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Georgia Families 360


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David Bolt explains the Georgia Families 360 health care plan administered by Amerigroup for children in foster care. His presentation explores applying for coverage, the role of plan coordinator, accessing services, and more.

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Georgia Families 360

  1. 1. 1 Georgia Families 360° Legal Community Training 2015
  2. 2. Who is Amerigroup Georgia? • Incorporated as Amerigroup Georgia Managed Care Company, Inc. Wholly owned subsidiary of Anthem, Inc. • Amerigroup is a part of the Georgia Families Medicaid program administered by the Georgia Department of Community Health (DCH). DCH is Georgia’s Medicaid authority. • Amerigroup was chosen to be the single statewide Care Management Organization (CMO) for the youth in the Georgia Families 360 program. – Georgia Families 360° is staffed separately from general Amerigroup CMO employees. 2
  3. 3. Georgia Families 360° Populations 3 Adoption Assistance ~ 12,000 Youth who have been adopted out of state custody – keep Medicaid til 18 Juvenile Justice ~ 200 – 400 Youth committed to the state who are in a non-secure, community placement Foster Care ~ 10,000 Youth in state custody due to abuse or neglect
  4. 4. Georgia Families 360°: Main Goals • Integration of care on the physical, behavioral health, and dental needs of Georgia’s children in foster care, receiving adoption assistance, and in juvenile justice community residential programs • Improve health and well-being outcomes 4
  5. 5. Intake Process • There are several key items to be done when a youth enters foster care – A Medicaid application must be submitted as soon as possible to determine eligibility – An initial E-Form should be sent to Amerigroup coinciding with the 72 hour hearing. – Amerigroup immediately assigns staff to the youth and begins outreach efforts to the identified placements, state agency staff, and providers 5
  6. 6. E-Form Importance • The E-Form is a vital tool as it is the primary method of communicating information/changes about the member. • The 72 hour notification is important as it impacts several down stream processes and timeliness • Completed E-Form within 72 hours of youth entering care • Demographic information • Medical Information • Placement Information • Identified CCFA provider • Other – other referrals 6
  7. 7. Other E-Form Uses • The E-Form must also be submitted for: – Placement changes – Change in demographic info (name change) – Child/Youth exits care – CCFA Provider: Chosen by DFCS case manager and noted on E-Form – Other referrals made for youth such as Babies Can’t Wait – E-form should be sent within 24 hours of any change to a youth’s record 7
  8. 8. What is a Care Coordinator? • Every youth in the Georgia Families 360° program will be assigned to a specified Care Coordinator. • Assigned based on county of custody for youth in foster care. • Care Coordinator are the primary partner for identifying and referring for services that a youth needs. 8
  9. 9. • Each youth will have an individualized care plan made with them that will address their identified physical and behavioral health needs. • Work with community agencies to ensure appropriate services are referred to families, children, youth and young adults. • Education to members, foster parent, and adoptive parents on the service needs of the members • The Care Coordinator will be the primary conduit for information regarding status of services to the DFCS Case Manager. No letters will be mailed directly to foster care members. 9 What Does an Amerigroup Care Coordinator Do?
  10. 10. Psychotropic Medication Management • Every youth with one or more psychotropic medication will have their meds reviewed by Georgia Families 360° Medical Director or pharmacy review team. • Goal is to ensure evidence based medication guidelines are followed for youth and that the medication is appropriate for the identified diagnosis. 10
  11. 11. DFCS/DJJ Responsibilities Amerigroup works in partnership with DFCS and DJJ state agency staff*. State agency staff will continue to make decisions regarding*: • Medical Care • Placements • Safety Issues • Medication • Transportation • Service Choices 11 * For children in foster care or juvenile justice.
  12. 12. How We Work with DFCS 12 • Youth enters GF 360°via foster care: – AGP is notified by E-form from DFCS worker • AGP depends on timely and accurate information, via the E-form, from DFCS to be able to reach out to appropriate people – Youth is assigned to Care Coordinator (CC) and Outreach Case Specialist – Outreach Case Specialist works with DFCS CM to make initial appointments • Medical/Dental check within 10 days • Trauma Assessment completed within 15 days of entering care • Health Risk Screening within 30 days – Once these items are completed the Outreach Case Specialist’s work is complete and the CC will be the primary contact for AGP
  13. 13. How We Work with DJJ GAPEC-0521-13 13 • Select DJJ youth entering non-secure placement setting • AGP is notified via E-Form by Office of Federal Programs • Youth is assigned to CC, based on placement location, and Outreach Case Specialist • Outreach Case Specialist works with DJJ Juvenile Probation and Parole Specialist to make initial appointments • Medical/Dental check within 10 days • Health Risk Screening within 30 days • Once these items are completed, the Outreach Case Specialist’s work is complete and the CC will be the primary contact for AGP
  14. 14. Placements • DFCS and DJJ retain placement responsibility and authority • Amerigroup does not decide placement • PRTF is considered a treatment service and not a placement – Children and adolescents who do not need the intensive services of a PRTF, but need a placement resource, may be referred by the Department of Human Services, Department of Juvenile Justice or Parent/Legal Custodian to Child Caring Institutions or Child Placing Agencies which are not covered under Medicaid, but are funded with State General Funds, Title IV-E funding and other private funding resources*. *DBHDD PRTF Provider Manual 14
  15. 15. Accessing Services • Many behavioral health services do not require any type of pre- authorization to commence with a youth. 15 Common Behavioral Health Services Pre-Authorization Required Pre-Authorization Not Required Inpatient mental health Individual therapy Partial Hospitalization program Group therapy Intensive Outpatient program Family therapy Chemical dependency services Trauma Assessments Residential treatment Facility Psychiatrist Appointments Psychological and neuropsychological testing Evaluation and Monitoring
  16. 16. Requirements for Psych Testing Must meet all points of medical necessity: – Must be for the purpose of helping to establish the diagnosis of and to develop a treatment plan for a mental disorder, when this information is not adequately available from one or more comprehensive medical or behavioral health evaluations with the member and appropriate ancillary sources (e.g., family members, health care providers, school records); AND – It should not be for the primary purpose of assessing learning disorders, vocational testing or educational planning. Custody evaluation, court referral for evaluation (unless medically necessary) and testing for research purposes, are not covered; AND – There is evidence to suggest that the testing results will have a timely and direct impact on the member's treatment plan 1 6
  17. 17. When Psych Testing is Not Medically Necessary • Educational/Vocational Services Assessment • Placement Determination • Annual/Regular Checkup • Admission to nonmedical programs • Non-medically indicated court-ordered tests 1 7
  18. 18. Applicable Uses of Psych Testing Examples: – When a youth has been treated for a condition, but has not made improvements and there is a need for additional diagnostic clarification – For purposes of differentiating between organic versus psychogenic conditions – When a provider has completed a thorough clinical assessment, obtained data from other sources (family, collateral contacts, medical records) and administered questionnaires/rating scales and the diagnosis is still unclear 1 8
  19. 19. Example Child with primary diagnosis of ADHD mixed with disturbances in mood and behavior: • Learning disorders have been ruled out by testing at school • Behavior rating scales have mixed or unclear findings (done by provider) • Child has been treated with various medications and behavioral treatment without improvement • Provider requests testing to aid in clarifying diagnosis and to shape treatment planning 1 9
  20. 20. Commonly Used Behavioral Health Assessment Types Standardized Bio-Psycho-Social type assessments used to determine need for therapeutic services: • Psycho-Educational Testing – administered by a school (typically) to determine educational needs/capacity. • Trauma Assessment – a component of the CCFA that is completed by an Amerigroup BH provider that is equipped to assess trauma-related issues. The Trauma Assessment should include service/treatment recommendations. 2 0
  21. 21. Requesting Psych Testing 21 Child Enters Care Child Currently In Care Ensure required Medicaid paperwork and e-form is complete 1) Find an AGP provider to do the testing 2) Discuss the need for testing with provider 3) Provide the necessary paperwork for provider to request psych test 1) Find an AGP provider to do the testing 2) Discuss the need for testing with provider 3) Provide the necessary paperwork for provider to request psych test After provider receives PA, schedule appt. Do not take youth to provider until the PA is received.
  22. 22. Additional Resources • The Care Coordinator can assist by: – Discuss with them the need for psych testing – They can help locate an Amerigroup provider – They can assist involved parties in gathering needed items for clinical documentation (i.e., dates of last PRTF admit) – Liaison between stakeholders, providers, and the Amerigroup Utilization Management department • You can also discuss the need for psych testing with your DFCS WEPAC Specialist 22
  23. 23. Ombudsman Role • The Amerigroup Ombudsman Office provides confidential, impartial assistance to members, their representatives, and caregivers of Georgia Families 360 ° who are experiencing health care related issues. • We also work with advocacy groups and state agencies to discuss trends and issues within the community. 23
  24. 24. Contact Information • Intake Number – Juvenile Court Email – • Ombudsman – 1-855-558-1436 (phone) – (email) – 1-888-375-5067 (fax) • Amerigroup Website – 24 For further information regarding the program, please contact the following: Amerigroup • Training Team -
  25. 25. Further Questions and Training • Amerigroup is committed to providing you and your court the information you need. If you have any further need of information or training, please contact: • Generally a training can be scheduled within 2 weeks of the request 25