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Presentation to: Voices for Georgia’s Children

Presented by: Janice Carson, MD

Assistant Chief

Division of Medical Assistance Plans

Date: 8/26/15

‘Check-Up’ on Medicaid and PeachCareSuccesses and Opportunities for Children

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MissionThe Georgia Department of Community Health

We will provide Georgians with access to affordable, quality health care through

effective planning, purchasing and oversight.

We are dedicated to A Healthy Georgia.

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Overview

Medicaid and CHIP Services for Children – the EPSDT Benefit

Measuring Service Delivery and Quality - CFR Requirements and Performance Reporting

Performance Improvement ActivitiesQuestions

OverviewOur Members – Enrollment and DemographicsFederal Requirements

The Code of Federal Regulations (CFR) The Early and Periodic Screening, Diagnostic and

Treatment (EPSDT) BenefitEPSDT and Bright FuturesSuccesses and OpportunitiesQuestions

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Our Members – Ages 0 - 20

Medicaid FFS, 60,331

Georgia Families, 1,154,859

PCK, 135,394

GF 360, 27,511

The membership as of August 1, 2015

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Our Members

0 100000 200000 300000 400000 500000 600000 700000 800000 900000

FFS

GF

PCK

GF 360

FFS GF PCK GF 360Unknown 15276 9 0 5607Rural 3241 363266 40974 2010Urban 41814 791584 94420 19894

Urban vs Rural

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Our Members

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Our Members

FFS Georgia Families

PCK GF 360

Male 38,934 574,808 69,408 14,358

Female 21,392 580,050 65,986 13,153

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Federal Requirements - The CFR A Roadmap for Medicaid Managed Care

Subpart D

Subpart E

Subpart F

Subpart B Subpart C

Subpart A

Managed Care Guidance Route42CFR438

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CFR – CITE: 42CFR438 Subparts

• Subpart A – General Provisions – Rules that managed care organizations and the contracts between the State and the CMOs must meet

• Subpart B – State Responsibilities – Choice of CMOs, disenrollment, etc.

• Subpart C – Enrollee Rights and Protections• Subpart D – Quality Assessment Performance Improvement• Subpart E – External Quality Review• Subpart F – Grievance System• Also Subparts H, I, J and recent NPRM

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The CFR Requirements

• Quality Assessment and Performance Improvement (QAPI) Program for Medicaid Managed Care42CFR438 Subpart D–Requires states to develop a quality assessment and performance improvement (QAPI) strategy to assess and improve the quality of managed care services; –Initial strategy, any significant revisions and regular reports about the implementation and effectiveness of the strategy submitted to CMS.

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The CFR Requirements

• QAPI Program must:– Have procedures that:

• assess quality and appropriateness of care• regularly monitor and evaluate compliance w/standards

– Include:• national performance measures developed by CMS – Child Core

Set of Measures (24 child and maternity-related measures)• provisions for an annual external independent quality review of

quality outcomes, timeliness of and access to services

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Federal EPSDT Benefit

• Available for all Medicaid-eligible children birth to twenty-one (21) years of age

• Available for all eligible PeachCare for Kids®

members, Georgia’s standalone CHIP program, from birth to nineteen (19) years of age. Majority of all Georgia Medicaid

members and the CHIP members are under age 21.

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EPSDT Benefit

• Section 1905(r) of the Social Security Act states the Georgia’s EPSDT Benefit must make available:

– Screening Services -- Screening services must include all of the following services:

– Comprehensive health and developmental history -- (including assessment of both physical and mental health development);

– Comprehensive unclothed physical exam -- (unclothed means to the extent necessary to conduct a full, age-appropriate examination);

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EPDST Benefit

– Appropriate immunizations based on ACIP guidelines. Vaccines available for Medicaid members via Vaccines for Children (VFC) program

– Appropriate Laboratory Tests – Lead Toxicity Screening – Health Education – including anticipatory guidance. Health

Education should assist with understanding what to expect relative to the child's development and provide information about the benefits of healthy lifestyles and practices, vaccine preventable diseases, as well as accident and disease prevention;

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EPSDT Benefit• Vision Services -- Including diagnosis and treatment for defects in

vision; and eyeglasses. Vision services must be provided according to the periodicity schedule and at other intervals as medically necessary;

• Dental Services – Including relief of pain and infections, restoration of teeth and maintenance of dental health. Services are provided in accordance with the AAPD dental periodicity schedule.

• Hearing Services – including diagnosis and treatment of hearing problems

• Other Necessary Health Care to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services.

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CFR, EPSDT and Bright Futures

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2014 Bright Futures Schedule

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EPSDT, BF and Continuous Improvement

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Measuring Successes and Opportunities

• CMS Child Core Set, the CMS 416 report, etc. used to track performance.

• Child Core Set focus areas include: – Perinatal Period: Timeliness of Prenatal Care; Maternity Behavioral Health Risk

Assessment; Ongoing Prenatal Care; LBW– Infancy, Childhood and Adolescence: Access to Primary Care, Well-Child Visits

for Infants, Children and Adolescents; Lead Screening, Immunizations; HPV Vaccine Use; Weight Assessment and Counseling for Nutrition and Physical Activity; Developmental Screening; Preventive Dental Services; Testing for Pharyngitis; Treatment for URIs; Follow-Up for ADHD

• GF 360 Data – Members enrolled on March 3, 2014 – baseline performance year for the program.

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Successes and Opportunities – GF and GF 360

Successes• Prenatal Visit within 1st

trimester or 42 days of enrollment – 79% - 82%

Opportunities• Ongoing prenatal visits 81% or

greater expected – 48% - 58%• BH Risk Assessments at first

visit for Pregnant Women (depression, alcohol, tobacco use, drug use, intimate partner violence) – 0% - 10%; GF 360 = 3.6%

• LBW rate – 8.9% - 9.2%• GF 360 Prenatal Visit within 1st

trimester = 47%

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Successes and Opportunities – GF and GF 360

Successes• Access to PCP for 12 – 24 mos > 97%;

GF 360 = 96%• Access to PCP for 25 mos – 6 yrs = 90%

- 91%; GF 360 = 86%• GF Access to PCP for 12 – 19 yrs = 89%

- 91%; GF 360 = 79%• Childhood Imm by age 2 = 79% - 84%• Lead Screening – 78% - 81%

Opportunities• Well Child Visits – six or more in first 15

mos = 65% - 67%; GF 360 = 43%• Annual WCV for 3 - 6 yrs = 67% - 74%;

GF 360 = 70%• Annual Adolescent WCVs for 12 – 21 yrs

= 49% - 53%; GF 360 = 46%• BMI – 54% - 69%; Counseling for nutrition

– 59% - 65%; Counseling for physical activity – 53% - 60%; GF 360 = 39%, 35%, 32%

• GF 360 Childhood Imm by age 2 = 45%• GF 360 Lead Screening = 64%

Blue measures linked to EPSDT and Bright Futures

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Successes and Opportunities – GF and GF 360

Successes• Adolescent Immunizations

(Mening & Td) – 76% - 80%• Appropriate Testing for

Pharyngitis – 79% - 81%• Annual Dental Visits – 67% -

69%; GF 360 = 75%

Opportunities• HPV Vaccine (3 doses by age

13) – 20% - 25%• 30 d Follow up Care for ADHD

(6 – 12 yo) – 44% - 49%; 9 mo Follow Up – 58% - 64%

• Appropriate treatment for children with URI – 83% - 86%

• Developmental screening – 38% - 46%; GF 360 = 24%

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Continuous Improvement

• Child-focused Performance Improvement Projects in place with the CMOs that focus on improvements in preventive service utilization, dental service utilization, ADHD follow up, and postpartum visits to reduce LBW rates.

• DCH and our partners are working collaboratively to improve the health outcomes for our members.

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Questions

Contact Information:

Janice Carson, MDAssistant ChiefGeorgia Department of Community HealthDivision of Medical Assistance Plansjcarson@dch.ga.gov404-463-2832