Require all CMO to offer the same services, fees,
providers and authorizations policies for all children services -
In 1997, the U.S. Congress created the state
based Children's Health Insurance Program (SCHIP) to expand coverage
to children of low income, Medicaid ineligible, families. The SCHIP
Program is funded by both the Federal and State governments and is
administered at the state level. The federal government provides
only broad guidelines for implementation, allowing states to design
programs that best fit their needs.
Currently, in the state of Georgia,
there is a convolution of child health management providers
(Medicaid managed care, Medicaid fee for service, state-funded
services, and Georgia’s SCHIP program Peachcare for Kids). A child’s
access to the state health care system is contingent and determined
by eligibility to the designated funding category. Additionally,
and depending on the child’s medical needs, care may be distributed
to one or a host of different management providers.
Medicaid managed care and Peachcare
for Kids contracts through the following care management
organizations: Amerigroup Community Care, Peach State Health Plan,
Simpatico, and Wellcare. These CMOs contracts are renegotiated and
update yearly.
The problem is that the funding
mechanism follows the child’s designated category, not the child.
When a child moves from home care to
foster care or from a residential provider to permanent guardianship
or from one managed care organization to another, the services,
level of care, and provider change even though the child’s medical
needs have remained the same. Navigating the multiple
category/multiple payor system is confusing to the parent and
cumbersome to the provider. Often, this disruption in care has
financial ramifications to the state, as well interruptions and lack
continuity in care can have serious health consequences to the
child. The network of providers has grown significantly;
unfortunately the provider base is not universal among the various
care management organizations. In addition, payors of service share
uncommon institutional procedures and have little authorization
criteria overlap. This means that children with similar needs, when
services are provided by different payors often receive varying
levels of treatment.
“To ensure continuity of care for
children. . . . Georgia should establish a single [community and
family based] benefit package that allows for children to receive
the same service options from the same providers regardless of which
state agency provides or funds the service” (Georgia Mental Health
Service Delivery Commission, 2008).
We propose that Georgia should adjust
and renegotiate existing contractual standards and create a uniform
set of procedures and services with the existing CMOs. In addition,
Georgia should implement added and more acute fiscal discloser for
payors of service.
Development of an Integrated Care Model for all
Children and Family Services -
Georgia has toyed with a multi-systemic approach to care for
children that touches several systems within Georgia. It is not
unusual, and probably likely, that a child who comes into either the
Juvenile Justice system or the Child Protective Service system will
be touched by several systems. For example, the likelihood is
strong that the child who enters Georgia's Juvenile Justice system
will have a mental health diagnosis--we know from Georgia's own
research that more than 65% of these children have a diagnosable
mental health issue. These children will have their mental health
services delivered either through the Department of Community Health
or even through the school system and the Department of Education.
There will be a strong likelihood that this child will have
experience in the Department of Human Services as a victim of
neglect or abuse.
Each of these systems will touch this
child with some type of case management. This duplication of effort
costs money, increases the aggravation for the families involved,
decreases providers' ability to prevent "bad things from happening
to children," and is very ineffective.
Georgia has implemented through the
Governor's Office of Children and Families and through the
Department of Behavioral Health and Developmental Disabilities
pilots for the "Systems of Care" model philosophy. "Systems of Care"
is a family centered model that believes in collaboration from all
who touch children both within government and outside. Natural
supports are emphasized.
These pilots are local pilots. Real
traction for real reform will happen when "Systems of Care" can be
institutionalized in Georgia. For this to happen, an integrated
approach to the care of children will have to be coordinated through
the Governor's Office. Participation will have to be mandated.
Real outcomes will have to be tracked through some type of
integrated data system.
