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us-ga/policy/cms/chip-state-plan/spa · Axiom

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 t . M Ls

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 2 0 2015

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department Community Health 2 Peachtree, N.W., 37" Floor

Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number GA-13-0016 submitted on November 14, 2013, with additional information provided on May 19, 2015. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number GA-13-0016, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. The first CS10 page uses the maintenance of agency contribution criteria to allow CHIP coverage for children of State Health Benefit Plan employees, and the second CS10 page uses the hardship exception criteria to allow CHIP coverage for children of the Board of Regents employees. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled as targeted low- income children in CHIP and children deemed eligible in another state. These approved pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income counting

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, 4.1.3: Supersede all CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on Employee Coverage dependents of employees of a public agency CS10: Maintenance of Agency Contribution Appendix: Supersede current documentation (State Health Benefit Plan Employees) CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on Employee Coverage dependents of employees of a public agency

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OMB Control Number: 0938-1148 iration date: 10/31/2014

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (1 Include a prorated portion of the reasonably predictable increase in future income and/or family size. (J Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

1 attachment is submitted. a

PRA Disclosure Statement

SPA# GA-13-0016 Approval pate__ MAY 20 2015 —

Effective Date: January 1, 2014 Page | of 2

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CHIP Eligibility

State Name:|Georgia | OMB Control Number: 0938-1148

Transmittal Number: GA - 13 - 0016 Expiration date: 10/31/2014

S10

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

aw Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to children whose household income is:

Select one of the options for the income standard when compared to Targeted Low Income Children

@ The same as the standards for Targeted Low-Income Children

C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

C All children who have access to public employee coverage @ Certain children who have access to public employee coverage:

Employees of certain public agencies.

Type of agency

State Health Benefit Plan Employees x

(] Certain types of public employees.

[i] Attach methodology the state has used to calculate maintenance of agency contribution.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore.not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

MAY 20 2015

SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

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CHIP Eligibility

State Name:|Georgia | OMB Control Number: 0938-1148 Transmittal Number: GA - 13 - 0016 Expiration date: 10/31/2014

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

wl Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: C Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA.

@ Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children

@ The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

C All children who have access to public employee coverage @ Certain children who have access to public employee coverage:

Employees of certain public agencies.

Type of agency

F ||Board of Regents x

(C1 Certain types of public employees.

[m@] Attach methodology the state has used to calculate financial hardship.

"Am attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate the financial status to determine if the hardship condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

MAY 2 6 2015

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CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2112(e) of the SSA and 42 CFR 457.360

Cl Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one.

The state operates this covered group in accordance with the following provisions: [m] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

a The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

Ba The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the requirements of section 2112(e) of the SSA.

oO The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# GA-13-0016 Approval vate, MAY 20 2615

Effective Date: January 1, 2014 Page | of |

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CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[i] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision,

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

A The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

first renewal applying MAGI methods. The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

% FPL.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program.

@ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their

SPA# GA-13-0017 Approval Date: FEB 0 6 aura Effective Date: January 1, 2014

Page | of 2

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CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457. subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard:

P| The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single. stream lined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. [2] Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

wl Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs: and

fa] Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as otentially eligible for Medicaid or other insurance afforgabjlity programs based on household income; and p y elig fp vi ra ais

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cms CHIP Eligibility

A A

Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the plicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[MH] Once every 12 months.

mw Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [Mf] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals

screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.34 8(b)-and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

‘esta nt

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

FEB 2 1 2014

SPA# GA-13-0018 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

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Georgia Department of Human Services

Application for Benefits

cit

‘Georgia Department ‘of uman Services

If you need help filling out this application, ask us or call 1-877-423-4746. If you have a hearing impairment, call GA Relay at 1-800-255-0135. Our services are free.

What Services Do We Offer at the Division of Family and Children Services (DFCS)?

DFCS offers the following services:

Food Assistance

Food Stamps are benefits that you can use to buy food at any store that has the EBT/Quest sign. We will subtract the price of your food purchase from your Food Stamp account.

Cash Assistance/Employment Support Services Temporary Assistance for Needy Families (TANF) provides cash assistance to families with dependent children for a limited time. Parents or caretakers who are included in the grant are required to participate in a work program.

Cash Assistance program also provides financial assistance to refugee households who are not eligible for the TANF program.

Medical Assistance Medicaid, for those who are eligible, may help pay medical bills, doctor's visits, and Medicare premiums.

Community Outreach Services

For more information about Community Outreach Services, please

visit our website at: http://www.dfcs.dhr.georgia.gov or call 1-877- 423-4746.

“Giessen How Do | Apply for Benefits? Step 1. Fill out the application.

Read the questions carefully and give accurate information. Sign and date the application.

Step 2. Turn in the application. You will need to tear off pages 1 and 2 and keep it for yourself.

Mail, fax, or bring in pages 3-6 of this application to your local Division of family & Children Services (DFCS) office. If you or the person for whom you are applying is eligible for benefits, Food Stamps or TANF benefits will be provided from the date thatwe receive the application with your name, address, and signature on it.

If you apply for Food Stamps, and/or Medicaid you can file an application for benefits with only your name, address and signature. However, it may help us to process your application quicker if you complete the entire form.

Step 3. Talk with us. You may need to complete an interview with a case manager. If so,

we will give you an appointment. This interview can be completed by phone.

Form 297 (Rev. 03/12) 1

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“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is also prohibited on the basis of religion or political beliefs.”

To file a complaint of discrimination, you may contact USDA or HHS.

Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9411 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).

Write HHS, Director, Office of Civil Rights, Room 509-F, 200 Independence Avenue, S.W., Washington, D.C., 20201 or call (202) 619- 0403 (voice) or (202) 619-3257 (TTY).

USDA and HHS are equal opportunity providers and employers

You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, N.W., Suite 19- 248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404) 463-3978.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health's Office of Program Integrity (local 404-463-7590) (toll free) 800-533-0686.

What Do the Words Used in this Application Mean? This chart explains the words we have used in this application.

Caretaker

Aparent, relative or legal guardian who applies for and receives TANF with children in his or her care.

Grantee Relative

A parent, relative or legal guardian who applies for and receives TANF in his or her name on behalf of the children.

Disqualified

The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the truth and received benefits that they should not have received.

Electronic Benefit Transfer (EBT)

The system used in Georgia to pay benefits to individuals who are eligible for Food Stamps or TANF. Individuals receiving assistance are issued an EBT debit card, which is used to withdraw cash benefits and to access their food stamp accounts.

Household Members

Individuals who live in your home.

Income

Payments such as wages, salaries, commissions, bonuses, worker's compensation, disability, pension, retirement benefits, interest, child support or any other form of money received

Migrant Farm Workers

Individuals who are seasonal farm workers and move from one home base to another to work or look for farm work

Resources

Cash, property, or assets such as bank accounts, vehicles, stocks, bonds, and life insurance

Seasonal Farm Workers

Individuals who work at certain times of the year planting, picking or packing produce. They are hired on a temporary basis when a job requires more workers than the farm employs on a regular basis

Trafficking

Selling or trading Food Stamp benefits for profit

Qualified Alien/Immigrant

A qualified alienimmigrant is a person who is legally residing in the U.S. who falls within one of the following categories: a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act (INA); Amerasian immigrant under section 584 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees, admitted under section 207 of the INA; A person paroled into the US under section 212(d)(5) of the INA for at least one year; A person whose deportation is being withheld under section 243(h) of the INA as in effect prior to April 1, 1997 , or section 241(b)(3) of the INA, as amended; a person who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980; Cuban or Haitian immigrants as defined in section 501(e) of the Refugee Education Assistance Act of 1980; victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000; battered immigrants who meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, as amended; Afghan or Iraqi immigrants granted special immigrant status under section 101(a)(27) of the INA (subject to specified conditions); American Indians born in Canada living in the U.S. under section 289 of the INA or non-citizens of federally-recognized Indian tribe under Section 4(e) of the Indian Self-Determination and Education Assistance Act and Hmong or Highland Laotian tribal members that rendered assistance to U.S. personnel by taking part in military or rescue operation during Vietnam Era (8/05/1964 — 5/07/1975).

Applicant

An individual who chooses to apply for or to receive public assistance/benefits

Non-applicant

An Individual who chooses NOT to apply for or to receive public assistance/benefits; non-applicants are not required to provide an SSN, citizenship or immigration status.

Assistance Unit

An assistance unit includes eligible individuals who live together and receive public assistance/benefits together.

Form 297 (Rev. 03/12)

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information about his or her citizenship, immigration status, or social security numbers, then that person can be designated as a non-applicant. This means that the person will not be considered an applicant and will not be eligible for benefits. However, other household members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. You will still need to tell us about your income and resources to determine the eligibility and benefit level of the household. Individuals will not be reported to the United States Citizenship and Immigration Services if they do not give us their citizenship or immigration status.

NAME Relation Is this Birth Social Security | Sex Hispanic/ Race Are you a U.S -ship person Date Number Latino? Code citizen, qualified First Middle Initial Last to You applying alien/immigrant for or benefits? (Optional) | (Optional) | Hmong/Highland Laotian Immigrant? (Applicants only) (Y/N) Format (Applicants (See codes (--1--1--) Only) (MIF) (YIN) Below) (YIN) SELF

Race Codes (Choose all that apply): : Al — American Indian/Alaska Native AS — Asian BL — Black/African American HP — Native Hawaiian/Pacific Islander WH — White

By providing Race/Ethnicity information, you will assist us in administering our programs in a non-discriminatory manner. Your household is not required to give us this information and it will not affect your eligibility or benefit level.

Tell Us More about the Applicant and All Household Members

We need more information about the applicant and all household members in order to decide who is eligible for benefits. Please answer only the questions about the benefits you want to receive on the page below.

1. Has anyone received any benefits in another county or state? Q Yes O No Who: What: Where: When:

2. Did anyone in your house hold voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week since the last application or review? Q Yes Q No

If yes, who quit? Why did he/she quit?

Form 297 (Rev. 03/12) 5

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Cems. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [M] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

ry An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[Ml A child who is a ward of the state regardless of where the child lives, or

im A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [®] A non-institutionalized pregnant woman who is living in the state and:

1, Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

= An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

rh An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

rl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

Approval Date: FEB 0 6 2014

SPA# GA-13-0019

Effective Date: January 1, 2014 Page | of 2

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CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

S18

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[Bf] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirem ents of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380 .

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date . ee . Perris Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

(@ Other date, as described:

The month following the date that all other eligibility requirements are met and any required premiums are paid. (Citations: Georgia State Plan: Section 2.2, Page 6, Section 4.3, Page 3)

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state N also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- °

Income Pregnant Women. FEB it] 6 2014

SPA# GA-13-0019 Approval Date:

Effective Date: January 1, 2014 Page | of 2

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Cems. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established reli gious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

im The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[| The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their

SSN. [yes

When requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

ry The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

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ornate a

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services jn C* M Ss

7500 Security Boulevard, Mail Stop S2-01-16 CENTER om MEDICARE & MEDION vices Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 3 2016

Dr. Linda Wiant

Chief of the Medicaid Assistance Plans

State of Georgia, Department of Community Health 2 Peachtree Street, NW, Suite 36450

Atlanta, GA 30303

Dear Dr. Wiant:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) GA-15-0021, submitted on December 31, 2015, has been approved. Through this SPA, Georgia eliminates its Express Lane Eligibility (ELE) program. This SPA has an effective date of April 1,2016. ELE is also eliminated in Medicaid, effective March 31, 2016.

Georgia implemented ELE on April 1, 2011 through a partnership with the Special Nutritional Assistance Program for Women, Infants, and Children (WIC). Georgia’s ELE program is no longer needed due to the implementation of the state’s integrated human services and health programs eligibility system, which assesses individuals’ eligibility for Medicaid, CHIP, WIC and other programs through a single application.

Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lagorio’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-4554

Facsimile: (410) 786-5943

E-mail: Cassandra.Lagorio@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Jackie Glaze, Associate Regional Administrator in our Atlanta Regional Office. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909 + |

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.1 Page: 1

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

Of the 2,219,179 children in the state, Georgia estimates (using the Current Population Survey data from 2000) that 193,558 are without any creditable coverage. Of the 2.03 million who do have creditable coverage, 912,116 (almost half) have coverage through Georgia Medicaid. The 193,558 without coverage includes 141,489 children with income below 235% of the FPL. Of these children, 104,446 could be eligible for the Medicaid program. The other 37,043 are potentially eligible for PeachCare for Kids. FPL changed to 247% of FPL January 2014.

When compared to figures from the 1993-1995 period, the current data show that while the number of children in the state has grown by about 10%, the number of children without coverage has declined by about 40%. Part of this improvement is due to a decrease in the number of Medicaid eligible uninsured children from 39% to 24%, and a decrease in the number of PeachCare eligible uninsured children form 32% to 6%. The remaining uninsured children, whether eligible for PeachCare or Medicaid, will be targeted for enrollment through the state’s marketing and outreach efforts.

The estimates of children with creditable coverage in the following table are based on the Current Population Survey and are submitted as requested to allow comparisons to be made between states and on a nationwide basis. The sources of the data are the Current Population Survey for the year 2000, and the combined tape 1994, 1995, 1996 (data for years 1993, 1994, 1995).

Unfortunately at this time we are unable to examine the insurance status of children in Georgia by income level, age, race, and location for the year 2000. The Census has only released a small sample of records for Georgia at this time. Due to the small sample size it is unadvisable to estimate the numbers of uninsured eligible children within each demographic grouping. The Census is

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 1

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

PeachCare for Kids®

PeachCare for Kids’ outreach effort was launched in September 1998. Outreach initiatives have included a wide array of mass-media and local grassroots efforts. PeachCare for Kids has had massive advertising, in both English and Spanish, through television, radio, newspaper, and outdoor billboard and transit advertising. In 2001 and 2002, PeachCare has teamed up with WSB Channel 2’s, Atlanta’s ABC affiliate, Family 2 Family Community Program. Through this partnership, PeachCare for Kids is able to participate in hundreds of family-oriented community events in the metro Atlanta area. PeachCare also benefits from the extensive public service campaigns.

In 2000, the Department created a “minigrant” program to facilitate grassroots efforts to educate targeted populations about PeachCare for Kids and Medicaid. The grantee organizations were diverse in the populations they served, including African-American, Hispanic, Asian and rural communities. An evaluation of the grantees showed a 16% increase in applications submitted over other similar counties during the same time, and a 19% increase in applications for the targeted populations.

In 2000, 2001, and 2002, the Department has teamed up with the Department of Education, Division of School Nutrition Services to distribute flyers, in English and Spanish, to each student during Back-to- School registration. The Right from the Start Medicaid (RSM) outreach

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 2

staff worked with many elementary schools to be on site promoting PeachCare for Kids and Medicaid to the parents.

PeachCare for Kids®, RSM, March of Dimes and Kmart stores partnered in 1999 and 2000 to promote PeachCare for Kids and Medicaid. In 1999, outreach workers were at each Kmart store on the Saturday before Halloween educating parents while their children shopped for costumes and treats. In 2000, the outreach workers returned to Kmarts on the Saturday before school started to talk to parents as they were getting their kids ready for the new school year.

The Department has created a simple, one-page mail-in application for PeachCare for Kids, available in English, Spanish, Vietnamese, Chinese, Korean and Somalian. The application is distributed by request through the PeachCare for Kids call center and throughout the state in many hospitals, provider offices, Department of Families and Children offices, health departments, and libraries.

In 2001, the Department launched www.peachcare.org, a web-based application designed to provide parents with instant access to complete the enrollment process. In its first year, applications have been received for nearly 40,000 children through the website. The site has also been successful reaching families of Medicaid-eligible children. Nearly half of all web-based applicants have been eligible for the Medicaid program. The advantages of the website are numerous. It eliminates mail delays. It provides parents with instant confirmation that the application has been received and gives parents an estimation of potential eligibility. The website also generates a list of participating primary care physicians to assist parents in the selection of a doctor for their child.

Division of Family and Children Services (DFCS)

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 3

are offered by DFCS. DFCS is also responsible for Food Stamps, Temporary Assistance for Needy Families (TANF), Child Protective Services and Foster Care. The Medicaid application process is coordinated with that for cash assistance and employment related services available through TANF. Children in families seeking these services also have their Medicaid eligibility determined. The State of Georgia has 159 counties. Each county has at least one DFCS office, and some counties have multiple sites for Medicaid eligibility intake. Some workers from these local DFCS offices are assigned to Federally Qualified Health Centers (FQHCs) and Disproportionate Share Hospitals.

While the bulk of the state’s Medicaid determinations are made locally at the county DFCS offices, the RSM Outreach Project is an aggressive outreach program targeted at enrolling uninsured and underinsured poverty level pregnant women and children in Medicaid and PeachCare. This project operates under a separate interagency agreement between the Department of Community Health and the Department of Human Resources. The eligibility workers who are part of this project are housed in locations other than the local DFCS offices.

Public Health Departments and Federally Qualified Health Centers

DCH also coordinates Medicaid enrollment efforts with the activities of the Division of Public Health, a part of the Department of Human Resources. Across the state, perinatal case management services and the Medicaid application process are linked. At the public health departments and federally qualified health centers, a pregnant woman can apply for Presumptive Medicaid eligibility, and begin receiving prenatal services immediately. As part of this process, the pregnant woman applies for RSM Medicaid to ensure ongoing Medicaid eligibility. When the pregnant woman applies for RSM, any children in the family are also included on the application form and the form with the children’s names are routed to

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 4

DFCS for a determination of their eligibility along with that of the pregnant woman.

Express Lane Eligibility was implemented effective April 1, 2011 and ended April 1, 2016

(1902 (e) (13) of the Social Security Act). The program partnered with the Special Nutritional Assistance Program for Women, Infants, and Children (WIC) to implement the program.

Other State Initiatives For Special Needs Children

The following programs are some of the State’s own initiatives to provide health care to special needs children. All are administered by the Department of Human Resources, three by the Division of Public Health, two by the Division of Mental Health, Mental Retardation and Substance Abuse and one by an interagency team. As mentioned previously, RSM outreach workers are stationed in many county public health departments or visit on a routine basis to process Medicaid applications. Uninsured children who present to these programs for their services are referred to outreach workers or county DFCS offices to have a Medicaid eligibility determination completed.

Division of Public Health “Babies Can’t Wait”

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 5

individuals from both the public and private sectors. Some are offered at no cost. For others, state funds are available to assist families that have been determined unable to pay. Medicaid eligible children may participate in this program.

Children’s Medical Services

Children’s Medical Services (CMS), formerly the Crippled Children’s Program, provides medical care to low income children with disabling conditions or chronic diseases. It also provides specialized health care for certain disorders, e.g., chronic lung disease, craniofacial anomalies, and cystic fibrosis. Eligibility is based on the age of the child ( 0-21 years), type of medical condition, Georgia residency and annual family income. Some services are covered by Medicaid and Medicaid eligible children may participate in this program. CMS serves approximately 15,000 to 16,000 children yearly.

Department of Behavioral Health and Developmental Disabilities

Core and Specialty Services include evaluation/assessment, diagnosis, counseling and medication, therapy (individual, group, and family), community support services, crisis assessments, and physician services. These services are provided in clinics and other locations as needed, including homes, schools, detention facilities, and other community settings.

Crisis Services include crisis stabilization and mobile crisis response services.

Mobile Crisis Response Services (MCRS) provides community-based, face-to-face crisis response 24 hours a day, seven days a week to individuals in an active state of crisis. MCRS offers short-term, behavioral health services for persons in need who may have been unable to successfully maintain stability.

Psychiatric Residential Treatment (PRTF) Services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults ages 5-21 who, due to severe emotional disturbance, are in need of quality active treatment that can only be provided in an inpatient treatment setting and for whom alternative, less restrictive forms of treatment have been tried and found unsuccessful or are not medically indicated.

Uninsured children who present to these programs for their services are

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 6

referred for a Medicaid eligibility determination, but services are provided to uninsured or underinsured children on a sliding fee scale and are not denied due to inability to pay.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

The State of Georgia has one public-private program designed to provide health care to uninsured children; however, this program does not offer “creditable coverage.” The PeachCare for Kids and Medicaid program’s eligibility processes have a significant role in the efforts of the program. The application process for The Georgia Partnership for Caring Program begins with the RSM Outreach Project worker.

Georgia Partnership for Caring Foundation

The Georgia Partnership for Caring Foundation (GPCF) was established in 1994 and represents a unique partnership between state government and the private sector. The mission of GPCF is to establish a free health care referral program for Georgians who cannot afford private health insurance but are not eligible for governmental medical assistance such as PeachCare for Kids, Medicaid or Medicare. Funding has been provided by grants from individuals, associations, and the Departments of Human Resources and Community Health.

The program includes the limited voluntary services of physicians, nurse practitioners, dentists, ophthalmologists, optometrists, physician’s assistants, hospitals, pharmacists, pharmaceutical manufacturers, and many health provider groups and agencies. These volunteers are not paid for their services or products, but are committed to assisting Georgians obtain access to needed health care coverage. The program is available in about three-fifths of Georgia’s counties. GPCF is not insurance coverage. It is not for emergencies or urgent care situations. Application processing time averages 1 month. As previously stated, RSM outreach workers are involved in the referral and application process for GPCF. They perform the screening function to determine that individuals who are referred to GPCF are not eligible for Medicaid.

The Georgia Partnership for Caring Program ended in 2010.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.3 Page: 1

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

As part of its effort to decrease the number of uninsured children, Georgia targets children who are under the age of nineteen (19), who have family income that is at or below 235% of the Federal Poverty Level (FPL), and who do not have other creditable health coverage. PeachCare for Kids health benefit coverage is provided to these children through a state child health insurance program that is administered by the DCH, the same agency that administers the Medicaid program.

PeachCare enrolls only eligible, targeted low-income children because marketing, outreach and eligibility determination efforts will be completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be enrolled in Medicaid rather than PeachCare. The marketing and outreach efforts target all children at or below 235% of the FPL. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers have a variety of program information on both creditable and non-creditable coverage and other ways to access health care services. The order of priority for the outreach workers is first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation, and DHR public health care programs and services. The marketing and outreach efforts are coordinated with community based organizations and health care providers.

Applications for PeachCare for Kids contain the information necessary to determine eligibility for Medicaid as well as for PeachCare for Kids. Applications are mailed to and processed by a Third Party Administrator (TPA) at a centralized location. As part of the eligibility determination process, the TPA screens applications for Medicaid eligibility before determining eligibility for PeachCare for Kids. If a child or children on the application appear to possibly be eligible for Medicaid, the application for that child or those children is processed by RSM workers. The processing provides for investigation and verification of both the financial and non- financial requirements for the Medicaid program. If the child or

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Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The PeachCare for Kids® legislation mandates that “Any health care provider who is enrolled in the Medicaid program shall be deemed to be enrolled in the program.” Therefore, the current Medicaid health assistance delivery and utilization control system is the system used for PeachCare for Kids. Service delivery is accomplished through a variety of relationships and agreements with private medical providers and state agencies.

The PeachCare for Kids legislation allows the DCH to contract with licensed care management organizations (CMOs) as a condition of receiving coverage under the program. As a condition of participation, all enrolled providers in each category of service must be fully licensed and/or certified under all applicable state and federal laws to perform the services provided to participants.

Georgia Families

PeachCare for Kids® members will be enrolled in a commercially licensed care management organization (CMO) that is contracted by DCH. Membership in Georgia Families (GF) is mandatory for all PeachCare for Kids® members and most pregnant women and children eligible for Medicaid.

Through GF, each CMO contracts with primary care physicians, specialists and other providers to deliver and coordinate health care services for PeachCare for Kids members. The CMO receives a per member per month capitation rate for providing and coordinating members’ health care services, regardless of whether the member is seen.

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Five key goals of the program are to (1) improve the health care status of enrolled populations (2) Establish a “provider home” for Members through its use of assigned Primary Care Providers (PCPs) (3) Establish contractual accountability for access to, and quality of, healthcare (4) Slow the rate of growth in PeachCare costs (4) Implement an intelligent health system where members have accurate, timely knowledge of their health needs, access to the best information about how to maintain their health, knowledge of who and where to go if they have health needs, and an assurance that their health providers will be using best practices based on the most recent understanding of outcomes based medicine.

Members are given an opportunity to select a CMO in his or her area as well as a PCP within that CMO. For those who do not make a selection, a computer algorithm is used to assign a member to a CMO. Conditioned on continued eligibility, all members will be enrolled in a CMO plan for a period of twelve (12) consecutive months. The member has 90 days to change CMO plans before the continuous enrollment period or lock-in period begins.

The contracted CMOs must assure that PeachCare for Kids members are offered freedom of choice in selecting a PCP. Each contracted CMO includes in its network of PCPs physicians who routinely provide primary care services in the areas of Family Practice, General Practice, or Internal Medicine. Also, Nurse Practitioners Certified (NP-C) specializing in Family Practice or Pediatrics may enroll as PCPs. Finally, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) may be included as PCPs.

In the event a PCP is auto-assigned, the member may change to another PCP by making a PCP selection and requesting the change. The contracted enrollment broker handles the CMO assignment functions (both self-selection and auto-assignment).

Payment Methodologies of FQHC/RHC Unit

Our providers are paid the Prospective Payment Method (PPS) or Alternative Payment plan method. When a Federal Qualified Health Center (FQHC) and/or Rural Health Clinic (RHC) application is received from DCH Enrollment unit, they are paid utilizing the PPS method. Only the Critical Access Hospital RHC’s (CAH RHC) are given the option of choosing the PPS method or the Alternative method of payment.

PPS Rate Method

The basis of the PPS reimbursement is providing for “core” services and other ambulatory services per encounter visit cost during FY 1999 and FY 2000. This

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baseline rate, effective January 2001, is utilized as the basis for rates in succeeding years. Annually, each FQHC/RHC’s per visit rate is calculated by adjusting the prior year’s rate by the Medical Economic Index (MEI). The MEI is announced in Recurring Update Notifications (RUNs) issued by Centers for Medicare and Medicaid Services (CMS) each year.

For newly qualified FQHCs and RHCs that participate in PPS payments after FY 2000 have their rates established by a statewide average for similar centers. Similar meaning, all FQHCs, hospital based RHCs, and free standing RHCs; each have an average state rate. After the initial year, payment will be set using the MEI and change of scope methods used for other clinics.

Change of Scope

A change in scope of services for a FQHC and RHC is defined as a change in the type, intensity, duration and/or amount of services. It is the clinics responsibility to recognize any changes in their scope of services and to notify the Department of those changes and to provide documentation and projections of the cost and volume impact of the change. Once all documents are received, a review of clinic activity is completed. This may happen once a year.

Alternative Payment Method

This method is only available to critical access hospital RHCs; they have the choice of the PPS method of payment listed above or the Alternative Payment Method (APM). The APM is a cost based reimbursement method. The Department will calculate the settlement based on the hospital cost report. If the hospital cost is lower than the equivalent PPS rate, the Department will make the additional payment up to the equivalent of PPS rate. This information is derived from the latest cost report and the critical access hospital reports (HS&R reports) for the same period. The Department reviews CAH-RHC activity annually to determine if payment is due to the hospital from the Department or if the hospital owes the Department for over payment.

Settlement Calculation

Annually the department obtains the latest available cost report as well as the hospital statistical and reimbursement report (HS&R reports) from each CAH-RHC. The new percentage is derived from the information from the cost report annually. The comparison of cost to expenses is obtained from the HS&R reports. The amount the Department paid to the CAH-RHC as well as the number of visits are obtained from the HS&R reports. The visits are multiplied by the PPS rate (normally the state average) to determine what the PPS total amount would have been if chosen by the clinic. The reimbursement amount is compared to the PPS amount

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3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Reimbursement Limitations

The federal government allows DCH to place appropriate limits in regard to medical necessity and utilization control. Reimbursement limitations such as prior approval requirements, service limitations, non-covered procedures, and eligibility limitations are used by DCH to guarantee appropriate utilization of funds.

Georgia Families

• Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-utilization and under- utilization. Such protocols and criteria comply with Federal and State laws and regulations. • Address which services require PCP Referral; which services require Prior-Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review. • Describe mechanisms in place that ensure consistent application of review criteria for authorization decisions. • Require that all Medical Necessity determinations be made in accordance with DCH’s Medical Necessity definition.

Georgia Families also provides care coordination, case management, disease management, clinical outcome studies, and physician incentive programming.

Specifically, each CMO must provide individual needs assessment and diagnostic assessments; develop individual treatment plans, as necessary, based on the needs assessment; establish treatment objectives; monitor outcomes; and maintain a process to ensure that treatment plans are revised as necessary. The CMOs must also guarantee a strategy is in place to ensure that

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Superseded by ACA SPA

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 21 02)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.0.  Non-Financial Eligibility – Citizenship

4.1.1.  Geographic area served by the Plan: Georgia’s Title XXI plan is available statewide to children in all 159 Georgia counties

4.1.2.  Age: The plan will be available to children 0 through 18 years of age. If the child is otherwise eligible, coverage will continue through the month of his/her nineteenth birthday.

4.1.3.  Income: Eligible children will have family income that is at or below 235% of the federal poverty level and will not be eligible for Medicaid.

4.1.4.  Resources (including any standards relating to spend downs and disposition of resources): There is no resource test.

4.1.5.  Residency (so long as residency requirement is not based on length of time in state): Georgia residency is required. Residency is based on current circumstances. There is no requirement that a child must live in Georgia a specified length of time prior to application.

Non-Financial Eligibility – Residency

4.1.6.  Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child will be denied eligibility based on disability status.

4.1.7.  Access to or coverage under other health coverage: A child will be denied eligibility if it is determined that he or she: 1) is covered

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Superseded by ACA SPA under a group health plan or under health insurance coverage as

defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The CHIP application will contain questions about current and past coverage under group health plans. Access to State health benefits will be verified through monthly matches with the State Merit System and the Board of Regents. In addition, as claims are paid, if the providers report coverage under other health plans, eligibility will be terminated if the coverage meets any of the three criteria listed above.

4.1.8.  Duration of eligibility: With the approval of the PeachCare application, a child will be eligible for twelve months as long as eligibility criteria continue to be met. The family will be notified of its responsibility to report changes in income, residency or health insurance coverage. There will be monthly matches with the Medicaid MMIS to ensure that Title XXI children have not been certified for Medicaid. At the end of the twelve-month eligibility period, the family will be sent a letter detailing the information on the family’s account pertinent to eligibility. The family will be required to report any changes to the information and provide verification of all sources of income at this time. Eligibility will be redetermined for another twelve-month period so long as the family provides the required documentation within the requested timeframe.

4.1.9.  Other standards (identify and describe):

• Consistent with 42 CFR 457.340(b), PeachCare does not require Social Security numbers for any applicant. Eligibility is not denied for failure to provide a Social Security Number; however, Social Security Numbers are requested of individuals listed on the application.

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4.3. Describe the methods of establishing eligibility and continuing entart Medicaid program (Title XIX Poverty Level Group).

DCH contracts with a Third Party Administrator (TPA) who is responsible for receiving PeachCare applications, screening for Medicaid eligibility, determining PeachCare eligibility, processing monthly premium payments and coordinating coverage between PeachCare and Medicaid for applicant children who qualify for either the Title XIX or Title XXI program.

APPLICATION

PeachCare for Kids has a single-page mail-in application form and a web-based enrollment process that is available for families to quickly and easily apply for health care coverage for their children. Both the mail-in and web-based applications can be used to enroll children in either Medicaid or PeachCare for Kids, depending on each child’s eligibility. The PeachCare application gathers information about the applicant children and their parents. Requested information includes:

• Documentation of amount, frequency and source of earned and unearned income • Amount, frequency and source of child care expenses • Health insurance status of family members • Current address • U. S. Citizen/Lawful Alien Status of children

VERIFICATION OF INCOME, CITIZENSHIP/LEGAL RESIDENCY AND IDENTITY

Beginning July 1, 2007, all PeachCare applicants are required to provide verification of income, citizenship/legal residency and identity. The application

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directs families to send in the most recent proof of all earned and unearned income sources. The following documentation is requested:

A. Earned Income - money anyone in the household received from providing a service. • Weekly pay – (4) weeks of pay stubs (one week after the other) • Bi-Weekly pay – (2) pay stubs received every other week (one after the other) • Semi-Monthly – (2) pay stubs received two times a month (one after the other) • Monthly – (2) pay stubs received one time a month (one month after another) • Yearly – Federal Tax Form • Paid in cash-letter from Employer provided by an Officer of the Company. Must be provided on Company letterhead.

Self-employment documents: • business ledger/receipts • tax forms- 1040, 1040A, 1040EZ • bank deposits • applicant/recipient's signed statement if neither of the above is available.

NOTE: Assume that any deductions taken on a tax return or business record is allowable by the Internal Revenue Service.

Document the case record as to why federal income tax returns or business records were not used if the A/R’s statement was accepted as verification.

B. Unearned Income –money anyone in the household received from any agencies, parents or relatives, friends, or any other sources. a. SSI or SSA – Current year or most recent award letter b. Unemployment check – (4) weeks of pay stubs (one week after the other) or award letter c. Workman’s Compensation – letter from insurance company stating amount received and how often received, provide contact name and number d. Child Support (paid through court) – court papers or letter stating amount of income received and how often it is received. e. Contributions – written statement from the person who gives you money. Provide name, address, and contact number. Provide amount received and how often received f. Child Support (paid directly to custodial parent) – written statement from

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the parent who pays the child support to the applicant/recipient-. Provide the name, address, and contact number. Provide amount received and how often received. g. Other Unearned Income – letter from the source stating amount received and how often received. Provide name, address, and contact number or (4) weeks of pay stubs (one week after the other)

C. Citizenship/Identity/Legal Residency

For determining deemed newborn status, the TPA performs a data match with Georgia’s MMIS files to determine whether the applicant’s mother was Medicaid eligible per the date of the child’s birth. If citizenship cannot be verified through data match with vital records or MMIS records, the applicant is then required to submit a form of acceptable documentation as outlined in CFR 435.407.

The following groups of individuals are exempt from the requirements:

• Individuals receiving SSI benefits under title XVI of the Act. • Individuals entitled to or enrolled in any part of Medicare. • Individuals receiving disability insurance benefits under section 223 of the Act or monthly benefits under section 202 of the Act, based on the individual's disability (as defined in section 223(d) of the Act). • Individuals who are in foster care and who are assisted under Title IV-B of the Act, and individuals who are recipients of foster care maintenance or adoption assistance payments under Title IV–E of the Act.

Types of acceptable documentary evidence of citizenship.

For purposes of this section, the term “citizenship” includes status as a “national of the United States” as defined by section 101(a)(22) of the Immigration and Nationality Act

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(8 U.S.C. 1101(a)(22)) to include both citizens of the United States and non-citizen nationals of the United States.

(a) Primary evidence of citizenship and identity. The following evidence must be accepted as satisfactory documentary evidence of both identity and citizenship:

(1) A U.S. passport. The Department of State issues this. A U.S. passport does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation .Note: Spouses and children were sometimes included on one passport through 1980. U.S. passports issued after 1980 show only one person. Consequently, the citizenship and identity of the included person can be established when one of these passports is presented. Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity.

(2) A Certificate of Naturalization (DHS Forms N–550 or N–570.) Department of Homeland Security issues for naturalization.

(3) A Certificate of U.S. Citizenship (DHS Forms N–560 or N–561.) Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.

(4) A valid State-issued driver's license, but only if the State issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number from the applicant and verifies before certification that such number is valid and assigned to the applicant who is a citizen. (This provision is not effective until such time as a State makes providing evidence of citizenship a condition of issuing a driver's license and evidence that the license holder is a citizen is included on the license or in a system of records available to the Medicaid agency. The State must ensure that the process complies with this statutory provision in section 6036 of the Deficit Reduction Act of 2005. CMS will monitor compliance of States implementing this provision.).

(5) A Tribal document issued by a federally recognized Indian tribe evidencing membership, enrollment in, or affiliation with such Tribe is satisfactory documentary evidence of an individual’s U.S. citizenship or nationality.

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(1) A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain's Island, or the Northern Mariana Islands (after November 4, 1986 (NMI local time)). A State, at its option, may use a cross match with a State vital statistics agency to document a birth record. The birth record document may be issued by the State, Commonwealth, Territory, or local jurisdiction. It must have been recorded before the person was 5 years of age. A delayed birth record document that is recorded at or after 5 years of age is considered fourth level evidence of citizenship. (Note: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories.) The following will establish U.S. citizenship for collectively naturalized individuals:

(2) A Certification of Report of Birth (DS–1350). The Department of State issues a DS– 1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS–240. When the birth was recorded as a Consular Report of Birth (FS–240), certified copies of the Certification of Report of Birth Abroad (DS–1350) can be issued by the Department of State in Washington, DC. The DS–1350 contains the same information as that on the current version of Consular Report of Birth FS–240. The DS–1350 is not issued outside the U.S.

(3) A Report of Birth Abroad of a U.S. Citizen (Form FS–240). The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.

(4) A Certification of birth issued by the Department of State (Form FS–545 or DS– 1350). Before November 1, 1990, Department of State consulates also issued Form FS–545 along with the prior version of the FS–240. In 1990, U.S. consulates ceased to issue Form FS–545. Treat an FS–545 the same as the DS–1350.

(5) A U.S. Citizen I.D. card. (This form was issued until the 1980s by INS. Although no longer issued, holders of this document may still use it consistent with the provisions of section 1903(x) of the Act.) INS issued the I–179 from 1960 until 1973. It revised the form and renumbered it as Form I–197. INS issued the I–197 from 1973 until April 7, 1983. INS issued Form I–179 and I–197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid.

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(6) A Northern Mariana Identification Card (I–873). (Issued by the DHS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.) The former Immigration and Naturalization Service (INS) issued the I–873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.

(7) A final adoption decree showing the child's name and U.S. place of birth. The adoption decree must show the child's name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency that shows the child's name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.

(8) Evidence of U.S. Civil Service employment before June 1, 1976. The document must show employment by the U.S. government before June 1, 1976. Individuals employed by the U.S. Civil Service prior to June 1, 1976 had to be U.S. citizens.

(9) U.S. Military Record showing a U.S. place of birth. The document must show a U.S. place of birth (for example a DD–214 or similar official document showing a U.S. place of birth.) Alien Verification for Entitlements (SAVE) Program for naturalized citizens. A Stat (10) A data verification with the Systematic e may conduct a verification with SAVE to determine if an individual is a naturalized citizen, provided that such verification is conducted consistent with the terms of a Memorandum of Understanding or other agreement with the Department of Homeland Security (DHS) authorizing verification of claims to U.S. citizenship through SAVE, including but not limited to provision of the individual's alien registration number if required by DHS.

(11) Child Citizenship Act. Adopted or biological children born outside the United States may establish citizenship obtained automatically under section 320 of the Immigration and Nationality Act (8 U.S.C. 1431), as amended by the Child Citizenship Act of 2000 (Pub. L. 106–395, enacted on October 30, 2000). The State must obtain documentary evidence that verifies that at any time on or after February 27, 2001, the following conditions have been met:

(i) At least one parent of the child is a United States citizen by either birth or naturalization (as verified under the requirements of this Part);

(ii) The child is under the age of 18;

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(iii) The child is residing in the United States in the legal and physical custody of the U.S. citizen parent;

(iv) The child was admitted to the United States for lawful permanent residence (as verified under the requirements of 8 U.S.C. 1641 pertaining to verification of qualified alien status); and

(v) If adopted, the child satisfies the requirements of section 101(b) (1) of the Immigration and Nationality Act (8 U.S.C. 1101(b) (1) pertaining to international adoptions (admission for lawful permanent residence as IR–3 (child adopted outside the United States)), or as IR–4 (child coming to the United States to be adopted) with final adoption having subsequently occurred).

(c) Third level evidence of citizenship. Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is used when both primary and secondary evidence is unavailable. Third level evidence may be used only when the applicant or recipient alleges being born in the U.S. A second document from paragraph (e) of this section to establish identity must also be presented:

(1) Extract of a hospital record on hospital letterhead established at the time of the person's birth that was created 5 years before the initial application date and that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Do not accept a souvenir “birth certificate” issued by the hospital.

(2) Life, health, or other insurance record showing a U.S. place of birth that was created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth.

(3) Religious record recorded in the U.S. within 3 months of birth showing the birth occurred in the U.S. and showing either the date of the birth or the individual's age at the time the record was made. The record must be an official record recorded with the religious organization. CAUTION: In questionable cases (for example, where the child's religious record was recorded near a U.S. international border and the child may have been born outside the U.S.), the State must verify the religious record and/or document that the mother was in the U.S. at the time of birth.

(4) Early school record showing a U.S. place of birth. The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth, and the name(s) and place(s) of birth of the applicant's parents.

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(d) Fourth level evidence of citizenship. Fourth level evidence of citizenship is documentary evidence of the lowest reliability. Fourth level evidence should only be used in the rarest of circumstances. This level of evidence is used only when primary, secondary and third level evidence is unavailable. With the exception of the affidavit process described in paragraph (d) (5) of this section, the applicant may only use fourth level evidence of citizenship if alleging a U.S. place of birth. In addition, a second document establishing identity must be presented as described in paragraph (e) of this section.

(1) Federal or State census record showing U.S. citizenship or a U.S. place of birth. (Generally for persons born 1900 through 1950.) The census record must also show the applicant's age. Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC–600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for PeachCare for Kids® eligibility. This form requires a fee.

(2) One of the following documents that show a U.S. place of birth and was created at least 5 years before the application for PeachCare for Kids® (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) This document must be one of the following and show a U.S. place of birth:

(i) A delayed U.S. public birth record that is recorded more than 5 years after the person's birth.

(ii) Statement signed by the physician or midwife who was in attendance at the time of birth.

(3) Institutional admission papers from a nursing facility, skilled care facility or other institution created at least 5 years before the initial application date that indicates a U.S. place of birth. Admission papers generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth.

(4) Medical (clinic, doctor, or hospital) record created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.)

Medical records generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. (Note: An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.)

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(5) Written affidavit. Affidavits should ONLY be used in rare circumstances. If the documentation requirement needs to be met through affidavits, the following rules apply:

(i) There must be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant's or recipient's claim of citizenship (the two affidavits could be combined in a joint affidavit).

(ii) At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient.

(iii) In order for the affidavit to be acceptable the persons making them must be able to provide proof of their own citizenship and identity.

(iv) If the individual(s) making the affidavit has (have) information which explains why documentary evidence establishing the applicant's claim or citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well.

(v) The State must obtain a separate affidavit from the applicant/recipient or other knowledgeable individual (guardian or representative) explaining why the evidence does not exist or cannot be obtained.

(vi) The affidavits must be signed under penalty of perjury and need not be notarized.

(e) Evidence of identity. The following documents may be accepted as proof of identity and must accompany a document establishing citizenship from the groups of documentary evidence of citizenship in the groups in paragraphs (b) through (d) of this section.

(1) Identity documents described in 8 CFR 274a.2 (b) (1) (v) (B) (1).

(i) Driver's license issued by State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.

(ii) School identification card with a photograph of the individual. (iii) U.S. military card or draft record. (iv) Identification card issued by the Federal, State, or local government with the same information included on drivers' licenses.

(v) Military dependent's identification card.

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(vi) U.S. Coast Guard Merchant Mariner card.

Note to paragraph (e) (1): Exception: Do not accept a voter's registration card or Canadian driver's license as listed in 8 CFR 274a.2 (b) (1) (v) (B) (1). CMS does not view these as reliable for identity.

(2) The TPA may use a cross match with a Federal or State governmental, public assistance, law enforcement or corrections agency's data system to establish identity if the agency establishes and certifies true identity of individuals. Such agencies may include child support, corrections, including juvenile detention, motor vehicle, or child protective services.

(3) The TPA may also accept three or more documents that together reasonably corroborate the identity of an individual provided such documents have not been used to establish the individual's citizenship and the individual submitted second or third tier evidence of citizenship. The State must first ensure that no other evidence of identity is available to the individual prior to accepting such documents. Such documents must at a minimum contain the individual's name, plus any additional information establishing the individual's identity. All documents used must contain consistent identifying information. These documents include employer identification cards, high school and college diplomas from accredited institutions (including general education and high school equivalency diplomas), marriage certificates, divorce decrees and property deeds/titles.

(f) Special identity rules for children. For children under 16, a clinic, doctor, hospital or school record may be accepted for purposes of establishing identity. School records may include nursery or daycare records and report cards. If the State accepts such records, it must verify them with the issuing school. If none of the above documents in the preceding groups are available, an affidavit may be used. An affidavit is only acceptable if it is signed under penalty of perjury by a parent, guardian or caretaker relative (as defined in the regulations at 45 CFR 233.90(c) (v) stating the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided. The affidavit is not required to be notarized. The state may accept an identity affidavit on behalf of a child under the age of 18 in instances when school ID cards and drivers' licenses are not available to the individual in that area until that age.

For PeachCare for Kids® applicants, the affidavit requirement can be met when the parent attests to the to the child’s identity under penalty of perjury when the application is signed and submitted or certified when the information is entered online.

(g) Special identity rules for disabled individuals in institutional care facilities. The State may accept an identity affidavit signed under penalty of perjury by a residential care facility director or administrator on behalf of an institutionalized

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individual in the facility. States should first pursue all other means of verifying identity prior to accepting an affidavit. The affidavit is not required to be notarized.

(h) Special populations needing assistance. The state must assist individuals to secure satisfactory documentary evidence of citizenship when because of incapacity of mind or body the individual would be unable to comply with the requirement to present satisfactory documentary evidence of citizenship in a timely manner and the individual lacks a representative to assist him or her.

(i) Documentary evidence. (1) All documents must be either originals or copies certified by the issuing agency. Uncertified copies, including notarized copies, shall not be accepted.

(2) States must maintain copies of citizenship and identification documents in the case record or electronic data base and make these copies available for compliance audits.

(3) States may permit applicants and recipients to submit such documentary evidence without appearing in person at a PeachCare for Kids® office. States may accept original documents in person, by mail, or by a guardian or authorized representative.

(4) If documents are determined to be inconsistent with pre-existing information, are counterfeit, or altered, States should investigate for potential fraud and abuse, including but not limited to, referral to the appropriate State and Federal law enforcement agencies.

(5) Presentation of documentary evidence of citizenship is a one time activity; once a person's citizenship is documented and recorded in a State database subsequent changes in eligibility should not require repeating the documentation of citizenship unless later evidence raises a question of the person's citizenship. The State need only check its databases to verify that the individual already established citizenship.

(j) Record retention. The State must retain documents in accordance with 45 CFR 74.53.

(k) Reasonable opportunity to present satisfactory documentary evidence of citizenship. Eligible individuals who declare to be U.S. citizens or nationals must be provided a reasonable opportunity to present satisfactory documentation of citizenship or nationality and must be enrolled in coverage pending the reasonable opportunity to document that claim. New applicants are asked to provide citizenship verification after the application is received if they are not exempt from providing documents or there is no data match or other acceptable verification on file. (See §435.930 and §435.911.) Applicants are given up to 90 days to provide documents and their eligibility may be extended as long as they are making a good faith effort to comply. If an individual has

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Superseded by ACA SPA

not provided satisfactory documentation of citizenship by the end of the reasonable opportunity period, and any extension period, States may terminate that individual’s eligibility for Medicaid or CHIP benefits in accordance with Medicaid rules at 42 CFR 435.919 and 42 CFR 431 Subpart E (regarding timely notice and opportunity for a fair hearing).

APPLICATION PROCESSING

Upon receipt of the PeachCare application, the TPA screens the application for potential Medicaid eligibility. Potentially Medicaid eligible cases will be referred to Medicaid once income has been verified. The TPA provides the TPA Specialist with an electronic file of the application for eligibility determination. Since the income verification requirements for PeachCare for Kids are the same as in Medicaid, families will not have to go through the process again unless they report a change in income. The TPA Specialists reports back the eligibility and enrollment status for all referred children. If a child comes back to the TPA as not Medicaid eligible, the account will not be required to go through income verification. The case will be updated using information provided by the TPA Specialist. For children who are not Medicaid eligible, the TPA determines if net family income (gross income minus disregards) is at or below the 247% federal poverty level; the child is covered by a group health plan (either currently or in the past six months); the child is eligible for health benefits through a family member’s employment with a state agency; and if the child is a U.S. citizen or lawfully admitted alien. The TPA is also required to use customer service personnel to follow up on incomplete or unclear information found in the application.

The TPA checks Medicaid’s information system for enrollment in the Medicaid program and conducts matches with the State Health Benefit Plan and Board of Regents for enrollment in or eligibility for state-sponsored health benefit plans. If a child is determined to be ineligible for PeachCare for Kids®, the family receives a written notice describing the reason for ineligibility. The notice specifies the reason for the denial (e.g. excess income, age over eighteen years etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to accomplish this. This may include submission of additional or clarifying information to allow a review of the application decision. If the applicant is not satisfied with the final decision of the TPA, the case is sent to the Department of Community Health for further review.

If a child is found to be eligible for the PeachCare for Kids® program, the family receives a PeachCare for Kids® handbook that describes the program’s benefits, instructions on how to submit premium payments and a number to contact the

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TPA to report changes. The family is also contacted by the Georgia Families (GF) enrollment broker and receives a new enrollment package that explains the GF program and choices about CMO plans in the Member’s service region. The enrollment broker also provides information regarding how to access services through the GF CMO selected by, or assigned to the family.

CONTINUING ENROLLMENT

At the time of application approval, the family receives information requiring them to report changes in their income, place of residence or household size to the TPA. If a family reports a decrease in income, verification of all income is required. If the family remains PeachCare for Kids® eligible and is within 90 days of their annual renewal, the income verification process will be held until that time. The verification request for renewal is sent two months prior to the renewal month. If these changes result in ineligibility, the TPA reviews the account information for potential eligibility for the Medicaid program. If the child is potentially Medicaid eligible, the account information is sent immediately to the State Medicaid staff for review, just as the new applications are handled.

If the child is screened as ineligible for Medicaid and PeachCare for Kids® based on the information provided, the TPA sends the member a notice of termination and closes the case. The notice specifies the reason for termination (e.g. excess income, etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to submit any necessary documentation.

As long as the family continues to meet all eligibility requirements and continues to pay the monthly premium as required, the child(ren) may be eligible for coverage for twelve (12) months.

PREMIUM COLLECTION and REINSTATEMENT PROCESS

• Premiums: Premiums are not required for children ages 0 through 5 years. For children ages 6 through 18, the premiums are detailed in the table below. • The applicant must submit one (1) month's premium, if required, with the application for it to be complete. Once determined eligible, enrollment becomes effective the first day of month the application is determined complete. • When the applicant is enrolled, the TPA sends a coupon payment book (or other payment mechanism) to the member for use in making regular premium payments. Members may send in premiums for multiple months. • The first two months’ coverage will be funded with state/federal funds. The premium received with the application will be applied to the third month's coverage. With this model, the collection process will be one month ahead of coverage and a member has 45 days after being late with a payment to

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submit it before coverage is terminated. • If payments are late, the notification/cancellation process will begin. A letter will be sent before cancellation occurs.

An example follows:

Date Event January 6th Applicant submits complete application. January 15th Eligibility is determined. January 1st New applicant is enrolled, if eligible. Child is eligible to receive benefits effective January 1st. State/federal dollars fund January’s coverage. February 1st or March 1st. Child is enrolled in a Care Management Organization (CMO). State/federal dollars fund January and February’s coverage. March 1st Premium submitted with application is applied to March’s coverage. April premium is due.

RENEWAL PROCESS

Sixty days prior to a member’s annual anniversary date, PeachCare for Kids® sends a letter to the family detailing enrollment-related information on the account, including demographic information, children enrolled, and premiums required. Families are notified of the requirement to send in the appropriate verification documents. All families will be required to provide income verification at the annual renewal. A form detailing the required documentation will be sent with the renewal notice. After 3 weeks, a reminder notice will be sent. If a family makes an effort to comply with the verification process prior to the renewal date but needs additional time to provide the necessary documents, a thirty (30) day grace period will be granted. In circumstances where there is intent to comply, an additional (30) days of coverage can be granted manually by a supervisor with the TPA.

Children who remain eligible after the 12-month renewal period will continue coverage. If a change in income or household composition is reported, the account will be reprocessed, similar to a new application with the children being screened for potential Medicaid eligibility, referred if appropriate and then evaluated for continued eligibility for PeachCare for Kids®.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

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• All correspondence, as well as the PeachCare for Kids website, will be updated to indicate the capped enrollment status and explain what it will mean for members and potential members.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will be precluded from re-enrollment during any closed enrollment period.. These members will receive additional notice by direct mail informing them of their review rights as required by governing regulations.

• Members enrolled and/or determined eligible prior to any closed enrollment period will not be impacted by this particular change so long as they continue to pay premiums timely and comply with any requests for information, including income, citizenship and identity verification.

• Members who are suspended during a closed enrollment period will be able to re-instate their accounts once enrollment is open so long as they bring their account into balance. They will not be required to submit a new application. These accounts will be given a special designation in the eligibility system as “pending closed enrollment.”

• All individuals who submit an application during a closed enrollment period will receive a notice stating that PeachCare for Kids is in closed enrollment but that they will be notified once the program is open to new enrollment.

• PeachCare will continue to accept applications during any closed enrollment period. The TPA would enter them into the system and continue to screen for potential Medicaid eligibility. Upon re-opening of enrollment, applications would continue processing based on date of application or reinstatement request.

Applications received during any enrollment freeze will be retained based on original date of receipt. For children referred to Medicaid, the original date of receipt will be the date the application was received by PeachCare for Kids.

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4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

PeachCare for Kids utilizes the same income methodologies as are used for its Right from the Start Medicaid program (Title XIX Poverty Level Group), ensuring that there are no gaps or overlap in income eligibility for PeachCare for Kids and Medicaid based on income sources or income disregards.

Upon receipt of the completed application, including verification of income, citizenship and identity, the TPA screens the application for potential Medicaid eligibility. If the child is potentially Medicaid eligible based on verified income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information are included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

Prior to enrollment, each child who is screened for potential PeachCare eligibility is checked against the Medicaid information system for enrollment in Medicaid. The record of each child is also checked with the State Health Benefit plan and Board of Regents for enrollment of the child or a parent in the state health insurance plan.

Effective January 1, 2012, PeachCare for Kids®’ eligibility rule will allow the enrollment of children of employees of a public agency who meet all eligibility requirements. This change is made in compliance with section 10203 (d) (2) (D) of the Patient Protection and Affordable Care Act which allows exceptions to the exclusion of children of employees of a public agency from enrolling in CHIP.

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This condition is met through the Maintenance of Agency Contribution provision. Georgia’s public agency expenditures for health coverage for

employees that have dependent coverage is not less than the amount of such expenditures in the 1997 State fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index (CPI-M) for All Urban Consumers. The state monitors, on an annual basis, agency expenditures or the cost-sharing rules applicable to the coverage offered through the State health benefits plan to ensure that it continues to meet one of the conditions. Please see Attachment A.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Upon receipt of the application, the TPA screens the application for potential Medicaid eligibility. This process will continue during the PeachCare enrollment freeze. If the child is potentially Medicaid eligible based on reported income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information are included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Since the inception of PeachCare for Kids DCH has worked closely with Department of Family & Children Services to promote the program.The PeachCare for Kids application requests all of the information necessary to determine Medicaid eligibility for a child. DFCS offices use this application for parents who are only seeking coverage for their children. If the children

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See ACA pages at end of SPA document

4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

A child will be denied eligibility if it is determined that he or she: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefit plan based on a family member’s employment with a public agency in the State; or 4) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The PeachCare application contains questions about current and past coverage under group health plans and family member’s employment with State agencies. The application also contains questions about current and past coverage under group health plans. In addition to self- declaration of other coverage, providers report coverage under other health plans and PeachCare enrollment is terminated if the other coverage meets any of the four criteria listed above. Children who are currently insured, regardless of the amount of cost-sharing required by their policy will be ineligible for PeachCare for Kids. PeachCare also requires children to be uninsured for six months prior to being eligible to enroll, with exceptions for non-voluntary cancellations of coverage. The application asks parents to report if their children have cancelled insurance within the previous six months and provides an opportunity to report the reason the insurance is cancelled. Once a month, these applications are manually

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Superseded by ACA SPA reviewed by PeachCare for Kids staff to determine if the reason given meets one of the exceptions defined in Georgia’s state plan (such as change in employment, employer dropped coverage, etc.)

Effective January 1, 2012, children of state employees will be allowed to enroll in PeachCare for Kids® if they meet the other technical eligibility requirements including limits and lack of health insurance.

At this time, the application does not ask the parent to report the cost sharing required under their previous private policy. A letter is generated to request such information before a determination of the 5% of household income can be made.

To calculate the cost sharing imposed on a household and the 5% threshold, the enrollment system for PeachCare will have to be modified. With this information stored on the system, PeachCare for Kids will be able to monitor on an ongoing basis the number of letters sent, the number of families providing the information about their previous coverage, and the number of children who are exempted from the waiting period.

Once the revision has been made to collect this data on the application, PeachCare will continue to monitor the number of applications requesting to be exempted from the six- month wait due to the cost of their previous insurance and the number of children who are ultimately exempted.

The average percentage of children who had reported canceling private insurance due to excessive costs was 5.06% of the new eligibles for the 1st Federal Fiscal Quarter in 2002. If there are two consecutive quarters in which the percentage of new eligible who report losing coverage due to cost exceeds 5%, the Department of Community Health will increase the cost-sharing threshold from 5% to 7.5% before an exemption from the six-month wait is granted.

4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

See 4.4.4.1

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Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

PeachCare for Kids Outreach Through RSM Outreach

Outreach efforts are completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be reached and enrolled in Medicaid and those children eligible for PeachCare can be reached and enrolled in PeachCare. The outreach efforts target all children at or below 247% of the FPL. To build on and enhance our outreach efforts, Georgia utilizes our nationally recognized RSM outreach strategies for PeachCare for Kids. With over 143 representatives statewide, RSM outreach workers have been specifically trained in doing outreach for PeachCare for Kids. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers also have a variety of program information on both creditable and non-creditable coverage and other ways to access health care services. The order of priority for the outreach workers are first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation and DHR public health care programs and services. The outreach efforts are also coordinated with community- based organizations, health care providers, GF CMO plans and the enrollment broker.

RSM Outreach Project

The Right From the Start Medicaid (RSM) Project began in July 1993 as Georgia’s response to the high infant mortality rate and to improve health care access for all children and pregnant women.

The Department of Community Health (DCH) and the Department of Human Resources (DHR) entered into an agreement to place eligibility

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workers in community settings. The agreement provides for 143 eligibility workers. This staffs currently have offices in health departments, hospitals, clinics, day care centers, schools, community action agencies and other locations in the community. A major feature of the program is the availability of staff during non-traditional work hours so that clients may apply for RSM without having to lose time from their jobs or from school. Non- traditional hours are defined as any time other than 8 a.m. to 5 p.m. Monday through Friday.

Outreach staffs are housed throughout Georgia and, although not housed in all 159 counties, provide Medicaid enrollment information and access to the Medicaid application process in every county. This involvement with potential Medicaid clients on a local level greatly enhances Georgia’s outreach efforts. Outreach staff also actively pursue collaboration with other agencies and groups in their communities in order to maximize involvement at the local level and to educate other agencies in the basics of Medicaid eligibility and the availability of Medicaid services and to provide for mutual referral systems. Most of the local RSM project staff has partnerships with the county health departments, local schools, pregnancy centers, battered women’s shelters, Head Start programs and the health care community in their areas.

Workers and supervisory staff make presentations regularly to community groups, medical providers and employers. RSM project staffs often participate in health fairs and other local activities in order to reach potential Medicaid clients. Staffs have utilized creative techniques for distributing information to the public. Medicaid flyers have been sent home with school age children and workers have visited day care centers to pass out brochures. Employer contacts have resulted in opportunities to distribute literature through personnel offices and at employee forums, and to accept applications at job sites.

Simplified PeachCare for Kids Application

PeachCare for Kids has developed a simplified paper and web-based application in both English and Spanish for use by families who apply for the PeachCare for Kids program. The paper application is a one page, two-sided form designed to be submitted to PeachCare by mail. (Attachment 1)

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The web-based application is available on-line at www.peachcare.org. It was created to allow parents to apply quickly and easily at local libraries, community centers, hospitals and in their homes. When an application is submitted online, a cover form with the application confirmation number will be generated. Parents will be instructed to print out this form and attach required documents for income and/or citizenship and identity verification to then be mailed or faxed to the TPA. Both applications are designed to gather information needed to determine eligibility for both PeachCare and Medicaid. Marketing and Public Awareness

Advertising Campaign

The PeachCare for Kids outreach campaign includes television, radio, outdoor and transit advertising. The advertising campaign follows the theme, “Now You Can Afford Peace of Mind,” addressing the practical and the emotional needs of potential PeachCare families. Creatively, advertising is intended to evoke the heroism of the working-class parent, recognizing their love and dedication to their child. The radio commercial, “Vicky,” tells the story of a father and his daughter, and the TV commercial, “Emma,” spotlights a mother and her son.

Outreach Publications

PeachCare for Kids published informational brochures in both English and Spanish to educate and encourage enrollment. The brochures give a brief description of benefits available through PeachCare and a summary of PeachCare eligibility requirements. The brochures are distributed at outreach activities throughout the state and are available at doctor’s offices, DFACS, Department of Labor career centers, health departments, community centers, and daycare centers.

Outreach Video

The Georgia Department of Community Health produced a short promotional video, which details the benefits of PeachCare to parents and community outreach workers. It features two women talking about their experience with the program. The video explains how to apply, premiums, benefits and accessing services. For bilingual viewers, it is available with Spanish subtitles. The video is especially designed for broadcast in hospital and physician waiting rooms, health departments, and community health fairs.

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Back-to-School Outreach

To enhance back to school outreach activities, PeachCare for Kids partners with the Georgia Department of Education to distribute a program flyer to every child in the public school system. Through this effort, nearly every parent of a school-age child in the state receives information about PeachCare for Kids. To date, we distribute over 1.6 million brochures at the beginning of each school year.

Community Outreach Mini-grants

In 1999, the Georgia Department of Community Health created a minigrant program, “Improving Health Care Access: Innovations in Medicaid and PeachCare for Kids Outreach, to assist local efforts to raise awareness of both PeachCare and Medicaid programs among hard-to- reach populations. Twenty-four community organizations were awarded grants to conduct grassroots outreach activities specifically designed for their communities.

The minigrant outreach program had a positive impact on the number of applications submitted to PeachCare for Kids and Medicaid. The grantees were responsible for producing between 30,000 and 40,000 new applications between October 1999 and June 2000.

An evaluation performed by the Health Policy Center at Georgia State University looked at various differences by race and county size, as part of our goal was to reach the underserved hard-to-reach population. The evaluation found:

• An increase of 16% in new applications compared to non-outreach counties; • An increase of 18% in smaller counties (fewer than 42,000 people); • An increase of 11% in larger counties (more than 90,000 people); and • An increase of 19% in minority applications.

The activity level of the grantees produced the following results:

• 427,315 pieces of PeachCare for Kids informational materials were distributed; • 445 PeachCare for Kids presentations were conducted; and

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• 6,000 families were assisted with applications.

Local Media Partnerships

PeachCare for Kids became one of five partner organizations in Georgia’s largest and most comprehensive community service campaign, WSB-TV’s Family 2 Family Project. WSB-TV, the highest ranked television station in the state and has established partnerships with community and family organizations throughout Georgia to address family issues. As part of its partnership, PeachCare participates in several major events such as the Baby & Kid Expo, CPR Saturday trainings by the American Red Cross, the Susan B. Komen Foundation’s Race for the Cure, the Salute 2 America Fourth of July parade, and Give Kids a Boost. PeachCare brochures are also always on display in the other Family 2 Family sponsor locations, including Haverty’s Furniture, Verizon Wireless, Promina Health Systems, and Southtrust Bank.

The news and advertising exposure on one of Georgia’s most popular television stations, community event participation across northern Georgia, and exclusive program opportunities will continue to help us reach even more eligible families.

Georgia Families

The Georgia Families Care Management Organizations (CMOs)

The CMO plans are permitted to perform the following marketing activities:

• Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets); • Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor; • Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in which the Provider participates have an equal opportunity to be represented; and • Activities that benefit the entire community such as health fairs or

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 6.2 Page: 1

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

These services are the same as the services in the Georgia Medicaid Plan with the exceptions of non-emergency transportation, targeted case management, services solely for persons over age 19, and some services that to be needed require a level of disability that would qualify the child for Medicaid. All these services are subject to the same limitations and prior approvals as they are in the Georgia Medicaid Plan.

6.2.1.  Inpatient services (Section 2110(a)(1))

Inpatient services include medical and surgical services delivered during a hospital stay. Inpatient services are covered in full. See 6.2.10 for coverage for psychiatric hospital services. Prior approval is needed for some services.

6.2.2.  Outpatient services (Section 2110(a)(2))

Outpatient services include outpatient surgery, clinic services and emergency room care. Outpatient services are covered in full. Prior approval is needed for some services.

6.2.3.  Physician services (Section 2110(a)(3))

Physician services include services provided by a participating physician for the diagnosis and treatment of an illness or an injury. Physician services are covered in full. Prior approval is needed for some services.

6.2.4.  Surgical services (Section 2110(a)(4))

Surgical services are covered in full. See 6.2.1 for inpatient surgical services and 6.2.2 for outpatient surgical services. Prior approval is needed for certain procedures.

6.2.5.  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Rural Health Clinic Services (RHC) and Federally Qualified Health Center Services

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Provides both medical/surgical benefits and mental health or substance use disorder benefits in the same manner. Ensures that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are not more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.

6.2.11.  Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state- operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.12.  Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Durable medical equipment and supplies prescribed by a physician are covered. Prior approval is required for custom molded shoes and for repairs to certain prosthetic devices. Hearing aids are allowed every three years without prior approval. Medical necessity for hearing aids must be approved by Children’s Medical Services. This prior approval is based upon the completion of a hearing evaluation by the prescribing physician or other licensed practitioner. Medical equipment purchases and one-way mileage for delivery in excess of $200.00 require prior approval. See Vision Care under 6.2.28 for eyeglasses.

6.2.13.  Disposable medical supplies (Section 2110(a)(13))

6.2.14.  Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home health services, ordered by a physician and provided in the enrollee’s home, including part-time nursing services, physical, speech and occupational therapy, and home health aide services are covered for 75 visits per calendar year. Home health services exceeding 75 visits per calendar year may be covered when requested by a physician and determined to be medically necessary by DMA.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 6.2 Page: 4

6.2.15.  Nursing care services (See instructions) (Section 2110(a)(15))

Nursing care services are covered as follows. The Nurse Practitioner Services Program reimburses for a broad range of medical services provided by participating Pediatric, Family, Adult, and OB/GYN Nurse Practitioners, as well as Certified Registered Nurse Anesthetists (CRNA). Nurse Midwife services are also covered and include primary care services in addition to obstetrical care.

6.2.16.  Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17.  Dental services (Section 2110(a)(17))

Dental and oral surgical services are covered as follows: 2 visits (initial or periodic) for dental exams/screens and 2 emergency exams during office hours and two emergency exams after office hours per calendar year are allowed; 2 cleanings per calendar year; 1 restorative (filling) procedure per tooth per restoration; the maximum number of surfaces covered is four (4); sealants for first and second permanent molars only; orthodontic services with prior approval.

6.2.18.  Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Inpatient substance abuse treatment services are covered only for short-term acute care in general acute care hospitals up to 30 days per admission. Services furnished in a state-operated mental hospital are not covered. Services furnished in an Institution for Mental Disease (IMD) are not covered.

6.2.19.  Outpatient substance abuse treatment services (Section 2110(a)(19))

Outpatient substance abuse treatment services are covered through Community Mental Health Centers, subject to limitations specified in DHR standards. Outpatient short term acute care and substance abuse treatment services are covered in general acute care hospitals.

6.2.20. 

Case management services (Section 2110(a)(20))

6.2.21. 

Care coordination services (Section 2110(a)(21))

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Vision Care: Services including eyeglasses, refractions, dispensing fees, and other refractive services are covered. Medically necessary diagnostic services are also covered. Limitations are: 1 refractive exam, optical device, fitting, and dispensing fee within a calendar year; additional such services require prior approval. Prior approval is also required for other services including but not limited to: contact lenses, trifocal lenses, oversized frames, hi-index and polycarbonate lenses.

Children’s Intervention Services: Services covered for children from birth through 18 years of age are audiology, nursing, nutrition, occupational therapy, physical therapy, social work, speech- language pathology and developmental therapy instruction. Written prior approval is required for medically necessary Children’s Intervention Services once the annual service limitations listed in the Policy and Procedure Manual have been reached. Individualized Family Service Plan is required to document medical necessity for amount, duration and scope of services. Note that children 18 years of age are not covered under these program services.

Family Planning: Covered services include initial and annual examinations, follow-up, brief and comprehensive visits, pregnancy testing, birth control supplies, and infertility assessment.

Pregnancy-Related Services: Covered services help reduce infant mortality by providing home visits that assess the mother and child and teach the mother about specific subjects that will reduce infant mortality.

Podiatry: Services covered are diagnosis, medical, surgical, mechanical, manipulative and electrical treatment of ailments of the foot or leg as authorized within the Georgia statute governing podiatric services.

Physicians Assistant Services: Covered services are limited to primary care services and anesthesiologist’s assistant services authorized in the basic primary care job description, approved by the Georgia Composite State Board of Medical Examiners.

End Stage Renal Disease (ESRD) Dialysis: Services and procedures designed to promote and maintain the functioning of the kidney and related organs are covered when provided by a provider enrolled in the ESRD program. Acute renal dialysis services are covered under other programs.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 6.4 Page: 1

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1.  Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii))

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7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

To encourage utilization of primary and preventive care, PeachCare for Kids does not have any co-payments for services. Additionally, premiums are not required for children under the age of six, ensuring that all children up to the age of six in households with incomes up to 235% of the federal poverty level have access to care without any cost to the family.

PeachCare for Kids sends each child a birthday postcard each year that wishes them a healthy year and reminds their parents of the well-child care available through PeachCare.

PeachCare for Kids monitors the members’ appropriate Early Periodic Screening, Diagnostic and Testing (EPSDT) utilization. Each CMO must provide quarterly reports to DCH documenting the number of initial newborn visits, the number of members who received all scheduled EPSDT services on the periodicity schedule, the number of members who received any dental services, number of members that received an initial health visit and screening within 90 days of enrollment, the number of diagnostic and treatment services, including referrals, and the number and rate of lead screening for children.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

All members are enrolled in Georgia Families (GF), a managed care program. GF PCPs are required to have care accessible to their members 24 hours a day.

Members are informed in member handbooks mailed to each family upon enrollment, “If your child is in an emergency situation, call 911 or go immediately to the nearest hospital emergency room. You do not need prior approval from your child’s doctor if your child has a serious or disabling illness or injury. Be sure to call your doctor if your child has a serious or disabling illness or injury. Be sure to call your doctor as soon as you can after your child has received care.”

The Georgia Health Policy Center (GHPC), Georgia State University, has

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done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC has also conducted the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received.

Additionally, each CMO is required to provide quarterly timely access reports that monitor the time lapsed between a Member’s initial request for an office appointment and the date of the appointment. The CMOs are also required to submit a Provider Network Adequacy and Capacity Report that demonstrates that the Contractor offers an appropriate range of preventive, Primary Care and specialty services that is adequate for the anticipated number of enrollees for the service are and that its network of providers is sufficient in number, mix and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. Additionally, on an ad hoc basis DCH can request of each CMO a report of the availability of certain services and the coverage and authorization of services.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The Georgia Health Policy Center (GHPC), Georgia State University, has done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC also conducts the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received, including access to specialist care. Through these evaluations, PeachCare monitors access to specialist care for all members, including those with special or chronic conditions.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 7.2 Page: 3

All children enrolled in PeachCare for Kids are assigned a CMO and primary care provider (PCP) through GF. The PCP’s role is to assess, treat, and coordinate specialty care for the PeachCare members under their care.

PeachCare for Kids members who are identified as in need of special health care services by receiving care through CMS or Georgia Pediatric Program (GAPP) are excluded from GF and covered under PeachCare for Kids on a fee for service basis.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

As mentioned earlier, each CMO has written Utilization Management Policies and Procedures that have been reviewed and approved by DCH. Also, on a monthly basis CMO will provide to DCH a report of the availability of certain services and the coverage and authorization of services.

Certification processed within fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for extension of the fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for Prior Authorization and Pre- Certification processed within twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for the extension of the twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for authorization processed within thirty (30) Calendar Days for determination for services that have been delivered; • Total number of requests approved by type of service; and • Total number of requests denied by type of service.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 8.3 Page: 1

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

PeachCare for Kids® publicizes the cost sharing requirements in its brochures, applications, website, mass media campaigns and other outreach materials. If a parent applies for a child and does not include a premium payment with the application, if applicable, a letter is sent indicating that a payment must be received for the children to be enrolled in the program. The letter includes the specific amount due, depending on the number of children over 6 in the household, and the due date for premium payments for enrollment to be initiated and maintained monthly.

The Board of Community Health, a nine-person board appointed by the Governor, governs the Department of Community Health. The board meets regularly on a monthly basis and is open to the public. The FY 04-05 cost sharing changes were presented to and approved by the board on May 12, 2004.

Effective November 1, 2011, Families will be required to make co-payments for certain services for children ages 6 and above.

The PeachCare for Kids® Third Party Administrator will issue notices to all currently enrolled families regarding the new co-payments prior to July 18, 2011. Once the co-pay amounts are finalized, the information will be included in letters routinely generated to new enrollees by the Third Party Administrator when they are approved, re-instated and at redetermination.

A public notice will be issued and posted at the Department of Family and Children Services offices state-wide. The notice will also be sent to regional newspapers and posted on the Department of Community Health website. See Attachment #3

Prior to implementation of co-pays, the Board decided to change the co-pay amounts. Effective April 1, 2012, co-payment amounts previously approved were changed to lower amounts. A banner message will be sent to PeachCare for Kids® providers statewide to inform them of the new co-pay amounts required for children 6 and older.

The PeachCare for Kids® Third Party Administrator will issue notices to all currently enrolled families regarding the new co-payments prior to March 10, 2012. The co-pay information will be included in letters routinely generated to new enrollees by the Third Party Administrator when they are approved, re- instated and at redetermination.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 8.5 Page: 1

8.5. Describe how the state will ensure that the annual aggregate cost sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Effective April 1, 2012

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, the state keeps the co-pays and premiums the families are required to pay minimal. Because of the low premium and low co-payment, very few families are likely to exceed the limit and would not approach the 5 percent limit. The MMIS, Third Party Administrator and the Care Management Organization (CMO) will implement system changes designed to track all cost- sharing. When a family reaches 4.5% of their income for the eligibility period, the system will send the family a notice that no further cost-sharing is required for the remainder of the eligibility period. Each year consists of 12 months beginning with the approval month or the month of eligibility redetermination.

If out of pocket expenses still somehow manage to exceed 5% of the cap, the overage will be reimbursed to the family.

Families are notified of the premiums and co-pays when their applications are initially approved and when changes are reported that result in premium changes. Information about premiums and co-pays, including the 5% cap, is posted on the PeachCare for Kids® website, the Department of Community Health web-site and the Care Management Organization websites.

Families are not required to keep track of their expenses since they are tracked electronically by the agency, but if at any point, the family believes that their out of pocket expenses have exceeded 5% for the year, they may contact the PeachCare for Kids® Third Party Administrator to request a review of their expenses.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 8.7 Page: 2

send a notice no later than the 8th of the first grace period month, informing the family that failure to make a premium by the 15th of the 2nd grace period month will initiate the termination process and coverage will ultimately be terminated at the end of the 2nd grace period month. A call campaign is launched on the 15th of the first grace period month to inform parents of the past due premium payments. If the premium is not paid by the 15th of the 2nd grace period month, then the coverage termination process begins and is ultimately terminated by the end of the 2nd grace period month. Payments received after the 15th day of the 2nd grace period month will not stop the termination process. Once coverage is terminated due to non-payment of premium, the family is ineligible to reinstate for the following month. Families who are canceled due to non-payment of premium are notified by mail and informed of their right to a review of the termination.

In the case that a premium payment is made during the grace period, but there is still an outstanding premium(s), the payment would apply to the first missed premium payment. The grace period would then start again based on the date of the second missed premium payment such that a family always has a grace period starting at the first of the month of a new coverage period and ending 45 days later.

For example, on January first the premium is due for February coverage. If a family missed the January 1st due date, a letter is sent to the family on approximately January 4th informing them that their payment is due and that if payment is not received by the end of January, the grace period will begin on February 1st and last until March 15th, after which the coverage termination process will begin. If the family does not pay the January 1st premium due for February coverage by the 15th of March, the family’s coverage is terminated at the end of March. In this case, the family would be ineligible for coverage during the month of April, unless the family opts out of February coverage by January 31.

In the case where a family missed the January 1st and the February 1st premium, but made a single premium payment by February 15th , the payment would apply to the January missed payment and the family would be offered a new premium grace period starting on March 1st and requiring payment by April 15th before coverage is terminated. In the case where a family missed the January 1st premium, the February 1st premium, but made a single premium payment by March 15th, the February 1st premium due for March coverage would be required by April 15, after which coverage would end April 30. This cycle will continue for each new month of coverage and each grace period, where premium payments are late. Any late premium payments will always apply to the earliest premiums due.

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If the family requests a review of the termination due to a claim of reduced income that disrupts their ability to pay the premium, coverage is extended to the child during the appeal process.

If the family reports a reduction in income during the cancellation period, as well as any other time, the application is screened for potential Medicaid eligibility. If it appears that the child is eligible for Medicaid, the application will be referred to Right from the Start Medicaid for a full determination. If it appears that the child still qualifies for PeachCare for Kids®, but at a lower premium amount, the family will be notified of the new premium requirement and will be issued a new coupon book.

Prior to August 1, 2005 a Member who was cancelled for late/non-payment of premium was ineligible to reinstate for a period of three (3) months. PeachCare for Kids® enrollees and the public at large were made aware of the policy change from a three-month period to a one-month period in a variety of methods. Those enrollees that were in a 3-month waiting period were notified via a letter that they were eligible for reinstatement effective August 1, 2005. All other members were notified of changes in correspondence mailed to households, the Frequently Asked Questions posted on our website (www.peachcare.org), and call center customer service representatives.

During closed enrollment, there will be no reinstatement period. Any family cancelled for late/non-payment of premium will be ineligible to reinstate so long as PeachCare enrollment is closed. All effected families will be notified of this change in policy by a mailing. It will be reiterated in the final notice letter that will also inform them of their right to seek a review within 30 days of receipt of the notice and to continue services during the review period.

There are no coinsurance or deductible fees for PeachCare for Kids®, but effective April 1, 2012, co-payments are required for children 6 years and older. Providers are responsible for collecting the co-payments at the time of service. A provider may not refuse to render services covered under the plan to an individual who is eligible for PeachCare for Kids® if they are unable to pay a co- pay. Providers can not send the account to collections nor can they deny additional services based upon the past failure to pay.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.2 Page: 1

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) Objective 1: Increase insurance coverage of Georgia’s low-income children. Performance goals: 1.1 Enroll 75% of uninsured, non-Medicaid eligible children with family income below 235% of the federal poverty level. Measure: Percent of eligible children enrolled.

1.2 Employ marketing and outreach techniques that encourage parents of eligible, low-income children to enroll their children in PeachCare for Kids. Measure: Percent of eligible children enrolled and survey data of applicant families.

Baseline and Target Improvement Levels: Within one year, Georgia exceeded our two-year enrollment goal of 60,000 children, as indicated in our original state plan. For the upcoming fiscal year, we have set the goal of enrolling 85% of the estimated eligibles (169,142 children enrolled on June 30, 2003).

Objective 2: Increase the percentage of low-income children with a regular source of care.

Performance goals: 2.1 Over time, decrease the percent of children matched to a PCP through auto assignment. Measure: Percent of children who selected PCP on enrollment.

2.2 Encourage use of PCP through health plan policies and education. Measure: Percent of enrolled children who seek care from their assigned PCP.

2.3 Maximize the number of enrollees who stay with their PCP for 12 months. Measure: Percent of enrollees who stay with their PCP at least one year.

Baseline and Target Improvement Levels: As of November 30, 1999, there were 17,120 children who were matched to a PCP through auto assignment, and 41,713 (71%) who chose their own PCP. Our target improvement level is 80% by the end of federal fiscal year 2005.

Objective 3: Promote utilization of Health Check (EPSDT) services to achieve

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targets set by the Centers for Medicare and Medicaid Services and GF. These are 80% for screening and 90% for immunizations.

Performance goals: 3.1 Assess how many children receive recommended well visits and screenings. Measure: Percent of enrolled children receiving each screening on or about the recommended schedule.

3.2 Assess how many children receive immunizations. Measure: Percent of enrolled children receiving each immunization on or about the recommended schedule.

3.3 Increase provider and patient compliance with use of primary and preventive services by feeding back information to providers and health plans about their rates of screening for the enrolled population. Measure: Percent of PCP panels with improved screening rates in subsequent years.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 41% of all children enrolled 10 to 12 months had an EPSDT visit. Of the children ages 1 to 5, 55% had an EPSDT visit. Georgia’s goal is to increase this to 80% by the end of federal fiscal year 2005. With enhancements in our fiscal management system and the reporting provided by GF CMO plans, we anticipate being able to track services among children who have EPSDT services as their coverage changes among Medicaid and PeachCare for Kids. This will allow us to evaluate more children with 10 to 12 months of coverage and have a more complete picture of the percentage of children who are receiving these services, either through PeachCare exclusively or intermittent coverage through the Medicaid program.

Objective 4: Decrease unnecessary use of emergency departments for non- emergency services. A non-emergency service is one that does not meet the prudent layperson definition of emergency.

Performance goals: 4.1 Reduce the number of ED visits for non-emergency services. Measure: Rate of non-emergency ED visits per year for the population enrolled.

Baseline and Target Improvement Level: From claims data for fiscal year 2000,

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9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Initial Public Involvement

In 1996, the Georgia Coalition for Health was asked by the Governor to examine approaches for reforming Medicaid in Georgia. The Coalition sponsored extensive research on the views of the stakeholders in the state’s Medicaid system – healthcare providers, Medicaid members and Georgia citizens. Three separate but complementary processes—focus groups, community forums and community dialogues—offered the opportunity for about 6,000 Georgians to express their views.

This unique process of obtaining stakeholder input served as a foundation for convening people with varied perspectives and expectations, raising awareness about those perspectives, identifying areas of agreement and disagreement, and working together to find solutions to difficult problems.

Georgia Health Decisions was commissioned by the Coalition to conduct research to learn what changes citizens would support in the state’s Medicaid program. Citizen input was gathered through focus groups in all areas of the state, with almost 500 people participating. Focus group participants were randomly chosen to represent all socio-economic segments of Georgia’s population. Eleven focus groups were composed of Medicaid members, and six others were made up of healthcare providers. Further, Georgia Health Decisions conducted 200 open community forums throughout the state in which 5,000 Georgians had the opportunity to express their concerns about Medicaid reform.

In addition, the Georgia Health Policy Center engaged 14 communities across Georgia in Medicaid community dialogues. The objectives of the dialogues were to ensure a process for obtaining input from Medicaid consumers and health care providers around the state; to clarify an understanding of the issues related to Medicaid reform and the ramifications of those issues; and, to identify examples of system disincentives that could be corrected by changes in policy.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.9 Page: 2

disabilities, and people with mental retardation, mental illness, or those with substance abuse problems. The providers were selected by the Healthcare Providers Council and included representation from hospitals, physicians, nursing, dentistry, nursing homes, home health, pharmacy, public health, community health and others. County Commissioners as well as members of the legislature were also invited to attend. Overall, 443 consumers and advocates and 234 providers participated for a total of 677 statewide participants. The meetings were open to the public and at every Dialogue there were observers who did not participate in the discussions yet had the advantage of moving among groups and hearing all four conversations.

These statewide, public conversations on Medicaid contributed to dispelling barriers between consumers and providers; the process also indicated where consumers, advocates and providers stand on major issues and where they are willing to negotiate. The main themes identified through the process are summarized below. These themes served as a reference and defining force for developing general Medicaid reform recommendations and many are reflected in Georgia’s proposal for implementing the Title XXI program.

Citizens

The citizens, both Medicaid members and members of the general public, expressed a wide variety of views, but agreed on a few basic themes.

• Vulnerable people should be protected. Citizens generally believe in the concept of a health care safety net and are willing to pay taxes to provide health care to people who need help.

• Only truly needy individuals should qualify for Medicaid. Citizens want to make sure that eligibility is strictly defined and enforced to stop abuse.

• Nothing should be free. Citizens want all adult Medicaid members to make some financial contribution toward their care, generally favoring a sliding scale based on income. They believe welfare recipients should work. They also want to make sure that families contribute to the cost of caring for disabled children and, perhaps, elderly parents.

• Health care should be accessible to all Georgians. Citizens worry about rising health care costs and their own ability to get affordable coverage, even if they now have health benefits, they worry about losing them. People are also concerned about the uninsured and would like to broaden Medicaid

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• Providers who have traditionally served the Medicaid population with demonstrated quality should be included in a managed care or any other delivery system.

About six months after this public input process was completed, the Georgia Coalition for Health Board, concerned about the effects of Medicaid reform on uninsured children, asked the Health Policy Center to study mechanisms for providing coverage to this target population. In response to this charge, the Policy Center applied for (and was subsequently awarded) a Robert Wood Johnson Foundation grant to replicate the Florida Healthy Kids program. The Coalition also allocated funding to the Center to conduct preliminary planning activities so that Georgia could position itself for implementing the Healthy Kids program as well as the impending federal children’s health insurance legislation.

From May through December 1997, the Center established several advisory committees with representation from key agencies and organizations around the state. (It should also be noted that, according to the reviewers from the Robert Wood Johnson Foundation, one of the most impressive components of the initial grant and the subsequent planning efforts was the inclusive process for obtaining input from affected stakeholders into the design of the program.) The committee structure included a primary broad-based Children’s Health Insurance Advisory Committee and four subcommittees, each governed by specific charges that addressed the major programmatic issues of benefits package, eligibility criteria, program design, and local collaboration. There were a total of 40 individuals on the full advisory committee and four subcommittees, however, these meetings were open to and attended by several additional visitors and observers. There were about 25 meetings of the full advisory group and the subcommittees between April and December. Membership on these groups was comprised of representatives from the following agencies and organizations:

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.9 Page: 5

• Division of Mental Health/Mental Retardation/Substance Abuse • Division of Public Health (Division Director, Child and Adolescent Health Unit, Gwinnett County Health District, DeKalb County Board of Health) • Georgia Academy of Family Physicians • Georgia Association for Primary Health Care • Georgia Chapter/American Academy of Pediatrics • Georgia Dental Association • Georgia Partnership for Caring • Georgia Policy Council for Children and Families • Georgians for Children • Governor’s Office of Planning and Budget • Healthy Mothers, Healthy Babies Coalition of Georgia • March of Dimes • Office of the Commissioner of Insurance • Tanner Medical Center • The Family Connection • United Healthcare • Wachovia Bank of Georgia Compensation and Benefits Branch • West Georgia Medical Center

In addition, separate group meetings were held with child advocates, health plan representatives, and public health district officers to explain the program and obtain input about specific components of the program design for CHIP. During December, January, February and March, several legislative hearings were held in both the Senate and House of Representatives. The hearings focused on the Governor’s proposal for implementing Title XXI in Georgia. At these hearings, child advocates, state agencies, pediatricians and other health care providers provided testimony.

Public Notice

At the regular meeting of the Board of Medical Assistance on April 8, 1998, DMA staff provided a public briefing for the Board on the status of the Georgia CHIP planning process. Again, at the regular meeting of the Board on May 13, 1998, the DMA presented detailed information to the Board and the public about the proposed Georgia CHIP, and gave opportunity for public comment. The May meeting had been extensively publicized with a notice mailed to a large mailing list of stakeholders in Medicaid and CHIP, in addition to regularly published meeting notices.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.9 Page: 6

Ongoing Public Involvement

The House Appropriations Committee created the Medical Assistance Study Committee in June, 1997. It was charged with conducting a comprehensive study of the Medicaid system in Georgia. The rationale was for a core group of people on the Appropriations Committee to learn as much as possible about the complexities of the budget item known as Medicaid.

Identifying problems and finding opportunities in Georgia’s Medicaid system were main challenges of the committee. To meet these, a series of hearings were conducted around the state, sixteen (16) in all. They began in the summer and ended in the fall of 1997. Georgia is comprised of one hundred fifty-nine counties, urban and rural. Input was gathered from big metropolitan areas, such as Atlanta and Savannah, and small rural areas, such as Greensboro and Moultrie, to name a few. Providers and their respective associations, professional health care associations, community groups, patient advocates, Medicaid recipients, and interested citizens were invited to share their concerns with the committee.

Through the hearings, the Committee identified significant findings in fifteen different areas ranging from reimbursement to providers to health care for those with disabilities. Along with the findings, recommendations were made to DMA. A copy of the Committee’s report is on file with DMA. Members of the Committee took lead roles in drafting the Georgia CHIP legislation. The Medical Assistance Study Committee has since become a standing committee of the House Appropriations Committee, which is now known as the DCH Subcommittee of the House Appropriations Committee.

The Department of Community Health is governed by a nine-person board appointed by the Governor. The Board has an active role in developing and approving DCH’s proposed budget, setting priorities for the Department and working with DCH to affect policy and process to improve the health care delivered to its membership. During the budget development process, DCH holds public forums throughout the state for public input. The DCH has additional advisory committees. The Physician Advisory Committee provides a forum for health care providers and advocates to improve the health care delivery to Medicaid and PeachCare for Kids members.

Georgia Families

In February 2003, the State issued a request for information seeking

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.9 Page: 7

comprehensive proposals to redesign the Medicaid program to improve quality and provider accountability while achieving budget predictability and cost containment. Over 42 responses were received. For the next several months, meetings were held with providers, consumer groups, insurance representatives and other stakeholders to design a new program.

In October 2003, a diverse team of stakeholders, including senior executives from healthcare provider organizations and advocacy groups, assembled for several days to discuss state strategies to promote quality healthcare, enhanced access, shared member and provider responsibility, improved efficiency, and better cost management.

In August 2004, the State announced that it would implement a mandatory managed care program using Care Management Organizations. From September 2004 through October 2004, the State held stakeholder sessions with physician and hospital providers, senior associations, children and family coalitions, and others to ensure participation and input from all groups affected by the new mandatory managed care program.

Upon implementation of the program, the State will continue to utilize providers from the various medical advisory committees, recipients involved in NET advisory committees, staff liaisons to advocacy groups that include both providers and recipients, and member satisfaction survey.

Express Lane Eligibility effective April 1, 2011-

The Georgia Department of Community Health evaluated the feasibility of the options designed to facilitate enrollment and retention in the Medicaid and PeachCare for Kids® program and to receive bonus payments as outlined in the Children’s Health Insurance Program Reauthorization Act of 2009, section 203. Express Lane Eligibility was chosen as on of Georgia’s 5 of 8 efforts to enroll more eligible children in Medicaid and PeachCare for Kids® programs.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 9.9 Page: 8

WIC applicants will be informed that with their permission, their demographic and income information will be forwarded to the PeachCare for Kids®/Medicaid agency for an eligibility determination.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

There are no nationally recognized American Indian tribes or organizations in the state of Georgia. PeachCare for Kids, however, does not charge cost-sharing to enrolled members who are members of federally-recognized American Indian or Alaskan Native tribes.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

On February 8, DCH announced that it would quit enrolling new members in PeachCare for Kids effective March 11, 2007. State code allows for these changes to be made administratively, but public notice was provided in compliance with state laws. A public notice with comment period was published in regional newspapers, posted on the Department of Community Health’s website and made available for review at each county Department of Family and Children Services office. A widely attended public hearing was held on February 23, 2007. Current members, including those “locked-out” of coverage, will be notified by direct mail. The Department also issued a press release and is communicating with providers and stakeholders on the change. On March 8, 2007, the Board of Community Health approved the implementation of the closed enrollment period.

Upon receipt of additional federal funds, DCH issued a public notice announcing that enrollment would resume effective July 12, 2007, pending Board approval. The public notice further stated that in order to ensure that the funding adequately supports the cost of health care for members through September 30, 2007, enrollment will be limited to 295,000 children. The enrollment limit will be reassessed upon passage of SCHIP reauthorization legislation. Public comments were accepted for 30 days and a public hearing was held on June 27, 2007.

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 12.1 Page: 1

Section 12. Applicant and enrollee protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Upon denial of eligibility, a parent will be notified by mail of the reason for the denial and the process to notify PeachCare for Kids if the parent believes the denial is in error. Parents will first be directed to call the toll- free number and report additional information or clarify information on the applicant’s account. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the request will be directed to a senior supervisor and/or the account manager of the TPA. The management level will review if the determination made by the TPA system and supported by the staff is correct based on state and federal policy. If the supervisory level does not overturn the denial, the parent will once again be informed of the decision. If the parent continues to dispute the denial, the supervisory staff will inform the parent that they may submit a request in writing to the PeachCare for Kids, to be reviewed by state- level PeachCare for Kids staff.

Receipts of requests for review will be acknowledged in writing within 10 days, including notification that that member will receive a decision within 30 days. PeachCare for Kids will review requests for reconsiderations of denials. If PeachCare disagrees with the decision of the TPA, the child will be enrolled in PeachCare for Kids retroactive to the first day of the month in which the complete application, including any additional information affecting the outcome of PeachCare’s decision, is received. If PeachCare for Kids agrees with the decision to deny eligibility, a letter will be sent to the parent detailing the reason for denial. If the parent elects to dispute the decision, the parent will have the option of having the decision reviewed by the Formal Appeals Committee for the State Health Benefit Plan. The member will have 30 days from the issuance of the letter to

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Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 12.2 Page: 1

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

Upon denial of covered benefits, a parent will notify the Care Management Organization if the parent believes that the service should be covered. The information provided by the parent in the phone call will initiate a review. The contracted CMO will research the situation, including reviewing the medical policy, the claims system and any documentation submitted by the physician, if applicable. The CMO will ensure that all reviews are conducted by a health care professional with appropriate clinical expertise, as determined by DCH, in treating the Member’s Condition. If the initial review does not result in a change in the decision to deny a service, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the parent may submit a request in writing to the PeachCare for Kids, to be reviewed by DCH management staff, including the policy director of the service area and the Chief of the Division of Medicaid Services or his designee. If this decision of this review is maintain the denial of service, a letter will be sent to the parent detailing the reason for denial. If the parent elects to dispute the decision, the parent will have the option of having the decision reviewed by the Formal Appeals Committee for the State Health Benefit Plan. The decision of the Formal Appeals Committee will be the final recourse available to the member. In reference to the Formal Appeals level, the State assures:

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Georgia Department of Human Services

Application for Benefits

if you need help filling out this application, ask us or call 1-877-423-4746_ If you have a hearing impairment, call

(GA Relay at 1-800-255-0135. Our services are free.

What Services Do We Offer at the Division of Family and Children Services (DFCS)?

Food Assistance

Food Stamps are benefits that you can use to buy food at any store thathas the EBT/Quest sign. We will subtract the price of your food purchase from your Food Stamp account.

(Cash Assistance/Employment Support Services. Temporary Assistance for Needy Families (TAMF) provides cash assistance to families with dependent children for a limited time. Parents or caretakers who are incuded in the grant are required to:

‘Cash Assistance program also provides financial assistance to refugee households who are not eligible for the TANF program.

Medical Assistance Medicaid, for those who are eligible, may help pay medical bills, doctor's visits, and Medicare premiums.

Community Outreach Services: For more information about Community Outreach Services, please

visit our website at: httodiwww.dfes chr geongia.qow or call 1-277- 423-4746.

How Do | Apply for Benefits?

Step 1. Fill out the application.

and date the application.

Step 2. Tum in the application. You will need to tear off pages 1 -3 and keep it for yourself.

Mail, fax, or bring in pages 4-8 of this application to your local Division of family & Children Services (DFCS) office. If you or the person for whom you are applying is eligible for benefits, Food Stamps or TANF benefits will be provided from the date that we receive the application with your name, address, and signature on it.

Hr you apply for Food Stamps, and/or Medicaid you can file an application for benefits with only your name, address and signature. However, it may help us to process. your application quicker if you complete the entire form.

Step 3. Talk with us.

You may need to complete an interview with a case manager. If so, we will give you an appointment. This interwiew can be completed by phone.

Fom 237 (Rev. D413}

Frequently Asked Questions: How long does it take to get benefits?

Food Stampe: ‘up 1D 30 days:

TANF: up to 45 days:

‘Medicaid: 10 to 60 days

“You may be able to get Food Stamps within 7 days it you quay. S2= page S.

benefit amounts. We will be able to give you specific Information once we determine your eligibility.

How will | get my benefits?

For Food Stampe. and TANF, you will get an Electronic Benefit Transfer (EBT) card to access your benefits. For Medicaid, you will recelve a Medicaid card foreach eligible member.

What information will | need to provide? Itls a good Idea to provide the following:

‘= Proof of Identity for te appileant if apptying for Food Stamps andior TANF. Proof of kientity for everyone requesting Medicald If applying for Medicaid. Exc An identification card /iD) or driver's Ilbense {DL}

«© Proof of US cltizenship/qualfied Immigrant ‘status for everyone requesting benefits

« = Socal Security numbers of everyone: requesting assistance

= Proof of Income for example, pay stubs, child SUppOn payments, and Income award letters

«Proof of expenses like child care receipts, medical bills, medical transportation costs, and child support payments

‘You will be given time to retum any Information to

‘our oMce. Ifyou need help getting this Information,

please tell us.

How do we use the applicant's personal information?

“You only Nave to provide Social Security Numbers. (SSN) and cttizenship of immigration status for persons who want 1D apply Tor beens. This. Information wil De used to check the Income and

and local agencies io verify your Income and ellgibilty. Tf alhousenold member does not want to give us Information about thelr SSN, citizenship, or Immigration ‘status, other household members may sill recelve benefits.

(Can someone else apply for me?

"Yes, for Food Stamps and Medicaid, you may ask ‘someone to apply for you.

‘For TANF, anyone can apoty but the parent or ‘caretaker must be Interviewed.

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Georgia Department of Human Services Application for Benefits

“In accordance with Federal law and US. Deparment of Agriculture (USDA) and US. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national ongin, sex, age. or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is aiso prohibited on the basis of religion or political beliefs.”

To file a complaint of discrimination, you may contact USDA or HHS.

Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, 3.¥V.. Washington, D.C. 20250-0411 or calll (900) 785-2272 {woice) or (202) 720-6382 (TTY).

Write HHS. Director, Office of Civil Rights, Room 509-F_ 200 Independence Avenue, S.W., Washington, DLC, 20201 or call (202) 619- (0403 (voice) or (202) 619-3257 (TTY).

USDA and HHS are equal oppertunity providers and employers

‘You may also fle a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, N.W_, Suite 18- 248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404) 463-3078.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age. sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health's Office of Program Integrity local 404-463-7500) (toll free) B00-533-D686,

What Do the Words Used in this Application Mean?

This. chart explains the words we have used in this application.

(Caretaker A parent, relative or legal guardian who applies for and receives TANF with chikiren in his or her care.

(Grantee Relative A parent, relative or legal guardian who applies for and receives TANF in his or her name on behalf of the children

Disqualified The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the

Electronic Benefit The system used in Georgia to pay benefits to individuals who are eligible for Food Starnps. Individuals

Transfer (EBT) receiving assistance are issued an EBT debi card, which is used to access their food stamp accounts.

EPPICard debit New debit card issued by Merox for individuals receiving cash assistance in Georgia. The

MasterCard EPPIiCard debit MasterCard will be accepted for purchases and cash withdrawals anywhere the MasterCard is accepted.

Household Members Individuals who live in your home. For Food Stamps, individuats who live together and purchase and prepare their meals together.

Income Payments such as wages. salaries, commissions, bonuses, worker's compensation, disability, pension,

retirement benefits, interest, child support or any other form of money received.

Migrant Farm Workers Individuals who are seasonal fam workers and move from one home base to another to work or book fior farm work,

Resources ‘Cash, property, or assets such as bank accounts, wehicles, stocks, bonds, and lif insurance.

‘Seasonal Fam Workers | Individuals who work at certain times of the year planting, picking or packing produce. They are hired on a temporary basis when a job requires. more workers than the fanm employs on a regular basis.

Fom 297 (Rev. D413) 2

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Leas eet

‘Georgia Department of Human Services Application for Benefits 6

What Do the Words Used in this Application Mean? (cont'd)

This chart explains the words we have used in this application.

Trafficking in the SNAPiFood Stamp Program

Trafficking SMAP benefits means:

(1) Buying, selling, stealing, or othenvise exchanging SMAP benefits issued and accessed via EBT cards, card numbers and PIN numbers or by manual voucher and signature. for CASH or consideration other than eligible food, either directly, indirectly. in complicity or collusion with others, or acting alone: (2) The exchange of firearms, ammunition, explosives, or controlled substances; (3) Purchasing a product with SNAP benefits that has a container requiring a retum deposit with the intent of abtaining cash by discarding the product and retuming the container for the deposit amount, intentionally discarding the product, and intentionally retuming the container for the deposit amount; (4) Purchasing a product with SMAP benefits wath the intent of obtaining cash or consideration other than eligible food by reselling the product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration other than eigible food. (5) Intentionally purchasing products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible food.

‘Qualified Alien/immigrant

A qualifed alien‘immigrant is a person who is legally residing in the U.S. who falls wathin one of the following categories: a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act (INA): Amerasian immigrant under section £24 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees, admitted under section 207 of the INA; A person parofed into the US under section 212(d)(5) of the INA for at beast one year, A person whose deportation is being withheld under section 243(h) of the INA as in effect priorto Apel 1, 1227 , or section 241 (b\(3) of the INA, as amended; a person who is granted conditional entry under section 202{a){7) of the INA as in effect prior to Apel 1, 1980; Cuban or Haitian immigrants as defined in section 5D1(e) of the Refugee Education Assistance Act of 1980: victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000; batfered immigrants who meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, a5 amended; Afghan or Iraqi immigrants. granted special immigrant status under section 101/a (27) of the INA (subject to spectied conditions); American Indians bom in Canada living im the U.S. under section 280 of the INA or non- ‘citizens of federallyrecognized Indian tbe under Section 4(e) of the Indian Self-Determination and Education Assistance Act and Hmang or Highland Laotian inbal members that rendered assistance to U_S. personne! by taking part in military or rescue operation during Vietnam Era (8/06/1864 — S'07/1875).

An individual who chooses to apply for or to receive public assistancebenefts

An Individual who chooses NOT to apply for or to receive public assistance/benefits; non-applicants are ot required to provide an SSN, citizenship or immigration status.

An assistance unit includes eligible individuals who live together and recsive public assistancelbenefits together.

Form 237 (Rev. 04/13}

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Georgia Department of Human Services

> Application for Benefits

Tell Us about the Applicant and All Household Members

Please fill out the chart below about the

icant and all household members.

. The following federal

laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 20141-2036, 7. C.F.R. § 273.2, 45 CLFR. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security number(s).lf anyone in your household does not want to give us information about his or her citizenship, immigration status, or social security numbers, then that person can be designated as a non-applicant. This means that the person will not be considered an applicant and will not be eligible for benefits. However, other household menbers may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. ‘You will still need to tell us about your income and resources to determine the eligibility and benefit level of the household. Individuals will not be reported to the United States Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) system if they do not give us their citizenship or immigration status. However if immigration status information has been submitted on your application, this information may be subject to verification through the SAVE system and may affect the household's eligibility and benefit level.

NAME etation: is this Erin Socal Securty | Sex Hispanicy Race Are you a US ship person Date ‘Number Latino? Code clizen, qualited First Middle Initial «= Last toYou | applying allanvinmnigrant ‘tor or benefits? [Optionay | (Optional | HmongHighiand Lactan Imenigrant? (Applicants only} (ven Format (Applicants (See codes: and) only) (MIF) Ten) Belov) LYN SELF

Race Codes (Choose all that apply):

Al—Amencan Indian/Alaska Native AS — Asian HP — Native Hawaiian/Pacific Islander WH —White

BL — Black/African American

By providing Race/Ethnicity information, you will assist us in administering our programs in a non-discriminatory manner. ‘Your household is not required to give us this information and it will mot affect your eligibility or benefit level.

Tell Us More about the Applicant and All Household Members

We need more information about the applicant and all household members in order to decide who is eligible for

benefits. Please answer only the questions about the benefits you want to receive on the page below.

Form 297 (Rev. 0413)

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Georgia Department of Human Services Application for Benefits B

Food Stamp Program Penalties

Any household member who breaks any of the food stamp rules on purpose can be barred from the Food Stamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. She/he may also be subject to prosecution under other applicable Federal and State laws. She/he may also be barred from the Food Stamp Program for an additional 18 months if court ordered.

Any household member who intentionally breaks the rules may not get Food Stamps for one year for the first offense, two years for the second offense, and penmanently for the third offense.

If a court of law finds you or any household member guilty of using or receiving food stamp benefits in a transaction involving the sale of a controlled substance, you or that household member will not be eligible for benefits for two years for the first offense, and permanently for the second offense.

Ifa court of law finds you or any household member guilty of having used or received benefits ina transaction involving the sale of firearms, ammunition or explosives, you or that household member will be permanently ineligible to participate in the Food Stamp Program upon the first offense of this: violation.

If a court of law finds you or any household member guilty of having trafficked benefits for an aggregate amount of $500 or more, you or that household member will be permanently ineligible to Participate in the Food Stamp Program upon the first offense of this violation.

If you or any household member is found to have given a fraudulent statement or representation with respect to identity (who they are) or place of residence (where they live) in order to receive multiple Food Stamp benefits, you or that household member will be ineligible to participate in the Food Stamp Program for a period of 10 years.

For All Medicaid, Food Stamps and TANF Applicants: | have read and completed everything on this form that applies to the applicant and the applicant's

Applicant's Signature Date Authorized Representative’s Signature Date (Case Manager's Name and Signature Date

Fom 297 (Rev. D413) 3

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Georgia Department of Human Services Health Coverage Addendum

Please answer the following questions if you are applying for Health Coverage (Please complete all three pages of this form)

1. Ifyou are an adult applying for Health Coverage for your dependent child(ren), do you want to receive Health Coverage for yourself? O ‘Yes O No

2. Is anyone in the household pregnant? O ‘ves O No If yes, how many babies are expected during this pregnancy? 3. Is anyone applying for health coverage blind or disabled? O Yes O No If yes, please list 4. Does anyone have other health insurance that covers anyone in your household? O Yes O No 5. Ifyou answered yes to question 5 above, please complete the following information:

Name | Health Insurance Company | Type of Coverage Name of Persons Effective Policy

of Name, Address and (Hospital, Medicare Covered Date Number Policy Telephone Number Supplement, Drugs, holder Major Medical)

6. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. O Yes If yes, you'll need to complete Attachment A. Is this a state employee benefit plan? O Yes O No

7. Have you or anyone listed on this application lost any health coverage in the last 2 months? O Yes If yes, why was it lost? ONo

8. Was anyone in your household in Foster Care atage 1670 Yes OF No

9. Does. anyone in the household have any unpaid medical bills from the last 3 months? OO YesO No

10. Is anyone in your household American or Alaska Native? DO Yes O No If Yes, complete Attachment B.

If you are applying for Aged, Blind or Disabled Medicaid please answer questions 11-16 and complete the Resources section. Otherwise, skip to the tax filer questions on page 3.

11. Are you or your spouse currently covered by Medicare? OQ Yes QO No If Yes please list,

12. Are you applying for Medicaid to cover unpaid medical bills from the three months prior to a ‘Supplemental Security Income (SS!) application?

QO Yes O No If yes, date of SSI application: 13. Are you applying for someone who is now deceased and has unpaid medical bills within the last three (3) months? QO Yes 2 No

14. Are you applying for Medicaid to help pay for the care of a person who is in a nursing home? oO Yes O No ‘297M (01/14) -1-

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Income and Earmings: List all types of eamings and income that your household receives. List the income anvount before deductions such as taxes, insurance or Medicare premiums , health insurance, dental, and vision premiums or Spending accounts are taken out.

Income Type ‘Gross amount How often? (weekly, every 2 Name of Person

‘Child Support ‘Contributions ‘Other Income (please specify)

Does anyone expect any change im monthly mcome? O Yes Q No

If yes, please list who expects the change, the type of income that is changing. and the date it is expected to change below.

Deductions: Check all that apply, and give the amount and how often you pay it.

O Alimony § How often? O Other Deductions § How often?

Assignment of Rights of Payment for Medical Support and Other Medical Care:

(If you are applying on behalf of another individual and do not have the power to execute an assignment for that individual, the individual will need to execute an assignment of the rights described below, as a condition of his/her eligibility for Medicaid.) As a condition of my eligibility, | agree to assign to the State all rights to medical support and to payment for medical care from any third party (hospital amd medical benefits). | agree to cooperate with the state im identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. | understand that | must report any payments received for medical care within ten days. | agree to give the State the right to require an absent parent to provide medical insurance, if available. | understand | must get Medical support from the absent parent if it is available and must cooperate with the Division of Child Support Services. in obtaining this support. If | do not cooperate, | understand | may lose my Medicaid benefits, and only my child(ren) will receive benefits unless good cause is established.

| certify, under penalty of perjury, that all the information listed is truthful to the best of my knowledge.

Signature Date 297A (ULL) -3-

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PUBLIC NOTICE

Pursuant to 42 CFR § 457.65, the Georgia Department of Community Health is required to give public notice of any state plan amendment that limits or restricts eligibility in the State Children’s Health Insurance Program, known as the Georgia’s PeachCare for Kids® Program. PEACHCARE FOR KIDS

Pursuant to Title XXI of the Social Security Act, the PeachCare Program is a jointly funded state and federal insurance program for low-income children. Effective March 11, 2007, the Department will discontinue enrollment in the PeachCare for Kids® Program.

• Any new applications received or postmarked after March 11, 2007 will not be processed for PeachCare eligibility.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will also be affected by this change and will be precluded from re- enrollment. These members will receive additional notice by direct mail as required by governing regulations.

• Members enrolled and/or determined eligible prior to March 11, 2007 will not be impacted by this particular proposed change.

This change serves as an effort to sustain the PeachCare for Kids® Program so that low- income children currently enrolled in the program may continue to receive low-cost health insurance.

This public notice is available for review at each county Department of Family and Children Services office and will also be published in regional newspapers and on the Georgia Department of Community Health’s website. An opportunity for public comment will be held on February 23, 2007, 10:00 a.m.-12:00 p.m., at the Floyd Room of the Twin Towers Building, 20th Floor, West Tower, 200 Piedmont Avenue, Atlanta Georgia. Individuals who are disabled and need assistance to participate during the meeting should call (404) 656-4479. Citizens wishing to comment in writing on the proposed changes should do so before March 2, 2007 to the Board of Community Health, P.O. Box 38406, Atlanta, Georgia 30334.

Submitted comments will be available for review by the public at the Department of Community Health, Monday through Friday, 9:00 a.m. to 4:30 p.m., in Room 4074, 2 Peachtree Street, NW, Atlanta, Georgia 30303.

Comments from written and public testimony will be summarized and provided to the Board of Community Health prior to the March 8, 2007 Board meeting. The Board will vote on the proposed change at the March meeting which will be held 10:30 a.m. at the Floyd Room of the Twin Towers Building, 20th Floor, West Tower, 200 Piedmont Avenue, Atlanta, Georgia.

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To:

Parents/Guardians of PeachCare for Kids Members From: Commissioner Dr. Rhonda Medows, M.D. Date: February 20, 2007 Re:

PeachCare for Kids® Enrollment Freeze

It was with a heavy heart that I announced we will stop accepting new applications to enroll in the PeachCare for Kids® (PKC) program effective March 11, 2007. This freeze will then be in effect until further notice.

While we are no longer accepting new enrollees, I am writing to you as parents and guardians of children already enrolled in PKC to inform you that you should not be alarmed by this notification. This is NOT a notice announcing that the program is ending. As long as PKC has money to operate, your children will receive care under the terms of their current enrollment.

As a parent, I understand the importance of providing quality health care to your children, and I have notified providers that the enrollment freeze does not impact the health care services of current PKC members. Providers will continue to render health care services to current PKC members.

However, if you are required to pay a PCK premium, it is crucial that you make your monthly payment on time or your child(ren)’s coverage will be at risk. After March 11, 2007, any family whose participation in the program is cancelled for failure to pay premiums will no longer be re-enrolled during this period.

PCK, Georgia’s State Children's Health Insurance Program, is a partnership between the state and federal government to provide comprehensive health care program for uninsured children living in Georgia. The state has committed its share of the funds; however, the program has a $131 million federal funding shortfall for Federal Fiscal Year 2007.

We continue to work with members of Congress, the members of our State Legislature and the Governor' office to resolve the funding needs of this very important program.

For additional information on the PeachCare for Kids® program, please access http://www.dch.ga.gov.

If you have any questions or concerns, please feel free to call 1-877-GAPEACH (1-877-427- 3224)

Equal Opportunity Employer

Rhonda M. Medows, MD, Commissioner

2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Sonny Perdue, Governor

(ga-15-0021)(approval-package)(page-142)Page 142#

Rhonda M. Medows, MD, Commissioner 2 Peachtree Street, NW Atlanta, GA 30303-3159 Sonny Perdue, Governor www.dch.georgia.gov FOR IMMEDIATE RELEASE CONTACT: February 8, 2007 Dena’ Brummer 404-463-5391

PeachCare for Kids® Enrollment Closes to New Members

Children currently enrolled continue to receive care

ATLANTA – Today, Georgia Department of Community Health Commissioner Dr. Rhonda Medows informed the Board of Community Health that PeachCare for Kids® (PCK) will no longer accept new enrollees to the program as of March 11, 2007.

“We have seen this important program grow to cover over 270,000 children. It is a way for hard working parents to try to provide health care for their children,” Dr. Medows said. “We continue to wait for an act of Congress to occur so that we can provide care for the children currently enrolled in the program through October 2007.”

PCK, Georgia’s State Children's Health Insurance Program (SCHIP), is a partnership between the state and federal government to provide comprehensive health care program for uninsured children living in Georgia. The state has reserved its share of the funds needed; however, the program has a $131 million federal funding shortfall for Federal Fiscal Year 2007.

The announcement comes as the state is actively urging Congress to allot funds for the SCHIP shortfall that Georgia and 14 other states face. State projections show that PCK will run out of operating funds sometime in March 2007.

A public notice has been filed to cease the allowance of new members to the PCK program. Effective March 11, 2007, only those currently enrolled in the PCK program may continue to receive services via the state.

“Parents and guardians of children already enrolled in PCK should not be alarmed by this notification,” Dr. Medows said. “As long as the PCK has money to operate, your children will receive care under the terms of their current enrollment. We remain hopeful that Congress will fulfill its commitment to the SCHIP program.” For more information about the PeachCare for Kids® program, please access http://www.dch.ga.gov

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PUBLIC NOTICE

Pursuant to 42 C.F.R. § 457.525, the Georgia Department of Community Health is required to give public notice of any significant proposed change in its methods and standards for setting payment rates for services.

Copayments for Medicaid and New Copayments for PeachCare for Kids® Members

Effective for services provided on and after November 1, 2011 and subject to payment at fee-for- service rates, the Department will increase existing Medicaid co-payments to the current definition of nominal as defined in the Code of Federal Regulations 42 C.F.R. § 447.54. Additionally, the same co-payments will be applicable to PeachCare for Kids® members six (6) years of age and older. All other existing copayment exemptions will continue to apply. A copy of the proposed copayment rates is included in this public notice for illustrative purposes.

This action is anticipated to result in savings of approximately $3,397,100 in State funds in SFY 2012.

This public notice is available for review at each county Department of Family and Children Services office. An opportunity for public comment will be held on September 27, 2011, at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room at 2:00 pm. Individuals who are disabled and need assistance to participate during this meeting should call (404) 656-4479. Citizens wishing to comment in writing on any of the proposed changes should do so on or before September 30, 2011, to the Board of Community Health, Post Office Box 1966, Atlanta, Georgia 30303.

Comments submitted will be available for review by the public at the Department of Community Health, Monday – Friday, 9:00 a.m. to 4:30 p.m., in Room 4074, 2 Peachtree Street, N.W., Atlanta, Georgia 30303.

Comments from written and public testimony will be provided to the Board of Community Health prior to the October 13, 2011, Board meeting. The Board will vote on the proposed changes at the Board meeting to be held at 10:30 a.m. at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room.

NOTICE IS HEREBY GIVEN THIS 8th DAY OF September, 2011 David A. Cook, Commissioner

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PUBLIC NOTICE

Pursuant to 42 C.F.R. § 447.205, the Georgia Department of Community Health is required to give public notice of any significant proposed change in its methods and standards for setting payment rates for services.

NEW CO-PAYMENTS FOR PEACHCARE FOR KIDS® MEMBERS

Effective for services provided on and after April 1, 2012, and subject to payment at fee-for-service rates, the Department will implement co-payments for covered services to PeachCare for Kids® members six (6) years of age and older. These copayments will be consistent with CMS-approved Medicaid co-payments and co-payment exemptions for adults. This action is anticipated to result in state fund savings of $318,462 in the Amended SFY 2012 budget and $1,273,849 for SFY 2013.

ILLUSTRATIVE CO-PAYMENTS

Ambulatory Surgical Centers / Birthing $3.00 Durable Medical Equipment $1.00 or $3.00 (service based) Federally Qualified Health Centers $2.00 Free Standing Rural Health Clinic $2.00 Home Health Services $3.00 Hospital-based Rural Health Center $2.00 Inpatient Hospital Services $12.50 Oral Maxillofacial Surgery Cost Based Orthotics and Prosthetics $3.00 Outpatient Hospital Services $3.00 Pharmacy - Preferred Drugs $0.50 Pharmacy - Non-Preferred Drugs Cost Based Physician Program Services Cost Based Podiatry Cost Based Vision Care Cost Based

COST BASED CO-PAYMENTS

Cost of Service Proposed Co-Payment $10.00 or less $0.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00

This public notice is available for review at each county Department of Family and Children Services office. An opportunity for public comment will be held on December 28, 2011, at 1 p.m. at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room at 2:00 pm. Individuals who are disabled and need assistance to participate during this meeting should call (404) 656-4479. Citizens wishing to comment in writing on any of the proposed changes should do so on or before 5:00 p.m. on December 28, 2011, to the Board of

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GEORGIA DEPARTMENT OF COMMUNITY HEALTH

Nathan Deal, Governor Clyde L. Reese Ill, Esq., Commissioner

2 Peachires Street, NW | Atlanta, GA 30303-3159 | 404-656-4507 | www.dch.georgia.gov

December 2, 2013

Ms. Jennifer Ryan

Centers for Medicare & Medicaid Services RE: Renewal Waiver Request 7500 Security Boulevard, Mail Stop $2-26-12

Baltimore, Maryland 21244-1850

Dear Ms, Ryan:

In response to CMS' guidance regarding targeted enrollment strategies that are available to states to help facilitate a streamlined enrollment process for 2014, Georgia requests to amend the CHIP and Medicaid renewal period in erder to adopt the MAGI-based eligibility determination methods beginning on January 1, 2014. Georgia would like to extend the CHIP and Medicaid renewal periods.

Georgia requests a waiver under section 1902/e)(14){A) in order to extend the dates for the state's CHIP eligibility renewals scheduled for January 1, 2014 through March 31, 2014 (three (3) months).

Georgia requests a waiver under section 1902(2)(14)(A) in order to extend the dates far the state's Medicaid eligibility renewals scheduled for January 1, 2014 through June 30, 2014 (six (6) months),

We believe this extension is needed in order establ sh income and eligibility determination systems that protect our beneficiaries. In addition, Georgia intends ta delay action on income and household changes that may cause a negative adverse action beginning January 1, 2014 until the beneficiary's first regular renewal in 2014.

We are not requesting any modifications to the demonstration's budget neutrality agreement, as budget neutrality will not be affected by this amendment request.

If you have questions about this request, please contact Shella Niexander for CHIP questions at 404-657-9506 or salexanden@dch ga gov. Medicaid questions should be directed to Yvonne Greene at 404-463-2135 of yoreeneiidch qaqov.

Sinceraly,

Jerfy Dubberly Medicaid Chief

Healln Inlormation Techology | Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan Equal Opportunity Employer

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CHIP Eligibility

OME Control Number: (938-1148 Expiration date: lW'3 1/2014

Section 201} ofthe ACA and 42 CFR 457,31Nd)

ff Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

c The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(8) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CPR 437.3 10(d). Coverage for this population will cease when the last child protected

« from loss of Medicaid coverage as a resultof the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no liter than April 1, 2016 },

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f}of the Affordable Care Act:

@ ‘The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility becouse of an increase in family income at their first renewal applying MAGL methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or

c below the following percentage of FPL. The state bas demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

The state will enroll children in a separate CHIP who arte found to be ineligible for Medicaid based on MAGI but whose family income has nod inereased since the child's last determination of Medicaid eligibility or who would have remained eligible for

c Medicaid (based wn the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family inceme as determined by MAGI methodology.

Deseribe the benefits provided io this population:

(C This population will be provided the same benefits as are provided to children in the state’s Medicaid program, @ This population will be provided the sume benefits as are provided (wo children in the state's separate CLIP,

Deseribe premiums and cost sharing required of this population:

Cost shaving is the same as for children in the Medicaid program. SPAS GA-13-0017 Axpprcrval Date: FEB 05 201k

Effective Date: January 1, 2014 Page | of 2

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a a CHIP Eligibility on™ Taginton de: 10312014

42 CPR 437.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with » job commitment or seeking employment, whether or not currently employed, [i A non-institutionalized child not deseribed above and a child who is not a ward of the state:

|. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1 }, with whom the individual resides,

An instluutionalized child, who fs nota ward of the state, if the siate is the state of residence of the child's custodial parent or caretaker al the ime of placement, or {MA child who isa ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence,

If the state covers pregnant women, 2 pregnant woman is considered to be a resident under the following conditions:

[i] A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fined address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

An institutionglized pregnant woman residing in an in-state-institution, as defined im 42 CPR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

‘The state has in place related to the residency of children and pregnant women (if covered by the state):

SPat GAB0019 Approval Date: FEB a 6 201

Effactive Date: January 1, 2044 Page lof 2

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CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Sections 2105cX%9) and 2707110) ofthe SSA and 42 CFR 457.3200 bM6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, Y) including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

oy The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States: or

Who are qualified non-citizens aa defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 ULS.C. $141), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C, §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. 81614); or

Who have declared themselves to be citizens or nationals of the United Stutes, or an individual having satisfactory immigration| status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x}, 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the: individual,

‘The agency provides for an extension of the reasonable opportunity period ifthe individual is making a good faith effort | to resolve any Inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process,

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date

ka earlier than the date the notice is received by the individual, i

The date benefits are furnished is: (C The date of application containing the declaration of citizenship or immigration status. (© The date the reasonable opportunity notice is sent.

(@ Other date, as described:

The month following the date that all other eligibility requirements are met and any required premiums are paid. (Citations: Georgia State Plan: Section 2.2, Page 6, Section 4.3, Page 3)

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing in the United States, as provided in Section 2107(cy(1 XJ) of the SSA (Section 214 of CHIPRA 2009, PLL. 111-3}

The CHIP Agency elects the option to provide CHIP coverage to otherwise cligible pregnant women, lawfully residing in the United States, at provided in Section 214 of CHIPRA 2009, P.L. 111-3. The siate may not select this option unless the state

also elects to cover lawfully residing children. A state may not select this option unless. the state also covers Targeted Low- No Income Pregnant Women. _ FEB 0 6 2014 SPAS GA-TSO0T ‘Approval Date: Effective Date: January 1, 2014

Page | of 2

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ccms CHIP Eligibility

‘OMB Control Number: 0938-1145 Expiration date: L/31/2014

42 CFR 457.340(b)

Social Security Number

Asa condition of eligibility, the CHIP Agency must require individuals who have a social security number or art cligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a secial security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

w The CHIP Agency assisis individuals, who ere required to provide thel# SSN, to apply for or abtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[| The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the S5N.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicam. pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

‘The state requests non-applicant household members to voluntarily provide their ies | SSN.

[7] When requesting an SSN for non-apolicant household members, the stale assures that:

ml At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

for a purpose directly connected with the administration of the state plan,

im The state only uses the SSN for determination of eligibility for CHIP of other insurance affordability programs, or

PRA Disclosure Statement

FEB 0 6 2016

SPAd GA-13-0019 Approval Date: Effective Date: January 1, 2074 Page | of 2

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CHIP Eligibility

OMB Control Number: 0938-1145 Expiration date: 1091/2014

DOA bw) & ZIOTM!eM 1 WO) of the SSA and 42 CFR 457, subpart C The CHIP Ageney meets all of the requirements of 42 CFR 457. subpart C for application processing, eligibility screening and enrollment,

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible bused on the applicable modified adjusted gross income standard,

res] ‘The single, streamlined application developed by the Secretary in accordance with section 141 4bM 1 WA} of the Affordable Care Act.

re An alternative single. stream lined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act,

An alternative application used to apply for multiple humen service programs approved by the Secretary, provided that the FA agency makes readily available the single of alternative application used only for insurance affordability programs to individuals sceking assistance only through such programs.

wa ‘The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the intemet website described in CFR 457.340(a}, by telephone, via mail, in person and other commonly available electronic means

The agency accepts applications in the following other electronic means. (0 Other electronic means: Screen and Enroll Process

4 income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for o@her insurance affordability programs,

Procedures include: i Screening of application to identify all individuals cligible or potentially eligible for CHIP or other insurance affordability programs: and

fm Income eligibility test, with calculation of household income: consistent with 42 CFR 457.315 for individuals identified as filially eligible for Medicaid or other insurance affer ity programs based on household income; and. — i33:w ew)

SPA# GA-1S-O018 AporivalDate; Effective Date: Octaber 1, 2013 Page 1 of 2

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cems CHIP Eligibility

ml Sereening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single stream lined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced ¥ premium tax credits in acoordance with section 1943(h)(2) of the SSA. S

Redetermination Processing

[) Once every 12 months. | m= Without requiring iiformation from the individual if able to do so based on reliable Information contalned in the individuals | | account or other more current information available to the agency.

lf the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [® information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

Fd (CFR 457.348(b)-and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42

(CFR 457.340 to the same extent and in the samme manner as ifthe applicant had been dete nmined by the state to be eligible for CHIP,

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the ra] requirements of 457,348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required te respond to a collection of information unless it displays a valid OMB control pumber, The valid OMB control number for this information collection is (438-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data eaources, galher the data needed, and complete and review the information collection. Ifyou have comments conceming the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Atm: PRA Reports Clearance ‘Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

W210

FEB 2 { 2016

SPAS GAALO018 Approval Data: Eflective Date: Geteber 1, 2073 Page 2 of 2

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Georgia Department of Human Services

Application for Benefits

If you need help filling out this application, ask us or call 1-877-423-4746. If you have a hearing impairment, call GA Relay at 1-800-255-0135. Our services are free.

What Services Do We Offer at the Division of Family and Children Services (DFCS)?

DFCS offers the following services:

Food Assistance

Food Stamps ane benefits that you can use to buy food at any store that has the EBT/ Quest sign. We will subtract the price of your food purchase from your Food Stamp account.

Cash Assistance/Employment Support Services Temporary Assistance for Needy Families (TANF) provides cash assistance to families with dependent children for a limited time. benefits

Parents of caretakers whe are inctuded In the grant are required to For Foed Slarnpe anid TAME, fou igi bet an Electronic participate in a work program. fransfer (EBT) cake ena ca Gash Assistance program also provides financial assistance to Il racelve tard foreach refugee households whe are not eligible for the TANF program.

Medical Assistance Medicaid, for hase who are eligible, may help pay medical billa, E p tor doctor's visits, and Medicare premiuma. f fs of Mdentity: Community Outreach Services For mare Information @DOUL COMMUNITY QUITEach Services, please :

yy visit our website at; hite.www. dies dhe osorgia gov or call 1-877- ‘Bd ‘Security numbars ch eaayenid

ah 423-4746. requesting assistance:

coon pote set Fens Sort as.

How Dol Apply for Benefits? Step 1. Fill out the application.

Read the questions carefully and give accurate information. Sign y and date the application.

Step 2. Turn in the application. You will need to tear off pages 1 and 2 and keep it for yourself. 5

Mail, fax, or bring in pages 3-6 of this application to your local Division of farnily & Children Services (DFCS) offias. If you or the person for whom you are applying is eligible for benefits, Food Stamps or TANF benefits will be provided from the date that we receive the application with your name, address, and signature on it.

fyou apply tor Food Starnps, and/or Medicaid you can file an application for benefits with only your name, address and signature, However, it may help us to process your application quicker if you

‘complete the entire form. as someone else apply for

‘Step 3. Talk with us. Yes, for Food boplag Gnd Madicsid, you may ask Someone to apply for

You may need to complete an interview with a case manager. Ifso, For TANF, anyone ca py atte parent or we will give you an appolniment. This interview can be completed caretaker must be interviewed. = by phone,

etek fee

Form 207 (Rev. 0492) 1

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“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national ongin, sex, age, or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination Is also prohibited on the basis ef religion or political bellefs.”

To file a complaint of discrimination, you may contact USDA ar HHS,

Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9411 or call (200) 795-3272 (voice) or (202) 720-6382 (TTY).

‘Write HHS, Director, Office of Civil Rights, Roam 509-F, 200 Independence Avenue, S.WV., Washington, D.C., 20201 or call (202) 619- 0403 (voice) or (202) 619-3257 (TTY).

USDA, and HHS are equal opportunity providers and employers.

‘You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, NW, Suite 19- 246, Atlanta, Georgia 30009 or call (404) 657-3735 or fax (404) 463-3576,

Under the Department of Community Health (OCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin, of political or religious beliefs. To report Medicaid eligibility of provider discrimination, call the Georgia Department of Community Health's Office of Program Integrity (local 404-163-7590) (toll free) 800-533-0688.

What Do the Words Used in this Application Mean? This chart explains the words we have used in this application.

“sparand, relative orlogal guardian who appiles for and raceives TANF with children in his or her cane.

‘Caretaker

‘Grantee Relative ‘A parent, relative orlagal guardian who apples for and receives TANF in his or her name on behalf of fhe ctildrert.

Disqualified The action taken to remove an individual from a Food Stamp or TANF case because they did nod tell tha truth and raceved benefits ther they should not have received.

Electronic Benefit The system used in Geeegia to pay benefits to individuals who are abgible for Food Stamps or TANF. iindividusis

Transfer (EBT) ‘Sesistance are issued an EBT debit card, which Is used to withdraw cash benefits and to access their food

stamp accounts,

Household Members

Individuala who live in your hone.

Ineeerne

Payenents such as wages, salaries, commissions, bonuses, worker's compensation, disabiliy, pansion, resirement benefits, Interest, child support or any other form of money received

Migrant Farm Workers

Individuals who are seasonal farm workers. and move from one home base to another to work or look for farm: work

Resources

Cash, property, or assets such as bank accounts, vehides, stocks, bods, and Be insurance

Seasonal Farm Workers:

Individuals who work at certain times of the yaar planting, picking or packing produce. They are hired ana temparary basis when a job requires mora workers than the fam employe on a regular basis

Trafficking:

‘Selling or trading Food Stamp benefits for profit

‘Qualified Allenimmigrant.

Aquaified alevinemgrant is a person who i legally residing in the U.S. who falls within ane of the following catagories: a pergon lawfully admitted for parnanent residence (LPR) under the Immigration and Nationality Act INA}; Amarsaian immigrant under section 584 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees, admiltied under section 207 of the IMA; A person paroled into the US under section 212jd}(8) of the INA for at Inast one year; 4 person whose deportation Is being withheld under section 243/h) of the INA, as in effect prior to Apeil 1, 1997 , or section 241(b}(3) of the INA, aa amandod: a person who Is granted conditianal eaty under section 203(a)(7) af the INA ag in effet price to April 1, 1880; Guban or Radian immigrants 36 defined in section 501{e} of the Retupee Education Assistance Act of 1880; Welln of iunman iraffcting under section 107(b)(1) of the Trafficking Victims Protection Act of 2000: batterac! inimigrants whe meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1906, a5 amended; Afghan or Iraqi immignants granted specal immigrant status under section

101 (a)(27) of the INA, (subject to specified conditions): American indigns bern in Canada living im the ULS, under section 289 of the INA. or non-cilizens of federally-recognized Indian irise uriier Section 4c) of the indian Sea-Oeterminatan and Education Assistance Act and Among ar Highfanci Laotian trie! members that rendered assistanoa to U.S. personnel by taking part in milfary or rescue operation during Vietnam Era (BOS 964 — SV0FMOTS).

Applicant

An individual whe chooses to apply for or fo receive public asslstanca/beanefits

Non-applicant

An individual who chooses NOT to apply for orto receive public assistancavbanefite; non-apallcants are met required to provide an SSN, citizenship of immigration status.

Assistance Unit

An assistance unit incudes eligible Individuals who live together and receive public assistance/benefits together.

Form 297 (Rew. 0312)

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information about his or her citizanship, immigration status, or social security numbers, then that person can be designated as.a normapplicant. This means that the person will not be considered an applicant and will not be eligible for benefits. However, other household members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. ‘You will still need to tell

us about your income and resources to determine the eligibility and benefit level of the household.

Individuals

will not be reported to the United States Citizenship and Immigration Services if they do not give us their citizenship or immigration status.

NAME Relation Is this. Birth Soclal Secunty | Sex Hispamicr Race Are you a ULS -ahip person Date Number Latina? Cede eizen, qualified First = Middle Initial «= Last. to You senting allervimenigrant or benstts? (Optional) | (Optional) | HmomgiHightand Laotian Immigrant? (Applicants only} (vin Format (Applicants (ae codes fal-t--) ‘onty) (we) | __cviny Batow) {YN SELF _ Race Codes (Choose all that apply): . Al—American Indian/Alaska Native = AS— Asian BL = Black/African American

HP - Native Hawaiian/Pacific Islander WH- White

By providing Race/Ethnicity information, you will assist ue in administering our programe in a nen-diseriminatery manner. Your household is not required to give ua this information and i will not affect your eligibility or benefit level,

Tell Us More about the Applicant and All Household Members

We need more information about the applicant a benefits. Please answer only the questions about the benefits you want to receive on the page below.

1. Has anyone received any benefits in another county or state?

Who,

What:

Where:

When:

ers in order to decide who is eligible for

O Yes No

2. Did anyone in your house hold voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week since the last application or review?

If yes, who quit?

O Yes O No

Why did he/she quit?

Form 297 (Rev, 03/12)

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DEPARTMENT OF HEALTH & HUMAN SERVICES —— Centers for Medicare & Medicaid Services Ca Ss 7300 Security Boulevard, Mail Stop: 52-01-16

Baltimore, Maryland 21244-1850 CE TE TE Tg

Children and Adults Health Programs Group

MAR 3 1 2015

Dr. Linda Wiant

Chief of the Medicaid Assistance Plans

State of Georgia, Department of Community Health 2 Peachtree Strect, NW, Suite 36450

Atlanta, GA 30303

Your title XX1 Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number 20, submitted on May 2, 2014, with additional information submitted on March 30, 2015, has been approved, The SPA has an effective date of January 1, 2014.

Through this SPA, Georgia reduces the number of premium bands in the state’s CHIP program, PeachCare for Kids, from ten premium bands to six premium bands, The state also updates the federal poverty levels (FPLs) of the premium bands to be consistent with Modified Adjusted Gross Income (MAGI) eligibility levels and adjusts the premium amounts for inflation. This SPA also deletes obsolete information in the CHIP state plan and removes the cap on psychotherapy, which was previously limited to ten hours per month.

As you are aware, Georgia implemented proposed premiums on January 1, 2014 without prior approval by the Centers for Medicare & Medicaid Services (CMS). During review of the SPA, CMS identified errors. in the methodology used to collapse the premium bands into fewer categories, which resulted in increasing the premiums for some families. In response, Georgia submitted a corrective action plan to reimburse families for the difference between the approved premiums and the increased premiums charged from January 1, 2014 through March 31, 2015.

Your title XI project officer is Ms. Cassandra Lagorio. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lagorio's contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-4554

Facsimile: (410) 786-3943

E-mail: Cassandra.Lagorio(@cms.hhs.gow

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SPA # GA-17-0024 Approval Date: January 4, 2018 Effective Date: July 1, 2017

GA-17-0024

Sections of SPA to be replaced:

6.2.20.  Case management services (Section 2110(a) (20))

6.2.26.  Medical transportation (Section 2110(a) (26))

Emergency ambulance services are covered for an enrollee whose life and/or health are in danger. Non-emergency transportation is not covered.

6.2.27.  Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a) (27))

Sections of SPA that have been updated:

These services are the same as the services in the Georgia Medicaid Plan with the exceptions of services solely for persons over age 19, and some services that to be received require a level of disability that would qualify the child for Medicaid. These services are subject to the same limitations and prior approvals as they are in the Georgia Medicaid Plan.

6.2.20.  Case management services (Section 2110(a) (20))

6.2.26.  Medical transportation (Section 2110(a) (26))

6.2.27.  Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a) (27))

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 i iY | Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

October 13, 2020

Lynnette R. Rhodes, Esq.

Executive Director, Medical Assistance Plans Department of Community Health

2 Peachtree Street, 36th Floor

Atlanta, GA 30303

Dear Ms. Rhodes:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number GA-20-0030, has been approved. Through this SPA, Georgia has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of October 24, 2019.

Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Georgia demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Jack Mirabella. They are available to answer your questions concerning this amendment and other CHIP-related matters. Their contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-2424

E-mail: jack.mirabella@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Acting Division Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely, /Signed Amy Lutzky/ Amy Lutzky Acting Deputy Director

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If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

6.3.1- BH

Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age- appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools. The Georgia Division of Medical Assistance Plans Contract with each CMO requires that provider utilize the AAP 2019 Bright Futures “Recommendations for Pediatric Health Care” Periodicity Schedule as the periodicity schedule for EPSDT visits and services which reimburses pediatricians and pediatric extenders to provide developmental screenings, including behavioral health screenings. The state provides guidance for providers to utilize the training resources/references that are recommended by the AAP/BF and the training resources are referenced in Georgia’s EPSDT manual for pediatric providers. These trainings refer providers to validated screening and assessment tools required by the state. The plans are responsible for conducting provider education and training on screening and assessment tools which are required by the state, as well as disseminating information on the tools. .

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

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reliance on a shared primary workforce to deliver children’s behavioral health services since most behavioral health providers work both in the fee-for-service Medicaid sector, which is operationally managed by DBHDD, and the managed care sector. DCH holds an administrative contract with DBHDD to operationalize behavioral health services through the shared provider network, which includes provider training opportunities. These trainings refer providers to validated screening and assessment tools required by the state. Similarly, both Fee-for-Service Medicaid and the MCO Plans delivering services in CHIP authorize ongoing behavioral health services using assessment information offered by enrolled behavioral health providers via state required validated tools such as those noted above.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system. The CMO (MCO) contracts under which PeachCare for Kids® members receive behavioral health services include the following requirements and provide a clear mechanism for member information access including how to submit complaints should the Managed Care Plan fall short in meeting member needs in this or any other area: a. Each Contractor shall produce and make available all marketing materials in English and all prevalent, non-English languages spoken within the State of Georgia. b. Plan for interpretive services and written materials, to meet the needs of Members whose primary language is not English, using qualified medical interpreters (both sign and spoken languages), and make available easily understood Member oriented materials, including the posting of signage in the languages of the commonly encountered group and/or groups represented in the service area; c. The translator must be fluent in both the original source language and the target language and must translate the language to make it understandable. Translation Services may also include the use of computer tools or technology. d. Each Contractor shall notify its Members of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to the Member for interpretation services. e. Each Contractor shall have a comprehensive written Cultural Competency Plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Members, including those with limited English proficiency, hearing impairment, a speech or language disorder, physical disabilities, developmental disabilities, differential abilities, or diverse cultural and ethnic backgrounds. The Cultural Competency Plan must describe how the Providers, individuals and systems within the CMO will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individual Members and protects and preserves the dignity of each.

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group March 10, 2022 Stefanie Ashlaw Director, Peach Care for Kids State of Georgia, Department of Community Health 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303 Dear Ms. Ashlaw: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number GA-22-0031, submitted on February 25, 2022, has been approved. Through this SPA, Georgia has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act. Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost-sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID- 19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act. In addition, Georgia has elected to waive all copayments for all benefits for the duration of this SPA. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Georgia requested a waiver to obtain an earlier effective date and this letter approves the state’s request for an effective date of March 11, 2021. Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov

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State of Georgia SPA number: GA-2022-0031

This State Plan Amendment will update the following sections:

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

SPA number: GA-2022-0031

Purpose of SPA: The purpose of this SPA is to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID- 19 without cost sharing in CHIP.

Proposed effective date: March 11, 2021

Proposed implementation date: March 11, 2021

1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

The State of Georgia has no recognized Tribes and therefore no Tribal Consultation is necessary.

6.2.27.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

Health Check: Regular physical examinations (screening), health tests, immunizations and treatment for diagnosed problems are covered. Screening requirements are based on the recommendations for preventive pediatric health care adopted by the American Academy of Pediatrics. Treatment is covered within the limitations on covered services.

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Family Planning: Covered services include initial and annual examinations, follow-up, brief and comprehensive visits, pregnancy testing, birth control supplies, and infertility assessment.

Physician’s Assistant Services: Covered services are limited to primary care services and anesthesiologist’s assistant services authorized in the basic primary care job description, approved by the Georgia Composite State Board of Medical Examiners.

Effective March 11, 2021, and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan:

COVID-19 Vaccine:

X The state provides coverage of COVID-19 vaccines and their administration, in accordance with the requirements of section 2103(c)(11)(A) of the Act.

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COVID-19 Testing:

X The state provides coverage of COVID-19 testing, in accordance with the requirements of section 2103(c)(11)(B) of the Act.

X The state assures that coverage of COVID-19 testing is consistent with the Centers for Disease Control and Prevention (CDC) definitions of diagnostic and screening testing for COVID-19 and its recommendations for who should receive diagnostic and screening tests for COVID-19.

X The state assures that coverage includes all types of FDA authorized COVID-19 tests.

COVID-19 Treatment:

X The state assures that the following coverage of treatments for COVID-19 are provided without amount, duration, or scope limitations, in accordance with requirements of section 2103(c)(11)(B) of the Act : X The state provides coverage of treatments for COVID-19 including specialized equipment and therapies (including preventive therapies); X The state provides coverage of any non-pharmacological item or service described in section 2110(a) of the Act, that is medically necessary for treatment of COVID-19; and X The state provides coverage of any drug or biological that is

approved (or licensed) by the U.S. Food & Drug Administration (FDA) or authorized by the FDA under an Emergency Use Authorization (EUA) to treat or prevent COVID-19, consistent with the applicable authorizations.

Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: X The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without amount, duration, or scope limitations, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) of the Act.

8.2.3.

Coinsurance or copayments:

Copayments are not required for children ages 0-5 years old. American Indians/Alaska natives and children in Foster Care are also exempt from paying copayments. For children ages 6-18, the copayments are detailed in the table below:

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State of Georgia State Plan Amendment number: GA-2022-0032

This State Plan Amendment will update the following sections: 1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

SPA number: GA-2022-0032 Purpose of SPA: The purpose of the SPA is to add Express Lane Eligibility to the CHIP (PeachCare for Kids) program in order to increase the number of low- income children enrolled in CHIP (PCK).

Proposed effective date: 10/01/2022

Proposed implementation date: 10/01/2022 1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. The State of Georgia has no recognized Tribes and therefore no Tribal Consultation is necessary. Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both. 4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E)) 4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

Express lane eligibility will be applied to both applications and renewals.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies. Applications from the State’s Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF), which are both Department of Family Children Services agencies.

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4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option. All members eligible for the Express Lane option must be approved for SNAP and/or TANF during the initial application or redetermination process and may select the option to be considered for Express Lane CHIP (PCK) on the application or renewal form. The income used to determine the approval for SNAP and/or TANF, as well as other information that has been collected (e.g., verification of citizenship, State residency), will be used to determine Express Lane CHIP (PCK) eligibility. The following summarizes current methodology used by CHIP (PCK) to determine eligibility. CHIP (PCK) eligibility is determined using Modified Adjusted Gross Income (MAGI) household composition subject to its state plan in determining eligibility. The MAGI Budget Group (BG) consists of tax filers and their tax dependents, or non-tax filers and in their home their spouses, children under the age of 19 (natural, biological, adopted or step), and for children under the age of 19, natural, biological, adopted and stepparents, and natural, biological, adopted and step siblings under the age of 19. The BG also includes any unborn child of an individual included in the BG who is pregnant. The current CHIP MAGI household income for children under 19 is between 138% and 247% of the federal poverty level (FPL). CHIP utilizes a 5% income disregard if needed for eligibility. TPL is not allowed for PCK enrollees which includes ELE PCK enrollees. The following summarizes methodology used to determine eligibility for SNAP and TANF applicants. and will be used to determine Express Lane CHIP (PCK) eligibility as specified.

Budget Unit:

SNAP The household composition consists of the individual, individual spouse, minor children under 18 who are under parental control of a household member other than their parent, parents, and their children under the age of 22 (biological, adopted or step), and/or all individuals who purchase and prepare meals together. TANF The household composition consists of children within the specified degree of relationship to grantee relative. The following relationships meet the relationship requirement: parent (either by birth, legal adoption, or step relationship) , grandparent (up to great-great-great), sibling (half, whole, step), aunt/uncle (up to great-great), niece/nephew (including child and grandchild of niece/nephew), first cousin, first cousin once removed (the child of a first cousin), legal guardian, spouse of any person named in the above group even after the marriage is terminated by death or divorce, unless the child is born after termination of the marriage.

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SNAP The following income sources are not included in MAGI but are included in SNAP: • Child support • Contributions • Supplemental Security Income (SSI) • Temporary Assistance for Needy Families (TANF) TANF The following income sources are not included in MAGI but are included in TANF: • Child support • Contributions (This is not an all-inclusive list) • 4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane. The applicant must qualify for SNAP or TANF prior to ELE consideration. If the applicant selects the option to be considered for ELE CHIP (PCK) they must meet the following criteria to be eligible. The state assures that the citizenship/immigration status component is determined in compliance with 457.380(b). • Income between 236% and 247% of the FPL • citizenship/immigration status • identity • age (under the age of 19) • residency 4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI. SNAP and/or TANF applicants must be approved and have selected the option to be considered for ELE CHIP (PCK). The household income must be between 236% and 247% FPL, and enrollees must meet basic eligibility requirements such as age, citizenship, and residency requirements, to be enrolled in Express Lane CHIP (PCK). Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age- related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL and provide an explanation of how this was calculated. Describe whether the State is temporarily

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enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process. In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3)) 4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that: 4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women. 4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2)) Georgia implemented an Integrated Eligibility System that automatically screens all applicants for Medicaid and CHIP eligibility and enrolls them in the appropriate class of assistance based on household circumstances. 4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) Georgia implemented an Integrated Eligibility System that automatically screens all applicants for Medicaid and CHIP eligibility and enrolls them in the appropriate class of assistance based on household circumstances. 4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805) Children that are covered by creditable health coverage are not eligible for PeachCare for Kids. 4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42CFR 457.810(a)-(c)) PeachCare for Kids does not provide coverage under a premium assistance program. 4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a)) There are no federally recognized tribes in Georgia. Recognizing that a member of a tribe may re-locate to the State, CHIP will exempt children who are members of federally recognized tribes from the cost- sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the CHIP application will be notified that, upon receipt of

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documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid after October 1, 1999, will be reimbursed within 45 days of receipt of documentation of tribal membership. The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally recognized American Indian or Native Alaskan tribes to ensure that those not indicating race on the application will be notified of this exemption. Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process or elect one of two new options to fulfill these requirements. 4.4-EL The State should designate the option it will be using to carry out screen and enroll requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. Include the screening threshold(s) expressed as a percentage of the FPL and provide an explanation of how this was calculated. The Georgia Integrated Eligibility System (IES) will compare the household income to the highest Medicaid income threshold (205% FPL) applicable to a child (0-19) plus 30% which will equal to 235% FPL. If household income is over 235% FPL but at or below 247% FPL, the child should be evaluated for Express Lane CHIP (ELE PCK). If a child is found eligible for Express Lane CHIP PeachCare for Kids (ELE PCK) from the ELE determination, the applicant will be provided a notice that the child may qualify for Medicaid and/or lower premiums if evaluated using the regular eligibility determination and provide an avenue on how to request a full eligibility determination. A separate application is not required. An applicant is no longer considered ELE if a full eligibility determination is requested by the applicant and is determined eligible. Note: Children with third-party liability (TPL) are not eligible for PCK.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process. Section 5. Outreach and Coordination 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42CFR 457.80(b)) Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs. 5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

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Currently, Georgia’s public child health insurance plans include PeachCare for Kids® and the Medicaid program administered by the Georgia Department of Community Health (DCH), Division of Medical Assistance (DMA). The Department has several approaches to identifying and enrolling eligible children. These approaches are described in the following paragraphs. PeachCare for Kids® PeachCare for Kids®’ outreach effort was launched in September 1998. Outreach initiatives have included a wide array of mass-media and local grassroots efforts. PeachCare for Kids® has had massive advertising, in both English and Spanish, through television, radio, newspaper, and outdoor billboard and transit advertising. In 2001 and 2002, PeachCare for Kids ® will teamed up with WSB Channel 2’s, Atlanta’s ABC affiliate, Family 2 Family Community Program. Through this partnership, PeachCare for Kids® was able to participate in hundreds of family-oriented community events in the metro Atlanta area. PeachCare for Kids ® will also benefit from the extensive public service campaigns throughout the State of Georgia. In 2000, the Department created a “minigrant” program to facilitate grassroots efforts to educate targeted populations about PeachCare for Kids® and Medicaid. The grantee organizations will be diversed in the populations they served, including African American, Hispanic, Asian, and rural communities. An evaluation of the grantees showed a 16% increase in applications submitted over other similar counties during the same time, and a 19% increase in applications for the targeted populations. In 2000, 2001, and 2002, the Department has teamed up with the Department of Education, Division of School Nutrition Services to distribute flyers, in English and Spanish, to each student during Back-to- School registrations. The Right from the Start Medicaid (RSM) outreach staff worked with many elementary schools to be on site promoting PeachCare for Kids® and Medicaid to the parents. PeachCare for Kids®, RSM, March of Dimes and Kmart stores partnered in 1999 and 2000 to promote PeachCare for Kids ® and Medicaid. In 1999, outreach workers were at each Kmart store on the Saturday before Halloween educating parents while their children shopped for costumes and treats. In 2000, the outreach workers returned to Kmart on the Saturday before school started to talk to parents as they were getting their kids ready for the new school year. The Department has created a simple, one-page mail-in application for PeachCare for Kids®, available in English, Spanish, Vietnamese, Chinese, Korean and Somalian. The application is distributed by request through the PeachCare for Kids® call center and throughout the state in many hospitals, provider offices, Department of Families and Children offices, health departments, and libraries. In 2001, the Department launched www.peachcare.org, a web-based application designed to provide parents with instant access to complete the enrollment process. In its first year, applications have been received for nearly 40,000 children through the website. The site has also been successful reaching families of Medicaid-eligible children. Nearly half of all web-based applicants have been eligible for the Medicaid program. The advantages of the website are numerous. It eliminates mail delays. It provides parents with instant confirmation that the application has been received and gives parents an estimation of potential eligibility. The website also generates a list of participating primary care physicians to assist parents in the selection of a doctor for their child. Division of Family and Children Services (DFCS)

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The Department of Medical Assistance has an interagency agreement with the Department of Human Resources (DHR) to provide, through its Division of Family and Children Services (DFCS), Medicaid eligibility determinations for all Medicaid coverage groups other than SSI cash assistance. For pregnant women and children, these coverage groups include Low Income Medicaid, Medically Needy, Right From the Start Medicaid (RSM - Georgia’s poverty level Medicaid program), and the Katie Beckett Deeming Waiver programs. These programs are offered in conjunction with other entitlement programs and supportive services that are offered by DFCS. DFCS is also responsible for Food Stamps, Temporary Assistance for Needy Families (TANF), Child Protective Services and Foster Care. The Medicaid application process is coordinated with that for cash assistance and employment related services available through TANF. Children in families seeking these services also have their Medicaid eligibility determined. The State of Georgia has 159 counties. Each county has at least one DFCS office, and some counties have multiple sites for Medicaid eligibility intake. Some workers from these local DFCS offices are assigned to Federally Qualified Health Centers (FQHCs) and Disproportionate Share Hospitals. While the bulk of the state’s Medicaid determinations are made locally at the county DFCS offices, the RSM Outreach Project is an aggressive outreach program targeted at enrolling uninsured and underinsured poverty level pregnant women and children in Medicaid and PeachCare for Kids®. This project operates under a separate interagency agreement between the Department of Community Health and the Department of Human Resources. The eligibility workers who are part of this project are housed in locations other than the local DFCS offices. Public Health Departments and Federally Qualified Health Centers DCH also coordinates Medicaid enrollment efforts with the activities of the Division of Public Health, a part of the Department of Human Resources. Across the state, perinatal case management services and the Medicaid application process are linked. At the public health departments and federally qualified health centers, a pregnant woman can apply for Presumptive Medicaid eligibility, and begin receiving prenatal services immediately. As part of this process, the pregnant woman applies for RSM Medicaid to ensure ongoing Medicaid eligibility. When the pregnant woman applies for RSM, any children in the family are also included on the application form and the form with the children’s names are routed to DFCS for a determination of their eligibility along with that of the pregnant woman. The Division of Public Health, through its local health departments, and the federally qualified health centers administer the Special Nutritional Program for Women, Infants and Children (WIC). This program provides nutritious food to supplement the regular diet of pregnant women, breast- feeding women, infants, and children under age five who meet state income standards. Generally, on the initial visit to either of these facilities, the pregnant woman is certified for Presumptive Medicaid eligibility, applies for regular Medicaid for herself and her children, and receives WIC for herself and any children under the age of five (5). The PeachCare for Kids® program also recognizes the WIC program as an Express Lane agency. Express Lane Eligibility was implemented effective April 1, 2011, and ended April 1, 2016(1902 (e) (13) of the Social Security Act). The program partnered with the Special Nutritional Assistance Program for Women, Infants, and Children (WIC) to implement the program. Other State Initiatives For Special Needs Children The following programs are some of the State’s own initiatives to provide health care to special needs children. All are administered by the Department of Human Resources, three by the Division of Public Health, two by the Division of Mental Health, Mental Retardation and Substance Abuse and one by an interagency team. As mentioned previously, RSM outreach workers are stationed in many county public health departments or visit on a routine basis to process Medicaid applications. Uninsured children who

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present to these programs for their services are referred to outreach workers or county DFCS offices to have a Medicaid eligibility determination completed. Division of Public Health “Babies Can’t Wait” “Babies Can’t Wait” or the Early Intervention Program is Georgia’s statewide interagency service delivery system for children from birth to three years who have developmental delays or disabilities. This program guarantees that all children, regardless of their disability, have access to services that will enhance their development. Services are provided by agencies and individuals from both the public and private sectors. Some are offered at no cost. For others, state funds are available to assist families that have been determined unable to pay. Medicaid eligible children may participate in this program. Children’s Medical Services Children’s Medical Services (CMS), formerly the Crippled Children’s Program, provides medical care to low-income children with disabling conditions or chronic diseases. It also provides specialized health care for certain disorders, e.g., chronic lung disease, craniofacial anomalies, and cystic fibrosis. Eligibility is based on the age of the child (0-21 years), type of medical condition, Georgia residency and annual family income. Some services are covered by Medicaid and Medicaid eligible children may participate in this program. CMS serves approximately 15,000 to 16,000 children yearly. Department of Behavioral Health and Developmental Disabilities Core and Specialty Services include evaluation/assessment, diagnosis, counseling and medication, therapy (individual, group, and family), community support services, crisis assessments, and physician services. These services are provided in clinics and other locations as needed, including homes, schools, detention facilities, and other community settings. Crisis Services include crisis stabilization and mobile crisis response services. Mobile Crisis Response Services (MCRS) provides community-based, face-to-face crisis response 24 hours a day, seven days a week to individuals in an active state of crisis. MCRS offers short-term, behavioral health services for persons in need who may have been unable to successfully maintain stability. Psychiatric Residential Treatment (PRTF) Services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults ages 5-21 who, due to severe emotional disturbance, are in need of quality active treatment that can only be provided in an inpatient treatment setting and for whom alternative, less restrictive forms of treatment have been tried and found unsuccessful or are not medically indicated. Uninsured children who present to these programs for their services are referred for a Medicaid eligibility determination, but services are provided to uninsured or underinsured children on a sliding fee scale and are not denied due to inability to pay.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate. The state is implementing the Express Lane Eligibility option to provide a simplified determination process and expedited enrollment of eligible children into CHIP. The state agency will obtain information

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from approved SNAP and TANF applications to provide streamlined eligibility determinations for CHIP (PCK). DCH will work together with other state agencies, community partners, and social media platforms to encourage enrollment of low-income residents of Georgia.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership: The State of Georgia has one public-private program designed to provide health care to uninsured children; however, this program does not offer “creditable coverage.” The PeachCare for Kids® and Medicaid program’s eligibility processes have a significant role in the efforts of the program. The application process for The Georgia Partnership for Caring Program begins with the RSM Outreach Project worker. 9.10. Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140) Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child, and expected enrollment. • Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low-income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. • All cost sharing, benefit, payment, eligibility need to be reflected in the budget. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

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STATE: GA FFY Budget There will be no appreciable impact to the budget.

Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan. 12.1. Eligibility and Enrollment Matters- Describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Describe any special processes and procedures that are unique to the applicant’s rights when the State is using the Express Lane option when determining eligibility. Upon any adverse action as described in 42 CFR § 457.1130 (a), the parent or authorized representative (A/R) will be notified by mail of the reason for the adverse action and how to request a review if they believe the decision is in error. The notice of such action will meet the requirements of 457.340(e) and 457.1180. The opportunity for continued enrollment of a suspended or terminated enrollment will meet the requirements of 457.1170. If a hearing notice is required, it will meet the requirements of 457.1140. A written request for an initial administrative review may be submitted to the TPA, Division of Family and Children Services (DFCS) and forwarded to the Right from the Start Group (RSM Group) for processing which must be completed within 5 days. The request must be submitted within thirty (30) days of the written notification in which s(he) disagrees. If a verbal request is made, the parent or A/R must submit a written request within fifteen (15) days of the original request. If the written request is not received, no further action is required. If the RSM group is able to review the case and determine eligibility was determined correctly, discuss the complaint with the parent or A/R, and a mutual agreement is made, the parent or A/R may choose to withdraw the hearing request. If the RSM group is unable to obtain a hearing withdrawal either verbally or in writing from the parent or A/R, a hearing notice will be mailed to the parent or A/R in which they will have 10 days to respond. If no response is received, the administrative review is considered complete, and no further action is required. If the parent or A/R is not satisfied with the outcome of the administrative review, s/he can request a fair hearing which will be submitted to the Legal Services Office (LSO). If the RSM group finds the case was processed incorrectly, it will be corrected, and the same procedures as stated above will be followed accordingly.

The LSO will submit the hearing request to the Georgia Office of State Administrative Hearings (OSAH). OSAH will notify the parent or A/R of the time, place, and date of the hearing. Both the parent or A/R and RSM representative, on behalf of the state, can be present at the hearing. Each will be allowed to present their case to the Administrative Law Judge. The decision of the Administrative Law Judge will be provided in writing and will be final. The final decision could take up to 90 days from the date of the written

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request. There will be no further administrative recourse for the parent or A/R or RSM worker. NOTE: All hearing requests must be forwarded to the Legal Services Office (LSO) regardless of when the request was received. Untimely requests for a hearing will not be considered or forwarded to OSAH except for good cause. All hearing requests, oral or written, including requests received more than 30 days after notification is issued, must be forwarded to LSO within three (3) business days.

The decision of the Administrative Law Judge will be the final administrative recourse available to the parent or A/R. If at any level of the appeal, the child(ren) is/are determined eligible for enrollment in PeachCare for Kids®, the enrollment will become

effective retroactive to the first day of the month in which the completed application, including any additional information affecting the outcome of the program’s decision is received. The State assures that in the review process, parents or A/R will have the opportunity to fully participate in the review process; decisions are made in writing; and impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services. Applicant and Enrollee Protections for ELE include • If a child is found eligible but subject to premiums, based on an income finding from an Express Lane agency, the State must provide notice that the child may qualify for lower premiums if evaluated using the State’s regular eligibility determination procedures and receive information concerning how to request such an evaluation. • Children who are determined eligible and enrolled in CHIP using the screening threshold option for screening and enrollment, the State must provide notice to the family that the child may be eligible for Medicaid if evaluated using the State’s regular eligibility determination procedures. The notice must specify the process for requesting such an evaluation and the differences between Medicaid and CHIP, including differences in benefits and cost sharing. • Children who are found to be over the income threshold of 247% must be notified that they may be eligible for CHIP if evaluated using the State’s regular eligibility determination procedures. The notice must specify the process for requesting such an evaluation and the differences between Medicaid and CHIP, including differences in benefits and cost sharing. • After a full Medical Assistance eligibility determination, if the applicant is over income for CHIP or any other category of Medical Assistance their information will be electronically submitted to the Federally Facilitated Marketplace (FFM). The customer will be notified of this action and how to obtain coverage. • The state assures that all eligibility/renewal notices will provide information to applicants on how to request a review of their determination or how to file a state hearing.

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group October 26, 2022 Stefanie Ashlaw Director, Peach Care for Kids State of Georgia, Department of Community Health 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303 Dear Ms. Ashlaw: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number GA-22-0033, submitted on September 8, 2022, has been approved. Through this SPA, Georgia provides 12 months of continuous postpartum coverage to individuals enrolled in its separate CHIP, pursuant to section 9822 of the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of November 1, 2022 and extends through March 31, 2027, and is a companion to the Medicaid continuous postpartum coverage SPA, GA-22-0005-PPPG. Section 9822 of the ARP added section 2107(e)(1)(J) to the Social Security Act, which requires states to provide continuous eligibility throughout an individual’s pregnancy and 12-month postpartum period in CHIP if the state has elected this option in Medicaid. In Georgia, these provisions apply to targeted low-income children who are pregnant. In addition, this SPA updates section 6.2.9 of the CHIP state plan to provide lactation services for pregnant and postpartum individuals. Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (443) 934-2064. We look forward to continuing to work with you and your staff. Sincerely, Sarah deLone Director /Signed by Sarah deLone/

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Page 1 of 2 CHIP Eligibility State Name: Georgia OMB Control Number: 0938-1148 Transmittal Number: GA - 22 - 0033 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27 2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of the SSA Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This Option in Medicaid

At state option in Medicaid, states may elect to provide continuous eligibility for an individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If elected under Medicaid, states are required to provide the same continuous eligibility and extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP cannot implement this option if not also elected under the Medicaid state plan. State elected the Medicaid option to provide continuous eligibility through the 12- month postpartum period Yes The 12-month postpartum continuous eligibility applies for the period beginning on the effective date of this SPA (no earlier than April 1, 2022) and is available through March 31, 2027. The state assures the extended postpartum period available to pregnant targeted low-income children or targeted low- income pregnant women under section 2107(e)(1)(J) of the SSA is provided consistent with the following provisions: Individuals who, while pregnant, were eligible and received services under the state child health plan or waiver shall remain eligible throughout the duration of the pregnancy (including any period of retroactive eligibility) and the 12- month postpartum period, beginning on the day the pregnancy ends and ending on the last day of the 12th month consistent with paragraphs (5) and (16) of section 1902(e) of the SSA Continuous eligibility is provided to targeted low income children who are pregnant or targeted low-income pregnant women (if applicable) who are eligible for and enrolled under the state child health plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: The individual or representative requests voluntary disenrollment. ■ The individual is no longer a resident of the state. ■ The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to the individual. ■ The individual dies. ■ Unlike continuous eligibility for children, states providing the 12-month postpartum period may not end an individual’s continuous eligibility due to non-payment of premiums or becoming eligible for Medicaid. Consistent with section 2107(e)(1)(J) of the SSA, the state assures that continuous eligibility is provided through an individual’s pregnancy and 12-month postpartum period regardless of non-payment of premiums, or an individual becoming eligible for Medicaid. Benefits provided during the 12-month postpartum period must be the same scope of comprehensive services consistent with the benefit package elected by the state under section 2103(a) of the SSA that is available to targeted low income children and/or targeted low-income pregnant women and may include additional benefits as described in Section 6 of the CHIP state plan.

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State of Georgia State Plan Amendment number: GA-2022-0033

SPA number: GA-2022-0033 Purpose of SPA: The purpose of the SPA is to include 12-Month Post-Partum continuous eligibility for our CHIP enrollees.

Proposed effective date: 11/01/2022

Proposed implementation date: 11/01/2022 1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. The State of Georgia has no recognized Tribes and therefore no Tribal Consultation is necessary. 4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group: The plan will be available to children 0 through 18 years of age. If the child is otherwise eligible, coverage will continue through the month of his/her nineteenth birthday, with an income no greater than 247% FPL.

Continuous eligibility is provided to targeted low-income children/teens who are pregnant, eligible, and enrolled in the state CHIP plan beginning on the day the pregnancy ends and ending on the last day of the 12 month Post-Partum period, which may extend beyond their nineteenth birthday, and with an income no greater than 247% FPL. This Post-Partum coverage is available through March 31, 2027.

4.1.9.2 Continuous eligibility 12 months continuous Post-Partum option

4.1.9.2- a. The State includes eligibility for Pregnant CHIP enrollees who meet the following eligibility criteria. • Income does not exceed 247% of the FPL, and not eligible for Medicaid • citizenship/immigration status • identity • age (under the age of 19) • residency

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4.1.9.2- b. Continuous eligibility is provided to targeted low-income children/teens who are pregnant, eligible, and enrolled in the state CHIP plan beginning on the day the pregnancy ends and ending on the last day of the 12 month Post-Partum period, with an income no greater than 247% FPL, unless: • The individual or representative requests voluntary disenrollment • The individual is no longer a resident of the state • The agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual • The individual dies

4.1-PW Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

6.2.9. Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) These services are covered in full. This includes Childbirth Education Services, Lactation Consultants, a series of 8 classes regarding the birth experience and tools to prepare for a healthier pregnancy, birth, and 12-month continuous postpartum period. Full benefits are provided for a pregnant or postpartum individual under this option. This includes all items and services covered under the state plan that are not less in amount, duration, or scope than, or are determined by the Secretary to be substantially equivalent to, the medical assistance available for an individual described in subsection 1902 (a)(10)(A)(i) of the Act.

8.2.1. Premiums: Premiums are not required for children ages 0-5 years old. American Indians/Alaska natives and children in Foster Care are also exempt from paying a premium. For children ages 6-18, the premiums are detailed in the table below:

FPL One Child Family Cap 139%-158% 11.00 $16.00 159%-170% 22.00 $44.00 171%-190% 24.00 $49.00 191%-210% 29.00 $58.00

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May 10, 2023

Mr. Joshua Bougie Health Insurance Specialist Division of State Coverage Programs (DSCP) Centers for Medicare & Medicaid Services 7500 Security Blvd., MS S2-01-16, Baltimore, MD 21244

Re: Evergreen SPA Activation Letter

Dear Mr. Bougie:

According to the 2023 Consolidated Appropriations Act, the Public Health Emergency ends May 11, 2023. We are aware that the flexibilities approved for Georgia by CMS will end on that date.

Georgia has an approved evergreen relief SPA which includes the following flexibilities: delay applications/renewals and other changes in circumstances and waive premiums and copayments for our CHIP enrollees.

Please accept this letter as notice that Georgia has elected to begin our unwinding period on April 1, 2023. We have resumed processing renewals beginning April 1, 2023. We would like to activate our Evergreen SPA beginning May 12, 2023, and continue to waive premium payments through December 31, 2023. Effective January 1, 2024, Georgia will resume the collection of premiums for all enrollees who have had a renewal within the last 12 months (including new enrollees). The state will resume the collection of premiums on a rolling basis as renewals are conducted through the state’s COVID-19 PHE unwinding period, scheduled to end May 30, 2024. Upon renewal, each enrollee will be provided adequate and timely written notice that will include how the State determined eligibility, as well as their right and how to appeal the States decision. Effective June 1, 2024, the state will resume standard approved CHIP policies and processes except for imposing co- payments on any service, which will be waived through September 30, 2024, per Georgia State Plan: GA-2022-0031.

The States also attests that it will waive collecting cost sharing for COVID-19 testing, vaccination, and treatment through September 30, 2024, required under Section 9821 of the American Rescue Plan.

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State of Georgia State Plan Amendment number: GA-2023-0035

This State Plan Amendment will update the following secƟons: 1.4 Provide the eﬀecƟve (date costs begin to be incurred) and implementaƟon (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one eﬀecƟve date, but provisions within the SPA may have diﬀerent implementaƟon dates that must be aŌer the eﬀecƟve date.

SPA number: GA-2023-0035 Purpose of SPA: Provide coverage for lawfully residing children under the age of 19.

Proposed eﬀecƟve date: 01/01/2024

Proposed implementaƟon date: 01/01/2024

1.4-TC Tribal ConsultaƟon. (SecƟon 2107(e)(1)(C)) Describe the consultaƟon process that occurred speciﬁcally for the development and submission of this State Plan Amendment, when it occurred and who was involved. The State of Georgia has no recognized Tribes and therefore no Tribal ConsultaƟon is necessary. Guidance: States have the opƟon to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at secƟon 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at secƟon 2107(e)(1)(J) of the Act; or (3) both. A state elecƟng to cover children and/or pregnant women who are considered lawfully residing in the U.S. must oﬀer coverage to all such individuals who meet the deﬁniƟon of lawfully residing, and may not cover a subgroup or only certain groups. In addiƟon, states may not cover these new groups only in CHIP, but must also extend the coverage opƟon to Medicaid. States will need to update their budget to reﬂect the addiƟonal costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment esƟmates and the projected cost of providing coverage. Please remember to update secƟon 9.10 when elecƟng this opƟon. 4.1- LR Lawfully Residing OpƟon (SecƟons 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10- 006 issued July 1, 2010) Check if the State is elecƟng the opƟon under secƟon 214 of the Children’s Health Insurance Program ReauthorizaƟon Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as speciﬁed below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualiﬁed alien as deﬁned in secƟon 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admited or to which he or she has changed aŌer admission;

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(3) An alien who has been paroled into the United States pursuant to secƟon 212(d)(5) of the ImmigraƟon and NaƟonality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecuƟon, for deferred inspecƟon or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to secƟon 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respecƟvely); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to secƟon 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorizaƟon; (iii) Aliens who have been granted employment authorizaƟon under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneﬁciaries pursuant to secƟon 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred acƟon status; or (vii) Aliens whose visa peƟƟon has been approved and who have a pending applicaƟon for adjustment of status; (5) A pending applicant for asylum under secƟon 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under secƟon 241(b)(3) of the INA (8 U.S.C. § 1231) or under the ConvenƟon Against Torture who has been granted employment authorizaƟon, and such an applicant under the age of 14 who has had an applicaƟon pending for at least180 days; (6) An alien who has been granted withholding of removal under the ConvenƟon Against Torture; (7) A child who has a pending applicaƟon for Special Immigrant Juvenile status as described in secƟon 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigraƟon laws of American Samoa.

Elected for pregnant women. Elected for children under age 19

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing opƟon, it has veriﬁed, at the Ɵme of the individual’s iniƟal eligibility determinaƟon and at the Ɵme of the eligibility redeterminaƟon, that the individual conƟnues

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ccmMsS CHIP Eligibility

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

cl An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{@] An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than | year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

Page 2 of 3

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

July 22, 2024

Stefanie Ashlaw Director, Peach Care for Kids State of Georgia, Department of Community Health 2 Martin Luther King Jr. Drive, SE 19th Floor, East Tower Atlanta, GA 30334

Dear Stefanie Ashlaw:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number GA-24-0039, submitted on February 8, 2024 with additional information received on July 16, 2024, has been approved. The companion SPA number GA-24-0041, submitted on May 2, 2024 has also been approved. The effective dates for these SPAs are January 1, 2024 and October 1, 2024, respectively.

Through GA-24-0039, Georgia provides 12 months of continuous eligibility (CE) coverage to individuals enrolled in its separate CHIP, pursuant to section 5112 of the Consolidated Appropriations Act, 2023 (CAA, 2023). Section 5112 of the CAA, 2023 amended titles XIX and XXI of the Social Security Act to require that states provide 12 months of CE for children under the age of 19 in Medicaid and CHIP. In Georgia, this provision applies to targeted low-income children. Further, Georgia confirms the state will not disenroll children from coverage due to late premium payments during or at the end of the CE period. A copy of the approved CS21 and CS27 state plan pages are attached to be incorporated into the state’s approved CHIP state plan.

Through GA-24-0041, Georgia is aligning section 8.7 with companion SPA GA-24-0039 to update the description of timeframes, notice requirements, and consequences for an enrollee or applicant who does not pay a cost sharing charge. Also through this SPA, the state waives the collection of all CHIP premiums through September 30, 2024 and resumes premium collection effective October 1, 2024.

Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov

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8.2.1.

Premiums:

Premiums are not required for children ages 0-5 years old. American Indians/Alaska natives and children in Foster Care are also exempt from paying a premium. For children ages 6-18, the premiums are detailed in the table below:

FPL One Child Family Cap 139%-158% 11.00 $16.00 159%-170% 22.00 $44.00 171%-190% 24.00 $49.00 191%-210% 29.00 $58.00 211%-231% 32.00 $64.00 232%-247% 36.00 $72.00

The State assures that continuous eligibility is provided through an individual’s 12-month Post-Partum period regardless of non-payment of premiums, or an individual becoming eligible for Medicaid.

At State discretion, premiums may be waived for CHIP applicants and/or beneﬁciaries who meet income and other eligibility requirements and who reside and/or work in State or Federally declared disaster areas for a speciﬁed period of time.

Through Georgia’s DRAL dated May 10, 2023, the state waived premiums for all CHIP enrollees through December 31, 2023. The state will continue waiving premiums through 9/30/2024.

8.7. Provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)):

Applicants will be given forty-ﬁve (45) days from the date the application is processed to make their initial premium payment. When the initial premium payment is received, the applicant will be enrolled in PeachCare for Kids®, and eligibility will be eﬀective the ﬁrst day of the month in which the application was submitted. There will be one late notice sent to the applicant if their initial premium payment has not been received within thirty (30) days of initial authorization of the application. The notice will notify the member that their case will be denied if their premium payment is not received by the 45th day. The denial letter will be sent with timely notice which includes an explanation of the applicants Fair Hearing Rights. If the initial premium payment is not received the case will be denied. Late notices will not be sent after the initial premium payment is received. Enrollees do not lose coverage for non-payment of premiums after the initial premium payment is received for each new enrollment period, which includes the initial eligibility determination at application and annual renewals. PCK members submitting renewal and documentation timely will be given 30 days from the date the renewal is processed to make their initial premium payment for the new period of eligibility. When the

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initial premium payment is received, eligibility will be eﬀective the ﬁrst day of the month following the renewal month. There will be one late notice sent to the member if their initial premium payment has not been received within 15 days of the authorization at renewal. The notice will notify the member that their case will be closed if their premium payment is not received by the 30th day. The notice will be sent with timely notice which includes an explanation of the applicants Fair Hearing Rights. Families who are closed due to non-payment of premium are notiﬁed and informed of their right to a review of the termination. Applicants that do not return their renewal timely will be terminated and provided a Ninety (90) day reconsideration period to submit their renewal. A new application is not required during this 90-day reconsideration period. PCK members submitting renewal and documents during the reconsideration period will be given 30 days from the date the renewal is processed to make their initial premium payment for the new period of eligibility. The period of eligibility will begin on the ﬁrst day of the month after the termination date once premium payment is received. If premium payment is not received the case remains terminated.

There is no lock out period for non-payment of premiums.

Premiums are due the ﬁrst of the month, prior to the month of coverage. If a premium payment is not received on the ﬁrst, a late letter is sent to the family approximately four days after the late premium was due informing them that if payment is not received by the end of the month, they will be given 45 days of grace period before the coverage termination process begins, with coverage being canceled at the end of the 2nd month of the grace period. If the family does not pay the past due premium at the end of the month that it is due, the grace period begins the following month. The State will send a notice no later than the 8th of the ﬁrst grace period month, informing the family that failure to make a premium by the 15th of the 2nd grace period month will initiate the termination process and coverage will ultimately be terminated at the end of the 2nd grace period month. If the premium is not paid by the 15th of the 2nd grace period month, then the coverage termination process begins and is ultimately terminated by the end of the 2nd grace period month, unless the family makes a premium payment by the end of the 2nd grace period month. Payments received after the 15th day of the 2nd grace period month will stop the termination process, and the family will remain enrolled. Families who are canceled due to non-payment of premium are notiﬁed by mail and informed of their right to a review of the termination.

In the case that a premium payment is made during the grace period, but there is still an outstanding premium(s), the payment would apply to the ﬁrst missed premium payment. The grace period would then start again based on the date of the second missed premium payment such that a family always has a grace period starting at the ﬁrst of the month of a new coverage period and ending 45 days later.

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There is no lock out period for non-payment of premium. The family may make a payment within 90 days of the case terminating and the case will be re-opened without the need to re-apply.

For example, on January ﬁrst the premium is due for February coverage. If a family missed the January 1st due date, a letter is sent to the family on approximately January 4th informing them that their payment is due and that if payment is not received by the end of January, the grace period will begin on February 1st and last until March 15th, after which the coverage termination process will begin. If the family does not pay the January 1st premium due for February coverage by the 15th of March, the termination process begins, and the family’s coverage is terminated at the end of March. However, if the family makes a premium payment by the end of March, the termination process is stopped, and the family remains enrolled.

In the case where a family missed the January 1st and the February 1st premium, but made a single premium payment by February 15th , the payment would apply to the January missed payment and the family would be oﬀered a new premium grace period starting on March 1st and requiring payment by April 15th before coverage is terminated. In the case where a family missed the January 1st premium, the February 1st premium, but made a single premium payment by March 15th, the February 1st premium due for March coverage would be required by April 15, after which coverage would end April 30. This cycle will continue for each new month of coverage and each grace period, where premium payments are late. Any late premium payments will always apply to the earliest premiums due.

Exception to Disenrollment for Failure to Pay Premiums At State discretion, initial premiums will be waived at application and/or renewal, for existing beneﬁciaries and new applicants who reside and/or work in a State or Federally declared disaster area.

Guidance: Section 8.7.1 is based on Section 2101(a) of the Act provides that the purpose of title XXI is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an eﬀective and eﬃcient manner that is coordinated with other sources of health beneﬁts coverage for children.

8.7.1. Provide an assurance that the following disenrollment protections are being applied:

Guidance: Provide a description below of the State’s premium grace period process and how the State notiﬁes families of their rights and responsibilities with respect to payment of premiums. (Section 2103(e)(3)(C))

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8.7.1.1.

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

8.7.1.2.

The disenrollment process aﬀords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

8.7.1.3.

In the instance mentioned above, that the State will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

8.7.1.4

The State provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8. The State assures that it has made the following ﬁndings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward State matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copayments, coinsurance and all other types) will be used toward State matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Page 1 of 2 CHIP Eligibility State Name: Georgia OMB Control Number: 0938-1148 Transmittal Number: GA - 24 - 0039 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27 2107(e)(1)(K) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of the SSA Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This Option in Medicaid

At state option in Medicaid, states may elect to provide continuous eligibility for an individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If elected under Medicaid, states are required to provide the same continuous eligibility and extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP cannot implement this option if not also elected under the Medicaid state plan. State elected the Medicaid option to provide continuous eligibility through the 12- month postpartum period Yes The state assures the extended postpartum period available to pregnant targeted low-income children or targeted low- income pregnant women under section 2107(e)(1)(J) of the SSA is provided consistent with the following provisions: Individuals who, while pregnant, were eligible and received services under the state child health plan or waiver shall remain eligible throughout the duration of the pregnancy (including any period of retroactive eligibility) and the 12- month postpartum period, beginning on the day the pregnancy ends and ending on the last day of the 12th month consistent with paragraphs (5) and (16) of section 1902(e) of the SSA Continuous eligibility is provided to targeted low-income children who are pregnant or targeted low-income pregnant women (if applicable) who are eligible for and enrolled under the state child health plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: The individual or representative requests voluntary disenrollment. The individual is no longer a resident of the state. The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to the individual. The individual dies. Unlike continuous eligibility for children, states providing the 12-month postpartum period may not end an individual’s continuous eligibility due to becoming eligible for Medicaid. Consistent with section 2107(e)(1)(J) of the SSA, the state assures that continuous eligibility is provided through an individual’s pregnancy and 12-month postpartum period regardless of an individual becoming eligible for Medicaid. Benefits provided during the 12-month postpartum period must be the same scope of comprehensive services consistent with the benefit package elected by the state under section 2103(a) of the SSA that is available to targeted low-income children and/or targeted low-income pregnant women and may include additional benefits as described in Section 6 of the CHIP state plan.

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group April 23, 2026 Stefanie Ashlaw Director, PeachCare for Kids State of Georgia, Department of Community Health 2 Martin Luther King Jr. Drive, SE 19th Floor, East Tower Atlanta, GA 30334 Dear Director Ashlaw: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) GA-25-0042, submitted June 24, 2025, with additional information received on April 22, 2026, has been approved. The effective date for this SPA is January 1, 2025. Through GA-25-0042, Georgia demonstrates compliance with section 5121 of the Consolidated Appropriations Act, 2023 (CAA, 2023) by transitioning eligible children who are enrolled in CHIP to Medicaid when they become incarcerated. The state will provide pre-release services to eligible juveniles under the Medicaid state plan. We note that the state is in the process of establishing a new category within PeachCare for Kids which will permit incarcerated youth to remain in CHIP to receive pre-release services through the CHIP state plan, instead of transitioning eligible children to Medicaid. The state should inform the Centers for Medicare and Medicaid Services (CMS) when these updates are complete. Georgia will need to submit a CHIP SPA that includes an updated CS31 template to demonstrate compliance with section 5121 of CAA, 2023 provisions in CHIP. Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters and can be reached at Joshua.Bougie@cms.hhs.gov. If you have additional questions, please contact Mary Beth Hance, Director, Division of State Coverage Programs, at (410) 786-4299. We look forward to continuing to work with you and your staff. Sincerely, Jessica Stephens Acting Director /Signed by Jessica Stephens/

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Page 1 of 2 CHIP Eligibility V.20240322 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State Name: Georgia OMB Control Number: 0938-1148 Transmittal Number: GA - 25 - 0042 Incarcerated CHIP Beneficiaries CS31 2102(d) and 2110(b)(7) of the SSA Targeted Low-Income Children Who Become Incarcerated The state assures that it does not terminate eligibility for children enrolled in a separate CHIP because the child is an inmate of a public institution. States may either suspend CHIP coverage or continue to provide CHIP state plan (or waiver of such plan) services otherwise not covered by the carceral facility to children who are incarcerated. States that elect to suspend CHIP coverage for the duration of a child’s incarceration may implement a benefits or eligibility suspension. The state elects to suspend CHIP coverage for the duration of a child’s incarceration If yes, then check an option below: Benefits suspension Eligibility suspension The state assures that it redetermines eligibility for any child prior to their release if it has been longer than 12 months since the child’s last redetermination and restores coverage for child health assistance to eligible children upon their release. Within the 30 days prior to release (or within one week of release, or as soon as practicable after release), the state assures that it provides eligible children with any screenings, diagnostic services, or case management services that would otherwise be available to children under the CHIP state plan (or waiver of such plan). Additional information regarding implementation of mandatory provisions of section 5121 of the Consolidated Appropriations Act, 2023 (CAA, 2023), including providing screenings, diagnostic services, or case management services: When a child becomes incarcerated, their eligibility is redetermined based on a household size of one (1) and are moved to Medicaid if found eligible.

The state will maintain clear documentation in its internal operational plan indicating which carceral facility/ Under section 5122 of the CAA, 2023, states may consider otherwise eligible children who are inmates pending disposition of charges as eligible for CHIP and provide all services covered under the CHIP state plan. The state elects to provide all CHIP state plan benefits (or waiver of such plan) to eligible children who are inmates pending disposition of charges.

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SPA Number: GA-18-0027 Approval Date: September 13, 2018 Effective Date: July 1, 2018 Section 12. Applicant and enrollee protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1130

Upon any adverse action as described in 42 CFR § 457.1130 (a), the parent or authorized representative (A/R) will be notified by mail of the reason for the adverse action and how to request a review if they believe the decision is in error. The notice of such action will meet the requirements of 457.340(e) and 457.1180. The opportunity for continued enrollment of a suspended or terminated enrollment will meet the requirements of 457.1170. If a hearing notice is required, it will meet the requirements of 457.1140. A written request for an initial administrative review may be submitted to the TPA, Division of Family and Children Services (DFCS) and forwarded to the Right from the Start Group (RSM Group) for processing which must be completed within 5 days. The request must be submitted within thirty (30) days of the written notification in which s(he) disagrees. If a verbal request is made, the parent or A/R must submit a written request within fifteen (15) days of the original request. If the written request is not received, no further action is required. If the RSM group is able to review the case and determine eligibility was determined correctly, discuss the complaint with the parent or A/R, and a mutual agreement is made, the parent or A/R may choose to withdraw the hearing request. If the RSM group is unable to obtain a hearing withdrawal either verbally or in writing from the parent or A/R, a hearing notice will be mailed to the parent or A/R in which they will have 10 days to respond. If no response is received, the administrative review is considered complete and no further action is required. If the parent or A/R is not satisfied with the outcome of the administrative review, s/he can request a fair hearing which will be submitted to the Legal Services Office (LSO). If the RSM group finds the case was processed incorrectly, it will be corrected, and the same procedures as stated above will be followed accordingly. The LSO will submit the hearing request to the Georgia Office of State Administrative Hearings (OSAH). OSAH will notify the parent or A/R of the time, place, and date of the hearing. Both the parent or A/R and RSM representative, on behalf of the state, can be present at the hearing. Each will be allowed to present their case to the Administrative Law Judge. The decision of the Administrative Law Judge will be provided in writing and will be final. The final decision could take up to 90 days from the date of the written request.

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State: Georgia Section:2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

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State: Georgia Section:2.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

Currently, Georgia’s public child health insurance plans include PeachCare for Kids and the Medicaid program administered by the Georgia Department of Community Health (DCH), Division of Medical Assistance (DMA). The Department has several approaches to identifying and enrolling eligible children. These approaches are described in the following paragraphs.

PeachCare for Kids

In 2000, 2001, and 2002, the Department has teamed up with the Department of Education, Division of School Nutrition Services to distribute flyers, in English and Spanish, to each student during Back-to-School registration. The Right from the Start Medicaid (RSM) outreach staff worked with many elementary schools to be on site promoting PeachCare for Kids and Medicaid to the parents.

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State: Georgia Section:2.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

PeachCare for Kids, RSM, March of Dimes and Kmart stores partnered in 1999 and 2000 to promote PeachCare for Kids and Medicaid. In 1999, outreach workers were at each Kmart store on the Saturday before Halloween educating parents while their children shopped for costumes and treats. In 2000, the outreach workers returned to Kmarts on the Saturday before school started to talk to parents as they were getting their kids ready for the new school year.

In 2001, the Department launched www.peachcare.org, a web-based application designed to provide parents with instant access to complete the enrollment process. In its first year, applications have been received for nearly 40,000 children through the website. The site has also been successful reaching families of Medicaid-eligible children. Nearly half of all web-based applicants have been eligible for the Medicaid program. The advantages of the website are numerous. It eliminates mail delays. It provides parents with instant confirmation that the application has been received and gives parents a estimation of potential eligibility. The website also generates a list of participating primary care physicians to assist parents in the selection of a doctor for their child.

Division of Family and Children Services (DFCS)

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State: Georgia Section:2.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 application process is coordinated with that for cash assistance and employment related services available through TANF. Children in families seeking these services also have their Medicaid eligibility determined. The State of Georgia has 159 counties. Each county has at least one DFCS office, and some counties have multiple sites for Medicaid eligibility intake. Some workers from these local DFCS offices are assigned to Federally Qualified Health Centers (FQHCs) and Disproportionate Share Hospitals.

Covering Kids

In 1999, the State of Georgia received a grant through The Robert Wood Johnson Foundation’s Covering Kids initiative. Covering Kids conducted outreach for Medicaid, PeachCare for Kids and the Georgia Partnership for Caring program through schools, businesses, community-based organizations, health care and child care providers and the faith community.

Public Health Departments and Federally Qualified Health Centers

The Division of Public Health, through its local health departments, and the

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State: Georgia Section:2.2 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 federally qualified health centers administer the Special Nutritional Program for Women, Infants and Children (WIC). This program provides nutritious food to supplement the regular diet of pregnant women, breast-feeding women, infants, and children under age five who meet state income standards. Generally, on the initial visit to either of these facilities, the pregnant woman is certified for Presumptive Medicaid eligibility, applies for regular Medicaid for herself and her children, and receives WIC for herself and any children under the age of five (5).

In both the public health departments and the federally qualified health centers, outreach workers are stationed or visit on a weekly basis to process applications for regular ongoing RSM Medicaid for pregnant women and children. In addition to Medicaid certifications, they provide information on the services covered under the program and provide information on other supportive services in the communities. When appropriate they make referrals to these services as well.

Medicaid and PeachCare Participating Providers

Medicaid participating providers who treat newborn children, such as family practitioners, pediatricians and hospitals, play an integral part in enrolling uninsured children in the Medicaid and PeachCare programs. These providers have direct access to a special unit located with DCH’s fiscal agent. From this unit, they can obtain a Medicaid ID number for any child under the age of one year, born to and living with a Medicaid eligible woman, who is not yet enrolled in the program. In most instances, the infant is issued a Medicaid ID number shortly after delivery. Once the number is issued, a listing is sent to DFCS for follow-up eligibility. This process has served to reduce barriers to health care for the state’s infants.

Providers have been an enthusiastic supporter of PeachCare for Kids since its inception. A month before PeachCare for Kids launched statewide, DMA teamed up with the Georgia Hospital Association for a statewide outreach drive. Each of the approximately 200 hospitals in the state set up booths and housed outreach workers for families to learn about and apply for the new health care coverage program for kids. In 1999, Children’s Health Care of Atlanta, the state’s largest hospital for children, put its volunteers to work with a massive direct mail campaign to uninsured children who had received care in its facilities. Several other hospital systems have dedicated outreach efforts to promote PeachCare for Kids, including billboards and fast food trayliners. In addition to large-scale efforts, many individual physicians have

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State: Georgia Section:2.2 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 referred uninsured patients to www.peachcare.org and made applications available in their office.

Other State Initiatives For Special Needs Children

Division of Public Health

“Babies Can’t Wait”

“Babies Can’t Wait” or the Early Intervention Program is Georgia’s statewide interagency service delivery system for children from birth to three years who have developmental delays or disabilities. This program guarantees that all children, regardless of their disability, have access to services that will enhance their development. Services are provided by agencies and individuals from both the public and private sectors. Some are offered at no cost. For others, state funds are available to assist families that have been determined unable to pay. Medicaid eligible children may participate in this program.

Children’s Medical Services

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State: Georgia Section:2.2 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

Regional Perinatal System

This program is administered by the Division of Public Health with funding provided by the Department of Medical Assistance. It provides medical services for pregnant women and children. The pregnant women’s component provides tertiary level care to high risk pregnant women. The neonatal component provides intensive care to infants. The program also provides funds to cover unmet medical costs, including neonatal transport, for infants in families with income of up to 250% of the federal poverty level. Women and children who participate in this program have been determined to be ineligible for Medicaid.

Division of Mental Health, Mental Retardation and Substance Abuse (MH/MR/SA)

Mental Health Services for Children and Adolescents with Severe Emotional Disturbance

Currently some level of services for youth with severe emotional disturbance (SED) are available in all MH/MR/SA service areas. Public services available to the SED population include: • Outpatient including crisis intervention, case coordination and wraparound services • In-home crisis services (to avoid hospitalization or other out-of-home placement) • Day Treatment (after school, evenings and some weekends) • Respite • Therapeutic Foster Care • Therapeutic Group Home Care

The target population are youth with a primary diagnosis of a mental health disorder diagnosable under DSM-IV which has lasted a year or is likely to last for at least a year and causes serious functional limitations in at least two or more areas, such as risk of harm to self or others, need for assistance from multiple community agencies, behavior leading to demand for public intervention, etc. Uninsured children who present to these programs for their services are referred for a Medicaid eligibility determination, but services are provided to uninsured or underinsured children on a sliding fee scale and are not denied due to inability to pay.

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State: Georgia Section:2.2 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Substance Abuse Services for Adolescents

The public services available to youth with substance abuse diagnoses are: student assistance programs for early identification, day treatment, family treatment and adolescent residential treatment. These services are not currently available in all areas of the state. Uninsured children who present to these programs for their services are referred for a Medicaid eligibility determination, but services are provided to uninsured or underinsured children on a sliding fee scale and are not denied due to inability to pay.

Department of Human Resources

MATCH

The DHR Multi-Agency Team for Children (MATCH) arranges care for Georgia’s children with severe emotional disturbances who need mental health treatment in residential settings. The program is administered through the Division of Family and Children Services Treatment Services Unit. The mission of MATCH is to enable children to lead the most stable and productive lives possible. More than one hundred local interagency teams operate throughout the state to identify children. The locate team reviews the child’s history and response to the mental health services that have been provided. If the child’s needs for mental health care and safety is too great for the community to manage, then the child is referred to state MATCH.

State MATCH reviews the information from the community and makes placement decisions based upon the child’s needs, recommendations from the local community, placement availability, and available funds.

MATCH services are funded through a combination of state and federal funds. The program operates within an established budget so not every child who needs help can be funded. Services are provided through a variety of private and public residential treatment providers. If the child is eligible for Medicaid, Medicaid will pay for the treatment portion of the cost of the placement, but not the room and board, educational and other costs. DHR state funds are used to pay for any uncovered cost of the placement for uninsured and underinsured youth.

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State: Georgia Section:2.2 Page: 8

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Georgia Partnership for Caring Foundation

The program includes the limited voluntary services of physicians, nurse practitioners, dentists, ophthalmologists, optometrists, physician’s assistants, hospitals, pharmacists, pharmaceutical manufacturers, and many health provider groups and agencies. These volunteers are not paid for their services or products, but are committed to assisting Georgians obtain access to needed health care coverage. The program is available in about three- fifths of Georgia’s counties. GPCF is not insurance coverage. It is not for emergencies or urgent care situations. Application processing time averages 1 month. As previously stated, RSM outreach workers are involved in the referral and application process for GPCF. They perform the screening function to determine that individuals who are referred to GPCF are not eligible for Medicaid. To date, over 4,300 individuals have participated in this program.

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State: Georgia Section:2.3 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Applications for PeachCare for Kids contain the information necessary to determine eligibility for Medicaid as well as for PeachCare for Kids. Applications are mailed to and processed by a Third Party Administrator (TPA) at a centralized location. As part of the eligibility determination process, the TPA screens applications for Medicaid eligibility before determining eligibility for PeachCare for Kids. If a child or children on the application appear to possibly be eligible for Medicaid, the application for that child or those children is processed by RSM workers. The processing provides for investigation and verification of both the financial and non-financial requirements for the Medicaid program. If the child or children are eligible for Medicaid, Medicaid enrollment will occur, rather than eligibility determination for PeachCare for Kids. If the RSM worker finds the child or children ineligible for Medicaid, then the TPA determines eligibility for PeachCare for Kids.

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State: Georgia Section:3 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

The PeachCare for Kids legislation mandates that “Any health care provider who is enrolled in the Medicaid program shall be deemed to be enrolled in the program.” Therefore, the current Medicaid health assistance delivery and utilization control system is the system used for PeachCare for Kids. Service delivery is accomplished through a variety of relationships and agreements with private medical providers and state agencies.

Briefly, the current system includes a statewide primary care case management program, Georgia Better Health Care (GBHC) and a regional managed care structure, Georgia Health Families (GF). The PeachCare for Kids legislation allows the DCH to contract with licensed care management organizations (CMOs) as a condition of receiving coverage under the program. As a condition of participation, all enrolled providers in each category of service must be fully licensed and/or certified under all applicable state and federal laws to perform the services provided to participants.

Georgia Families

PeachCare for Kids members will be enrolled in a commercially licensed care management organization (CMO) that is contracted by DCH. Membership in Georgia Families (GF) is mandatory for all PeachCare for Kids members and most pregnant women and children eligible for Medicaid.

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State: Georgia Section:3 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 populations (2) Establish a “provider home” for Members through its use of assigned Primary Care Providers (PCPs) (3) Establish contractual accountability for access to, and quality of, healthcare (4) Slow the rate of growth in PeachCare costs (4) Implement an intelligent health system where members have accurate, timely knowledge of their health needs, access to the best information about how to maintain their health, knowledge of who and where to go if they have health needs, and an assurance that their health providers will be using best practices based on the most recent understanding of outcomes based medicine.

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State: Georgia Section:3.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Reimbursement Limitations

The CMO provides assistance to Members and Providers to ensure the appropriate utilization of resources, using the following program components: prior authorization and pre- certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management. Specifically, the CMO has written Utilization Management Policies and Procedures that: • Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-utilization and under-utilization. Such protocols and criteria comply with Federal and State laws and regulations. • Address which services require PCP Referral; which services require Prior- Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review. • Describe mechanisms in place that ensure consistent application of review criteria for authorization decisions. • Require that all Medical Necessity determinations be made in accordance with DCH’s Medical Necessity definition.

Georgia Families also provides care coordination, case management, disease management, clinical outcome studies, and physician incentive programming. Specifically, each CMO must provide individual needs assessment and diagnostic assessments; develop individual treatment plans, as necessary, based on the needs assessment; establish treatment objectives; monitor outcomes; and maintain a process to ensure that treatment plans are revised as necessary. The CMOs must

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State: Georgia Section:3.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 conditions such as diabetes and asthma. Additionally, each CMO must have programs for at least two additional conditions including: Perinatal case management, obesity, hypertension, Sickle cell disease; or HIV/AIDS.

By looking at other State’s experiences with Medicaid and SCHIP managed care, DCH expects that the GF program will save State and Federal dollars by appropriately controlling utilization, improving access to primary care services and enhancing continuity of care. Numerous studies support the theory that improving members’ access to primary care and providing appropriate disease management standards reduce the rate of growth in expenditures and ultimately result in savings through reduced likelihood of hospitalization for serious illnesses, reduced number of unnecessary visits to emergency rooms for non-emergency care, and reduced visits to specialists for care that could be provided through a primary care physician.

Treatment Residential Intervention Services Utilization Controls

The DHR Multi-Agency Team for Children (MATCH) Program, which was described under Section 2.2.1, is an interagency funding mechanism and prior approval, utilization review and discharge planning process for the purchase of out-of- community residential mental health treatment for SED children and adolescents. If a child is eligible for MATCH he or she is not eligible for GF. If the child is Medicaid or PeachCare for Kids eligible, Medicaid covers the treatment portion of the cost of the placement, but not the room and board, educational and other costs. As previously described, local MATCH groups staff and coordinate care for the most difficult to serve SED youth. If all family and local resources are exhausted and the youngster has treatment needs that cannot be met, the local MATCH sends an application to the state level MATCH to be staffed for a treatment placement. The local process includes a gate-keeping function as well as a coordination function.

At the state level, applications are reviewed and given prior approval or are denied based on an evaluation system which includes an assessment score based on the child’s past and current clinical and social history, diagnosis, involvement with and services from other child-serving agencies and an assessment score based on the child’s behavior and functioning. If approved and placed for residential treatment, the MATCH group (state level with local level participation) performs an on-site utilization review every six months from admission to discharge. Clinical, behavioral and functional outcomes are measured on a regular basis and are used as part of the utilization review process, along with interviews with the children and their clinicians. At the end of each utilization review an estimated discharge date is set that goes into effect unless clinical indicators change and an extension is sought and approved.

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State: Georgia Section:4.1 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefit plan based on a family member’s employment with a public agency in the State; or 4) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The CHIP application will contain questions about current and past coverage under group health plans and family members employment with State agencies. State employment information will be verified through monthly matches with the State Merit System and the Board of Regents. In addition, as claims are paid, if the providers report coverage under other health plans, eligibility will be terminated if the coverage meets any of the four criteria listed above.

4.1.8.

Duration of eligibility: With the approval of the PeachCare application, a child will be eligible for twelve months as long as eligibility criteria continue to be met. The family will be notified of its responsibility to report changes in income, residency or health insurance coverage. There will be monthly matches with the Medicaid MMIS to ensure that Title XXI children have not been certified for Medicaid. At the end of the twelve-month eligibility period, the family will be sent a letter detailing the information on the family’s account pertinent to eligibility. The family will be required to report any changes to the information and provide verification of all sources of income at this time. Eligibility will be redetermined for another twelve- month period so long as the family provides the required documentation within the requested timeframe.

4.1.9.

Other standards (identify and describe): Consistent with 42 CFR 457.340(b), PeachCare does not require Social Security numbers for any applicant.

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State: Georgia Section:4.3 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

PeachCare for Kids utilizes the same income methodologies as are used for its Right from the Start Medicaid program (Title XIX Poverty Level Group).

Customer Service is a major component of the functions required of the Third Party Administrator. The TPA’s telephone customer service staff is expected to furnish PeachCare applications upon request, provide assistance to potential applicants who may have questions about the program in general or who may need assistance in the completion of the form. In addition, the customer service staff provides support to the member in their choice of a GBHC primary care provider. The customer service staff is also responsible for responding to Medicaid/PeachCare providers who need to verify a member’s eligibility and service limitations.

The following process is used to establish eligibility and continuing enrollment:

APPLICATION

VERIFICATION OF INCOME, CITIZENSHIP AND IDENTITY

Beginning July 1, 2007, all PeachCare applicants are required to provide verification of income, citizenship and identity. The application directs families to

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State: Georgia Section:4.3 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 send in the most recent proof of all earned and unearned income sources. The following documentation is requested:

Paid in cash – letter from Employer provided by an Officer of the Company. Must be provided on Company letterhead.

Self-employment documents: • business ledger/receipts • tax forms W-2 or 1099 • bank deposits

B. Unearned Income –money anyone in the household received from any agencies, parents or relatives, friends, or any other sources. • SSI or SSA – Current year award letter • Unemployment check – (4) weeks of pay stubs (one week after the other) • Workman’s Compensation – letter from insurance company stating amount received and how often received, provide contact name and number • Contributions – letter from person who gives you money, provide name, address, and contact number. Provide amount received and how often received • Child Support (paid directly to you) – written statement from the parent who gives you money, provide the name, address, and contact number. Provide amount received and how often received. • Child Support (paid through court) – court papers or letter stating amount of income received and how often it is received. • Other Unearned Income – provide letter stating amount received and how often received. Provide name, address, and contact number or (4) weeks of pay stubs (one week after the other)

The TPA will first try to determine citizenship and identity through a match with the state’s Vital Records data. It is estimated that 85% of low-income children in the state are born in Georgia. Citizenship and/or identity documentation will only be requested for children that do not match with Vital Records. For these children copies of the following information is required:

List #1: Documents to Establish Both U.S. Citizenship and Identity (no other information is required if one of these is provided::

• U.S. Passport – The department of State issues passports. A U.S. passport

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State: Georgia Section:4.3 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 does not have to be currently valid to be accepted as evidence of U.S. Citizenship as long as it was originally issued without limitations. – OR - • Certification of Naturalization (N - 550 or N - 570) – Issued by the Department of Homeland Security for naturalization. – OR - • Certificate of Citizenship (N- 560 or N – 561) – Issued by the Department of Homeland Security to individuals derive citizenship through a parent.

List #2: Other Documents to Establish U.S. Citizenship, if you did not provide a document from list 1 please provide ONE of the following documents: • A U.S. public birth record (Birth Certificate) showing birth in: one of the 50 U.S. States, District of Colombia, American Samoa, Swain’s Island, Puerto Rico, Virgin Islands of the U.S., Northern Mariana Islands, or Guam. – OR - • Certification of Report of Birth (DS – 1350) – OR - • Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240) -OR - • Certification of Birth Abroad (FS-545) – OR - • United States Citizen Identification Card I-197 or the prior version I-179 • American Indian Card (I-872) – OR -Northern Mariana Card (I-873) – OR - • Final Adoption Decree – OR - • Extract of hospital record on hospital letterhead – OR - • Life or Health or other insurance record showing a U.S. place of birth and was created at least 5 years before the initial application date

List #3: Evidence of Identity, if sending from list 2 above please provide ONE of the following: • Identification card issued by federal, state, or local government agencies or entities - OR - • School record that shows date and place of birth and parent(s) name (under age 16 only) – OR - • Daycare or nursery school record showing date and place of birth – OR – • Clinic, doctor, or hospital record – OR- • Affidavit signed under penalty of perjury by a parent, guardian or caretaker relative attesting to the child’s identity, if other documents are unavailable – OR - • A current state driver’s license.

In addition, a signed Declaration of Citizenship form can be used for children under the age of 16 when other documentation is not available. This form can also be accepted to verify identity. A one-time match of all existing accounts against Vital Records will be performed and their

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State: Georgia Section:4.3 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 status documented in the PeachCare eligibility system. Citizenship and identity will only have to be verified once on a child. Once confirmed it will be entered into the eligibility system and not required again for PeachCare for Kids coverage.

A letter is sent to applicants confirming receipt of application and requesting any verification documents that were not submitted. If verification documents are still outstanding, a reminder letter is sent three (3) weeks later. In instances where partial information is received, a missing information letter is sent. If verification is not completed within 90 days, the application will not be activated for coverage.

APPLICATION PROCESSING

Upon receipt of the PeachCare application, the TPA screens the application for potential Medicaid eligibility. Potentially Medicaid eligible cases will be referred to Medicaid once income, identity and citizenship have been verified. The TPA provides the State Eligibility Specialist with an electronic file of the application for eligibility determination. Since the income verification requirements for PeachCare for Kids are the same as in Medicaid, families will not have to go through the process again unless they report a change in income. The State Eligibility Specialists reports back the eligibility and enrollment status for all referred children. If a child comes back to the TPA as not Medicaid eligible, the account will not be required to go through income verification.

For children who are not Medicaid eligible, the TPA determines if: net family income is at or below the 235% federal poverty level; the child is covered by a group health plan (either currently or in the past six months); the child is eligible for health benefits through a family member’s employment with a state agency; and if the child is a U.S. citizen or lawfully admitted alien. All income, citizenship and identity verification is completed before an eligibility decision is made.

The TPA is also required to use customer service personnel to follow up on incomplete or unclear information found in the application.

The TPA checks Medicaid’s information system for enrollment in the Medicaid program and conducts matches with the State Health Benefit Plan and Board of Regents for enrollment in or eligibility for state-sponsored health benefit plans. If a child is determined to be ineligible for PeachCare, the family receives a written notice describing the reason for ineligibility. The notice specifies the reason for the denial (e.g. excess income, age over eighteen years etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to accomplish this. This may include submission of additional or clarifying information to allow a review of the application decision. If the applicant is

(ga-cspa-14)(final-approved-state-plan)(page-31)Page 31#

State: Georgia Section:4.3 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 not satisfied with the final decision of the TPA, the case is sent to DCH for further review.

If a child is found to be eligible for the PeachCare program, the family receives a PeachCare handbook that describes the program’s benefits, instructions on how to submit premium payments and a number to contact the TPA to report changes. The family is also contacted by the GF enrollment broker and receives a new enrollment package that explains the GF program and choices about CMO plans in the Member’s service region. The enrollment broker also provides information regarding how to access services through the GF CMO selected by, or assigned to the family.

CONTINUING ENROLLMENT

At the time of application approval, the family receives information requiring them to report changes in their income, place of residence or household size to the TPA. If a family reports a decrease in income, verification of all income is required. If the family remains PeachCare eligible and is within 90 days of their annual renewal, the income verification process will be held until that time. The verification request for renewal is sent two months prior to the renewal month. If these changes result in ineligibility, the TPA reviews the account information for potential eligibility for the Medicaid program. If the child is potentially Medicaid eligible, the account information is sent immediately to the State Medicaid staff for review, just as the new applications are handled.

If the child is screened as ineligible for Medicaid and PeachCare for Kids based on the information provided, the TPA sends the member a notice of termination and closes the case. The notice specifies the reason for termination (e.g. excess income, etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to submit any necessary documentation.

As long as the family continues to meet all eligibility requirements and continues to pay the monthly premium as required, the child(ren) may be eligible for coverage for twelve (12) months.

PREMIUM COLLECTION and REINSTATEMENT PROCESS

• Premiums: Premiums are not required for children ages 0 through 5 years. For children ages 6 through 18, the premiums are detailed in the table below.

(ga-cspa-14)(final-approved-state-plan)(page-33)Page 33#

State: Georgia Section:4.3 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 An example follows:

Date Event January 6th Applicant submits complete application. January 15th Eligibility is determined. January 1st Applicant is enrolled, if eligible. Child is eligible to receive benefits effective January 1st. State/federal dollars fund January’s coverage. February 1st Child is enrolled in GBHC, the primary care case management program. State/federal dollars fund January and February’s coverage. March 1stth Parental premium submitted with application is applied to March’s coverage. April premium is due March 15th If March premium has not been received (postmarked by the 15th), cancellation will occur effective April 1. April 1st Premium for reinstatement is due. May 1st If premium is received by due date, reinstatement becomes effective.

RENEWAL PROCESS

Sixty days prior to a member’s annual anniversary date, PeachCare for Kids sends a letter to the family detailing enrollment-related information on the account, including demographic information, children enrolled, and premiums required. Families are notified of the requirement to send in the appropriate verification documents. All families will be required to provide income verification at the annual renewal. A form detailing the required documentation will be sent with the renewal notice. After 3 weeks, a reminder notice will be sent. If a family makes an effort to comply with the verification process prior to the renewal date but needs additional time to provide the necessary documents, a thirty (30) day grace period will be granted. In circumstances where there is intent to comply, an additional (30) days of coverage can be granted manually by a supervisor with the TPA.

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State: Georgia Section:4.3 Page: 8

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

Due to a lack of funding, effective March 11, 2007, DCH closed PeachCare for Kids to new enrollment. Receipt of federal funds from FFY2004 and FFY2005 redistribution and supplemental appropriations, provided sufficient resources to open enrollment. On June 14, 2007, a public notice was issued announcing the Department’s intent to resume enrollment. Upon DCH Board approval, enrollment resumed effective July 12, 2007. However, enrollment is limited to 295,000 children. The enrollment limit will be reassessed based on the availability of federal funding once SCHIP is reauthorized.

While the cap is in place, enrollment will be monitored weekly. Children will only be activated for coverage when the number of active children is under the cap (295,000). Once the cap is reached, no pending accounts whether they are new or reinstatements will be activated to receive coverage. In the chance occurrence that the cap is reached during the processing of a family group, all eligible children will be given coverage. The eligibility system will include notes and updated correspondence that will be “turned on” if the cap is reached. Public notice on the enrollment cap was issued.

In the event that the enrollment cap of 295,000 children is reached before adequate FFY08 is available and enrollment must be closed again, the following procedures will be in place:

All correspondence, as well as the PeachCare for Kids website, will be updated to indicate the capped enrollment status and explain what it will mean for members and potential members. • Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will be precluded from re-enrollment during any closed enrollment period.. These members will receive additional notice by direct mail informing them of their review rights as required by governing regulations.

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State: Georgia Section:4.3 Page: 9

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 • Members enrolled and/or determined eligible prior to any closed enrollment period will not be impacted by this particular change so long as they continue to pay premiums timely and comply with any requests for information, including income, citizenship and identity verification.

• The enrollment cap will be reassessed once SCHIP reauthorization occurs. If sufficient funding is available and the enrollment cap is to be removed or modified, the state will notify CMS in writing when this is to occur.

• New applications along with reinstatement requests will be processed based on the date they were received. The TPA will contact all families who applied or requested reinstatement during the closed enrollment period to verify their current information.

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State: Georgia Section:4.4 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 4.4. Describe the procedures that assure that:

Upon receipt of the completed application, including verification of income, citizenship and identity, the TPA screens the application for potential Medicaid eligibility. If the child is potentially Medicaid eligible based on verified income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information is included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

Upon receipt of the application, the TPA screens the application for potential Medicaid eligibility. This process will continue during the PeachCare

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State: Georgia Section:4.4 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 enrollment freeze. If the child is potentially Medicaid eligible based on reported income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information is included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Since the inception of PeachCare for Kids DCH has worked closely with DFCS to promote the program. The PeachCare for Kids application requests all of the information necessary to determine Medicaid eligibility for a child. DFCS offices use this application for parents who are only seeking coverage for their children. If the children are determined to be ineligible for Medicaid, the caseworker mails the application to PeachCare for processing, without requiring the family to complete an additional form or application.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

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State: Georgia Section:4.4 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The PeachCare application contains questions about current and past coverage under group health plans and family members employment with State agencies. The application also contains questions about current and past coverage under group health plans. In addition to self- declaration of other coverage, providers report coverage under other health plans and PeachCare enrollment is terminated if the other coverage meets any of the four criteria listed above.

Children who are currently insured, regardless of the amount of cost-sharing required by their policy will be ineligible for PeachCare for Kids. PeachCare also requires children to be uninsured for six months prior to being eligible to enroll, with exceptions for non-voluntary cancellations of coverage. The application asks parents to report if their children have cancelled insurance within the previous six months and provides an opportunity to report the reason the insurance is cancelled. Once a month, these applications are manually reviewed by PeachCare for Kids staff to determine if the reason given meets one of the exceptions defined in Georgia’s state plan (such as change in employment, employer dropped coverage, etc.)

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State: Georgia Section:5 Page: 6

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

PeachCare for Kids Outreach Through RSM Outreach

Outreach efforts are completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be reached and enrolled in Medicaid and those children eligible for PeachCare can be reached and enrolled in PeachCare. The outreach efforts target all children at or below 235% of the FPL. To build on and enhance our outreach efforts, Georgia utilizes our nationally recognized RSM outreach strategies for PeachCare for Kids. With over 143 representatives statewide, RSM outreach workers have been specifically trained in doing outreach for PeachCare for Kids. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers also have a variety of program information on both creditable and non- creditable coverage and other ways to access health care services. The order of priority for the outreach workers are first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation and DHR public health care programs and services. The outreach efforts are also coordinated with community-based organizations, health care providers, GF CMO plans and the enrollment broker.

RSM Outreach Project

The Right From the Start Medicaid (RSM) Project began in July 1993 as Georgia’s response to the high infant mortality rate and to improve health care access for all children and pregnant women.

The Department of Community Health (DCH) and the Department of Human Resources (DHR) entered into an agreement to place eligibility workers in community settings. The agreement provides for Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

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State: Georgia Section:5 Page: 6

143 eligibility workers. These staff currently have offices in health departments, hospitals, clinics, day care centers, schools, community action agencies and other locations in the community. A major feature of the program is the availability of staff during non-traditional work hours so that clients may apply for RSM without having to lose time from their jobs or from school. Non-traditional hours are defined as any time other than 8 a.m. to 5 p.m. Monday through Friday.

Outreach staff are housed throughout Georgia and, although not housed in all 159 counties, provide Medicaid enrollment information and access to the Medicaid application process in every county. This involvement with potential Medicaid clients on a local level greatly enhances Georgia’s outreach efforts. Outreach staff also actively pursue collaboration with other agencies and groups in their communities in order to maximize involvement at the local level and to educate other agencies in the basics of Medicaid eligibility and the availability of Medicaid services and to provide for mutual referral systems. Most of the local RSM project staff have partnerships with the county health departments, local schools, pregnancy centers, battered women’s shelters, Head Start programs and the health care community in their areas.

Workers and supervisory staff make presentations regularly to community groups, medical providers and employers. RSM project staff often participate in health fairs and other local activities in order to reach potential Medicaid clients. Staff have utilized creative techniques for distributing information to the public. Medicaid flyers have been sent home with school age children and workers have visited day care centers to pass out brochures. Employer contacts have resulted in opportunities to distribute literature through personnel offices and at employee forums, and to accept applications at job sites.

Simplified PeachCare for Kids Application

The web-based application is available on-line at www.peachcare.org. It was created to allow parents to apply Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

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State: Georgia Section:5 Page: 6

quickly and easily at local libraries, community centers, hospitals and in their homes. When an application is submitted online, a cover form with the application confirmation number will be generated. Parents will be instructed to print out this form and attach required documents for income and/or citizenship and identity verification to then be mailed or faxed to the TPA. Both applications are designed to gather information needed to determine eligibility for both PeachCare and Medicaid. Marketing and Public Awareness

Advertising Campaign

Outreach Publications

Outreach Video

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

(ga-cspa-14)(final-approved-state-plan)(page-45)Page 45#

State: Georgia Section:5 Page: 6

Back-to-School Outreach

Community Outreach Mini-grants

In 1999, the Georgia Department of Community Health created a minigrant program, “Improving Health Care Access: Innovations in Medicaid and PeachCare for Kids Outreach, to assist local efforts to raise awareness of both PeachCare and Medicaid programs among hard-to-reach populations. Twenty-four community organizations were awarded grants to conduct grassroots outreach activities specifically designed for their communities.

The activity level of the grantees produced the following results:

• 427,315 pieces of PeachCare for Kids informational materials were distributed; • 445 PeachCare for Kids presentations were conducted; and Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

(ga-cspa-14)(final-approved-state-plan)(page-46)Page 46#

State: Georgia Section:5 Page: 6

• 6,000 families were assisted with applications.

Local Media Partnerships

Georgia Families

The Georgia Families Care Management Organizations (CMOs)

The CMO plans are permitted to perform the following marketing activities:

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

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State: Georgia Section:6 Page: 13

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.

6.1.4.2. Coverage the same as Medicaid State plan Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid

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State: Georgia Section:6.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 6.2. The state elects to provide the following forms of coverage to children:

(Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

Outpatient services include outpatient surgery, clinic services and emergency room care. Outpatient services are covered in full. Prior approval is needed for some services.

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

Surgical services are covered in full. See 6.2.1 for inpatient surgical services and 6.2.2 for outpatient surgical services. Prior approval is needed for certain procedures.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

See 6.2.2 above.

(ga-cspa-14)(final-approved-state-plan)(page-51)Page 51#

State: Georgia Section:6.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

6.2.6.

Prescription drugs (Section 2110(a)(6))

Prescribed drugs (from participating rebate manufacturers) and supplies approved by DMA and dispensed by an enrolled pharmacist are covered in full. Some drugs require prior approval or have therapy limitations. Prescriptions or refills are limited to six per month per enrollee. There are procedures in place that allow a member to receive medically necessary prescriptions in excess of six (6) per month.

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

The following non-prescription drugs are covered up to a maximum allowable cost: Multi-vitamins and multiple vitamins with iron, enteric coated aspirin, diphenhydramine, insulin, NIX, iron, meclizine, insulin syringes, insulin delivery unit systems (NOVO pen for example) and urine test strips. No other over-the-counter medications are covered.

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

Radiology services are covered in a hospital setting or in a physician’s office only. Note: laboratory and radiological services are covered as two separate services.

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

These services are covered in full. This includes Childbirth Education Services, a series of 8 classes regarding the birth experience and tools to prepare for a healthier pregnancy, birth and postpartum period.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Inpatient mental health services are covered only for short-term acute care in general acute care hospitals up to 30 days per admission. Services furnished in a state-operated mental hospital are not covered. Services furnished in an Institution for Mental Disease (IMD) are not covered. Residential or other 24-hour therapeutically planned

(ga-cspa-14)(final-approved-state-plan)(page-52)Page 52#

State: Georgia Section:6.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 structural services are covered only through the DHR MATCH Program. (See Sections 2.2.1. and 3.2.) Psychotherapy is limited to 10 hours per calendar month.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Outpatient mental health services are covered through: Community Mental Health Centers, subject to limitations specified in DHR standards

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

(ga-cspa-14)(final-approved-state-plan)(page-53)Page 53#

State: Georgia Section:6.2 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17.

Dental services (Section 2110(a)(17))

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(21))

(ga-cspa-14)(final-approved-state-plan)(page-55)Page 55#

State: Georgia Section:6.2 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

Children’s Intervention Services: Services covered for children from birth through 18 years of age are audiology, nursing, nutrition, occupational therapy, physical therapy, social work, speech-language pathology and developmental therapy instruction. Written prior approval is required for medically necessary Children’s Intervention Services once the annual service limitations listed in the Policy and Procedure Manual have been reached. Individualized Family Service Plan is required to document medical necessity for amount, duration and scope of services. Note that children 18 years of age are not covered under these program services.

Family Planning: Covered services include initial and annual examinations, follow-up, brief and comprehensive visits, pregnancy testing, birth control supplies, and infertility assessment.

End Stage Renal Disease (ESRD) Dialysis: Services and procedures

(ga-cspa-14)(final-approved-state-plan)(page-58)Page 58#

State: Georgia Section:6.4 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase

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State: Georgia Section:7.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

PeachCare for Kids sends each child a birthday postcard each year that wishes them a healthy year and reminds their parents of the well-child care available through PeachCare.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

All members are enrolled in Georgia Families (GF), a managed care program. GF PCPs are required to have care accessible to their members 24 hours a day.

The Georgia Health Policy Center (GHPC), Georgia State University, has

(ga-cspa-14)(final-approved-state-plan)(page-62)Page 62#

State: Georgia Section:7.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC has also conducted the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received.

(ga-cspa-14)(final-approved-state-plan)(page-63)Page 63#

State: Georgia Section:7.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

PeachCare for Kids members who are identified as in need of special health care services by receiving care through MATCH, CMS or Georgia Pediatric Program (GAPP) are excluded from GF and covered under PeachCare for Kids on a fee for service basis.

The CMO must submit Prior Authorization and Pre-Certification Reports that summarize all requests in the preceding month for Prior Authorization and Pre-Certification. The Report includes, at a minimum, the following information: • Total number of requests for Prior Authorization and Pre-Certification requested by type of service; • Total number of requests for Prior Authorization and Pre-Certification processed within fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for extension of the fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for Prior Authorization and Pre-Certification processed within twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for the extension of the twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for authorization processed within thirty (30) Calendar Days for determination for services that have been delivered; • Total number of requests approved by type of service; and • Total number of requests denied by type of service.

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State: Georgia Section:8 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

PeachCare for Kids publicizes the cost sharing requirements in its brochures, applications, website, mass media campaigns and other outreach materials. If a parent applies for a child and does not include a premium payment with the application, if applicable, a letter is sent indicating that a payment must be received for the children to be enrolled in the program. The letter includes the specific amount due, depending on the number of children over 6 in the household, and the due date for premium payments for enrollment to be initiated and maintained monthly.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

For a family with only one child enrolled age 6 or older, the maximum a family could have to pay is $420. This is the maximum per child premium of $35 times 12 months. Since there are no deductibles, coinsurance, co-payments or other cost sharing methods, the annual aggregate cost sharing is the maximum family premium annually. In order for $420 to exceed 5 percent of a family’s annual income, the family’s annual income would have to be below $8,400. Uninsured children in a family with annual income below $8,400 would be eligible for Medicaid

(ga-cspa-14)(final-approved-state-plan)(page-66)Page 66#

State: Georgia Section:8 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 rather than PeachCare for Kids, if they met the other eligibility criteria in addition to income criteria.

For a family with 2 or more enrolled children age 6 and older, the maximum a family could have to pay is $840 annually. This is the maximum family premium of $70 times 12 months. Since there are no deductibles, coinsurance, co-payments or other cost sharing methods, the annual aggregate cost sharing is the maximum family premium annually. In order for $840 to exceed 5 percent of a family’s annual income, the family’s annual income would have to be below $16,800. Uninsured children in a family with annual income below $16,800 are below 150% FPL and would either be eligible for Medicaid or would have a maximum premium of $15 per household per month for enrollment in PeachCare for Kids, if they met the other eligibility criteria in addition to income criteria.

Therefore, with such a low cost-sharing requirement, PeachCare ensures that the aggregate cost sharing for a family never exceeds 5 percent of a family’s annual income.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

PeachCare for Kids notifies enrolled American Indian and Alaska Native families of the cost sharing exclusion by letter. The letter instructs families to mail their official tribal documentation to the PeachCare for review. Once the documentation is reviewed, a letter is sent to families to confirm receipt. This letter also notifies the families that they are no longer required to pay a monthly premium. If official tribal documentation is not submitted, families must continue to make premium payments.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

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State: Georgia Section:8 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

Premiums are due the first day of the month prior to the month of coverage. For example, the payment is due on January 1 for coverage in February. If the premium is not received, late letters will be sent to the family around the 4th day of each month. As a grace period, all premiums postmarked by the 15th of the month will receive coverage for the following month.

Late payment of premiums could result in a break in coverage. Individuals for whom premiums have not been received by the month-end closing date for eligibility processing and member roster production will be terminated from the program. Terminations will be effective the last day of the month covered by a paid premium. Individuals would be covered through the last day of that month.

Families who are cancelled for non-payment of premium are notified by mail of the cancellation process. They are also informed of their right to a review of the termination.

If the family requests a review of the termination due to a claim of reduced income that disrupts their ability to pay the premium, coverage is extended to the child during the appeal process.

If the family reports a reduction in income during the cancellation period, as well as any other time, the application is screened for potential Medicaid eligibility. If it appears that the child is eligible for Medicaid, the application will be referred to Right from the Start Medicaid for a full determination. If it appears that the child still qualifies for PeachCare for Kids, but at a lower premium amount, the family will be notified of the new premium requirement and will be issued a new coupon book.

Prior to August 1, 2005 a Member who was cancelled for late/non-payment of premium was ineligible to reinstate for a period of three (3) months. PeachCare for Kids enrollees and the public at large were made aware of the policy change from a three-month period to a one-month period in a variety of methods. Those enrollees that were in a 3-month waiting period were notified via a letter that they were eligible for reinstatement effective August 1, 2005.

(ga-cspa-14)(final-approved-state-plan)(page-68)Page 68#

State: Georgia Section:8 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 All other members were notified by changes to all premium-related correspondence mailed to households, the Frequently Asked Questions posted on our website (www.peachcare.org), and call center customer service representatives.

During closed enrollment, there will be no reinstatement period. Any family cancelled for late/non-payment of premium will be ineligible to reinstate so long as PeachCare enrollment is closed. All effected families were notified of this change in policy by a mailing. It will be reiterated in the final notice letter that will also inform them of their right to seek a review within 30 days of receipt of the notice and to continue services during the review period.

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

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State: Georgia Section:9 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

The six strategic objectives of PeachCare for Kids are to:

1. Increase insurance coverage among Georgia’s low income children 2. Increase the percentage of low-income children with a regular source of care. 3. Promote utilization of Health Check (EPSDT) services. 4. Decrease unnecessary use of emergency departments for non-emergency services. 5. Minimize preventable hospitalizations. 6. Promote the appropriate use of health care services by children with asthma (as defined by national standards).

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Objective 1: Increase insurance coverage of Georgia’s low-income children.

Performance goals: 1.1 Enroll 75% of uninsured, non-Medicaid eligible children with family income below 235% of the federal poverty level. Measure: Percent of eligible children enrolled.

Objective 2: Increase the percentage of low-income children with a regular source of care.

Performance goals:

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State: Georgia Section:9 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 2.1 Over time, decrease the percent of children matched to a PCP through auto assignment. Measure: Percent of children who selected PCP on enrollment.

2.2 Encourage use of PCP through health plan policies and education. Measure: Percent of enrolled children who seek care from their assigned PCP.

2.3 Maximize the number of enrollees who stay with their PCP for 12 months. Measure: Percent of enrollees who stay with their PCP at least one year.

Objective 3: Promote utilization of Health Check (EPSDT) services to achieve targets set by the Centers for Medicare and Medicaid Services and GF. These are 80% for screening and 90% for immunizations.

Performance goals: 3.1 Assess how many children receive recommended well visits and screenings. Measure: Percent of enrolled children receiving each screening on or about the recommended schedule.

3.2 Assess how many children receive immunizations. Measure: Percent of enrolled children receiving each immunization on or about the recommended schedule.

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State: Georgia Section:9 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 among Medicaid and PeachCare for Kids. This will allow us to evaluate more children with 10 to 12 months of coverage and have a more complete picture of the percentage of children who are receiving these services, either through PeachCare exclusively or intermittent coverage through the Medicaid program.

Objective 4: Decrease unnecessary use of emergency departments for non- emergency services. A non-emergency service is one that does not meet the prudent layperson definition of emergency.

Performance goals: 4.1 Reduce the number of ED visits for non-emergency services. Measure: Rate of non-emergency ED visits per year for the population enrolled.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 66% of visits to emergency departments met the criteria for an emergency. Georgia’s goal is to increase the percentage of emergency department visits for diagnoses considered to be medical emergencies to 70% by the end of federal fiscal year 2005.

Objective 5: Reduce preventable hospitalizations.

Performance goals: 5.1 Reduce preventable hospitalizations. Measure: Percentage of hospitalizations for preventable diagnoses.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 32% of hospitalizations were for diagnoses which could be considered preventable. Georgia’s goal is to decrease the percentage of preventable hospitalizations to 25% by the end of federal fiscal year 2005.

Objective 6: Promote the appropriate use of health care services by children with asthma (as defined by standards of the National Heart Lung and Blood Institute of the National Institutes of Health).

Performance goals: 6.1 Assess the number of children whose asthma is managed through appropriate outpatient care. Measure: Percent of children seeing PCP within two weeks of ER or hospital visit.

(ga-cspa-14)(final-approved-state-plan)(page-72)Page 72#

State: Georgia Section:9 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Baseline and Target Improvement Level: From claims data for fiscal year 2000, 93% of children had a follow-up visit within 2 weeks of a visit to an emergency department or a hospitalization. Georgia’s goal is to increase the percentage of children who have a follow-up visit within 2 weeks of a visit to an emergency department or a hospitalization due to asthma to 95% by 2005.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well child care 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list:

9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

(ga-cspa-14)(final-approved-state-plan)(page-73)Page 73#

State: Georgia Section:9 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

PeachCare for Kids will comply with the annual assessment by submitting a report, utilizing the Framework for Annual Evaluation developed by the National Academy for State Health Policy in conjunction with state SCHIP staff and CMS. This report will be completed by PeachCare staff. Independent evaluators will be responsible for measuring PeachCare’s progress in meeting the performance measures defined in Section 9 “Strategic Objectives and Performance Goals and Administration” and for nationally-mandated measures when they become available.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

Initial Public Involvement

In 1996, the Georgia Coalition for Health was asked by the Governor to examine approaches for reforming Medicaid in Georgia. The Coalition sponsored extensive

(ga-cspa-14)(final-approved-state-plan)(page-74)Page 74#

State: Georgia Section:9 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 research on the views of the stakeholders in the state’s Medicaid system – healthcare providers, Medicaid members and Georgia citizens. Three separate but complementary processes—focus groups, community forums and community dialogues—offered the opportunity for about 6,000 Georgians to express their views.

The consumers and advocates participating in the dialogues were identified by a coalition of consumers and advocates incorporated under the name Healthcare for a Lifetime. This group represents the four primary populations that receive Medicaid: low income Mothers and children, older people, people with physical disabilities, and people with mental retardation, mental illness, or those with substance abuse problems. The providers were selected by the Healthcare Providers Council and included representation from hospitals, physicians, nursing, dentistry, nursing homes, home health, pharmacy, public health, community health and others. County Commissioners as well as members of the legislature were also invited to attend. Overall, 443 consumers and advocates and 234 providers participated for a total of 677 statewide participants. The meetings were open to the public and at every Dialogue there were observers who did not participate in the discussions yet had the advantage of moving among groups and hearing all four conversations.

(ga-cspa-14)(final-approved-state-plan)(page-75)Page 75#

State: Georgia Section:9 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 These statewide, public conversations on Medicaid contributed to dispelling barriers between consumers and providers; the process also indicated where consumers, advocates and providers stand on major issues and where they are willing to negotiate. The main themes identified through the process are summarized below. These themes served as a reference and defining force for developing general Medicaid reform recommendations and many are reflected in Georgia’s proposal for implementing the Title XXI program.

Citizens

The citizens, both Medicaid members and members of the general public, expressed a wide variety of views, but agreed on a few basic themes.

• Vulnerable people should be protected. Citizens generally believe in the concept of a health care safety net and are willing to pay taxes to provide health care to people who need help.

• Only truly needy individuals should qualify for Medicaid. Citizens want to make sure that eligibility is strictly defined and enforced to stop abuse.

Medicaid Members

In the community dialogues, Medicaid members generally shared the opinions of the general population, as described above, but also expressed some specific concerns.

• Medicaid costs should not be cut by reducing eligibility, since not enough truly needy people are covered today.

• There should be no stigma attached to receiving Medicaid, and any managed

(ga-cspa-14)(final-approved-state-plan)(page-76)Page 76#

State: Georgia Section:9 Page: 8

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 care plans used in the program should serve both Medicaid members and non- Medicaid patients.

• Prevention and education should be integral components of any benefits package.

Providers

In addition to participating in the focus groups and community dialogues, many health care providers were interviewed for a separate study as part of a detailed analysis of the current health care delivery system in Georgia. Key findings from that research are summarized below:

• The delivery system is in rapid transition. Organized health plans are widespread in the state, displacing traditional fee-for-service reimbursement plans. Hospitals and other providers are restructuring, merging and forming networks to compete with insurer-sponsored managed care organizations.

• A quick-budget-fix approach to Medicaid reform could harm public health and actually raise costs in the long run. Providers would support a serious, well- reasoned reform effort, developed through a fair process that listens to providers’ concerns, and includes realistic transition periods.

• Any reform plan should include performance standards, outcome measures, accountability, competition, and choice (for both members and providers). Providers should be able to at least break even financially if they participate in Medicaid, and a small profit would be appropriate as recompense for taking risk.

• Providers who have traditionally served the Medicaid population with demonstrated quality should be included in a managed care or any other delivery system.

(ga-cspa-14)(final-approved-state-plan)(page-77)Page 77#

State: Georgia Section:9 Page: 9

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

• Association of County Commissioners of Georgia • Augusta/Richmond County Community Partnership • Caring Program for Children • Chatham-Savannah Youth Futures Authority • Child Psychologist • Children’s Hospitals (Egleston, Hughes-Spalding, Scottish Rite) • Council on Maternal and Infant Health • Department of Education • Department of Medical Assistance (Division of Maternal and Child Health, Eligibility and Quality Control, and Strategic Planning) • Division of Family and Children Services • Division of Mental Health/Mental Retardation/Substance Abuse • Division of Public Health (Division Director, Child and Adolescent Health Unit, Gwinnett County Health District, DeKalb County Board of Health) • Georgia Academy of Family Physicians • Georgia Association for Primary Health Care • Georgia Chapter/American Academy of Pediatrics • Georgia Dental Association • Georgia Partnership for Caring • Georgia Policy Council for Children and Families • Georgians for Children • Governor’s Office of Planning and Budget • Healthy Mothers, Healthy Babies Coalition of Georgia

(ga-cspa-14)(final-approved-state-plan)(page-78)Page 78#

State: Georgia Section:9 Page: 10

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 • March of Dimes • Office of the Commissioner of Insurance • Tanner Medical Center • The Family Connection • United Healthcare • Wachovia Bank of Georgia Compensation and Benefits Branch • West Georgia Medical Center

Public Notice

Ongoing Public Involvement

(ga-cspa-14)(final-approved-state-plan)(page-79)Page 79#

State: Georgia Section:9 Page: 11

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 few. Providers and their respective associations, professional health care associations, community groups, patient advocates, Medicaid recipients, and interested citizens were invited to share their concerns with the committee.

Georgia Families

In February 2003, the State issued a request for information seeking comprehensive proposals to redesign the Medicaid program to improve quality and provider accountability while achieving budget predictability and cost containment. Over 42 responses were received. For the next several months, meetings were held with providers, consumer groups, insurance representatives and other stakeholders to design a new program.

(ga-cspa-14)(final-approved-state-plan)(page-80)Page 80#

State: Georgia Section:9 Page: 12

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 hospital providers, senior associations, children and family coalitions, and others to ensure participation and input from all groups affected by the new mandatory managed care program.

(ga-cspa-14)(final-approved-state-plan)(page-86)Page 86#

State: Georgia Section:12 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Upon denial of eligibility, a parent will be notified by mail of the reason for the denial and the process to notify PeachCare for Kids if the parent believes the denial is in error. Parents will first be directed to call the toll-free number and report additional information or clarify information on the applicant’s account. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the request will be directed to a senior supervisor and/or the account manager of the TPA. The management level will review if the determination made by the TPA system and supported by the staff is correct based on state and federal policy. If the supervisory level does not overturn the denial, the parent will once again be informed of the decision. If the parent continues to dispute the denial, the supervisory staff will inform the parent that they may submit a request in writing to the PeachCare for Kids, to be reviewed by state-level PeachCare for Kids staff.

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State: Georgia Section:12 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 either in person or through written communication. The decision of the Formal Appeals Committee will be the final recourse available to the member. If at any level of dispute, the appropriate party determines the child is eligible for enrollment in PeachCare for Kids, the enrollment will become effective retroactive to the first day of the month in which the complete application, including any additional information affecting the outcome of PeachCare’s decision, is received.

The State assures that in the review process, enrollees have the opportunity to fully participate in the review process; decisions are made in writing; and impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services.

Members whose coverage is cancelled due to closed enrollment will follow all of the same procedures for review as detailed in this section, including having the right to continue services pending completion of a review.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

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State: Georgia Section:12 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Committee will be the final recourse available to the member. In reference to the Formal Appeals level, the State assures:

• Enrollees receive timely written notice of any determinations that include the reasons for the determination, an explanation of applicable rights to review, the standard and expedited time frames for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review. • Enrollees have the opportunity for an independent, external review of a delay, denial, reduction, suspension, termination of health services, failure to approve, or provide payment for health services in a timely manner. The independent review is available at the Formal Appeals level. • Decisions are written when reviewed by the CMO, DCH and the Formal Appeals Committee. • Enrollees have the opportunity to represent themselves or have representatives in the process at the Formal Appeals level. • Enrollees have the opportunity to timely review of their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the timeframes for the appeals process once an appeal is filed with the Formal Appeals Committee. • Enrollees have the opportunity to fully participate in the review process, whether the review is conducted in person or in writing. • Reviews that are not expedited due to an enrollee's medical condition will be completed within 90 calendar days of the date a request is made consistent with 42 CFR §457.1160(b)(1). • Reviews that are expedited due to an enrollee's medical condition are completed within 72 hours of the receipt of the request consistent with 42 CFR §457.1160(b)(2).

Consistent with 42 CFR §457.1130(c), DCH and its Agents are not required to provide an opportunity for review of medical or eligibility matters if the sole basis for the decision is a provision in the State Plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees without regard to their individual circumstances.

(ga-cspa-14)(final-approved-state-plan)(page-92)Page 92#

PUBLIC NOTICE

PEACHCARE FOR KIDS

• Any new applications received or postmarked after March 11, 2007 will not be processed for PeachCare eligibility.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will also be affected by this change and will be precluded from re-enrollment. These members will receive additional notice by direct mail as required by governing regulations.

• Members enrolled and/or determined eligible prior to March 11, 2007 will not be impacted by this particular proposed change.

This change serves as an effort to sustain the PeachCare for Kids Program so that low-income children currently enrolled in the program may continue to receive low-cost health insurance.

NOTICE IS HEREBY GIVEN THIS 8TH DAY OF FEBRUARY, 2007

Rhonda M. Medows, M.D., Commissioner

(ga-cspa-14)(final-approved-state-plan)(page-93)Page 93#

To:

Parents/Guardians of PeachCare for Kids Members From: Commissioner Dr. Rhonda Medows, M.D. Date: February 20, 2007 Re:

PeachCare for Kids Enrollment Freeze

It was with a heavy heart that I announced we will stop accepting new applications to enroll in the PeachCare for Kids (PKC) program effective March 11, 2007. This freeze will then be in effect until further notice.

We continue to work with members of Congress, the members of our State Legislature and the Governor' office to resolve the funding needs of this very important program.

For additional information on the PeachCare for Kids program, please access http://www.dch.ga.gov.

If you have any questions or concerns, please feel free to call 1-877-GAPEACH (1-877- 427-3224)

Equal Opportunity Employer

(ga-cspa-14)(final-approved-state-plan)(page-95)Page 95#

Rhonda M. Medows, MD, Commissioner 2 Peachtree Street, NW Atlanta, GA 30303-3159 Sonny Perdue, Governor www.dch.georgia.gov

FOR IMMEDIATE RELEASE CONTACT:

February 8, 2007 Dena’ Brummer 404-463-5391

PeachCare for Kids Enrollment Closes to New Members

Children currently enrolled continue to receive care

ATLANTA – Today, Georgia Department of Community Health Commissioner Dr. Rhonda Medows informed the Board of Community Health that PeachCare for Kids (PCK) will no longer accept new enrollees to the program as of March 11, 2007.

(ga-cspa-15)(final-approved-state-plan)(page-6)Page 6#

State: Georgia Section: 2.1 Page: 1

Effective Date: September 1, 1998

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

(ga-cspa-15)(final-approved-state-plan)(page-9)Page 9#

State: Georgia Section: 2.2 Page: 1

Effective Date: September 1, 1998

Currently, Georgia’s public child health insurance plans include PeachCare for Kids™ and the Medicaid program administered by the Georgia Department of Community Health (DCH), Division of Medical Assistance (DMA). The Department has several approaches to identifying and enrolling eligible children. These approaches are described in the following paragraphs.

PeachCare for Kids™

In 2000, 2001, and 2002, the Department has teamed up with the Department of Education, Division of School Nutrition Services to distribute flyers, in English and Spanish, to each student during Back-to-School registration. The Right from the Start Medicaid (RSM) outreach staff worked

(ga-cspa-15)(final-approved-state-plan)(page-10)Page 10#

State: Georgia Section: 2.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 with many elementary schools to be on site promoting PeachCare for Kids and Medicaid to the parents.

PeachCare for Kids™, RSM, March of Dimes and Kmart stores partnered in 1999 and 2000 to promote PeachCare for Kids and Medicaid. In 1999, outreach workers were at each Kmart store on the Saturday before Halloween educating parents while their children shopped for costumes and treats. In 2000, the outreach workers returned to Kmarts on the Saturday before school started to talk to parents as they were getting their kids ready for the new school year.

Division of Family and Children Services (DFCS)

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State: Georgia Section: 2.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 responsible for Food Stamps, Temporary Assistance for Needy Families (TANF), Child Protective Services and Foster Care. The Medicaid application process is coordinated with that for cash assistance and employment related services available through TANF. Children in families seeking these services also have their Medicaid eligibility determined. The State of Georgia has 159 counties. Each county has at least one DFCS office, and some counties have multiple sites for Medicaid eligibility intake. Some workers from these local DFCS offices are assigned to Federally Qualified Health Centers (FQHCs) and Disproportionate Share Hospitals.

Covering Kids

Public Health Departments and Federally Qualified Health Centers

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State: Georgia Section: 2.2 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

Medicaid and PeachCare Participating Providers

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State: Georgia Section: 2.2 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 efforts to promote PeachCare for Kids, including billboards and fast food trayliners. In addition to large-scale efforts, many individual physicians have referred uninsured patients to www.peachcare.org and made applications available in their office.

Other State Initiatives For Special Needs Children

Division of Public Health

“Babies Can’t Wait”

Children’s Medical Services

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State: Georgia Section: 2.2 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 participate in this program. CMS serves approximately 15,000 to 16,000 children yearly.

Regional Perinatal System

Division of Mental Health, Mental Retardation and Substance Abuse (MH/MR/SA)

Mental Health Services for Children and Adolescents with Severe Emotional Disturbance

Currently some level of services for youth with severe emotional disturbance (SED) is available in all MH/MR/SA service areas. Public services available to the SED population include: • Outpatient including crisis intervention, case coordination and wraparound services • In-home crisis services (to avoid hospitalization or other out-of-home placement) • Day Treatment (after school, evenings and some weekends) • Respite • Therapeutic Foster Care • Therapeutic Group Home Care

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State: Georgia Section: 2.2 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 not denied due to inability to pay.

Substance Abuse Services for Adolescents

Department of Human Resources

MATCH

The DHR Multi-Agency Team for Children (MATCH) arranges care for Georgia’s children with severe emotional disturbances who need mental health treatment in residential settings. The program is administered through the Division of Family and Children Services Treatment Services Unit. The mission of MATCH is to enable children to lead the most stable and productive lives possible. More than one hundred local interagency teams operate throughout the state to identify children. The locate team reviews the child’s history and response to the mental health services that have been provided. If the child’s need for mental health care and safety is too great for the community to manage, then the child is referred to state MATCH.

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State: Georgia Section: 2.2 Page: 8

Effective Date: September 1, 1998

Georgia Partnership for Caring Foundation

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State: Georgia Section: 2.3 Page: 1

Effective Date: September 1, 1998

Applications for PeachCare for Kids contain the information necessary to determine eligibility for Medicaid as well as for PeachCare for Kids. Applications are mailed to and processed by a Third Party Administrator (TPA) at a centralized location. As part of the eligibility determination process, the TPA screens applications for Medicaid eligibility before determining eligibility for PeachCare for Kids. If a child or children on the application appear to possibly be eligible for Medicaid, the application for that child or those children is processed by RSM workers. The processing provides for investigation and verification of both the financial and non-financial requirements for the Medicaid program. If the child or children are eligible for Medicaid, Medicaid enrollment will occur, rather than eligibility determination for PeachCare for Kids. If the RSM worker finds the child or children ineligible for Medicaid, then the TPA

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State: Georgia Section: 3.1 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

The PeachCare for Kids™ legislation mandates that “Any health care provider who is enrolled in the Medicaid program shall be deemed to be enrolled in the program.” Therefore, the current Medicaid health assistance delivery and utilization control system is the system used for PeachCare for Kids. Service delivery is accomplished through a variety of relationships and agreements with private medical providers and state agencies.

Georgia Families

PeachCare for Kids™ members will be enrolled in a commercially licensed care management organization (CMO) that is contracted by DCH. Membership in Georgia Families (GF) is mandatory for all PeachCare for Kids™ members and most pregnant women and children eligible for Medicaid.

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State: Georgia Section: 3.1 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Five key goals of the program are to (1) improve the health care status of enrolled populations (2) Establish a “provider home” for Members through its use of assigned Primary Care Providers (PCPs) (3) Establish contractual accountability for access to, and quality of, healthcare (4) Slow the rate of growth in PeachCare costs (4) Implement an intelligent health system where members have accurate, timely knowledge of their health needs, access to the best information about how to maintain their health, knowledge of who and where to go if they have health needs, and an assurance that their health providers will be using best practices based on the most recent understanding of outcomes based medicine.

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State: Georgia Section: 3.2 Page: 1

Effective Date: September 1, 1998

Reimbursement Limitations

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State: Georgia Section: 3.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 process to ensure that treatment plans are revised as necessary. The CMOs must also guarantee a strategy is in place to ensure that all Members and/or family members or guardians are involved in treatment planning.

The CMO is required to develop disease management programs for individuals with chronic conditions such as diabetes and asthma. Additionally, each CMO must have programs for at least two additional conditions including: Perinatal case management, obesity, hypertension, Sickle cell disease; or HIV/AIDS.

Treatment Residential Intervention Services Utilization Controls

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State: Georgia Section: 4.1 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1.1.  Geographic area served by the Plan: Georgia’s Title XXI plan is available statewide to children in all 159 Georgia counties

4.1.2.  Age: The plan will be available to children 0 through 18 years of age. If the child is otherwise eligible, coverage will continue through the month of his/her nineteenth birthday.

4.1.3.  Income: Eligible children will have family income that is at or below 235% of the federal poverty level and will not be eligible for Medicaid.

4.1.4.  Resources (including any standards relating to spend downs and disposition of resources): There is no resource test.

4.1.6.  Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child will be denied eligibility based on disability status. 4.1.7.  Access to or coverage under other health coverage: A child will be denied eligibility if it is determined that he or she: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefit plan based on a family member’s employment with a public agency in the State; or 4)

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State: Georgia Section: 4.1 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The CHIP application will contain questions about current and past coverage under group health plans and family member’s employment with State agencies. State employment information will be verified through monthly matches with the State Merit System and the Board of Regents. In addition, as claims are paid, if the providers report coverage under other health plans, eligibility will be terminated if the coverage meets any of the four criteria listed above.

4.1.8.  Duration of eligibility: With the approval of the PeachCare application, a child will be eligible for twelve months as long as eligibility criteria continue to be met. The family will be notified of its responsibility to report changes in income, residency or health insurance coverage. There will be monthly matches with the Medicaid MMIS to ensure that Title XXI children have not been certified for Medicaid. At the end of the twelve-month eligibility period, the family will be sent a letter detailing the information on the family’s account pertinent to eligibility. The family will be required to report any changes to the information and provide verification of all sources of income at this time. Eligibility will be redetermined for another twelve- month period so long as the family provides the required documentation within the requested timeframe.

4.1.9.  Other standards (identify and describe): Consistent with 42 CFR 457.340(b), PeachCare does not require Social Security numbers for any applicant.

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State: Georgia Section: 4.3 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 4.3. Describe the methods of establishing eligibility and continuing

enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

PeachCare for Kids utilizes the same income methodologies as are used for its Right from the Start Medicaid program (Title XIX Poverty Level Group).

APPLICATION

VERIFICATION OF INCOME, CITIZENSHIP/LEGAL RESIDENCY AND IDENTITY

Beginning July 1, 2007, all PeachCare applicants are required to provide verification of income, citizenship/legal residency and identity. The application

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State: Georgia Section: 4.3 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 directs families to send in the most recent proof of all earned and unearned income sources. The following documentation is requested:

Self-employment documents: • business ledger/receipts • tax forms- 1040, 1040A, 1040EZ • bank deposits • applicant/recipient's signed statement if neither of the above is available.

NOTE: Assume that any deductions taken on a tax return or business record is allowable by the Internal Revenue Service.

Document the case record as to why federal income tax returns or business records were not used if the A/R’s statement was accepted as verification.

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State: Georgia Section: 4.3 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 the parent who pays the child support to the applicant/recipient-. Provide the name, address, and contact number. Provide amount received and how often received. g. Other Unearned Income – letter from the source stating amount received and how often received. Provide name, address, and contact number or (4) weeks of pay stubs (one week after the other)

C. Citizenship/Identity/Legal Residency

Georgia follows the DRA provisions regarding citizenship/nationality and as of January 1, 2010, has updated its process to comply with section 211 of CHIPRA. PeachCare for Kids applicants must declare their citizenship or alien status and provide documentation, as described in CFR 435.407, that verify they are in an eligible status to receive benefits. As required in CHIPRA section 211, the State will not deny, delay, reduce, or terminate benefits while the documentation is gathered during a reasonable opportunity period. If an applicant is determined to be eligible for PeachCare for Kids, but citizenship documentation is still outstanding, the State will continue to provide PeachCare for Kids benefits until the end of the reasonable opportunity period. For determining deemed newborn status, the TPA performs a data match with Georgia’s MMIS files to determine whether the applicant’s mother was Medicaid eligible per the date of the child’s birth. If citizenship cannot be verified through data match with vital records or MMIS records, the applicant is then required to submit a form of acceptable documentation as outlined in CFR 435.407. The following groups of individuals are exempt from the requirements: • Individuals receiving SSI benefits under title XVI of the Act. • Individuals entitled to or enrolled in any part of Medicare. • Individuals receiving disability insurance benefits under section 223 of the Act or monthly benefits under section 202 of the Act, based on the individual's disability (as defined in section 223(d) of the Act). • Individuals who are in foster care and who are assisted under Title IV-B of the Act, and individuals who are recipients of foster care maintenance or adoption assistance payments under Title IV–E of the Act.

Types of acceptable documentary evidence of citizenship. For purposes of this section, the term “citizenship” includes status as a “national of the United States” as defined by section 101(a)(22) of the Immigration and Nationality Act (8 U.S.C. 1101(a)(22)) to include both citizens of the United States and non-citizen nationals of the United States.

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State: Georgia Section: 4.3 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 (a) Primary evidence of citizenship and identity. The following evidence must be accepted as satisfactory documentary evidence of both identity and citizenship: (1) A U.S. passport. The Department of State issues this. A U.S. passport does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation .Note: Spouses and children were sometimes included on one passport through 1980. U.S. passports issued after 1980 show only one person. Consequently, the citizenship and identity of the included person can be established when one of these passports is presented. Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity. (2) A Certificate of Naturalization (DHS Forms N–550 or N–570.) Department of Homeland Security issues for naturalization. (3) A Certificate of U.S. Citizenship (DHS Forms N–560 or N–561.) Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent. (4) A valid State-issued driver's license, but only if the State issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number from the applicant and verifies before certification that such number is valid and assigned to the applicant who is a citizen. (This provision is not effective until such time as a State makes providing evidence of citizenship a condition of issuing a driver's license and evidence that the license holder is a citizen is included on the license or in a system of records available to the Medicaid agency. The State must ensure that the process complies with this statutory provision in section 6036 of the Deficit Reduction Act of 2005. CMS will monitor compliance of States implementing this provision.). (5) A Tribal document issued by a federally recognized Indian tribe evidencing membership, enrollment in, or affiliation with such Tribe is satisfactory documentary evidence of an individual’s U.S. citizenship or nationality.

(b) Secondary evidence of citizenship. If primary evidence from the list in paragraph (a) of this section is unavailable, an applicant or recipient should provide satisfactory documentary evidence of citizenship from the list specified in this section to establish citizenship and satisfactory documentary evidence from paragraph (e) of this section to establish identity, in accordance with the rules specified in this section. (1) A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain's Island, or the Northern Mariana Islands (after November 4, 1986 (NMI local time)). A State, at its option, may use a cross match with a State vital statistics agency to document a birth record. The birth record document may be issued by the State,

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State: Georgia Section: 4.3 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Commonwealth, Territory, or local jurisdiction. It must have been recorded before the person was 5 years of age. A delayed birth record document that is recorded at or after 5 years of age is considered fourth level evidence of citizenship. (Note: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories.) The following will establish U.S. citizenship for collectively naturalized individuals: (2) A Certification of Report of Birth (DS–1350). The Department of State issues a DS– 1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS–240. When the birth was recorded as a Consular Report of Birth (FS–240), certified copies of the Certification of Report of Birth Abroad (DS–1350) can be issued by the Department of State in Washington, DC. The DS–1350 contains the same information as that on the current version of Consular Report of Birth FS–240. The DS–1350 is not issued outside the U.S. (3) A Report of Birth Abroad of a U.S. Citizen (Form FS–240). The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these. (4) A Certification of birth issued by the Department of State (Form FS–545 or DS– 1350). Before November 1, 1990, Department of State consulates also issued Form FS–545 along with the prior version of the FS–240. In 1990, U.S. consulates ceased to issue Form FS–545. Treat an FS–545 the same as the DS–1350. (5) A U.S. Citizen I.D. card. (This form was issued until the 1980s by INS. Although no longer issued, holders of this document may still use it consistent with the provisions of section 1903(x) of the Act.) INS issued the I–179 from 1960 until 1973. It revised the form and renumbered it as Form I–197. INS issued the I–197 from 1973 until April 7, 1983. INS issued Form I–179 and I–197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid. (6) A Northern Mariana Identification Card (I–873). (Issued by the DHS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.) The former Immigration and Naturalization Service (INS) issued the I–873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.

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State: Georgia Section: 4.3 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 (7) A final adoption decree showing the child's name and U.S. place of birth. The adoption decree must show the child's name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency that shows the child's name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate. (8) Evidence of U.S. Civil Service employment before June 1, 1976. The document must show employment by the U.S. government before June 1, 1976. Individuals employed by the U.S. Civil Service prior to June 1, 1976 had to be U.S. citizens. (9) U.S. Military Record showing a U.S. place of birth. The document must show a U.S. place of birth (for example a DD–214 or similar official document showing a U.S. place of birth.) (10) A data verification with the Systematic Alien Verification for Entitlements (SAVE) Program for naturalized citizens. A State may conduct a verification with SAVE to determine if an individual is a naturalized citizen, provided that such verification is conducted consistent with the terms of a Memorandum of Understanding or other agreement with the Department of Homeland Security (DHS) authorizing verification of claims to U.S. citizenship through SAVE, including but not limited to provision of the individual's alien registration number if required by DHS. (11) Child Citizenship Act. Adopted or biological children born outside the United States may establish citizenship obtained automatically under section 320 of the Immigration and Nationality Act (8 U.S.C. 1431), as amended by the Child Citizenship Act of 2000 (Pub. L. 106–395, enacted on October 30, 2000). The State must obtain documentary evidence that verifies that at any time on or after February 27, 2001, the following conditions have been met: (i) At least one parent of the child is a United States citizen by either birth or naturalization (as verified under the requirements of this Part); (ii) The child is under the age of 18; (iii) The child is residing in the United States in the legal and physical custody of the U.S. citizen parent; (iv) The child was admitted to the United States for lawful permanent residence (as verified under the requirements of 8 U.S.C. 1641 pertaining to verification of qualified alien status); and (v) If adopted, the child satisfies the requirements of section 101(b) (1) of the Immigration and Nationality Act (8 U.S.C. 1101(b) (1) pertaining to international

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State: Georgia Section: 4.3 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 adoptions (admission for lawful permanent residence as IR–3 (child adopted outside the United States)), or as IR–4 (child coming to the United States to be adopted) with final adoption having subsequently occurred). (c) Third level evidence of citizenship. Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is used when both primary and secondary evidence is unavailable. Third level evidence may be used only when the applicant or recipient alleges being born in the U.S. A second document from paragraph (e) of this section to establish identity must also be presented: (1) Extract of a hospital record on hospital letterhead established at the time of the person's birth that was created 5 years before the initial application date and that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Do not accept a souvenir “birth certificate” issued by the hospital. (2) Life, health, or other insurance record showing a U.S. place of birth that was created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. (3) Religious record recorded in the U.S. within 3 months of birth showing the birth occurred in the U.S. and showing either the date of the birth or the individual's age at the time the record was made. The record must be an official record recorded with the religious organization. CAUTION: In questionable cases (for example, where the child's religious record was recorded near a U.S. international border and the child may have been born outside the U.S.), the State must verify the religious record and/or document that the mother was in the U.S. at the time of birth. (4) Early school record showing a U.S. place of birth. The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth, and the name(s) and place(s) of birth of the applicant's parents. (d) Fourth level evidence of citizenship. Fourth level evidence of citizenship is documentary evidence of the lowest reliability. Fourth level evidence should only be used in the rarest of circumstances. This level of evidence is used only when primary, secondary and third level evidence is unavailable. With the exception of the affidavit process described in paragraph (d) (5) of this section, the applicant may only use fourth level evidence of citizenship if alleging a U.S. place of birth. In addition, a second document establishing identity must be presented as described in paragraph (e) of this section.

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State: Georgia Section: 4.3 Page: 8

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 (1) Federal or State census record showing U.S. citizenship or a U.S. place of birth. (Generally for persons born 1900 through 1950.) The census record must also show the applicant's age. Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC–600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for PeachCare for Kids™ eligibility. This form requires a fee. (2) One of the following documents that show a U.S. place of birth and was created at least 5 years before the application for PeachCare for Kids™ (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) This document must be one of the following and show a U.S. place of birth: (i) A delayed U.S. public birth record that is recorded more than 5 years after the person's birth. (ii) Statement signed by the physician or midwife who was in attendance at the time of birth. (3) Institutional admission papers from a nursing facility, skilled care facility or other institution created at least 5 years before the initial application date that indicates a U.S. place of birth. Admission papers generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. (4) Medical (clinic, doctor, or hospital) record created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Medical records generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. (Note: An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.) (5) Written affidavit. Affidavits should ONLY be used in rare circumstances. If the documentation requirement needs to be met through affidavits, the following rules apply: (i) There must be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant's or recipient's claim of citizenship (the two affidavits could be combined in a joint affidavit). (ii) At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient.

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State: Georgia Section: 4.3 Page: 9

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 (iii) In order for the affidavit to be acceptable the persons making them must be able to provide proof of their own citizenship and identity. (iv) If the individual(s) making the affidavit has (have) information which explains why documentary evidence establishing the applicant's claim or citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well. (v) The State must obtain a separate affidavit from the applicant/recipient or other knowledgeable individual (guardian or representative) explaining why the evidence does not exist or cannot be obtained. (vi) The affidavits must be signed under penalty of perjury and need not be notarized. (e) Evidence of identity. The following documents may be accepted as proof of identity and must accompany a document establishing citizenship from the groups of documentary evidence of citizenship in the groups in paragraphs (b) through (d) of this section. (1) Identity documents described in 8 CFR 274a.2 (b) (1) (v) (B) (1). (i) Driver's license issued by State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color. (ii) School identification card with a photograph of the individual. (iii) U.S. military card or draft record. (iv) Identification card issued by the Federal, State, or local government with the same information included on drivers' licenses. (v) Military dependent's identification card. (vi) U.S. Coast Guard Merchant Mariner card. Note to paragraph (e) (1): Exception: Do not accept a voter's registration card or Canadian driver's license as listed in 8 CFR 274a.2 (b) (1) (v) (B) (1). CMS does not view these as reliable for identity. (2) The TPA may use a cross match with a Federal or State governmental, public assistance, law enforcement or corrections agency's data system to establish identity if the agency establishes and certifies true identity of individuals. Such agencies may include child support, corrections, including juvenile detention, motor vehicle, or child protective services. (3) The TPA may also accept three or more documents that together reasonably corroborate the identity of an individual provided such documents have not been used

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State: Georgia Section: 4.3 Page: 10

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 to establish the individual's citizenship and the individual submitted second or third tier evidence of citizenship. The State must first ensure that no other evidence of identity is available to the individual prior to accepting such documents. Such documents must at a minimum contain the individual's name, plus any additional information establishing the individual's identity. All documents used must contain consistent identifying information. These documents include employer identification cards, high school and college diplomas from accredited institutions (including general education and high school equivalency diplomas), marriage certificates, divorce decrees and property deeds/titles. (f) Special identity rules for children. For children under 16, a clinic, doctor, hospital or school record may be accepted for purposes of establishing identity. School records may include nursery or daycare records and report cards. If the State accepts such records, it must verify them with the issuing school. If none of the above documents in the preceding groups are available, an affidavit may be used. An affidavit is only acceptable if it is signed under penalty of perjury by a parent, guardian or caretaker relative (as defined in the regulations at 45 CFR 233.90(c) (v) stating the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided. The affidavit is not required to be notarized. The state may accept an identity affidavit on behalf of a child under the age of 18 in instances when school ID cards and drivers' licenses are not available to the individual in that area until that age. For Peachcare for Kids™ applicants, the affidavit requirement can be met when the parent attests to the to the child’s identity under penalty of perjury when the application is signed and submitted or certified when the information is entered online. (g) Special identity rules for disabled individuals in institutional care facilities. The State may accept an identity affidavit signed under penalty of perjury by a residential care facility director or administrator on behalf of an institutionalized individual in the facility. States should first pursue all other means of verifying identity prior to accepting an affidavit. The affidavit is not required to be notarized. (h) Special populations needing assistance. The state must assist individuals to secure satisfactory documentary evidence of citizenship when because of incapacity of mind or body the individual would be unable to comply with the requirement to present satisfactory documentary evidence of citizenship in a timely manner and the individual lacks a representative to assist him or her. (i) Documentary evidence. (1) All documents must be either originals or copies certified by the issuing agency. Uncertified copies, including notarized copies, shall not be accepted. (2) States must maintain copies of citizenship and identification documents in the case record or electronic data base and make these copies available for compliance audits.

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State: Georgia Section: 4.3 Page: 11

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 (3) States may permit applicants and recipients to submit such documentary evidence without appearing in person at a PeachCare for Kids™ office. States may accept original documents in person, by mail, or by a guardian or authorized representative. (4) If documents are determined to be inconsistent with pre-existing information, are counterfeit, or altered, States should investigate for potential fraud and abuse, including but not limited to, referral to the appropriate State and Federal law enforcement agencies. (5) Presentation of documentary evidence of citizenship is a one time activity; once a person's citizenship is documented and recorded in a State database subsequent changes in eligibility should not require repeating the documentation of citizenship unless later evidence raises a question of the person's citizenship. The State need only check its databases to verify that the individual already established citizenship. (j) Record retention. The State must retain documents in accordance with 45 CFR 74.53. (k) Reasonable opportunity to present satisfactory documentary evidence of citizenship. Eligible individuals who declare to be U.S. citizens or nationals must be provided a reasonable opportunity to present satisfactory documentation of citizenship or nationality and must be enrolled in coverage pending the reasonable opportunity to document that claim. New applicants are asked to provide citizenship verification after the application is received if they are not exempt from providing documents or there is no data match or other acceptable verification on file. (See §435.930 and §435.911.) Applicants are given up to 90 days to provide documents and their eligibility may be extended as long as they are making a good faith effort to comply. If an individual has not provided satisfactory documentation of citizenship by the end of the reasonable opportunity period, and any extension period, States may terminate that individual’s eligibility for Medicaid or CHIP benefits in accordance with Medicaid rules at 42 CFR 435.919 and 42 CFR 431 Subpart E (regarding timely notice and opportunity for a fair hearing).

APPLICATION PROCESSING

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State: Georgia Section: 4.3 Page: 12

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Medicaid eligible, the account will not be required to go through income verification. The case will be updated using information provided by the State Eligibility Specialist. For children who are not Medicaid eligible, the TPA determines if net family income (gross income minus disregards) is at or below the 235% federal poverty level; the child is covered by a group health plan (either currently or in the past six months); the child is eligible for health benefits through a family member’s employment with a state agency; and if the child is a U.S. citizen or lawfully admitted alien. The TPA is also required to use customer service personnel to follow up on incomplete or unclear information found in the application.

The TPA checks Medicaid’s information system for enrollment in the Medicaid program and conducts matches with the State Health Benefit Plan and Board of Regents for enrollment in or eligibility for state-sponsored health benefit plans. If a child is determined to be ineligible for PeachCare for Kids™, the family receives a written notice describing the reason for ineligibility. The notice specifies the reason for the denial (e.g. excess income, age over eighteen years etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to accomplish this. This may include submission of additional or clarifying information to allow a review of the application decision. If the applicant is not satisfied with the final decision of the TPA, the case is sent to the Department of Community Health for further review.

If a child is found to be eligible for the PeachCare for Kids™ program, the family receives a PeachCare handbook that describes the program’s benefits, instructions on how to submit premium payments and a number to contact the TPA to report changes. The family is also contacted by the Georgia Families (GF) enrollment broker and receives a new enrollment package that explains the GF program and choices about CMO plans in the Member’s service region. The enrollment broker also provides information regarding how to access services through the GF CMO selected by, or assigned to the family.

CONTINUING ENROLLMENT

At the time of application approval, the family receives information requiring them to report changes in their income, place of residence or household size to the TPA. If a family reports a decrease in income, verification of all income is required. If the family remains PeachCare eligible and is within 90 days of their annual renewal, the income verification process will be held until that time. The verification request for renewal is sent two months prior to the renewal month. If these changes result in ineligibility, the TPA reviews the account information for potential eligibility for the Medicaid program. If the child is potentially Medicaid eligible, the account information is sent immediately to the State Medicaid staff for review, just as the new applications are handled.

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State: Georgia Section: 4.3 Page: 13

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

If the child is screened as ineligible for Medicaid and PeachCare for Kids™ based on the information provided, the TPA sends the member a notice of termination and closes the case. The notice specifies the reason for termination (e.g. excess income, etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to submit any necessary documentation.

As long as the family continues to meet all eligibility requirements and continues to pay the monthly premium as required, the child(ren) may be eligible for coverage for twelve (12) months.

PREMIUM COLLECTION and REINSTATEMENT PROCESS • Premiums: Premiums are not required for children ages 0 through 5 years. For children ages 6 through 18, the premiums are detailed in the table below.

FPL One Child Family Cap 100-150% $10.00 $15.00 151-160% $20.00 $40.00 161-170% $22.00 $44.00 171-180% $24.00 $48.00 181-190% $26.00 $52.00 191-200% $28.00 $56.00 201-210% $29.00 $58.00 211-220% $31.00 $62.00 221-230% $33.00 $66.00 231-235% $35.00 $70.00 • The applicant must submit one (1) month's premium, if required, with the application for it to be complete. Once determined eligible, enrollment becomes effective the first day of month the application is determined complete. • When the applicant is enrolled, the TPA sends a coupon payment book (or other payment mechanism) to the member for use in making regular premium payments. Members may send in premiums for multiple months. • The first two months’ coverage will be funded with state/federal funds. The premium received with the application will be applied to the third month's coverage. With this model, the collection process will be one month ahead of coverage and a member has 45 days after being late with a payment to submit it before coverage is terminated. • If payments are late, the notification/cancellation process will begin. A letter will be sent before cancellation occurs.

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State: Georgia Section: 4.3 Page: 14

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

An example follows:

RENEWAL PROCESS

Sixty days prior to a member’s annual anniversary date, PeachCare for Kids™ sends a letter to the family detailing enrollment-related information on the account, including demographic information, children enrolled, and premiums required. Families are notified of the requirement to send in the appropriate verification documents. All families will be required to provide income verification at the annual renewal. A form detailing the required documentation will be sent with the renewal notice. After 3 weeks, a reminder notice will be sent. If a family makes an effort to comply with the verification process prior to the renewal date but needs additional time to provide the necessary documents, a thirty (30) day grace period will be granted. In circumstances where there is intent to comply, an additional (30) days of coverage can be granted manually by a supervisor with the TPA.

Children who remain eligible after the 12-month renewal period will continue

coverage. If a change in income or household composition is reported, the account will be reprocessed, similar to a new application with the children being

screened for potential Medicaid eligibility, referred if appropriate and then evaluated for continued eligibility for PeachCare.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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State: Georgia Section: 4.3 Page: 15

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

Check here if this section does not apply to your state.

In the event that the enrollment cap of 295,000 children is reached before adequate FFY08 is available and enrollment must be closed again, the following procedures will be in place:

• All correspondence, as well as the PeachCare for Kids website, will be updated to indicate the capped enrollment status and explain what it will mean for members and potential members.

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State: Georgia Section: 4.4

Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 4.4. Describe the procedures that assure that:

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State: Georgia Section: 4.4

Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Upon receipt of the application, the TPA screens the application for potential Medicaid eligibility. This process will continue during the PeachCare enrollment freeze. If the child is potentially Medicaid eligible based on reported income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information are included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

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State: Georgia Section: 4.4

Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 employment with a public agency in the State; or 4) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The PeachCare application contains questions about current and past coverage under group health plans and family member’s employment with State agencies. The application also contains questions about current and past coverage under group health plans. In addition to self- declaration of other coverage, providers report coverage under other health plans and PeachCare enrollment is terminated if the other coverage meets any of the four criteria listed above.

To calculate the cost sharing imposed on a household and the

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State: Georgia Section: 5

Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

PeachCare for Kids Outreach Through RSM Outreach

Outreach efforts are completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be reached and enrolled in Medicaid and those children eligible for PeachCare can be reached and enrolled in PeachCare. The outreach efforts target all children at or below 235% of the FPL. To build on and enhance our outreach efforts, Georgia utilizes our nationally recognized RSM outreach strategies for PeachCare for Kids. With over 143 representatives statewide, RSM outreach workers have been specifically trained in doing outreach for PeachCare for Kids. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers also have a variety of program information on both creditable and non-creditable coverage and other ways to access health care services. The order of priority for the outreach workers are first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation and DHR public health care programs and services. The outreach efforts are also coordinated with community-based organizations, health care providers, GF CMO plans and the enrollment broker.

RSM Outreach Project

The Right From the Start Medicaid (RSM) Project began in July 1993 as Georgia’s response to the high infant mortality rate and to improve health care access for all children and pregnant women.

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State: Georgia Section: 5

Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 centers, schools, community action agencies and other locations in the community. A major feature of the program is the availability of staff during non-traditional work hours so that clients may apply for RSM without having to lose time from their jobs or from school. Non-traditional hours are defined as any time other than 8 a.m. to 5 p.m. Monday through Friday.

Simplified PeachCare for Kids Application

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State: Georgia Section: 5

Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 attach required documents for income and/or citizenship and identity verification to then be mailed or faxed to the TPA. Both applications are designed to gather information needed to determine eligibility for both PeachCare and Medicaid. Marketing and Public Awareness

Advertising Campaign

Outreach Publications

Outreach Video

Back-to-School Outreach

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State: Georgia Section: 5

Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 parent of a school-age child in the state receives information about PeachCare for Kids. To date, we distribute over 1.6 million brochures at the beginning of each school year.

Community Outreach Mini-grants

In 1999, the Georgia Department of Community Health created a minigrant program, “Improving Health Care Access: Innovations in Medicaid and PeachCare for Kids Outreach, to assist local efforts to raise awareness of both PeachCare and Medicaid programs among hard-to-reach populations. Twenty-four community organizations were awarded grants to conduct grassroots outreach activities specifically designed for their communities.

The activity level of the grantees produced the following results:

• 427,315 pieces of PeachCare for Kids informational materials were distributed; • 445 PeachCare for Kids presentations were conducted; and • 6,000 families were assisted with applications.

Local Media Partnerships

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State: Georgia Section: 5

Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 state and has established partnerships with community and family organizations throughout Georgia to address family issues. As part of its partnership, PeachCare participates in several major events such as the Baby & Kid Expo, CPR Saturday trainings by the American Red Cross, the Susan B. Komen Foundation’s Race for the Cure, the Salute 2 America Fourth of July parade, and Give Kids a Boost. PeachCare brochures are also always on display in the other Family 2 Family sponsor locations, including Haverty’s Furniture, Verizon Wireless, Promina Health Systems, and Southtrust Bank.

Georgia Families

The Georgia Families Care Management Organizations (CMOs)

The CMO plans are permitted to perform the following marketing activities:

If the CMO performs an allowable activity, the CMO shall conduct these activities in the entire Service Region. The State must approve all CMO marketing materials prior to their use. All materials are in compliance with the information requirements in 42 CFR 438.10.

The GF Enrollment Broker (EB)

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State: Georgia Section: 6.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 6.2. The state elects to provide the following forms of coverage to children:

6.2.1.  Inpatient services (Section 2110(a)(1))

6.2.2.  Outpatient services (Section 2110(a)(2))

Outpatient services include outpatient surgery, clinic services and emergency room care. Outpatient services are covered in full. Prior approval is needed for some services.

6.2.3.  Physician services (Section 2110(a)(3))

6.2.4.  Surgical services (Section 2110(a)(4))

Surgical services are covered in full. See 6.2.1 for inpatient surgical services and 6.2.2 for outpatient surgical services. Prior approval is needed for certain procedures.

6.2.5.  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

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State: Georgia Section: 6.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 See 6.2.2 above.

6.2.6.  Prescription drugs (Section 2110(a)(6))

6.2.7.  Over-the-counter medications (Section 2110(a)(7))

6.2.8.  Laboratory and radiological services (Section 2110(a)(8))

Radiology services are covered in a hospital setting or in a physician’s office only. Note: laboratory and radiological services are covered as two separate services.

6.2.9.  Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

6.2.10.  Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Inpatient mental health services are covered only for short-term acute care in general acute care hospitals up to 30 days per admission.

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State: Georgia Section: 6.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Services furnished in a state-operated mental hospital are not covered. Services furnished in an Institution for Mental Disease (IMD) are not covered. Residential or other 24-hour therapeutically planned structural services are covered only through the DHR MATCH Program. (See Sections 2.2.1. and 3.2.) Psychotherapy is limited to 10 hours per calendar month.

6.2.11.  Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Outpatient mental health services are covered through: Community Mental Health Centers, subject to limitations specified in DHR standards

6.2.13.  Disposable medical supplies (Section 2110(a)(13))

6.2.14.  Home and community-based health care services (See instructions) (Section 2110(a)(14))

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State: Georgia Section: 6.2 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 exceeding 75 visits per calendar year may be covered when requested by a physician and determined to be medically necessary by DMA.

6.2.15.  Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16.  Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17.  Dental services (Section 2110(a)(17))

6.2.18.  Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.19.  Outpatient substance abuse treatment services (Section 2110(a)(19))

Outpatient substance abuse treatment services are covered through

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State: Georgia Section: 6.2 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Secretary and not included under this section (Section 2110(a)(28))

Children’s Intervention Services: Services covered for children from birth through 18 years of age are audiology, nursing, nutrition, occupational therapy, physical therapy, social work, speech-language pathology and developmental therapy instruction. Written prior approval is required for medically necessary Children’s Intervention Services once the annual service limitations listed in the Policy and Procedure Manual have been reached. Individualized Family Service Plan is required to document medical necessity for amount, duration and scope of services. Note that children 18 years of age are not covered under these program services.

Family Planning: Covered services include initial and annual examinations, follow-up, brief and comprehensive visits, pregnancy testing, birth control supplies, and infertility assessment.

Podiatry: Services covered are diagnosis, medical, surgical, mechanical, manipulative and electrical treatment of ailments of the

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State: Georgia Section: 6.4 Page: 1

Effective Date: September 1, 1998

(ga-cspa-15)(final-approved-state-plan)(page-67)Page 67#

State: Georgia Section: 7.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

PeachCare for Kids sends each child a birthday postcard each year that wishes them a healthy year and reminds their parents of the well-child care available through PeachCare.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

All members are enrolled in Georgia Families (GF), a managed care program. GF PCPs are required to have care accessible to their members 24 hours a day.

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State: Georgia Section: 7.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

The Georgia Health Policy Center (GHPC), Georgia State University, has done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC has also conducted the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received.

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State: Georgia Section: 7.2 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 All children enrolled in PeachCare for Kids are assigned a CMO and primary care provider (PCP) through GF. The PCP’s role is to assess, treat, and coordinate specialty care for the PeachCare members under their care.

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State: Georgia Section: 8.5 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 8.5. Describe how the state will ensure that the annual aggregate cost sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

For a family with 2 or more enrolled children age 6 and older, the maximum a family could have to pay is $840 annually. This is the maximum family premium of $70 times 12 months. Since there are no deductibles, coinsurance, co-payments or other cost sharing methods, the annual aggregate cost sharing is the maximum family premium annually. In order for $840 to exceed 5 percent of a family’s annual income, the family’s annual income would have to be below $16,800. Uninsured children in a family with annual income below $16,800 are below 150% FPL and would either be eligible for Medicaid or would have a maximum premium of $15 per household per month for enrollment in PeachCare for Kids™, if they met the other eligibility criteria in addition to income criteria.

Therefore, with such a low cost-sharing requirement, PeachCare ensures that the aggregate cost sharing for a family never exceeds 5 percent of a family’s annual income.

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State: Georgia Section: 8.7 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:  State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, co- payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))  The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))  In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))  The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

Premiums are due the first of the month, prior to the month of coverage. If a premium payment is not received on the first, a late letter is sent to the family approximately four days after the late premium was due informing them that if payment is not received by the end of the month, they will be given 45 days of grace period before the coverage termination process begins, with coverage being canceled at the end of the 2nd month of the grace period. This notification also explains their option to opt out of receiving coverage for the grace period months. If the family does not pay the past due premium at the end of the month that it is due, the grace period begins the following month. The State will send a notice no later than the 8th of the first grace period month, informing the family that failure to make a premium by the 15th of the 2nd grace period month will initiate the termination process and coverage will ultimately be terminated at the end of the 2nd grace period month. A call campaign is launched on the 15th of the first grace period month to inform parents of the past due premium payments. If the premium is not paid by the 15th of the 2nd grace period month, then the coverage termination process begins and is ultimately terminated by the end of the 2nd grace period month. Payments received after the 15th day of the 2nd grace period month will not stop the termination process. Once coverage is terminated due to non-payment of premium, the family is ineligible to reinstate for

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State: Georgia Section: 8.7 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 the following month. Families who are canceled due to non-payment of premium are notified by mail and informed of their right to a review of the termination.

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State: Georgia Section: 9.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Objective 1: Increase insurance coverage of Georgia’s low-income children.

Performance goals: 1.1 Enroll 75% of uninsured, non-Medicaid eligible children with family income below 235% of the federal poverty level. Measure: Percent of eligible children enrolled.

Objective 2: Increase the percentage of low-income children with a regular source of care.

Performance goals: 2.1 Over time, decrease the percent of children matched to a PCP through auto assignment. Measure: Percent of children who selected PCP on enrollment.

2.2 Encourage use of PCP through health plan policies and education. Measure: Percent of enrolled children who seek care from their assigned PCP.

2.3 Maximize the number of enrollees who stay with their PCP for 12 months. Measure: Percent of enrollees who stay with their PCP at least one year.

Objective 3: Promote utilization of Health Check (EPSDT) services to achieve

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State: Georgia Section: 9.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 targets set by the Centers for Medicare and Medicaid Services and GF. These are 80% for screening and 90% for immunizations.

Performance goals: 3.1 Assess how many children receive recommended well visits and screenings. Measure: Percent of enrolled children receiving each screening on or about the recommended schedule.

3.2 Assess how many children receive immunizations. Measure: Percent of enrolled children receiving each immunization on or about the recommended schedule.

Objective 4: Decrease unnecessary use of emergency departments for non- emergency services. A non-emergency service is one that does not meet the prudent layperson definition of emergency.

Performance goals: 4.1 Reduce the number of ED visits for non-emergency services. Measure: Rate of non-emergency ED visits per year for the population enrolled.

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State: Georgia Section: 9.9 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Initial Public Involvement

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State: Georgia Section: 9.9 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 problems. The providers were selected by the Healthcare Providers Council and included representation from hospitals, physicians, nursing, dentistry, nursing homes, home health, pharmacy, public health, community health and others. County Commissioners as well as members of the legislature were also invited to attend. Overall, 443 consumers and advocates and 234 providers participated for a total of 677 statewide participants. The meetings were open to the public and at every Dialogue there were observers who did not participate in the discussions yet had the advantage of moving among groups and hearing all four conversations.

Citizens

The citizens, both Medicaid members and members of the general public, expressed a wide variety of views, but agreed on a few basic themes.

• Vulnerable people should be protected. Citizens generally believe in the concept of a health care safety net and are willing to pay taxes to provide health care to people who need help.

• Only truly needy individuals should qualify for Medicaid. Citizens want to make sure that eligibility is strictly defined and enforced to stop abuse.

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State: Georgia Section: 9.9 Page: 3

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Medicaid Members

In the community dialogues, Medicaid members generally shared the opinions of the general population, as described above, but also expressed some specific concerns.

• Medicaid costs should not be cut by reducing eligibility, since not enough truly needy people are covered today.

• There should be no stigma attached to receiving Medicaid, and any managed care plans used in the program should serve both Medicaid members and non- Medicaid patients.

• Prevention and education should be integral components of any benefits package.

Providers

• Providers who have traditionally served the Medicaid population with demonstrated quality should be included in a managed care or any other delivery system.

(ga-cspa-15)(final-approved-state-plan)(page-93)Page 93#

State: Georgia Section: 9.9 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 About six months after this public input process was completed, the Georgia Coalition for Health Board, concerned about the effects of Medicaid reform on uninsured children, asked the Health Policy Center to study mechanisms for providing coverage to this target population. In response to this charge, the Policy Center applied for (and was subsequently awarded) a Robert Wood Johnson Foundation grant to replicate the Florida Healthy Kids program. The Coalition also allocated funding to the Center to conduct preliminary planning activities so that Georgia could position itself for implementing the Healthy Kids program as well as the impending federal children’s health insurance legislation.

(ga-cspa-15)(final-approved-state-plan)(page-94)Page 94#

State: Georgia Section: 9.9 Page: 5

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 • Georgia Association for Primary Health Care • Georgia Chapter/American Academy of Pediatrics • Georgia Dental Association • Georgia Partnership for Caring • Georgia Policy Council for Children and Families • Georgians for Children • Governor’s Office of Planning and Budget • Healthy Mothers, Healthy Babies Coalition of Georgia • March of Dimes • Office of the Commissioner of Insurance • Tanner Medical Center • The Family Connection • United Healthcare • Wachovia Bank of Georgia Compensation and Benefits Branch • West Georgia Medical Center

Public Notice

Ongoing Public Involvement

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State: Georgia Section: 9.9 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 the Appropriations Committee to learn as much as possible about the complexities of the budget item known as Medicaid.

Georgia Families

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State: Georgia Section: 9.9 Page: 7

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 In October 2003, a diverse team of stakeholders, including senior executives from healthcare provider organizations and advocacy groups, assembled for several days to discuss state strategies to promote quality healthcare, enhanced access, shared member and provider responsibility, improved efficiency, and better cost management.

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State: Georgia Section: 9.10 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 • The calculations for projecting the enrollment in the PeachCare for Georgia plan include the use of historical enrollment data and trending formulas within Excel.

Suspensions • October 2010 – September 2011 suspensions (Grace Period members) are projected based on similar suspension activity in 2009-2010.

PMPM • We used $128.65 PMPM for October 2010 – June 2011 and used $132.25 PMPM for July – September 2011.

Premium Paid • This amount represents the average premium paid by PeachCare members.

Other • The cost driver for this budget request is the number of Grace Period members. This group of members impacts the funds required to keep them in the program and also impacts the amount of revenue DCH collects.

Calculations: $11,241,511 Total Benefit Cost Increase  Per month, two different sets of members need to be considered when calculating the impact of the expanded grace period. Each month starting with October 2010, the projected suspended members for that month should be included with an adjusted number from the prior month. The prior month adjusted number is added each month because the expansion of the grace period will now cover parts of two months.  Each month’s total of Grace Period First Month and Grace Period Second Month is multiplied by the PMPM for the federal fiscal year in which the month falls. The sum of all the PMPM calculations for October 2010-Septmber 2011 totals $11,251,511.

Decrease in Offsetting beneficiary cost sharing payments by $907,882  As detailed above, the same monthly total of Grace Period First Month and Grace Period Second Month are multiplied by $10.45 which represents the average premium payment made by PeachCare members. This calculation shows the loss or revenues from the grace period members.  The sum of the each FFY 2011 months’ Grace Period Total multiplied by the premium rate equals the $907,882.

(ga-cspa-15)(final-approved-state-plan)(page-106)Page 106#

State: Georgia Section: 12.1 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 12. Applicant and enrollee protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Upon denial of eligibility, a parent will be notified by mail of the reason for the denial and the process to notify PeachCare for Kids if the parent believes the denial is in error. Parents will first be directed to call the toll-free number and report additional information or clarify information on the applicant’s account. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the request will be directed to a senior supervisor and/or the account manager of the TPA. The management level will review if the determination made by the TPA system and supported by the staff is correct based on state and federal policy. If the supervisory level does not overturn the denial, the parent will once again be informed of the decision. If the parent continues to dispute the denial, the supervisory staff will inform the parent that they may submit a request in writing to the PeachCare for Kids, to be reviewed by state-level PeachCare for Kids staff.

(ga-cspa-15)(final-approved-state-plan)(page-108)Page 108#

State: Georgia Section: 12.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

(ga-cspa-15)(final-approved-state-plan)(page-113)Page 113#

PUBLIC NOTICE

• Any new applications received or postmarked after March 11, 2007 will not be processed for PeachCare eligibility.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will also be affected by this change and will be precluded from re-enrollment. These members will receive additional notice by direct mail as required by governing regulations.

• Members enrolled and/or determined eligible prior to March 11, 2007 will not be impacted by this particular proposed change.

This change serves as an effort to sustain the PeachCare for Kids Program so that low- income children currently enrolled in the program may continue to receive low-cost health insurance.

NOTICE IS HEREBY GIVEN THIS 8TH DAY OF FEBRUARY, 2007 Rhonda M. Medows, M.D., Commissioner

(ga-cspa-15)(final-approved-state-plan)(page-114)Page 115#

To:

Parents/Guardians of PeachCare for Kids Members From: Commissioner Dr. Rhonda Medows, M.D. Date: February 20, 2007 Re:

PeachCare for Kids Enrollment Freeze

We continue to work with members of Congress, the members of our State Legislature and the Governor' office to resolve the funding needs of this very important program.

For additional information on the PeachCare for Kids program, please access http://www.dch.ga.gov.

If you have any questions or concerns, please feel free to call 1-877-GAPEACH (1-877- 427-3224)

Equal Opportunity Employer Rhonda M. Medows, MD, Commissioner

2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Sonny Perdue, Governor

(ga-cspa-15)(final-approved-state-plan)(page-116)Page 117#

Rhonda M. Medows, MD, Commissioner 2 Peachtree Street, NW Atlanta, GA 30303-3159 Sonny Perdue, Governor www.dch.georgia.gov

FOR IMMEDIATE RELEASE CONTACT:

February 8, 2007 Dena’ Brummer 404-463-5391

PeachCare for Kids Enrollment Closes to New Members

Children currently enrolled continue to receive care

(ga-cspa-18)(final-approved-state-plan)(page-10)Page 10#

State: Georgia Section: 2.2 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 with many elementary schools to be on site promoting PeachCare for Kids and Medicaid to the parents.

Division of Family and Children Services (DFCS)

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State: Georgia Section: 2.2 Page: 3

Effective Date: September 1, 1998

Covering Kids

Public Health Departments and Federally Qualified Health Centers

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State: Georgia Section: 2.2 Page: 4

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002

The Division of Public Health, through its local health departments, and the federally qualified health centers administer the Special Nutritional Program for Women, Infants and Children (WIC). This program provides nutritious food to supplement the regular diet of pregnant women, breast-feeding women, infants, and children under age five who meet state income standards. Generally, on the initial visit to either of these facilities, the pregnant woman is certified for Presumptive Medicaid eligibility, applies for regular Medicaid for herself and her children, and receives WIC for herself and any children under the age of five (5). The PeachCare for Kids® program also recognizes the WIC program as an Express Lane agency. Express Lane Eligibility- effective April 1, 2011 The PeachCare for Kids® program elects the option to rely on the income findings from the Special Nutritional Assistance Program for Women, Infants and Children (WIC) when determining whether a child is potentially eligible for PeachCare for Kids®. The WIC program is approved by the PeachCare for Kids® program as an Express Lane agency. The process provides a simplified eligibility determination process and expedited enrollment of eligible children in Medicaid and CHIP. PeachCare for Kids® agrees to meet all of the Federal statutory and regulatory requirements for this option. The Express Lane option is applied to initial determinations. WIC is limited to children under age 5 with a nutritional need and it is not limited to U.S. citizens. Identity information from the express lane agency will also be used to satisfy verification requirements for PeachCare for Kids® eligibility, but additional documents may be required for some applicants WIC applicants will be informed that with their permission, their demographic and income information will be forwarded to the PeachCare for Kids®/Medicaid agency for an eligibility determination.

• The data file from WIC to PSI contains o Data elements  WIC Certification date  Household demographics • Street address • City • Zip Code • County code • Telephone number • Family Size

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State: Georgia Section: 9.9 Page: 4

Effective Date: September 1, 1998

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State: Georgia Section: 9.9 Page: 5

Effective Date: September 1, 1998

Public Notice

Ongoing Public Involvement

(ga-cspa-18)(final-approved-state-plan)(page-102)Page 102#

State: Georgia Section: 9.9 Page: 6

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 the Appropriations Committee to learn as much as possible about the complexities of the budget item known as Medicaid.

Georgia Families

(ga-cspa-18)(final-approved-state-plan)(page-103)Page 103#

State: Georgia Section: 9.9 Page: 7

Effective Date: September 1, 1998

Express Lane Eligibility effective April 1, 2011- The Georgia Department of Community Health evaluated the feasibility of the options designed to facilitate enrollment and retention in the Medicaid and PeachCare for Kids® program and to receive bonus payments as outlined in the Children’s Health Insurance Program Reauthorization Act of 2009, section 203. Express Lane Eligibility was chosen as on of Georgia’s 5 of 8 efforts to enroll more eligible children in Medicaid and PeachCare for Kids® programs.

On December 6, 2010 Medicaid and CHIP (PeachCare for Kids ™) representatives met with the Public Health agency to discuss requirements for Express Lane Eligibility and to develop a plan for data file exchanges. A meeting was also scheduled with the TPA (Policy Studies, Inc.) for PeachCare for Kids® on January 12, 2010 & February 4, 2011. Additional meetings were held with these groups to discuss the implementation. WIC applicants will be informed that with their permission, their demographic and income information will be forwarded to the PeachCare for Kids®/Medicaid agency for an eligibility determination.

(ga-cspa-18)(final-approved-state-plan)(page-104)Page 104#

State: Georgia Section: 9.9 Page: 8

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

The following documents are enclosed in Attachment 2: • Public Notices • Letter to PeachCare Families • Message to Providers • DCH Press Release

(ga-cspa-18)(final-approved-state-plan)(page-114)Page 114#

State: Georgia Section: 12.1 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Section 12. Applicant and enrollee protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Upon denial of eligibility, a parent will be notified by mail of the reason for the denial and the process to notify PeachCare for Kids if the parent believes the denial is in error. Parents will first be directed to call the toll-free number and report additional information or clarify information on the applicant’s account. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the request will be directed to a senior supervisor and/or the account manager of the TPA. The management level will review if the determination made by the TPA system and supported by the staff is correct based on state and federal policy. If the supervisory level does not overturn the denial, the parent will once again be informed of the decision. If the parent continues to dispute the denial, the supervisory staff will inform the parent that they may submit a request in writing to the PeachCare for Kids, to be reviewed by state-level PeachCare for Kids staff.

(ga-cspa-18)(final-approved-state-plan)(page-115)Page 115#

State: Georgia Section: 12.1 Page: 2

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 parties adequate time to prepare documentation and schedule of the appeal, either in person or through written communication. The decision of the Formal Appeals Committee will be the final recourse available to the member. If at any level of dispute, the appropriate party determines the child is eligible for enrollment in PeachCare for Kids, the enrollment will become effective retroactive to the first day of the month in which the complete application, including any additional information affecting the outcome of PeachCare’s decision, is received.

Express Lane Eligibility- If a child is found eligible but subject to premiums, based on an income finding from an Express Lane agency, PeachCare for Kids® will provide notice that the child may qualify for lower premiums when evaluated using the State’s regular eligibility determination procedures, and they will receive information concerning how to request an evaluation. However, children enrolled in the WIC program are under age 5 and as of February 2011, no premium is required for PeachCare for Kids® enrollees below the age of 6 years old. Both PeachCare for Kids® and Medicaid Children are enrolled in the same Care Management organizations. They have the same benefit package. The benefits are the same (including EPSDT) unless there is a level of disability that would require the child to be in FFS Medicaid.

If a child is denied eligibility after being reviewed using the express lane process, the parent/guardian will be notified by mail of the reason for the denial and the process to request that the case be reviewed using PeachCare for Kids®’ normal eligibility determination process. Parents will first be directed to call the toll-free number to report additional information or clarify information on the applicant’s account.

The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not

(ga-cspa-18)(final-approved-state-plan)(page-117)Page 117#

State: Georgia Section: 12.2 Page: 1

Effective Date: September 1, 1998

Approval Date: September 3, 1998 Revision Effective Date: August 1, 2002 Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

(ga-13-0016-mc1)(approval-package)Georgia CHIP SPA GA-13-0016-MC1: Approval Package (approved May 20, 2015, effective January 1, 2014)#

(ga-13-0016-mc1)(approval-package)Georgia CHIP SPA GA-13-0016-MC1: Approval Package (approved May 20, 2015, effective January 1, 2014)#

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(ga-13-0017-mc3)(approval-package)Georgia CHIP SPA GA-13-0017-MC3: Approval Package (approved February 6, 2014, effective January 1, 2014)#

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(ga-13-0018-mc4)(approval-package)Georgia CHIP SPA GA-13-0018-MC4: Approval Package (approved February 21, 2014, effective October 1, 2013)#

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(ga-13-0019-mc5)(approval-package)Georgia CHIP SPA GA-13-0019-MC5: Approval Package (approved February 6, 2014, effective January 1, 2014)#

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(ga-13-0025-mc2)(approval-package)Georgia CHIP SPA GA-13-0025-MC2: Approval Package (approved February 25, 2014, effective January 1, 2014)#

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(ga-15-0021)(approval-package)Georgia CHIP SPA GA-15-0021: Approval Package (approved February 3, 2016, effective April 1, 2016)#

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