This powerpoint presentation was put together by Dr. Janice Carson, Assistant Chief for Performance Quality and Outcomes, Medical Assistance Plans, Dept. of Community Health, and presented on August 26 as part of our GA-CAN! Community Conversation on Medicaid and Peachcare.

1. 1
Presentation to: Voices for Georgia’s Children
Presented by: Janice Carson, MD
Assistant Chief
Division of Medical Assistance Plans
Date: 8/26/15
‘Check-Up’ on Medicaid and PeachCare
Successes and Opportunities for Children

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Mission
The Georgia Department of Community Health
We will provide Georgians with access to
affordable, quality health care through
effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.

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Overview
Medicaid and CHIP Services for Children – the
EPSDT Benefit
Measuring Service Delivery and Quality - CFR
Requirements and Performance Reporting
Performance Improvement Activities
Questions
Overview
Our Members – Enrollment and Demographics
Federal Requirements
 The Code of Federal Regulations (CFR)
 The Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) Benefit
EPSDT and Bright Futures
Successes and Opportunities
Questions

4. 4
Our Members – Ages 0 - 20
Medicaid FFS, 60,331
Georgia Families,1,154,859
PCK, 135,394
GF 360,27,511
The membership as of August 1, 2015

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Our Members
0 100000 200000 300000 400000 500000 600000 700000 800000 900000
FFS
GF
PCK
GF 360
FFS GF PCK GF 360
Unknown 15276 9 0 5607
Rural 3241 363266 40974 2010
Urban 41814 791584 94420 19894
Urban vs Rural

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Our Members

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Our Members
FFS Georgia
Families
PCK GF 360
Male 38,934 574,808 69,408 14,358
Female 21,392 580,050 65,986 13,153

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Federal Requirements - The CFR
A Roadmap for Medicaid Managed Care
Subpart D
Subpart E
Subpart F
Subpart B Subpart C
Subpart A
Managed Care Guidance
Route
42CFR438

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CFR – CITE: 42CFR438 Subparts
• Subpart A – General Provisions – Rules that managed care
organizations and the contracts between the State and the
CMOs must meet
• Subpart B – State Responsibilities – Choice of CMOs,
disenrollment, etc.
• Subpart C – Enrollee Rights and Protections
• Subpart D – Quality Assessment Performance Improvement
• Subpart E – External Quality Review
• Subpart F – Grievance System
• Also Subparts H, I, J and recent NPRM

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The CFR Requirements
• Quality Assessment and Performance Improvement
(QAPI) Program for Medicaid Managed Care
42CFR438 Subpart D
–Requires states to develop a quality assessment and performance
improvement (QAPI) strategy to assess and improve the quality of
managed care services;
–Initial strategy, any significant revisions and regular reports about the
implementation and effectiveness of the strategy submitted to CMS.

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The CFR Requirements
• QAPI Program must:
– Have procedures that:
• assess quality and appropriateness of care
• regularly monitor and evaluate compliance w/standards
– Include:
• national performance measures developed by CMS – Child Core
Set of Measures (24 child and maternity-related measures)
• provisions for an annual external independent quality review of
quality outcomes, timeliness of and access to services

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Federal EPSDT Benefit
• Available for all Medicaid-
eligible children birth to
twenty-one (21) years of age
• Available for all eligible
PeachCare for Kids®
members,
Georgia’s standalone CHIP
program, from birth to
nineteen (19) years of age.
Majority of all Georgia Medicaid
members and the CHIP members are
under age 21.

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EPSDT Benefit
• Section 1905(r) of the Social Security Act states the
Georgia’s EPSDT Benefit must make available:
– Screening Services -- Screening services must
include all of the following services:
– Comprehensive health and developmental history
-- (including assessment of both physical and mental
health development);
– Comprehensive unclothed physical exam --
(unclothed means to the extent necessary to conduct
a full, age-appropriate examination);

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EPDST Benefit
– Appropriate immunizations based on ACIP guidelines.
Vaccines available for Medicaid members via Vaccines for
Children (VFC) program
– Appropriate Laboratory Tests
– Lead Toxicity Screening
– Health Education – including anticipatory guidance. Health
Education should assist with understanding what to expect
relative to the child's development and provide information
about the benefits of healthy lifestyles and practices, vaccine
preventable diseases, as well as accident and disease
prevention;

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EPSDT Benefit
• Vision Services -- Including diagnosis and treatment for defects in
vision; and eyeglasses. Vision services must be provided according
to the periodicity schedule and at other intervals as medically
necessary;
• Dental Services – Including relief of pain and infections, restoration
of teeth and maintenance of dental health. Services are provided in
accordance with the AAPD dental periodicity schedule.
• Hearing Services – including diagnosis and treatment of hearing
problems
• Other Necessary Health Care to correct or ameliorate defects,
and physical and mental illnesses and conditions discovered by the
screening services.

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CFR, EPSDT and Bright Futures

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2014 Bright Futures Schedule

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EPSDT, BF and Continuous Improvement

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Measuring Successes and Opportunities
• CMS Child Core Set, the CMS 416 report, etc. used to track
performance.
• Child Core Set focus areas include:
– Perinatal Period: Timeliness of Prenatal Care; Maternity Behavioral Health
Risk Assessment; Ongoing Prenatal Care; LBW
– Infancy, Childhood and Adolescence: Access to Primary Care, Well-Child
Visits for Infants, Children and Adolescents; Lead Screening, Immunizations;
HPV Vaccine Use; Weight Assessment and Counseling for Nutrition and
Physical Activity; Developmental Screening; Preventive Dental Services;
Testing for Pharyngitis; Treatment for URIs; Follow-Up for ADHD
• GF 360 Data – Members enrolled on March 3, 2014 – baseline
performance year for the program.

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Successes and Opportunities – GF and GF 360
Successes
• Prenatal Visit within 1st
trimester
or 42 days of enrollment – 79%
- 82%
Opportunities
• Ongoing prenatal visits 81% or
greater expected – 48% - 58%
• BH Risk Assessments at first
visit for Pregnant Women
(depression, alcohol, tobacco
use, drug use, intimate partner
violence) – 0% - 10%; GF 360
= 3.6%
• LBW rate – 8.9% - 9.2%
• GF 360 Prenatal Visit within 1st
trimester = 47%

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Successes and Opportunities – GF and GF 360
Successes
• Access to PCP for 12 – 24 mos > 97%;
GF 360 = 96%
• Access to PCP for 25 mos – 6 yrs = 90%
- 91%; GF 360 = 86%
• GF Access to PCP for 12 – 19 yrs = 89%
- 91%; GF 360 = 79%
• Childhood Imm by age 2 = 79% - 84%
• Lead Screening – 78% - 81%
Opportunities
• Well Child Visits – six or more in first 15
mos = 65% - 67%; GF 360 = 43%
• Annual WCV for 3 - 6 yrs = 67% - 74%;
GF 360 = 70%
• Annual Adolescent WCVs for 12 – 21 yrs
= 49% - 53%; GF 360 = 46%
• BMI – 54% - 69%; Counseling for
nutrition – 59% - 65%; Counseling for
physical activity – 53% - 60%; GF 360 =
39%, 35%, 32%
• GF 360 Childhood Imm by age 2 = 45%
• GF 360 Lead Screening = 64%
Blue measures linked to EPSDT and Bright Futures

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Successes and Opportunities – GF and GF 360
Successes
• Adolescent Immunizations
(Mening & Td) – 76% - 80%
• Appropriate Testing for
Pharyngitis – 79% - 81%
• Annual Dental Visits – 67% -
69%; GF 360 = 75%
Opportunities
• HPV Vaccine (3 doses by age
13) – 20% - 25%
• 30 d Follow up Care for ADHD
(6 – 12 yo) – 44% - 49%; 9 mo
Follow Up – 58% - 64%
• Appropriate treatment for
children with URI – 83% - 86%
• Developmental screening –
38% - 46%; GF 360 = 24%

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Continuous Improvement
• Child-focused Performance Improvement Projects
in place with the CMOs that focus on improvements
in preventive service utilization, dental service
utilization, ADHD follow up, and postpartum visits to
reduce LBW rates.
• DCH and our partners are working collaboratively to
improve the health outcomes for our members.

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Questions
Contact Information:
Janice Carson, MD
Assistant Chief
Georgia Department of Community
Health
Division of Medical Assistance Plans
jcarson@dch.ga.gov
404-463-2832