Tim Burgess, Commissioner 
 
Sonny Perdue, Governor 
 
2 Peachtree Street, NW Atlanta, GA 30303-3159 www.communityhealth.state.ga.us 
 
PeachCare Premium Payments 
 
Background Information The PeachCare for Kids program cost-shares with enrollees by requiring monthly premium payments. Premiums are required for all children age 6 and above. Georgia is similar to all other states in using its premium income to offset program costs. 
 
These are the current monthly premium payment guidelines established by the State of Georgia:  $10 per child  Federal Poverty Level 0%  150% maximum family contribution is $15  Federal Poverty Level above 150% maximum family contribution is $20 
 
Based on federal guidelines, the PeachCare for Kids program is currently not charging the maximum amount allowed for premium payments. The current federal premium payment guidelines are: 
 Federal Poverty Level 0% - 150%: $19 per month per family for 1  2 enrollees $16 per month per family for 3  4 enrollees $15 per month per family for 5 or more enrollees 
 Federal Poverty Level above 150% maximum family contribution is 5% of income 
 
The following chart shows how much has been received in revenue from premium payments. 
 
SFY 2001 
 
SFY 2002 
 
SFY 2003 
 
Premium Revenue 
 
$5,636,371 
 
$8,015,333 
 
$9,492,998 
 
Governor's Recommendation The Governor's Recommendation includes the implementation of a sliding scale premium policy. Under this proposed policy, a family's premium payment would be based on family income, the number of children in the family, and the federal poverty level (see chart below). 
 
Federal Poverty Level 
 
Proposed Sliding Scale Monthly Premiums* 
 
Number of children impacted* 
 
Annual income for a family of 3 
 
1 child 
 
100  150% 
 
89,903 
 
$15,260 - $22,890 $10.00 
 
>150  160% 
 
13,278 
 
>$22,890 - $24,416 $20.00 
 
>160  170% 
 
12,492 
 
>$24,416 - $25,942 $22.50 
 
>170  180% 
 
9,316 
 
>$25,942 - $27,468 $25.00 
 
>180  190% 
 
8,011 
 
>$27,468 - $28,994 $27.50 
 
>190  200% 
 
6,418 
 
>$28,994 - $30,520 $30.00 
 
>200  210% 
 
5,017 
 
>$30,520 - $32,046 $37.50 
 
>210  220% 
 
2,795 
 
>$32,046 - $33,572 $40.00 
 
>220  230% 
 
3,808 
 
>$33,572 - $35,098 $42.50 
 
>230  235% 
 
828 
 
>$35,098 - $35,861 $45.00 
 
*Premiums are required for all children age 6 and above Page 1 of 2 
 
2 or more children 
$15.00 $40.00 $45.00 $50.00 $55.00 $60.00 $75.00 $80.00 $85.00 $90.00 
 
Equal Opportunity Employer 
 
 Newborns One of the proposed policy changes for the PeachCare program is to eliminate coverage for the month of application. The Department is currently considering making newborns an exception to this policy change, so that newborns will have medical coverage at the time of birth. The mother would be able to pre-apply for coverage based on the expected delivery date or apply for coverage before being discharged from the hospital. The PeachCare program would then pay for all hospital costs related to the newborn except for the delivery (the mother would be responsible for the delivery charges). 
Current Premium Payment Guidelines Under the current premium payment guidelines, an application for PeachCare coverage is considered complete when the premium payment and application have both been received. If the premium payment is received with the application, coverage will be effective the first day of the month of application. If the premium payment is not received with the application, the applicant has 45 days to submit payment in order for coverage to be effective the first day of the month of application. If the premium payment is received after 45 days, coverage will be effective the first day of the month in which the payment was received. The Department is not proposing changes to these guidelines. See scenarios below: 
 
Scenario 1  Timely Payment January 15th  Application is submitted without premium payment. January 16th  Letter is sent stating the premium payment is needed within the next 45 days for 
application to be considered complete. February 2nd  Premium payment is received. Child is enrolled effective January 1st. The 
premium payment received will be for March coverage. The state pays for the 
first two months of coverage (January and February) of a new eligible per family. 
 
Scenario 2  Payment after 45 days January 15th  Application is submitted without premium payment. January 16th  Letter is sent stating the premium payment is needed within the next 45 days 
for application to be considered complete. March 10th  Premium payment is received. Child is enrolled effective March 1st. The 
premium payment received will be for May coverage. The state pays for the first two months of coverage (March and April) of a new eligible per family. The state will not pay for January or February coverage. 
PeachCare Coverage Reinstatement If a parent misses a premium payment, a payment reminder will be sent. If the premium payment is not received by the specified deadline, the child's coverage will be cancelled. The parent will have to call and request their child be reinstated. The parent must submit payment within the next 45 days for coverage to be effective. Coverage can only be reinstated for the current month; a parent cannot request reinstatement for more than one month of missed payments. 
 
For additional information please contact: 
 
Carie Summers 
 
phone: (404) 657-4859 
 
Laura Jones 
 
phone: (404) 657-7196 
 
email: csummers@dch.state.ga.us email: ljones@dch.state.ga.us 
 
Page 2 of 2 
 
Equal Opportunity Employer 
 
 Department of Community Health FY2005 Budget Reductions 
Based on the Governor's Office of Planning and Budget review during September 2003, the Department was instructed to identify $140.8 million state funds reduction from the FY 2005 base appropriations. 
 
DCH Request FY 2005 
State Funds 
 
Governor's Recommendation 
FY 2005 State Funds 
 
Target Amount ($140,835,101) 
 
Recommended ($84,332,590) 
 
Reduce Price: 
 
Nursing Homes - Reduce Nursing Home cost as follows: 
 
RED #1 Change cost center standards and reduce incentives and add-ons in nursing home rate calculations 
 
(Total FY05=$46.7 million). 
 
TSB #3 Governor recommends to offset state fund cut to nursing home provider reimbursement with additional 
 
nursing home provider fee collected beginning 2/1/2004. 
 
RED #2 Reduce reimbursement for planned leave and bed hold days (Total FY05=$3.8 million). 
 
Hospice Services 
 
RED #3 Reflect adjustments to payments for nursing-home based hospice care (see #1) 
 
(Total FY05=$1.4 million). 
 
Outpatient Hospital 
 
RED #4 Move to a fixed fee reimbursement methodology for Ambulatory Surgical services provided in an outpatient 
 
hospital setting (effective date January 1, 2005) (Total FY05=$24.4 million). 
 
Physicians 
 
NR 
 
Reduce physician rates by reducing the percent of the 2000 RBRVS from the current 
 
84.5% to 82%. (Total FY05=$21.1 million). Governor did not recommend reducing physician rates. 
 
Pharmacy - Reduce cost as follows: 
 
RED #5 Implement a supplemental drug rebate program for all drug classes including classes for mental health drugs 
 
(Total FY05=$24.3 million). 
 
RED $6 Increase the Average Wholesale Price (AWP) discount from 10% to 14%. 
 
(Total FY05=$12 million). Governor's Recommendation reflects increasing AWP discount from 10% to 12% 
 
(Gov. Total $6 million). 
 
RED #7 Eliminate the incentive for dispensing generic drugs 
 
(Total FY05=$5 million). Governor's recommendation - Eliminate the incentive for dispensing generic drugs, 
 
except in situations where the pharmacist, via consultation with the prescribing physician, converts a written 
 
prescription from a brand to a generic status. 
 
Require additional cost-sharing by Medicaid members: 
 
RED #8 Require premiums for the Katie Beckett Waiver Program using a sliding scale based on income 
 
(Total FY05=$3.8 million) 
 
RED #9 Implement Estate Recovery to offset cost of Nursing Home care 
 
(Total FY05 = $3.0 million) 
 
RED #10 Reflect savings for implementing patient liability collections for Hospice recipients in nursing homes 
 
(effective date July 1, 2003) (Total FY05=$5.6 million) 
 
RED #11 Governor's Recommendation - Require non-custodial parents with access to health insurance to 
 
provide coverage for their children currently insured by Medicaid (Total funds $7.3 million). 
 
RED #12 Governor's Recommendation - To implement a premium payment structure based on income for 
 
members covered by PeachCare (Total funds - $38.1 million) 
 
SUBTOTAL - PRICE 
 
(18,587,535) 0 
(1,502,826) (570,271) 
(9,500,000) 
(8,259,249) 
(9,310,408) (4,692,973) 
(1,963,416) 
(1,506,185) (1,193,250) (2,245,222) 
0 0 (59,331,335) 
 
Reduce Utilization: ADJ #8 Implement a targeted case management program for high users of emergency room services (effective date January 1, 2004). ADJ #9 Use existing SOURCE sites to provide disease and case management to selected members with the highest Medicaid costs (effective date January 1, 2004). RED #14 Children's Intervention Services - Require medical necessity for the provision of therapy services utilizing a prior approval program (Total FY05 = $3.5 million). RED #13 Home Health - reduce coverage of in-home therapy visits from 75 to 50 per calendar year (effective January 1, 2004) (Total FY05=$1.5 million). SUBTOTAL - UTILIZATION 
 
Yes Yes (1,401,647) (600,101) (2,001,748) 
 
Limit Scope of Services: 
 
Eliminate Optional Services in Medicaid and PeachCare 
 
RED #15 Adult Dental Program (Total FY05=$14.3 million) 
 
NR 
 
Psychology (Total FY05=$21.2 million). Governor did not recommend. 
 
RED #16 Orthotics and Prosthetics for adults (Total FY05=$8 million) 
 
NR 
 
Podiatry (Total FY05=$3 million) Governor did not recommend. 
 
Eliminate PeachCare Services 
 
NR 
 
Dental Program (Total FY05=$64 million) Governor did not recommend. 
 
NR 
 
Vision Care (Total FY05=$3.6 million) Governor did not recommend. 
 
SUBTOTAL - SCOPE 
 
(5,681,030) (7,946,745) (3,206,109) (1,185,482) 
(17,784,833) (989,892) 
(36,967,075) 
 
Eligibility Reductions 
 
RED #17 Eliminate coverage for Medicaid members whose incomes exceed 185% of the federal 
 
poverty level. (Total FY05=$44.4 million) 
 
RED #18 Eliminate coverage for the Medically Needy in nursing homes. 
 
(Total FY05=$24.5 million) 
 
NR 
 
Eliminate coverage for PeachCare members whose incomes exceed 200% of the federal poverty level and 
 
implement administrative policy changes (Total FY 05=$50.8 million). Governor did not recommend. 
 
SUBTOTAL - ELIGIBILITY 
 
(17,675,912) (9,743,453) 
(14,119,186) (42,938,553) 
 
Administration Reductions/Adjustments TSA #19 To reduce various operating expenses in Health Care Regulation and Licensing Program TSA #20 To reduce various operating expenses in Health Care Access and Improvement Program TSA #21 To eliminate 3 positions in the Health Care Regulation and Licensing - Certificate of Need (CON) Program TSA #23 To eliminate the Health Care Workforce Policy Advisory Committee Program including 1 position. SUBTOTAL - ADMINISTRATION 
 
(15,026) 0 0 0 
(15,026) 
 
Total FY 2005 Reductions 
 
(141,238,708) 
 
Numbers include Medicaid and PeachCare RED = Reductions attached ADJ = Adjustments attached TSA = Tracking Shee Unit A TSB = Tracking Sheet Unit B 
 
(18,587,535) 16,852,640 (1,502,826) 
(570,271) 
(9,500,000) 
0 
(9,310,408) (2,346,487) 
(1,963,416) 
(1,506,185) (1,193,250) (2,245,222) (2,800,000) (10,609,078) (45,282,038) 
Yes Yes (1,401,648) (600,101) (2,001,749) 
(5,681,030) 0 
(3,206,108) 0 0 0 
(8,887,138) 
(17,675,912) (9,743,452) 0 
(27,419,364) 
(97,478) (121,283) (180,900) (342,640) (742,301) (84,332,590) 
 
 Department of Community Health Governor's Recommendations FY2004 Amended and FY2005 Budget Reductions Total Recommendation: $83.6 million state funds 
 
CY 2002 
 
SubProgram Average PMPM 
 
Children $ 
 
148.27 
 
Medically Fragile Children $ 
 
568.97 
 
Disabled Adults $ 
 
800.56 
 
Elderly $ 
 
907.66 
 
Adults $ 
 
366.81 
 
PeachCare for Kids $ 
 
100.52 
 
FY 05 Budget Impact by Provider Type 
 
DME/O&P 
 
Admin 1% 
 
Other 4% 
 
4% Physician 
4% 
 
Hospital 27% 
 
Dental 7% 
 
Nursing Home 15% 
 
Member Responsibility 
19% 
 
Pharmacy 19% 
 
FY 05 Budget Reductions by Cost Drivers 
 
Eligibility 33% 
 
Scope of Services 
11% 
 
Utilization 2% 
 
Price 54% 
 
FY 05 Budget Reductions by Subprogram 
 
PCK Children 15% 
 
Children 10% 
 
Medically Fragile Children 
7% 
 
Adults 28% 
 
Elderly 13% 
 
Disabled Adults 27% 
 
 Department of Community Health FY2005 Budget Reductions 
 
Based on the Governor's Office of Planning and Budget review during September 2003, the Attached Agencies were instructed to identify $3 million in state funds reductions from their FY 2005 base appropriation. 
 
Georgia Board for Physician Workforce 
 
FY05 Tracking Sheet 
 
Page 12 
 
#24 
 
To reduce funding for the Mercer School of Medicine Grant 
 
#25 
 
To reduce funding for the Morehouse School of Medicine Grant 
 
#26 
 
To reduce rates through medical student capitation 
 
#27 
 
To reduce rates for specialties and residencies through capitation 
 
* Capitation Contracts for Family Practice ($241,988) 
 
* Residency Capitation Grants ($128,852) 
 
* Pediatric Residency Capitation ($27,740) 
 
* Preventive Medicine Capitation ($7,020) 
 
#28 
 
To eliminate funding for Student Preceptorships 
 
** 
 
GBPW requested to eliminate funding for the Southern Regional Education Board 
 
DCH Request FY 2005 
State Funds 
Target Amount ($3,071,477) 
 
Governor's Recommendation 
FY 2005 State Funds 
Recommended ($2,648,252) 
 
(1,155,053) (506,494) (227,516) (405,600) 
 
(1,155,053) (506,494) (227,516) (405,600) 
 
(100,000) (401,225) 
 
(100,000) 0 
 
** 
 
GBPW had requested reinstatement of reductions to the following: 
 
* Mercer University School of Medicine - $372,114 
 
* Morehouse School of Medicine - $163,174 
 
* Medical Student Capitation - $73,297 
 
* Family Practice Residency Capitation - $77,959 
 
* Residency Capitation - $41,510 
 
* Pediatric Residency Capitation - $8,938 
 
* Preventive Medicine Capitation - $2,260 
 
Total Georgia Board for Physician Workforce 
 
739,252 
 
0 
 
(2,056,636) 
 
(2,394,663) 
 
State Medical Education Board 
 
FY05 Tracking Sheet 
 
Page 12 
 
#29 
 
To reduce funding for the Medical Fair 
 
#30 
 
To reduce funding for the Loan Repayment Program 
 
** 
 
To reduce funding for Medical Scholarships 
 
** 
 
SMEB requested to reinstate the following cuts: 
 
Medical Fair - $1,132 
 
Loan Repayment Program - $6,000 
 
Medical Scholarships - $2,260 
 
** 
 
SMEB requested to increase real estate rental 
 
Total State Medical Education Board 
 
(15,489) (65,000) (22,000) 27,132 
1,686 (73,671) 
 
(15,489) (65,000) 
0 0 
0 (80,489) 
 
Composite Board of Medical Examiners 
 
FY05 Tracking Sheet 
 
Page 11 #19 
 
To reduce regular operating expense. (Included in Health Care Regulation Reduction) 
 
#22 
 
To reduce per diem and fees to reflect completion of the initial stages of the 
 
Physician Profile project. 
 
** 
 
Realign object classes to reflect proper operating expenditures. 
 
** adjusted base 
 
Total Composite Board of Medical Examiners 
 
(15,026) (158,074) 
yes 
(173,100) 
 
(15,026) (158,074) 
yes 
(173,100) 
 
Total FY 2005 Reductions - Attached Agencies 
 
(2,303,407) 
 
(2,648,252) 
 
 Chart1 
 
Total Checkwrite 
 
$200,000,000 
 
Comparison of Checkwrites ACS and EDS - CY2002 and CY2003 
 
ACS Claims (CY2003) 
 
ACS Prospective Payments (CY2003) 
 
EDS Claims (CY2002) 
 
$180,000,000 
 
$160,000,000 
 
$140,000,000 
 
$120,000,000 
 
$100,000,000 
 
$80,000,000 
 
$60,000,000 
 
$40,000,000 
 
$20,000,000 
 
$- 
Week 1 (April) 
 
Week 5 (May) 
 
Week 9 Week 13 Week 17 (June) (June/July) (July) 
 
Week 21 Week 25 Week 29 Week 33 Week 37 Week 41 (August) (September) (October) (November) (December) (January) 
 
Page 4