 approvals from APS At GRN, they’ve had 10 approvals from APS for PRTFs since 7/1/07; ZERO from CMOs.for PRTFs since 7/1/07; ZERO from CMOs.

WaiversWaivers New Options Waiver ProgramNew Options Waiver Program Comprehensive Supports Waiver ProgramComprehensive Supports Waiver Program

MR/DDMR/DD Katie Beckett WaiverKatie Beckett Waiver

Waives the income limits so parents of children Waives the income limits so parents of children with serious disabilities can get Medicaid.with serious disabilities can get Medicaid.

http://www.parenttoparentofga.org/roadmap/http://www.parenttoparentofga.org/roadmap/insurance/insurancedeeming.htmc insurance/insurancedeeming.htmc

Manual: Manual: http://dch.georgia.gov/vgn/images/portal/cit_12http://dch.georgia.gov/vgn/images/portal/cit_1210/26/56/46098632Katie_Beckett_Manual.pdf 10/26/56/46098632Katie_Beckett_Manual.pdf

Ongoing QuestionsOngoing Questions1.1. What are we going to do about What are we going to do about

children who are caught in the children who are caught in the middle, because of:middle, because of:

A.A. Changes in status – Medicaid Changes in status – Medicaid CMO/FFS/Private Insurance, CMO/FFS/Private Insurance, Parental/State CustodyParental/State Custody

B.B. Turf wars between the various Turf wars between the various agencies and companies who might agencies and companies who might have responsibilityhave responsibility

Ongoing QuestionsOngoing Questions2.2. Is there anything we can do to Is there anything we can do to

standardize the process, so that standardize the process, so that kids who are on a CMO are ensured kids who are on a CMO are ensured of receiving the same consideration of receiving the same consideration and standard of care as one with and standard of care as one with private insurance or one on fee-for-private insurance or one on fee-for-service Medicaid?service Medicaid?

Ongoing QuestionsOngoing Questions3.3. What will be the relationship now What will be the relationship now

between the CMOs and:between the CMOs and:A.A. The CourtsThe Courts

B.B. The Interagency Teams and Systems of The Interagency Teams and Systems of CareCare

C.C. The SchoolsThe Schools

Must-See ResourcesMust-See Resources

www.kidstarga.comwww.kidstarga.com DFCS’ “Out of Home Care” website, which has DFCS’ “Out of Home Care” website, which has

lots of good, technical information on RBWO, lots of good, technical information on RBWO, specialized foster care, etc.specialized foster care, etc.

www.apsero.com www.apsero.com APS’ website has dozens of Powerpoints, pdfs, APS’ website has dozens of Powerpoints, pdfs,

and other documents discussing every aspect of and other documents discussing every aspect of Georgia’s behavioral health care system. Most of Georgia’s behavioral health care system. Most of the training that providers receive, and the the training that providers receive, and the criteria and processes used to access care, are criteria and processes used to access care, are posted here in some form. There are also posted here in some form. There are also AUDITS of various providers.AUDITS of various providers.

Must-See ResourcesMust-See Resources

www.ghp.georgia.gov www.ghp.georgia.gov The official website for Georgia Medicaid The official website for Georgia Medicaid

providers, with provider manuals for providers, with provider manuals for every service imaginable.every service imaginable.

www.georgia-families.comwww.georgia-families.com The website for the Georgia Medicaid The website for the Georgia Medicaid

CMO program, with enrollment CMO program, with enrollment information and access to all three CMOs.information and access to all three CMOs.

Must-See ResourcesMust-See Resources

www.gachildadvocate.org www.gachildadvocate.org The website of Georgia’s Office of the The website of Georgia’s Office of the

Child Advocate. We’ll keep updated Child Advocate. We’ll keep updated information on Georgia’s children’s information on Georgia’s children’s behavioral healthcare system going behavioral healthcare system going forward.forward.

One Last ThoughtOne Last Thought

For hundreds of For hundreds of years, sailors told years, sailors told stories of a huge, stories of a huge, tentacled monster tentacled monster that would surface that would surface and occasionally and occasionally attack ships. attack ships. Scientists dismissed Scientists dismissed it as foolishness.it as foolishness.

One Last ThoughtOne Last Thought Until scientists discovered the Giant Until scientists discovered the Giant

Squid.Squid.