Summary of Georgia’s Medicaid Care Management Organization (CMO) Law August 19, 2008

1. Summary of Georgia’sMedicaid Care Management Organization (CMO) LawAugust 19, 2008 Robert D. Stone, Esq.Alston & Bird LLP1201 West Peachtree StreetAtlanta, Georgia 30309404-881-7270 rob.stone@alston.com

2. Introduction & Background • Brief History of Medicaid Managed Care in Georgia • Basic Structure • Provider Complaints • Myers & Stauffer Report • Development of CMO Bill

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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”

10. Summary of Georgia Medicaid Care Management Organization LawGeorgia Hospital AssociationT2421 - WebinarAugust 19, 2008 Robert D. Stone, Esq.Alston & Bird LLP1201 West Peachtree StreetAtlanta, Georgia 30309404-881-7270 rob.stone@alston.com /