Medicaid Issues/Questions

Medicaid Issues/Questions

Private Agency Foster Parents

Orthodontic Care

One foster parent has had issues with getting orthodontic care for her foster child. Medicaid does not pay for most orthodontic cases, especially braces. She would like to know more about the qualifications for Medicaid covering the cost of braces.

Cosmetic orthodontic care is not covered by Medicaid.

Transition from Foster Care

Another foster parent asked what is in place to help a youth transitioningout of the system at age 18. This usually means transition from Medicaid through DFCS to receiving Medicaid on their own. She has a foster child in her home who will be 18 in a few months and probably won’t be signing herself back into care. The foster parents would like to help her apply or prepare for the steps to receive Medicaid, if possible, after she turns 18.

A foster child must sign them self back within 30 days after turning 18 to remain on Medicaid. Dental is not covered for adults.

Physical and Occupational Therapy

Most foster parents are concerned about the cutback on Physical and Occupational therapy. They used to receive these services four times per month, and now, Medicaid only covers twice per month. Providers have submitted letters of medical necessity to request increase in services, but have not received response or approval from Medicaid.

PT and OT FY07, passed March 2006, moved services to an administrative services vendor and gatekeeper model. Preauthorization is required for more than eight units (four visits) per month per discipline (approx one rx per week for PT/OT and two sessions per week for speech therapy).

Physical Examinations

Does Medicaid still only cover one physical per year? They are concerned because some DFCS offices have begun to require two.

Children with foster care Medicaid are eligible for up to twelve visits to a primary pediatrician per year before prior authorization is required.

Different Evaluation & Management Codes (E & M codes) are available for doctors to bill for services, such as:

• Comprehensive Exam Code, one per year
• New Patient Code
• Established Patient Code

When doctor states that a child is not eligible for an annual exam, the foster parent should inquire whether another code can be used to bill for service. However, the doctor will make the final decision and may not agree to use another code, instead of comprehensive exam code, as this pays the most.

Psychological Evaluations for Children in Foster Care

Full-scale psychological evaluations are covered by Medicaid every three years. However, an evaluation can be approved earlier with supporting documentation from the provider to demonstrate the psychological/medical necessity.

Referrals to Specialists

Foster parents experience a hard time getting referrals to specialists, such as orthopedists, neurologists, gastroenterologists, ENT, etc. that will take Medicaid.

Georgia Medical Care Foundation is used for medical reviews. Requests are sent to peer-specialists in the community for medical review.

Lack of Physicians Accepting Medicaid

Some doctors and dentists are not accepting Medicaid patients at all or not accepting new Medicaid patients. Doctors who accept Medicaid are becoming a very limited resource. Foster parents often have to travel to Children’s Healthcare of Atlanta for specialized services.

DCH is conducting ongoing trainings with providers to educate them on new policies and pre-authorization requirements. List of doctors, specialists who take Medicaid can be found at:

Timely Appointments Difficult

Appointments cannot be scheduled for two to three months with doctors who accept Medicaid due to long waiting lists.

Concern was noted.

Obtaining Durable Medical Equipment

A letter of medical necessity is needed to justify the need for durable medical equipment. Equipment should be received 30 days from the point the letter of medical necessity is received and approved. Foster parents are encouraged to email MarkTrail when experiencing delays beyond 30 days. Also, if a request is denied, foster parents are encouraged to appeal when there is enough documentation to support the medical need for the equipment.

Cutbacks in Hours for Occupational, Physical and Speech Therapy for Children

Pre-authorization required for hours in services beyond the following:

• Speech therapy: 8 episodes (30 minutes each) per month
• Occupational therapy: 30 minutes per week
• Physical therapy: 30 minutes per week

To obtain authorization to increase speech, occupational or physical therapy, the provider must submit a letter of medical necessity to justify the increase in services and Children Intervention Services (CIS) will approve or deny the request. CIS approves all medically necessary services (See CIS Frequently Asked Questions).

Foster parents can refuse to provide the school with the child’s Medicaid number when a child has an IEP and receives speech, occupational or therapy services through the school. If the school charges Medicaid for services, then this may take away from available units for services. However, if services provided by the school differ from services from provider, additional units may be approved with proof of medical necessity.

Medications Covered by Medicaid

Medications previously covered by Medicaid are no longer covered by Medicaid (i.e. Strattera).

Due to the cost of medications increasing, pre-authorization is required for medications in order to determine if a generic medication can be substituted at a lower cost. If the doctor does not want to have the child receive the generic medication, the doctor must obtain pre-authorization for approval of the medication and should do this prior to writing prescription to the foster parent, so the foster parent does not experience any problems in filling the prescription at the pharmacy. Lists of medications that need pre-authorization are listed at

Medicaid Approval

Approval of Medicaid when a child enters foster cares can take a long time, especially when a child comes into foster care and the child was enrolled with another private insurance program or Medicaid CMO.

Conversation should include DFCS.

Medicaid Numbers

Medicaid numbers,which becomeinactive, can take one or two months before DFCS CW can re-activate them.

Concern was noted. Medicaid contact information was provided.

Medicaid Cards

Obtaining the original Medicaid card for foster parents can be difficult, because the DFCS address is listed on the Medicaid application instead of the foster parent’s address.

Concern was noted. Medicaid contact information was provided.

EPSTD Issues

According to the EPSTD well check standards, a child requires a Health Check/Physical every other year after age eight, but ORS and Kenny A. require annually.

According to the EPSTD well check standards, children age three and older require a dental exam, but Kenny A. requires a dental screening for all children within ten days of placement.

Will Medicaid cover the cost of the physical every year, and the dental exam for children under the age of three? If not, can agency bill DFCS for reimbursement of these expenses?

This will require additional discussion with DFCS.

Contact information:

MarkTrail, Chief

Medical Assistance Plans

Office: 404-651-8681

Fax: 1-866-283-0128

Email: (best way to contact)

• Can assist with questions regarding Medicaid coverage, coding, eligibility, claim denials, appeals, and advocating for additional services for children who receive Medicaid to be added to Georgia Medicaid plan.

Dr. Sherry Collins

Department of Community Health

Office: 404-463-6096

• Can assist with checking the status of requests submitted by speech, occupational and physical therapy providers to increase services for children based on medical necessity; can also assist providers with process if need help.

Joanne Wheeler

DHRState Office

Office: 404-657-3606

• Can assist with Medicaid being inactive for child for a long time or in a crisis situation, after attempts to have Medicaid re-activated by DFACS are unsuccessful.

Brian Dowd
OFI Unit Manager/Medicaid
2 Peachtree ST, NW Ste 21-493
Atlanta, GA 30303
Office: 404-657-3596

Email:

• Can assist with questions regarding denial of services, general questions.

Medicaid Fraud: 1-800-533-0686

Medicaid Member Services: 1-866-211-0950

Additional Notes:

Chronic/persistent need may be covered up to six months with prior authorizations. (Approved April 2007). Specifications can be found in the July policy manual, which will be posted on the web. The policy manual is released quarterly.

Medical records sent to Medicaid require inclusion of therapist documentation, care plan, doctor orders and progress notes.

Legislation passed in 1988 included the Individual Education Disability Act (IEDA). Medicaid pays for therapists in school. With an IEP Medicaid can be payer of first resort in school. It is important to avoid duplicative therapy between school and community.

Evaluation Management Codes are used to process records. The CPY codes are the evaluation and management codes from the AMA. Codes vary for new patients versus established patients.

The Medicaid definition for “medically necessary” is to correct or ameliorate (make better/prevent from getting worse). Diagnosis is found in the EPST screening.

Medicaid does not cover routine supplies. It does cover equipment. Recommendation is to have provider/physician make argument for requirement. Supplies such as diapers could be covered in some waiver programs:

1)GAP (nursing and medically fragile day care) GAP through 21 years of age.

2)MR Waiver – has a waiting list. There are 1500 slots with 2500 on the waiting list. Slots are available through the regional offices. This waiver covers certain supplies (no age limit). Can only have one waiver.

An appeals process is available.

The Medicaid system is loaded from the DFCS system, SUCCESS.