p. Mbnrlee pierce
Mommieeianer
October 1, 1981
The Honorable George Eusbee, Governor Members of t h e General Assembly of Georgia State of Georgia Atlanta, Georgia 30334
Ladies and Gentlemen:
As d i r e c t e d by t h e Board of Medical Assistance, I am submitting f o r your review t h e Annual S t a t i s t i c a l Report of t h e Georgia Department of Medical Assistance sumnarizing agency a c t i v i t y through t h e f i s c a l year ending June 30, 1981. This r e p o r t provides a d i v e r s e range of d a t a concerning r e c i p i e n t s , services, providers and c o s t s of t h e Georgia Medicaid program.
In a d d i t i o n , a surmzary is included of endeavors of t h e Department i n its fourth year as an independent agency i n t h e a r e a s of program c o s t containment and provider r e l a t i o n s .
We wish t o acknowledge t h e e s s e n t i a l r o l e of t h e Department of Human Resources, t h e various health professions i n t h e S t a t e and a l l other associated agencies i n S t a t e Government in bringing medical a s s i s t a n c e t o approxim-tely one-half million Georgians during t h e past year.

BOARD OF MEDICAL ASSISTANCE
TIIC Board of Medical Assistance is the policy-making authority for the Georgia Department of Medical Assistance. The Board is coniposed of five (5) persons appointed bj, the Governor and confirmed by the Senate for staggered four (4) year ternis of office following the initial appointments. Board nieetings are held monthly.

MEMBERS
Mr. D. .Jack Davis. Chairnian Ila. Georgia
Mr. Janies E. Barnett. Secretary Atlanta. Georgia
Ms. Vikian P. Hartnian Milledge\ ille. Georgia
Mr. Ronald Tigner Atlanta, Georgia
Mr. Clem Hosea Toccoa. Georgia

TERM OF OFFICE Through June 30, 1981 Through June 30, 1983 Through June 30. 1984 Through June 30. 1982 71-hroughJune 30, 1984

TABLE OF CONTENTS
Program Abstract .............................................................. 1
Commissioner's Foreword ....................................................... 2 Expenditures .................................................................. 5
A Decade of Medicaid Benefits Expenditures FY 8 1 Benefits Expenditures Sources of Medicaid Revenue (Federal/ State Breakdown) Where the Medicaid Dollar Comes From (Federal/ State Breakdown)
Where the Medicaid Dollar Goes (9% Benefits/ Administration)
Administrative Budget Collections Benefits Payments by Aid Category, Sex, Race and Age Group Services Paid by Aid Category, Sex, Race and Age Group Georgia Counties by Medicaid Dollars Paid for Recipients Analysis of Recipients & Expenditures by Recipient County of Residence
Eligibles, Recipients, Services, Claims and Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1
Monthly Average Eligibles for All Aid Categories Types of Services Used by Recipient Group and Service Category Average Yearly Payments per Recipient by Basis of Eligibility Claims Processed Medicaid Recipients Utili7ing Services Benefits Paid by Recipient Group and Type of Service Cost of Services per Recipient Total Number of Physicians' Visit by Location Enrolled Providers by Type of Service Glossary of Terms
Department of Medical Assistance Advisory Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

ABSTRACT OF FISCAL YEAR 1981 ANNUAL REPORT
Georgia Department of Medical Assistance
Expenditures Benefits Administration
Kuniber of claims paid Enrolled Providers (as of' .June 30, 1981 ) A\.erage number of monthly eligibles Unduplicated count of recipients served annually Average yearly expenditure per recipient
Who Is Eligible Medical assistance eligibility is automatic for recipients of cash paynients under the Aid to
Fanlilies with Dependent Children (AFDC)and Suppleniental Security Income (SSl)categorical assistance programs. In addition, reinibursement for niedical services is made under the Medical Assistance Only ( M A O ) prograni for persons who would be receiving cash paynients under the a b o ~ eprograms if they were not residing in a long-term care institution o r who are related t o a categorical assistance household but are not personally receiving a cash paynient (e.g., 18-21 year-old dependents in AFIIC families). The Georgia Medicaid program also pays the "buy-in" medicare preniiunis for persons who ;ire eligible for both Medicaid and Medicare (coverage for persons 65 and older and certain disabled persons). For these persons. Medicare is the primary payor for niedical services with Medicaid paying for only coinsurance. deductibles and any services cowred by Medicaid but not by Medicare.
Covered Services lnpatient and outpatient hospital services: physician services, skilled nursing home and inter-
mediate care facility sel-\,ices:prescribed drugs: laboratory and radiological services: home health services: fanlily planning services: Early and Periodic Screening, Diagnosis and Treatment ( E P S D T ) for eligibles under 2 1: ambulance and non-emergency transportation services: niental health clinic ser\,ices: rural health clinic ser\,ices: dental services: and services by certain other practitioners.

COMMISSIONER'S FOREWORD
Charles K. Pierce
I would like to take this opportunity to thank Governor George Busbee and the Georgia General Assembly for their continued support during the past fiscal year and to recognize the cooperation of thousands of providers throughout the state in the delivery of health services t o Georgians in need of medical assistance.
During State Fiscal Yea- 1981 (July I , 1980to June 30, 198I). more than $5 19 million was paid by the Department for medical care for 445,406 recipients. Over 30,000 more Georgians received health services than in the previous fiscal year.
The Department has continued to make progress toward its goal of administration of a quality and cost-effective medical assistance program. The cost of program administration remained low -4.2% of the total Medicaid budget.
Throughout the Department, each division has attempted to make a contribution to a more effective Medicaid program administration. Below, are some of the past year's accon~plishments.
OPERATIONS
The turnaround document was introduced this year which is a facsimile of the original claim, identifying the reason(s) for which a claim was rejected. The provider may correct errors on this document and resubmit this to the Department. Corrected or completed data is directly entered into the computer system bypassing the normal data entry process and is processed for payment. Turnaround documents are produced for all claim types except for hospital claims. Implementation for this claim type is expected in FY 82.
The Direct Provider Input Program has continued to exhibit strong growth and acceptance. This program enables pharmacy, physician, hospital and laboratory providers to submit claims on magnetic tape instead of paper claims. The number of providers now using this method has increased 30'8 over the previous year to a total of 1,156. More than half of all claims received are tape-to-tape and this is a contributing factor to our ability to hold down claims processing costs and to process them in a timely manner. We now have the capability to process pharmacy claims generated on computer diskettes and will extend this capability to physician and hospital claims in FY 82.
The Department, in conjunction with the Department of Administrative Services (DOAS)and the Governor's Task Force on Medicaid, began a major redesign of the Medicaid claims processing system (Medicaid Management lnfornlation System-MMIS) and its supporting subsystems. This was done to provide better user control over clainls payment edits and procedures and to improve overall processing efficiencies. Completion is scheduled by December 1982.
The Department now has the capability to receive information from the Social Security Administration via computer tape to identify those recipients who are eligible for Medicare. As a payor of last resort, Medicaid is able to identify those claims which should be submitted to Medicare for complete or partial payment before the Department makes payment.
SPECIAL SERVICES
Legal Services
A number of changes were implemented by the Legal Services Office in addition to representing the Department at all provider hearings and providing sound legal advice to the Department. The Appeals Procedure chapter was rewritten in each of the provider manuals to standardize the process for all services and nunlerous other policy provisions were rewritten. In addition, a new

appeals process for recovering overpayments to providers was initiated. The Benefits Recovery Section is now able to recoup any incorrect payments to providers within 30 days after they are identified, while maintaining a high degree of due process for the protection of Medicaid providers.
Benefits Recovery
Total funds recovered this year by the Benefits Recovery Section was in excess o f $ [ 1.8million, an increase of $4.2 million over the previous year. Approximately $3.3 million of this increase is due to the initiation of the Hospital Cost Settlement procedure to cover the past six annual accounting periods. Of the remaining increase in recovery, $433,000 can be attributed to funds received directly from insurance carriers after the funds were initially paid with Medicaid funds, and $467,000 is a result of voluntary refunds from providers.
The M MIS redesign includes automation of Benefits Accounts Receivable and will result in a more manageable system to provide maximum utilization of available Medicaid funds.
ADMINISTRATION
Budget
As this report went to press, there was a n estimated $67 niillion shortfall in the Medicaid Benefits budget for FY 82. The Department's staff has spent many hours along with others from the Legislative Budget Office and the Office of Planning and Budget in an attempt to provide the best possible services with the funds available. This required extensive staff time during the last quarter of FY 8 1.
Nursing Home Reimbursement
During fiscal year 8 1, the decision was made to utilize a staff of ten state auditors to perform reviews and audits of nursing home cost reports. Within the next two years, every nursing home will be audited with a projected savings of four to six million dollars in audit disallowances. Previously, only 15% of the homes were required to be audited.
Hospital Reimbursement
During FY 8 1, the Alternative Hospital Reimbursement System was in~plenientedthrough waiver from the Department of Health and Human Services (DH HS). This system, which has been under development since 1977,establishes hospital peer groups for cost coniparisons and reimbursement rate determination.
INVESTIGATION AND COMPLIANCE
The Department's investigative efforts, both through direct discovery and resulting deterrent effects, has resulted in tighter management of potential program fraud and abuse by both recipients and providers. During fiscal year 1981 , the investigative effort led to the identification of $77,06 1 in overpayments and $1 1,650 in fines and penalties. Over 150 complaints of program abuse were handled during this period. These complaints led to the development of a number of criminal cases: 10were brought tQaconclusion during the year with two pleas of nolo contendre, one no1 pros, two prosecutions declified, one conviction, one subject disappeared, one subject deceased, and two guilty pleas. At the close of the fiscal year, 29 fraud cases were pending further disposition.
PROGRAM MANAGEMENT
Cost Containment
This division utilized a number of methods to effect the tremendous increase in niedical costs which resulted in savings to the Department. Through prior approval and prepaying review, a total of $6,036,796 in expenditures was denied from more than 87,000 claims. A podiatry consultant

accounted for $173,800 of that amount. Two dental consultants reviewing both adult and E P S D T dental claims denied another $5 1.500 in clainis. Physician claini reviews were initiated in May 1981 , so total benefit in service will not be realbed until next year. Reviews and prior approvals in other claim areas accounted for the remaining savings.
Additional conlputer edits were implemented this year a s a cost containment tool in the Dental Program. Pre\iously, manual review was required to monitor many of the policies.
l'he Surveillance and Utilization Review Unit began desk reviews in FY 81 and as the year ended was beginning on-site reviews. This unit identifies providers whose services are not within a n acceptable range when compared to similar providers. It is anticipated that this unit will have a considerable effect on cost-savings in FY 82.
A "New Enrollee Packet" was designed for physician providers to acquaint them with some of the niost common billing problems, Medicaid ternlinology, suggested claini reconciliation and contact points within the agency. This effort assisted providers to subniit error-free clainis and help reduce costs in the processing tinie and expense.
The Division also inlplenlented some new computer edits which will assist in n1axinlii.ing cost-sakings. One edit alone could save a projected $100.000 by reviewing the place where electrocardiogranis are performed.
The Alternative Health Services Progranis (AHS) served the seven county metropolitan Atlanta area and ten counties surrounding Athens in FY 8 1. Statewide inlplen~entationis expected at the end of Fiscal Year 84 and will divert about 2,500 recipients from nursing honie care to conimunity-based serkices resulting in reduced nledical care costs to the Departnient.
Earlj Periodic Screening. Diagnosis and Treatnient ( E P D S T )experienced a 169; increase in 5creens pertornled and reached 74,186 children Ln Fiscal Year 81. Early inlmuni7ation and identification of nledical problenis through this program should result in reduced costs in nledical care.
Provider Relations
During the year, a pilot project was developed to conduct nine fornial workshops for physicians in the metropolitan Atlanta area. An additional 191 workshops in other service categories were held throughout the state. In addition, the Division responded t o more than 80,000 written and telephone inquiries.
l'he physician fee schedule was implemented August 1 , 1980 and provided a more equitable reinibursen~entof fees paid to physicians, podiatrists, psychologists and optonietrists. Fees are based on procedure codes instead of historical charges made by practitioners. A dental fee schedule was inlpleniented October 1 , 1980.
Mandatory coding of diagnosis and procedure codes by independent practitioners went into effect October I . 1980. The result was a n improvement in the tinie required to process a claini for reimbursement.
Pro\,ider enrollment increased rapidly in Fiscal Year 1981 providing more accessibility to health care for the state's Medicaid recipients. The physicians'prograni alone increased enrollnlent so now 755; of the state's 13,800 licensed physicians are enrolled in Medicaid.
It is hoped that lhese documents will add depth of the accon?plishnients of the Department during Fiscal Year 8 1 as depicted on the charts which follow.

EXPENDITURES

Fiscal Year

A DECADE OF MEDICAID BENEFITS EXPENDITURES

Actual Benefits Payments

Percentage Change

Projected Cost of Services Rendered*

Percentage Change

*By date of service as of June 30, 1980.

NOTE:

Beginning in 1976,expenditures were on an accrual-based accounting system as opposed to a cash basis system utilized in previous years. A State Attorney General's ruling held that payments must be made from the budget for the same year in which the Medicaid service was rendered. For this reason, final expenditure amounts are not known until some time after a fiscal year has ended. The figures reported here are cash payments made during each fiscal year. Total expenditures for services rendered during each fiscal year will usually exceed payments.

MEDICAID BENEFITS EXPENDITURES
Dollars in Millions
Fiscal Year

SOURCES OF MEDICAID BENEFITS REVENUE FY 81
Federal Funds
State Funds

TOTAL Revenue

*Cash Paynients

WHERE THE MEDICAID DOLLAR COMES F R O M . . .
Georgia's Medicaid program receives reinibursenient for a portion of its budget based on the activity. Reimbursenicnt level for benefits, faniily planning, the Medicaid Management Information Systenl ( M MIS) and for administration of the program is determined each fiscal year by the federal government.

Benefits

Medicaid Management Information System

TATE FUND

FEDERAL FUNDS

Farnil? Planning Benefits

Administration

FEDERAL FUNDS

Total

Out of each dollar spent for Medicaid benefits, approximately 4 2 . 6 ~goes for skilled nursing care, intermediate care or intermediate care for the mentally retarded. Hospital providers receive 2 9 . 6 ~of each dollar and the remaining 2 7 . 8 ~goes to providers of other care.
Of the administration dollar, the Division of Program Management utilizes 42c and computer servicesaccount for over 3 1c of the dollar. The cost of adniinistration is 4 . 2 ~of the total Medicaid dollar.
. WHERE THE MEDICAID DOLLAR G O E S . .

FY 81 BENEFITS $5 19,934.060

1.ONGTERM CARE 42.6%

Prograni Management 42.0%
$9,588,142

mCommissioner's Office* I . 1');
$244.657

FY 81 TOTAL EXPENDITURES
$542,762,509

FY 81 BENEFITS EXPENDITURES

Category of Service
Skilled Nursing Facilities ICF-M R 1CF-Other Inpatient Hospital Outpatient Hospital Prescribed Drugs Physicians Dental
Other Care *
Clinic (Mental Health) Fanlily Planning
Other Practitioners **
Home Health Laboratory/ Radiology Rural Health Clinic EPSDT
TOTAL BENEFITS ADMINISTRATIVE COSTS
TOTAL COSTS

Amount
$5 19,934,060 $ 22,828,449 $542,762,509

- --
Percent of Payments By Service

* Other Care includes: Durable Medical Equipment, Prosthetics/Orthotics, Ambulance and
Non-Emergency Transportation and Alternative Health Services.
** Other Practitioners includes: Optometrists, Podiatrists, Chiropractors and Psychiatrists. *** Less than .I%.

ADMINISTRATIVE BUDGET FY 81

Division
Program Management DOAS Computer Services Operations Administration Commissioner's Office Special Services Investigation and Compliance Quality Control
TOTAL

Budget

Percent of Total

$22,828,449

100.0%

COLLECTIONS
Efforts are made to collect money erroneously paid for Medicaid services in a number of areas. Each fiscal year. nursing home audits disallow some of the costs billed to Medicaid and these adjustnients decrease total dollars paid to nursing homes.
The Office of ln~estigationand Compliance recoups funds paid to pro\,idersfor claims in cases of fraud or abuse. In some cases. when a recipient has received Medicaid ser\,icesfraudulently, the recipient is required to make restitution to the Department. A third party reco\,ery effort attempts to collect payments in cases where a recipient has private insurance and where overpayments were niade to pro\,iders.

Nursing Home Audit Disallowances
Investigation & Compliance Rec~pient& Pro\ ider Recoupnient4
Third Party Liability Insurance Recoupnients O~erpaynient4Erroneous Payments Hospital Co4t Settlement*"

287.108
4,999.684 1.5 14.842

* Estimated ** Begun in FY 81. retlects four years collections.

285.386
6,108.95 1 1,209.424

77.06 1
6.825.105 1.742.947 3.292.169

PAYMENTS BY AID CATEGORY, SEX, RACE, AGE GROUP
BY AID CATEGORY BY SEX BY RACE BY AGE GROUP

SERVICES BY AID CATEGORY, SEX, RACE, AGE GROUP
BY AID CATEGORY BY SEX BY RACE BY AGE GROUP

GEORGIA COUNTIES BY MEDICAID DOLLARS PAID FOR RECIPIENTS FISCAL YEAR 1981
Dollar Amounts for Recipients in FY 8 1
Over $5,000.000 $2,000,000 - $5,000,000
0$ 1,000.000 - $2,000,000
Less than $1,000,000

Counties Receiving Over $5,000,000

County
Fulton Richmond DeKalb Chatham Bibb Muscogee Cobb Dougherty Floyd Baldwin Lowndes Clayton Houston Troup Hall Thomas Carroll Ware Whitfield Laurens Gwinnett Clarke

Amount

During the past year recipients received more than $519,000,000 in Medicaid services. These 22 counties accounted for more than half of the dollars paid to recipients.

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY COUNTY FOR FISCAL YEAR 1981

County
Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly

Total Benefits
Paid
$ 2,070.701 86 1,134
1,558,003 319,817
7.726.784 264,127
2,230,527 2,134,866 2,863,439 1,469,784 16,182,559 1,585,303
46 1,968 2.766,72 1
670,2 18 4,073.029 3,260,858 2,023,545
87 1,286 1,177,459 2,775,640 5,486,024 1,436,O 18 1.O 1 1,367 17,671.6 17
1 14,374 1,766,739 2,639,8 17 5,149,23 1
785,006 6,655.838 1.4 13,299 9,673,799 3,349,927 4,131,070 1,407.5 12 1,703.38 1 2,984,847 1,102,703 3,336,353
761,109 385,340 3,420.583 26,727.1 14 2,9 12,367 1.7 10,352

Population*
15,500 6,000 8,900 3,800 34.400 7,400 2 1,000 40,700 15,500 13,300 149,200 10,800 8,700 15,300 10,000 35,500 19,200 13,500 5.800 13.100 7.500 56,200 37,000 7.200 197,400 2 1,800 2 1,800 5 1,700 72,400 3,600 149,600 6,600 295,400 26,200 35,200 39,000 1 3,400 39,200 7,700 19.300 12,400 4,700 25,400 475,700 16,800 10,800

Recipients (Unduplicated)

% Population

Receiving

Recipients/

Medicaid Total Recipients

County Cost Per Recipient

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY COUNTY FOR FISCAL YEAR 1981

County
Dougherty Douglas Early Echols Effinghani Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grad y Greene Gwinnett Habershani Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes

Total Benefits
Paid

Population*

Recipients (Unduplicated)

% Population

Receiving

Recipients/

Medicaid Total Recipients

County Cost Per Recipient
757.16 1.445.09
849.18 609.52 805.04 1,100.67 1.288.39 1,233.18 1,137.21 673.23 1.4 15.43 1,013.27 1,096.25 605.33 1.096.79 2.390.38 1.087.36 1.064.0 1 896.1 1 1.348.02 1,565.81 1,3 13.04 1.244.25 1.181.80 1,677.04 842.76 1,310.85 1.210.83 1,165.80 1.325.24 1,157.56 1,152.91 986.20 1,205.90 1,105.77 961.81 1.163.26 1,296.72 988.18 1,238.08 1.261.79 456.44 824.10 476.94 656.28 1.151.22

ANALYSIS OF RECIPIENTS A N D EXPENDITURES BY COUNTY FOR FISCAL YEAR 1981

County
Lunipkin Macon Madison Marion McDuffie Mclntosh Meriwether Miller Mitchell Monroe Montgonlery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnanl Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sunlter Talbot Taliaferro Tattnall Taylor Telfair 'Terrell Thomas

Total Benefits
Paid

Population*

Recipients (Unduplicated)

% Population

Receiving

Recipients/

Medicaid Total Recipients

County Cost Per Recipient

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY COUNTY FOR FISCAL YEAR 1981

County
Tift l~oonibs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth STATEWIDE

Total Benefits
Paid

Population*

Recipients (Unduplicated)

% Population

County

Receiving

Recipients/

Cost Per

Medicaid Total Recipients Recipient

"U.S. C e n s u s 1980 Preliminary ""Recipients are unduplicated within each county, but a single recipient may have received medical services in
more than one county. The number of recipients served when cross-county duplication are controlled is 445,406.

ELIGIBLES, RECIPIENTS, SERVICES, CLAIMS AND PROVIDERS

MONTHLY AVERAGE ELIGIBLES FOR ALL AID CATEGORIES

July August September October November December January February March April May June
Monthly Average

424,292

40 1,53 1

404,535

420,574

TYPES OF SERVICES USED BY RECIPIENT
GROUP AND TYPE OF SERVICE RECIPIENTS RECEIVING MAINTENANCE ASSISTANCE AND
M A 0 (MEDICAL ASSISTANCE ONLY) FY 81

Type of Medical Services
Skilled Nursing Homes Intermediate Care lntermediate Care for the
Mentally Retarded Inpatient Hospital Outpatient Hospital Physician Prescribed Drugs Dental Other Practitioners* Clinic (Mental Health) Family Planning Home Health Laboratory/ Radiology Early Periodic Screening,
Diagnosis and Treatment Rural Health Clinic Other Care**

Age 65 or Over

Blind

Disabled A F D C Adults AFDC Children

Unduplicated Totals

*Other Practitioners includes: Optometrists, Chiropractors and Psychiatrists. **Other Care includes: Durable Medical Equipment, Prosthetics/ Orthotics, Ambulance, Non-Emergency Transportation and Alter-
native Health Services. ***Recipients are counted no more than once in each category of service in which service was provided. Recipients are also counted in
each aid category in which they were eligible during the year. This is particularly noticeable in the nursing home category where recipients are counted twice when they become M A 0 (Medical Assistance Only) after having received Maintenance Assistance.

AVERAGE YEARLY PAYMENTS PER RECIPIENT BY BASIS OF ELIGIBILITY FY 81
Expenditures for the elderly (age 65 a n d over) a n d the permanently a n d totally disabled accounted for over 75 percent of the total spent for medical services in F Y 8 1. These aid categories receive more nursing home, inpatient hospital and pharmacy services than any other recipient group. A comparison of recipients t o dollars spent in each program is shown in the chart below.

Basis of Eligibility
Elderly (age 65 and over) Blind Disabled AFDC Children AFDC Adults
TOTAL
P
*Unduplicated Count

Expenditures
$188,023,925 4,084,909
209,544,823 54,628,722 63.65 1,682

Percentage of Total
36.2% .8%
40.3% 10.5% 12.2%

Recipients
102,197 2,959
93,005 189,274 84,3 18

Percentage of Total
2 1.7% .6%
19.8% 40.2% l7.7%,

Average Paid Per Recipient
$1,839.82 1,380.50 2,253.05 288.62 754.90

CLAIMS PROCESSED BY CATEGORY OF SERVICE FY 81

Category of Service
Prescribed Drugs Physician Outpatient Hospital Nursing Homes Inpatient Hospital Other

Number of Claims Processed

Percent

TOTAL

10,725,030
-

-

-

-

-

-

100.0%

"Nursing home claims are usually for one recipient per calendar month.

Medicaid services are used most frequently by A F D C children and adults. The aged recipient is the second most frequent user of services followed by the disabled and the blind. Prescribed drugs are used by more than 75% of the recipients followed by physician services which are used by 73% of the recipients. Inpatient hospital users accounted for 23% of the recipients. Only 9% of the recipients are in nursing homes but this accounts for 43% of all Medicaid costs. Inpatient hospital dollars are about 23% of the total Medicaid bill.

MEDICAID RECIPIENTS UTILIZING SERVICES BY PERCENTAGE FY81

Total Recipients

445,406

100%

Prescribed Drugs Physicians Outpatient Hospital Inpatient Hospital Dental EPSDT Other Care* Other Practitioners** Family Planning Laboratory and X-Ray ICF Mental Health Clinic SNF Home Health ICF-M R Rural Health

*Other Care includes: Durable Medical Equipment, Orthotics/ Prosthetics, Ambulance, Non-Emergency Transportation and Alternative Health Services.
**Other Practitioners includes: Optometrists, Podiatrists, Chiropractors and Psychiatrists.

BENEFITS PAID BY RECIPIENT GROUP AND TYPE OF SERVICE
FY 81 BASIS OF ELIGIBILITY

Type of Medical Service
Skilled Nursing Homes Intermediate Care Intermediate Care for the
Mentally Retarded Inpatient Hospital Outpatient Hospital Physician Prescribed Drugs Dental Other Practitioners* Clinic (Mental Health) Family Planning Home Health l,aboratory/ Radiology Rural Health Clinic Early Periodic Screening,
Diagnosis and Treatment Other Care**
TOTAL PAYMENTS***

Age 65 or Over Blindness Disability AFDC Adults A F D C Children TotalPayrnents

$188,023,925

$4,084,908 $209,544,823 $63,65 1,682 $54,628,722 $5 19,934,060

*Other Practitioners includes: Optometrists, Podiatrists, Chiropractors, and Psychiatrists. **Other Care includes: Durable Medicaid Equipment, Orthotics/ Prosthetics, Ambulance, Non-Emergency Transportation and AHS. ***Total Payments d o not reflect the "buy-in" payments (Medicare premiums) paid for those persons eligible for both Medicare and
Medicaid. "Buy-In" amounted to: $14,709,606 in F Y 8 1.

COSTS OF SERVICES PER RECIPIENT FOR FISCAL YEAR 1981

Type of Service
Nursing Homes ICF-MR ICF-Other SNF
Inpatient Hospital Home Health Clinic (Mental Health) Physicians Dental Drugs Other Care* Outpatient Hospital Family Planning Other Practitioners** Laboratory/ Radiology Rural Health Clinic Early Periodic Screening,
Diagnosis and Treatment
Average Cost Per Recipient for All Services

Average Cost Per Recipient for FY 81

*Other Care includes: Durable Medical Equipment, Prosthetics/ Orthotics, Ambulance, Non-Emergency Transportation and AHS. **Other Practitioners includes: Optometrists, Podiatrists, Chiropractors and Psychiatrists.

TOTAL NUMBER OF PHYSICIANS' VISITS BY LOCATION
FOR FISCAL YEAR 1981

Place of Visit
Physicians' Office Hospital Inpatient Hospital Outpatient Clinic Skilled Nursing Home Intermediate Care Nursing Home Elsewhere Recipients' Home
TOTAL

Number of Visits

Percent

ENROLLED PROVIDERS BY TYPE OF SERVICE* June 30,1981

Type of Service

Number of Providers

Hospital Nursing Home Pharmacy Ambulance Home Health Independent Laboratory and X-ray Durable Medical Equipment Supplier (DME) Prosthetics/ Orthotics Optical Supplier Mental Health Clinic Health District Family Planning Center Non-Emergency Transportation Physician Dentist Optometrist Podiatrist Psychologist Chiropractor** Rural Health Services Speech, Occupational and Physical Therapist** Outpatient Mental Health

TOTAL

16,87 1

--

--- - - -

*Includes Medicaid and Medicare providers. **Enrolled in Medicare only.

The number of enrolled providers has increased since F Y 78, particularly in the physician category. A continuous effort is made by the Providers Relations section to encourage enrollment in the Medicaid program. There continues to be a very uneven distribution of specialist physicians throughout the State, but most Georgia counties have a good to excellent availability of primary care physicians. It should be noted that the top 600 physicians recieve more than 50% of the total payments.

Enrolled providers include both in-state and out-of-state providers.

GLOSSARY OF TERMS

Medicaid and Medicare
Medicaid and Medicare are two governmental programs which exist to pay for health care for two different, but overlapping, groups of Americans.
Medicaid buys medical care for several low-income groups, including people of all ages. Medicare buys medical care for most people, including some people from all income groups. Many aged people who have low incomes are eligible for both Medicaid and Medicare, and those who are eligible for both get a Medicaid card and a Medicare card. For those people Medicare pays most of their medical bills, and Medicaid pays the balance. or most of it.
Medicaid is administered by the state governments and thus each program is different. There are Medicaid programs in49 states and Puerto Rico, Guam, the Virgin Islands and Washington, D.C. Arizona does not have a Medicaid program. Medicare is administered by the federal government and the program coverage is uniform throughout the nation.

Eligibles and Recipients
Eligibles are people who have Medicaid cards and thus are eligible for health care service paid for by Medicaid.
Recipients are people who actually received one or more medical services for which Medicaid paid all or part of the bill.

Providers
All physicians, dentists, hospitals, nursing homes, and other individuals or businesses that provide medical care are called providers.

Charges, Payments and Expenditures
A charge is the amount of money the provider requests for a service when he submits his bill to Medicaid.
A payment is the amount Medicaid pays for a service. Medicaid rules limit payments, so sometimes a provider cannot be paid as much as he requests.
Expenditures are the total dollars which Medicaid paid for services and may include the dollars paid for program administration.

Health Care Services

Medicaid pays for the following categories of service:

Nursing Homes Drugs Mental Health Clinics EPSDT (Early Periodic
Screening and Diagnostic Treatment) Alternative Health Services Durable Medical Equipment

Orthotics/ Prosthetics Hospitals Dental Optometry Rural Health Clinics Laboratory1 Radiology Chiropractic Non-Emergency Travel

Physicians Family Planning Home Health Podiatry Ambulance Psychiatric

Buy-In
Medicaid buys insurance from Medicare to cover physicians' services for those who are eligible for Medicare and already receive hospital coverage without payment. State funds in the amount of $2,974,300 were used to pay for insurance for M A 0 recipients (Medical Assistance Only) in FY 8 1 . The usual federal match (66.76Ypfedera1,33.249: state) is provided for all other recipients who are Medicare eligible.
3 1

DEPARTMENT OF MEDICAL ASSISTANCE ADVISORY COMMITTEE
A Medical Assistance Advisory Committee was created to give technical advice to the Department and to provide liaison between the Department and each provider community. Sub-committees of this group, representing ten medical professional groups and a consumer group, are appointed by the Commissioner and meet a t the discretion of their respective chairmen. An important function of these sub-committees is to delineate the effects of proposed policy changes and relay the concerns of their associates t o the Department. The subcommittees and their members are as follows:

I. Ambulance Sub-committee Charles B. Gillespie, M.D., Chairman Albany, Georgia Don Sirmans Lakeland, Georgia Doug Waters Jefferson, Georgia
11. Dentists' Sub-committee DeWitt Walton, D.D.S., Acting Chairman Macon, Georgia A. J. Webster ,D.D.S. Rome, Georgia Mike Kennedy, D.D.S. Columbus, Georgia Walker Moore, D.D.S. Atlanta, Georgia
111. Durable Medical Equipment, Orthotics, & Prosthetics Sub-committee
A. M. Hancock, Chairman Atlanta, Georgia
H. G. Bowden Warm Springs, Georgia
Dean Cox Cartersville, Georgia
Grant Rice
- Atlanta. Georgia
IV. Home Health Sub-committee Ms. Hester Fortson, Chairwoman Athens, Georgia Ms. Loretta Roberts Atlanta, Georgia Ms. Aleise Sockell Atlanta, Georgia

V Hospital Sub-committee Ewing S. Barnett Newnan, Georgia Charles L. Foster, Jr. LaGrange, Georgia Ernest Bacon, Atlanta, Georgia Charles H. Wilson, Jr. Atlanta, Georgia
V1. Nursing Home Sub-committee Eugene M. Bishop, Chairman Roswell, Georgia Tom F. Satterfield Atlanta, Georgia Ed L. Stephens Cleveland, Georgia Myrtle Vickers Douglas, Georgia James R. Westbury Jenkinsburg, Georgia
VI1. Optometric Sub-committee ~ b b e r Ht . Thurmond, O.D., Chairman East Point, Georgia Joe H. Dew, O.D. Dalton, Georgia Allan V. Wexler, O.D. Savannah, Georgia Lovick H. Williamson, 0 . D Quitman, Georgia Earl W. Lusk, O.D. Dalton, Georgia Linda Edmonds Decatur, Georgia

VIII. Pharmacy Sub-committee Larry J. Parrish, R. Ph., Chairman Swainsboro, Georgia Wallace G. Whiten, R. Ph. Toccoa, Georgia 1. Peter Mills, Jr., R. Ph. Millen, Georgia William R. Thomas, R. Ph. Thomasville, Georgia Oren H. Harden, Jr., R. Ph. Sylvester, Georgia
IX. Physicians' Sub-committee David A. Wells, M.D., Chairman Dalton, Georgia W. Carl Gordon, M.D. Albany, Georgia Wesley S. Wilborn, M.D. Atlanta, Georgia Frank T. Robbins, M.D. Hinesville, Georgia Garnett A. Fisher, D.O. Norcross, Georgia
X. Psychologists' Sub-committee Irving P. Unikel, Ph. D., Chairman Decatur, Georgia George Anderson, Ph. D. Dublin, Georgia Fred Huff, Ph. D. Marietta, Georgia John Adams, Ph. D. Statesboro, Georgia Hugh Christie, Ph. D. Griffin, Georgia Ronald J. Berlin, Ph. D. Atlanta, Georgia
XI. Consumer Sub-committee Ms. Pat Kalmans, Chairwoman Atlanta, Georgia Mr. Joe Reidlinger Brunswick, Georgia Mr. Lewis Sinclair Atlanta, Georgia Ms. Pamela Harris Decatur, Georgia Ms. Eloise Pitts Atlanta, Georgia

STATE OF GEORGIA DEPARTMENT OF MEDICAL ASSISTANCE
1010 W. PEACHTREE STREET, N.W. ATLANTA, GEORGIA 30367