Medicare/Medicaid News

Georgia Academy Comments to CMS on Proposed New Affordable Care Act Exchange                        

CMS has confirmed that Georgia’s Section 1332 state innovation waiver, which changes the Affordable Care Act exchange model, is complete. The waiver will now move into a public comment period.  As it currently stands, the state innovation waiver would shift Georgia’s individual health insurance marketplace from to its Georgia Access Model. It would also pursue a reinsurance program through tiered coinsurance.

The state expects the reinsurance program to stabilize the market, reducing premiums by over ten percent.   The proposal projected that the Georgia Access Model would increase individual health insurance market enrollment by 25,000 and, as a result, bring down premiums by 3.5 percent. The cost to fund this project would be $144 million for its starting year 2022.

The Georgia Academy sent comments to Governor Kemp when the proposal was first up for review, and again has submitted comments to CMS.  A summary of those comments is below:

While we appreciate that this proposal will not interrupt coverage with patients with pre-existing conditions, we are concerned about allowing non-ACA compliant plans into Georgia.  Furthermore, removing Georgia from the platform would penalize Georgians looking for a one-stop marketplace to compare and select insurance plans, forcing them to rely on scattershot network of web-brokers and other actors that may take into account Georgians’ financial or health needs. Under this arrangement, Georgia would be the only state nationwide to remove itself from this marketplace.

The current proposal to allow Georgians to buy extended, short-term health insurance (non-ACA compliant) is a step back to the days when companies sold low-value insurance policies that subjected our patients to catastrophic medical bills and medical bankruptcy.

The current proposal would allow exempt these non-compliant plans from Affordable Care Act consumer protections such as covering essential benefits, which include prescriptions, laboratory tests, hospitalization, and maternity care. It would allow plans to establish caps once again on annual benefits. Limiting benefits can expose patients to extraordinarily high out-of-pocket costs, particularly for people who have chronic or life-threatening conditions that require costly treatment, close monitoring and ongoing medication.

Equally troublesome, these plans further destabilize the individual market by drawing young, healthy people away from meaningful, comprehensive coverage that meets ACA standards. Allowing the healthy to gamble with low-quality insurance will also raise ACA-compliant plans’ premiums, putting better coverage beyond the reach of millions of the sickest Americans.

The Georgia Academy has stood with the American Academy of Family Physicians in steadfastly calling for policies that ensure all Americans have access to affordable, meaningful health insurance. Georgia policies should support patient-centered insurance reforms that prohibit insurers from selling plans that fail to provide meaningful coverage.

Any plan allowed to be sold to Georgians in our state should have these minimum essential health benefits:


At a minimum, these would include items and services in the following benefit categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

In addition to requiring coverage for essential health benefits, all proposals or options will ensure that primary care is provided through the patient’s primary care medical home. To foster a longitudinal relationship with a primary care physician, all proposals or options will provide the following services independent of financial barriers (i.e., deductibles and co-pays) if the services are provided by the patient’s designated primary care physician:

  1. Evaluation & management services
    b.     Evidence-based preventive services
    c.      Population-based management
    d.     Well-childcare
    e.     Immunizations
    f.       Basic mental health care

The leadership will continue to monitor the progress of this CMS waiver and inform the membership when news develops.

AAFP and GAFP Respond: We Are Fighting for a Medicare Fee Schedule that Works for Family Physicians

AAFP and GAFP Respond:  We Are Fighting for a Medicare Fee Schedule that Works for Family Physicians

Both the American Academy and the Georgia Academy have submitted a response to CMS’ proposed 2019 extensive rule change for Medicare payment.  The AAFP emphasized four points to CMS in its response to the proposed 2019 Medicare physician fee schedule: pay family physicians properly and slash their administrative burden, APMs are the best way to support family medicine, family physicians must be free to give patients the best care, and solo and small practices need better support.  To read the entire 80-page response from the AAFP click here:

In its letter, the Georgia Academy said in part:

Re:      CMS’ E&M Proposal Will Disproportionately Harm Small Practices

Support AAFP’s Proposed 15 Percent Increase for E&M Services by Primary Care Physicians

On behalf of the Georgia Academy of Family Physicians, I write in response to the proposed rule titled, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program” published by the Centers for Medicare & Medicaid Services (CMS) in the July 27, 2018, Federal Register.

The Georgia Academy commends your continued leadership and commitment to identifying and implementing policies that improve the Medicare program. We share your goals of reducing the administrative burden of modern medical practice and preserving independent physician practices. We support your stated goal of transforming the Medicare program into one that prioritizes the delivery of high-quality, patient-centered, comprehensive and efficient care.

We respectfully offer commentary on three high-level items for your consideration. The three items are:

  1. Priority Proposals in the 2019 Medicare Physician Fee Schedule
  2. Impact on Medicare Beneficiaries
  3. Impact on Solo and Small Physician Practices

To read the entire letter click here:

The AAFP and the GAFP will push out information to our members as soon as a final decision by CMS has been reached.  Also, the renowned coding expert, Steve Adams, will spend four hours (CME credit) at our Annual Meeting on Friday, November 9th breaking down the 2019 Medicare payment changes.  Sign up now to attend the annual meeting (and bring your practice administrator).  Click here to see more information and register for the meeting

CMS Study on Burdens Associated with Reporting Quality Measures

The Centers for Medicare & Medicaid Services (CMS) is conducting the 2018 Burdens Associated with Reporting Quality Measures Study, as outlined in the Quality Payment Program Year 2 final rule (CMS 5522- FC). Chapters may wish to share this information with members.

Clinicians and groups who are eligible for the Merit-based Incentive Payment System (MIPS) that participate successfully in the study will receive full credit for the 2018 MIPS Improvement Activities performance category. Applications for this study will be accepted through March 23, 2018 and will be notified in spring of 2018 if selected.

The study runs from April 2018 to March 2019. Study participants will have to meet the following requirements in order to complete the study and receive full Improvement Activity credit. For participants reporting as a group, their entire group will receive credit. For participants reporting as individuals, only the participating clinician will receive credit.

  • Complete a 2017 MIPS participation survey in April/May 2018.
  • Complete a 2018 MIPS planning survey in September/October 2018.
  • The Study team will invite selected participants to join a virtual 90-minute focus group between November 2018 and February 2019.
  • Meet minimum requirements for the MIPS Quality performance category by submitting data for at least three measures in the MIPS Quality performance category, as required for 2018 MIPS participation. The data submitted must:
  • Include one outcome measure;
  • Be submitted to CMS by the final MIPS reporting deadline (March 31, 2019);
  • Be submitted through any method accepted under MIPS for year 2 of the Quality Payment Program (2018).

For more information about the study or to apply(, please visit the CMS website( or email

Save the Date: Georgia Medicaid Fair

Dear Georgia Medicaid Providers and Stakeholders:

The Department of Community Health (DCH) and DXC Technology encourage you to save the following date for our next Medicaid Fair!

Wednesday, April 25, 2018
UGA Tifton Campus Conference Center

15 RDC Road

Tifton, Georgia 31794

The Medicaid Fair will open with important updates on emergent issues by DCH Leadership and over a dozen break-out sessions will cover a variety of topics. The Care Management Organizations will be onsite to answer your questions about their new contracts that are effective July 1, 2018. DCH and DXC Technology are also bringing back several 30-minute break-out sessions so you can get as much out of your Medicaid Fair day as possible. Please stay tuned for additional details registration information which will be posted soon.

Do you want to help shape our agenda?

To ensure that our planned break-out sessions (including time for questions and answers) address relevant topics for you, please submit your suggested breakout topics to no later than Wednesday, February 28, 2018. Based on your feedback the agenda will be developed and posted.

Do you need more information about UGA Tifton Campus Conference Center?

For location and directions to the Medicaid Fair, please visit the UGA Tifton Conference Center website at:

Thank you for your continued participation in the Georgia Medicaid program.

We look forward to seeing you on, Wednesday, April 25, 2018 in Tifton!


Georgia Department of Community Health

DXC Technology

Medicaid Changes – Effective July 1 – Check Patient’s Insurance

Dear Providers:

Beginning July 1, 2017, the Georgia Families® program will provide Members a choice of four Care Management Organizations (CMOs): Amerigroup, CareSource, Peach State Health Plan, and WellCare. Georgia Families® Members were given the opportunity to select a CMO during the Open Enrollment process which took place during the month of March 2017. Some Members who did not make affirmative selections were auto-assigned to a CMO. During the choice change period of July 1, 2017 through September 30, 2017, all Members will have a one-time opportunity to change their assigned CMO without cause. The change will become effective on the first day of the month after the change is requested. In order to ensure a smooth transition and that all Members have access to care, each CMO has implemented Transition of Care processes which include the following:

Existing/Open Prior Authorizations:

If you are rendering services to a Member who has a newly assigned CMO effective July 1, 2017, the newly assigned CMO will honor any current/open Prior Authorizations for forty-five (45) days beginning on July 1, 2017 through August 14, 2017. This applies to in-network and out-of-network (non-par) Providers. Thus, if you are rendering services to a Member who has a newly-assigned CMO, and you are not contracted with the newly-assigned CMO, the newly-assigned CMO will honor any current/open Prior Authorizations for forty-five (45) days beginning on July I, 2017 through August 14, 2017. If the Member requires services beyond August 14, 2017, Providers must contact the Member’s new CMO to obtain authorization to continue services. Providers will be required to follow the new CMO’s prior authorization process for any continued services the Member needs.

New Requests for Prior Authorization (i.e., requests submitted on or after July 1, 2017):

Providers will be required to submit new requests for Prior Authorization based upon the applicable CMO’s guidelines. This applies to in-network and out-of-network (non-par) Providers. Prior authorization decisions for non-urgent services will be made within three (3) business days. Expedited service authorization decisions will be made within twenty-four (24) hours.

Pharmacy-Related Prior Authorizations:

Each CMO will honor prescriptions ordered/issued prior to July 1, 2017. All current prescriptions (including medication step therapy) will be transitioned and honored by the new CMO for a period of forty-five (45) days, beginning on July 1, 2017 and ending on August 14, 2017. This is part of the Transition of Care process. Claims Reimbursement for Office Visits and Sick Visits for Out-of-Network Providers (Non-Par)


If you are rendering services to a Member who has a newly-assigned CMO effective July 1, 2017, and you are an out-of-network Provider, you may submit claims for reimbursement for office-based and sick visits rendered to Georgia Families® Members and Planning for Healthy Babies® enrollees without an authorization. Claims may be submitted to Amerigroup, CareSource, Peach State Health Plan, and WellCare by out-of-network Providers for services provided from July 1, 2017 through August 14, 2017. In all instances timely filing requirements must be met.

Please Note: Effective Friday, June 23, 2017, Providers will be able to submit CareSource PAs via the Centralized PA Portal. All PAs associated with the Centralized PA Portal will be processed for CareSource members beginning on July 1, 2017.

The following forms are currently associated with the Centralized PA Portal:
• Newborn Delivery Notification
• Pregnancy Notification
• Inpatient Hospital Admissions and Outpatient Procedures
• Hospital Outpatient Therapy
• Durable Medical Equipment
• Children ‘s Intervention Services
• Outpatient Behavioral Health

For any other CareSource PA submissions, please refer to https:/, call 1-855-202-1058, or email



Department of Community Health

View Georgia Families® Frequently Asked Questions & Answers