Annual report, 1985

4
GEORGIA
DEPARTMENT OF MEDICAL ASSISTANCE
Annual Report 1985
Aaron J. Johnson Commissioner

Aaron J. Johnson Commissioner

State of Georgia Department of Medical Assistance
- Floyd Veterans Memorial Bldg. West Tower
2 Martin Luther King, Jr. Drive, S.E.
Atlanta, Georgia 30334

The Honorable J o e Frank H a r r i s Governor of Georgia Members of t h e General Assembly of Georgia Citizens of t h e State of Georgia
Ladies and Gentlemen:
I am s u b m i t t i n g f o r y o u r r e v i e w t h e Annual R e p o r t o f t h e D e p a r t m e n t of Medical Assistance. This report summarizes agency a c t i v i t y through t h e f i s c a l y e a r e n d i n g J u n e 30, 1985. During t h i s y e a r ne made h e a l t h c a r e a r e a l i t y t o nearly one-half million c i t i z e n s and expanded t h e program t o cover t h e medically needy.
I n i s h t o e x p r e s s my a p p r e c i a t i o n , a n d t h a t o f my s t a f f , f o r y o u r support and assistance.

An Equal Opportunity Employer

TABLE OF CONTENTS
Abstract ................................................................... 1 Board of Medical Assistance ................................................... 2 Organization Chart .......................................................... 3 Highlightsoftheyear ........................................................ 5 Tablesandcharts ........................................................... 11
A History of Medicaid Benefits Expenditures .................................. 11 Where the Medicaid Dollar Comes From ..................................... 12 Sources of Medicaid Benefits Revenue ........................................ 12 Where the Medicaid Dollar Goes ............................................ 13 FY 85 Benefits Expenditures ................................................ 14 FY 85 Administrative Expenditures .......................................... 15 Collections and Measurable Cost Avoidance. FY82-FY85 ......................... 16 Payments and Recipients by Aid Category. Sex. Race. and Age Group ............. 17 Recipients by Aid Category by Type of Service. FY85 ........................... 18 Benefits Paid by Aid Category by Type of Service. FY85 ......................... 19
PeRrceecnitpaigeentobfyEAxpidenCdaittuergeosrayn.d.o.f..R.e.c.ip.i.e.n.ts..an.d..A..v.er.a.g.e.Y..e.a.rl.y.P..ay.m..e.n.t.p.e.r........ 20 Payments for Services per Recipient. FY82-FY85 ............................... 21 Percentage of Total Recipients Utilizing Each Service. FY82-FY85 ................. 22 Claims Processed by Category of Service. FY85 ................................ 23 Total Number of Physicians' Visits by Location. FY85 . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Providers with Paid Claims during FY82-FY85 by Type of Service ................. 24 Analysis of Recipients and Expenditures by County of Residence .................. 25 Comparison of Eligibles. Expenditures. and Expenditures per Eligible. FY82-FY85 . . . . 29 Department of Medical Assistance Advisory Committee ............................. 30

ABSTRACT OF FISCAL YEAR 1985 ANNUAL REPORT
Georgia Department of Medical Assistance

Expenditures Benefits Administration
Number of Medicaid claims paid Enrolled Providers (as of June 30, 1985) Average number of monthly eligibles Unduplicated count of recipients served annually Average yearly expenditure per recipient

$694,279,055 24,473,506

12,088,688

24,211

430,825

454,823

$

1,526

Who is Eligible
I. Categorically Needy (Cash Assistance) A. Aid to Families with Dependent Children (AFDC) Households with dependent children deprived of support due to death, absence or incapacity of one or both parents. B. Supplemental Security Income (SSI) Recipients Aged, blind or disabled.
11. Categorically Needy (No Cash Assistance) A. Families with Dependent Children Mainly households who have recently become ineligible for cash assistance. Pregnant women whose unborn children are expected to be eligible are also covered, as are foster care children. Certain foster care and "special needs" (adoption supplement) children became eligible in January 1985. Pregnant women in intact, unemployed households and children under five in intact households were covered starting April 1985. B. Aged, Blind or Disabled Eligible for SSI except for income and in institutions. Any income in excess of a small allowance is applied to the cost of care. (Similar community care recipients were covered starting in July 1985.)
111. Medically Needy Pregnant women in deprived or intact, unemployed households and children in deprived or intact households. All must meet same qualifications as categorically needy, except for income or resources. Income in excess of 133 113%of the AFDC standard is applied to the cost of care.
(NOTE: Starting in October 1985all pregnant women and children in two parent households which met the income, resource, and health expense requirements of one of the above groups were eligible.)

Covered Services
Inpatient and Outpatient Hospital Services
Physician Services Skilled Nursing Facility Intermediate Care Facility Intermediate Care for Men-
tally Retarded Facility Prescribed Drugs Laboratory and Radiological
Services Home Health Services Family Planning Services Early and Periodic Screening,
Diagnosis and Treatment (under age 21) Ambulance and Non-Emergency Transportation Mental Health Clinic Rural Health Clinic Dental Services Durable Medical Equipment Orthotics and Prosthetics Community Care (Alternative Health) Optometry Services Podiatry Services Psychological Services Nurse Midwife Services
(NOTE: Medicare-Medicaid recipients may also receive chiropractic services, speech therapy, physical therapy and rehabilitation therapy.)

BOARD OF MEDICAL ASSISTANCE
As of June 30,1985
The Board of Medical Assistance is the policy-making authority for the Georgia Department of Medical Assistance. The Board is composed of five persons appointed by the Governor and confirmed by the Senate for four year terms of office. Board meetings are held monthly.

MEMBERS
Mr. William Pitts Carr, Chairman Atlanta, Georgia
Mr. Ronald Tigner, Secretary Atlanta, Georgia
Ms. Beauty Baldwin Lawrenceville, Georgia
Ms. Ann McKee Parker Atlanta, Georgia
Joseph H. Patterson, M.D. Atlanta, Georgia

TERM OF OFFICE Through June 30, 1987 Through June 30, 1986 Through June 30, 1989 Through June 30,1988 Through June 30, 1988

HIGHLIGHTS OF THE YEAR
During State Fiscal Year 1985(July 1, 1984to June 30, 1985),over $694 million was paid by the Department for medical care for 454,823 recipients. The cost of administration of the program remained low - less than four percent of the total Medicaid budget.
In the following summary we have included highlights of major Fiscal Year 1985 (FY85) activities within the Department.
PROGRAM MANAGEMENT
The Division of Program Management develops reimbursement, coverage and other policies and conducts training for providers in more than twenty program service areas. Policies are developed, implemented and interpreted based on federal regulations, state laws, and directives of the Board of Medical Assistance.
Nursing Home Services
During FY85 the Department reimbursed 332 providers for 9,858,308 days of nursing home care for 36,063 recipients of service.
I . Audits The State Department of Audits' nursing home staff performed on-site audits of the 1983cost reports for 140nursing facilities during FY85. Total audits during FY84 and FY85 accounted for approximately 62 percent of the facilitieswith FY83 cost reports.
2. Reimbursement Rates For the period from April 1, 1984, through January 31, 1985, reimbursement rates were based upon 1980cost reports with a growth allowance of 22.5% and a return on equity of 11%. Effective February 1, 1985, the base year for nursing home rates was changed from 1980 to the 1983 cost report with a 9% inflation factor. This resulted in an average rate increase of 5.5% for skilled nursing facilities and a 5.2% increase for intermediate care facilities.
3. On-Site Review The Georgia Medical Care Foundation completed 624 on-site reviews of care in nursing facilities during FY85.
4. Patient Care Effective October 1, 1984, the Department began a more agressive approach to obtaining fully responsive plans of correction that respond to specific findings identified by the Georgia Medical Care Foundation's On-Site Review Teams. "Specific findings" involve conditions that endanger the health, safety and welfare of nursing home residents. Failure to submit or comply with an approved plan of correction now can result in denial of reimbursement for future admissions or suspension or termination from the program.
5. Preventive Treatment Effective April 1, 1985, intermediate care facilities for the mentally retarded were required to provide their residents with immunization of Hepatitis B virus vaccine without additional charge. This was a recommendation of the Public Health Services Committee on Immunization Practices and the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.
6. Private Room and Sitter Supplementation Beginning October 1, 1984, the Department permitted voluntary third party supple-

mentation for the additional cost of a private room or sitter or both for a Medicaid recipient. Under this policy no provider of Medical Assistance may charge for private rooms in excess of the additional rate charged to private patients.
Hospital Services
The Department reimbursed approximately 200 providers for 349,408 days of inpatient hospital care for 60,426 discharges during FY85, not counting days for which Medicare covered all but a copayment or deductible.
1. Return on Equity Effective April 1, 1985, return on equity costs were no longer recognized as allowed costs in determining reimbursement rates.
2. Settlement Under a new policy the Department will compare payments to charges and seek refunds from those hospitals which were paid amounts exceeding charges Cor cost, if greater than charges).
3. Staff Claim Review Staff review of claims to determineif certain surgical procedures were performed on an outpatient basis resulted in $306,043 in savings.
4. Rate Determination Effective November I, 1984,each hospital's fiscal period 1982cost report was used to determine its base period cost per case.
5. Outliers Hospitals were paid $456,652 in FY85 for inpatient claims with unusually high charges ("outliers'?, ir.addition to the $184,485,522 paid for inpatient hospital servicesthrough the per case rate.
Individual Practitioners Services
1. Five Percent Increase Effective October 1, 1984, reimbursement rates for services provided by individual practitioners were increased so as to increase total expenditures by five percent. This adjustment was made to provide more reasonable and equitable reimbursement.
2. vision Care Program The Department's contract with a sole source optical device supplier was in effect throughout FY85. Projected savings of approximately $300,000 were realized on approximately 21,000 prescriptions under the contract.
3. Independent Laboratory Program Maximum allowable payments for laboratory services were changed where necessary to comply with the federal Deficit Reduction Act of 1984.This Act limited Medicaid's payment for certain procedures to Medicare's prevailing rate for the same procedures.
4. Podiatry Prepayment review of podiatry claims resulted in the review of 5,830 invoices for savings of $14,575.
5. Billing Patterns Fourteen individual practitioners were referred to the Surveillance and Utilization Review (SUR) Section because of aberrant billing patterns. The SUR Section completed eleven referrals resulting in refund requests of $1 1,372.

6. Provider Training Six formal workshops were held for physicians and their billing staff. One hundred thirtyeight physicians were represented by 111 participants. Forty-seven physicians' offices received individual provider training.
7. Multiple Surgery Prepayment review of multiple surgery claims resulted in the review of 9,925 invoices for savings of $1,985,000.
Ancillary Services
I . Pharmacy Services The Department paid 1,660 providers for 6,188,430 prescriptions for 362,022 recipients during FY85. a) Maximum Allowable Cost (MAC) limits were placed on two additional highly utilized generic drugs in June 1984,producing estimated savingsof approximately $125,000 for the fiscal year. b) There were approximately 7,044 requests for exceptions to the six prescription limit for which there was sufficient information available upon which to make an approval decision. Of these, 72 percent were approved completely and another 28 percent were approved in part. c) Training was given to 437 providers in seven workshops during FY85.
2. Dental Services During FY85 payments were made to approximately 1,000 providers for 91,148 recipients of dental care, about 80 percent of whom were children and 20 percent were adults.
3. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Plans were made during FY85 to improve coordination of outreach, tracking and follow-up of children with possible abnormalities. Beginning July 1, 1985, scheduling and tracking of EPSDT screenees became the responsibility of the county health departments. Approximately 48,600 screens were reimbursed during FY85.
4. Durable Medical Equipment The Department reimbursed 359 providers for 18,092 recipients of durable medical equipment items during FY85, including items which were primarily paid for by Medicare. a) Durable medical equipment savings from the prior approval requirement were $155,080 during FY85. b) Savings through review prior to payment of out-of-state claims were $41,112.
5. Other Prior Approval and Prepayment Review In FY85 the Department saved $3,233,832 through its review of certain medical surgical procedures prior to the surgery and through review of sterilizations and hysterectomies prior to payment.
Community Care and Home Health Services
I . Community Care Services formerly Alternative Health Services) a) During FY85 serviceswere extended to all parts of the state. Mandatory prescreening of nursing home applicants for suitability of community care services began in some areas by the end of FY85. Payments of $6,980,830 were made for 2,984 recipients in FY85.

b) The Department completed a working agreement with large area hospitals allowing them to complete assessments on inpatients prior to discharge.
c) The Department received federal approval to continue special waivered service coverage for an additional three year period.
2. Home Health The Department paid 74 providers for 357,405 home health visits in FY85.
3. Rate Increase Both community care and home health providers received a five percent rate increase effective January 1, 1985.
4. Utilization Review Department utilization review activitiesbegan during FY85. Consultants representing the Department conduct period utilization reviews to assure medical necessity for continued care and to assure the effectiveness of the care being rendered. Reviews of each provider are conducted at least once a year. Fifty-three home health and 31 community care providers were reviewed in FY85.
PROGRAM INTEGRITY
The Division of Program Integrity is primarily responsible for ensuring compliance with state and federal regulations. Division staff conduct on-site field reviews and investigations of providers and recipients, develop eligibility policy, identify program overpayments and conduct evaluative studies of service program areas.
Medicaid Eligibility and Quality Control
I . Quality Control Unit The Quality Control Unit is responsible for monitoring eligibility determinations performed by the Department of Human Resources. During FY85, the eligibility status of approximately 2,100 Medicaid cases was reviewed. As errors were detected, referrals were made to the Department of Human Resourcesfor correctiveaction on individual cases. In conjunction with corrective action on individual cases, the Department of Medical Assistance and the Department of Human Resources conducted an indepth analysis of error trends and developed an extensive Corrective Action Plan addressing error conditions and implementing measures to correct errors in the eligibilitydetermination process.
2. Eligibility Policy Unit The Eligibility Policy Unit is responsible for making or recommending to the Department's Board certain state Medicaid eligibility policy decisions and developing eligibility policies for implementation by the Department of Human Resources. Activities during FY85 included: a) Coverage of Medically Needy The State's Medicaid program was expanded to cover children under 18and pregnant
women who are "medically needy," that is, who live in households with income 33 1/ 3
percent greater than the AFDC payment standard: i) January 1, 1985 - Children under 18 in one parent families; ii) January 1, 1985 - Pregnant women in one parent families; iii) April 1, 1985 - Children under the age of five living in two parent families; iv) April 1,1985-Pregnant women in families in which the principalbreadwinneris
unemployed.

b) Increase in Medicaid "Cap" The Department increased its maximum allowable monthly income "cap" for eligibility of a nursing home recipient from a net figure of $716 in December 1984 to $741 in January 1985 and to $897 in February 1985. These changes were expected to allow approximately 900 more individuals to be eligible for Medicaid (Medical Assistance Only) on an annual basis.
c) Planning for FY86 During FY85, the General Assembly approved funds for covering children under 18 and pregnant women in two parent families. This coverage began October 1,1985.The Department also began planning for the implementation of coverage for a new group of recipients in the community care program. Eligibility for this "Medical Assistance Onlyngroup is determined in the same manner as for nursing home recipients.
Investigations and Compliance
Investigative efforts in FY85 led to the conviction of two providers and three recipients. The Investigations and Compliance Section initiated 344 investigations and referred 10 cases to District Attorneys for prosecution;most are stillpending. Investigatorsidentified$1 14,289 in overpayments to providers and $1,804in refunds to recipients. Judicial finesand penaltiesof $738 were assessed against Medicaid providers, and $220 was assessed against Medicaid recipients.
Surveillance and Utilization Review
The Surveillanceand Utilization Review (SUR) Section is responsible for identifyingand investigatingpatterns of inappropriate care and misutilization of Medicaid services.Investigations are prompted by automated exception reports or by referrals from Department staff. These investigations are intended to identify and deny inappropriate Department expenditures and monitor the quality of care provided to Medicaid recipients.
The SUR Sectionstaff in FY85 completed the followingaudits (case reviews): physicians, 81;hospitals, 1I; pharmacy,46; other provider categories,40; and recipients, 112.Thisvolume of completed cases represents an increase of 13percent over FY84. As a result of these reviews, $463,000 in overpayments to providers was identified.
Third Party Liability
During the last half of FY85, the Third Party Liability Field Review Unit was established. Eight professional reviewers were hired to conduct on-site audits of participating providers throughout the State. These audits are conducted to assure that Medicaid is the payor of last resort and to recoverfunds where a third party is legally liableto pay for medicalservices.This unit also produces third party resource leads by providing detailed information to the caseworker staff of the Department of Human Resources, Division of Family and Children Services, and by working closely with representatives of major insurance carriers.
The Third Party Liability Section had a number of personnel changes associated with the Department's contracting with a fiscal agent. As a result of these changes, it was necessary to train a new Health Insurance Unit staff and establish a Financial Unit to record third party recoveries.
Program Evaluation
The Program Evaluation Section conducts statisticalanalyses on the effects of Medicaid policy changes, develops cost and service projections, monitors routine reports for accuracy

and edits the Annual Report. In FY85 Program Evaluation projected the number of intermediate care beds available for the mentally retarded, evaluated the need for heavy care nursing home service,and evaluated the cost-effectivenessof severalhome and community-based care waivers.
ADMINISTRATION
The Division of Administration performs those functions necessary to support the day-today operation of the Department, including accounting, budget, personnel and benefits recovery.
Benefits Recovery
The Benefits Recovery Section collected $13,988,967 in FY85. This includes collection on voluntary refunds and accounts receivable.
Personnel
Through the Personnel Office, the Department implemented the Fair Labor Standards Act in FY85. Personnel also developed the plan used to redistribute staff following the FY84 Reduction-in-Force.
SPECIAL SERVICES
In addition to coordinating all provider hearings and representing all Divisions at those hearings, the Office of SpecialServicesworked more closely than ever before in its supervisory role with the Fair Hearings Unit of the Department of Human Resources to ensure that applicantsand recipients are accorded ampleand consistent reviews of eligibilityand of level of care determinations by the Georgia Medical Care Foundation.
During FY85 the Office coordinated a high volume of hearings for home health program recipients as a result of the Department's new field auditing effort to eliminate overutilization in that program. This was the first time such a large number of similarly-situated hearings had been generated by Department action. Nearly 90% of all service terminations were agreed to by the providers or subsequently affirmed by hearing officers.
SYSTEMS MANAGEMENT
The Systems Management Division coordinates all data processing services for the Department and manages the Fiscal Agent contract for claims payment.
During FY85 the Fiscal Agent (The Computer Company) modified all subsystems of its Medicaid Management Information System during its first full year of operation. By the end of the year all subsystemswere operatingand all claim types were being paid weekly, except for nursing home claims, which are paid monthly.
Because of savings associated with the Fiscal Agent contract, computer services costs were over $3,000,000 lower than in FY84, a decrease of about 40 percent. Systems Management costs were about $1,600,000lower than costs for its predecessor, the Operations Division, in FY84, a decrease of about 40 percent. As a result of these savings, total Department administrative expenditures were reduced from 4.0 percent in FY84 to 3.4 percent of total expenditures in FY85.

Fiscal Year

A HISTORY OF MEDICAID BENEFITS EXPENDITURES

Cash Benefits Payments a

Percentage Change

Payments By Date of Service

Percentage Change

$308,142,782 $345,764,146 $386,973,307 $456,444,146 $55 1,269,783 $56 1,830,940 $625,823,785 $665,750,094 $755,435,075 (est.)
a Paid during each fiscal year. In this Annual Report all "expenditures," "benefits" or "payments" are cash benefits payments, with the exception of "payments by date of servicenabove (fourth column). Expenditures for servicesprovided during each fiscal year. Since FY77, based on a State Attorney General's ruling, payments have been made from the budget for the same year in which the Medicaid service was rendered. Final expenditure amounts are not known until some time after a fiscal year has ended, since providers have six months from the date of service to file a claim. Date of service figures are expenditures as of June 30, 1985,for FY77-FY84; FY85 is an estimate. Total expenditures for services rendered during each fiscal year will generally exceed payments made during that year.

. WHERE THE MEDICAID DOLLAR COMES FROM..

Georgia's Medicaid program receives different levels of federal reimbursement for different

types of activity. Reimbursemknt levels for benefits, family planning, the Medicaid Management

Information System (MMIS) and for administration of the program are determined each fiscal

year by the federal government.

Medicaid Management Information System

Most Benefits

& Systems Management Division

FEDERAL FUNDS
Family Planning Benefits
Medical Assistance Only Medicare Premiums

*Subject to Federal Certification of System.
Most Other Administration
FEDERAL STATE
Total

Sources of Medicaid Benefits Revenue FY85

Federal Funds State Funds Total Revenue

$464,488,745 $229,790,3 10 $694,279,055

. WHERE THE MEDICAID DOLLAR G O E S . .
BENEFITS

ADMINISTRATION

TOTAL EXPENDITURE $7 18,752,561

I Benefits 96.6%

Program Integrity Administration
Commissioner's Office Georgia Medical Care Foundation

3.4%

I

FY 85 BENEFITS EXPENDITURES "

Category of Service

Amount

Percent of Payments By Service

Skilled Nursing Facility Intermediate Care-Mentally Retarded Intermediate Care-Other Inpatient Hospital Outpatient Hospital Prescribed Drugs Physician Dental Other Care Clinic (Mental Health) Family Planning Other Practitioner Home Health Laboratory1 Radiology Rural Health Clinic Early and Periodic Screening
Diagnosis and Treatment

$ 69,645,955 57,059,704 134,31 1,309 184,485,522 42,968,8 15 79,226,180 65,741,827 9,929,286 15,762,831 10,410,391 5,437,470 2,280,478 14,537,632 920,946 245,890
1,314,819

TOTAL EXPENDITURES
MEDICARE PREMIUMS d USUAL FEDERAL MATCH 100% STATE FUNDS TOTAL PREMIUMS

$694,279,055
$18,070,938 $ 3,837,396 $2 1,908,334

a Cash benefits payments (by date of payment) as reported in Annual Statistical Report on Medical Care. "Total Expenditures" include copayments and deductibles for persons eligible for Medicare and Medicaid; Medicare premiums are not included.
Other care includes ambulance, community care (alternative health), durable medical equipment, nonemergency transportation and orthotics/ prosthetics.
Other practitioners include chiropractors, nurse midwives, optometrists, podiatrists, psychologists and therapists.
The State is required to pay the total Medicare premium for an individual who is eligible for both Medicare and Medicaid, lives in an institution, and has an income above the SSI Standard. The usual federal match applies for others.

FY85 ADMINISTRATIVE EXPENDITURES

Administrative Function
Fiscal Agent Computer Services Department of Human Resources
Interagency Contract *
Systems Management Administration Program Management Program Integrity Ga. Medical Care
Foundation Contract Commissioner's Office
TOTAL

Expenditures Percent of Total

$24,473,506

100.0%

* Federal funds only. State match funds appear in Department of Human Resources budget.

COLLECTIONS AND MEASURABLE COST AVOIDANCE
Collections Third Party Liability a (Insurance Recoupments) Hospital Cost Settlement Other Collections Total Collections
Measurable Cost Avoidance Nursing Home Audit Disallowances d Prior Approval and Prepayment Review
Total Measurable Cost Avoidance GRAND TOTAL
a The decrease in third party liability collections in FY84 and FY85 is due in part to the institution of cost avoidance edits for individuals who have other health insurance coverage. This approach avoids paying certain claims at all, so fewer collectionsare required. Collectionsalso were lower in FY85 due to problems related to the fiscalagent's initial year of operation. Hospital settlement collections are for service dates prior to January 1, 1983. Includes collectionsoriginating from Investigationsand Compliance, Surveillanceand Utilization Review, audits of providers other than nursing homes, and voluntary refunds. Estimated from 1980cost reports for dates through January 1985and from 1983cost reports for February through June 1985. The decrease in FY85 prior approval and prepayment review is related to the fiscal agent's initial year of operation.

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

PAYMENTS

RECIPIENTS

BY AID CATEGORY

BLIND 0.9%

BY SEX

BY RACE

BY AGE GROUP

RECIPIENTS BY AID CATEGORY BY TYPE OF SERVICE a
FY 85

Type of Medical Service

Age 65 or Over

Blind

Disabled

AFDC Adults

AFDC Children

Unduplicated Totals

Skilled Nursing Facility

Intermediate Care-Other

Intermediate Care for the

Mentally Retarded

Inpatient Hospital

Outpatient Hospital

Physician

Prescribed Drugs

Dental

Other Practitioner

-

Clinic (Mental Health) Family Planning

00

Home Health

Laboratory1 Radiology

Early & Periodic Screening,

Diagnosis & Treatment

Rural Health Clinic

Other Care

TOTALS

90,474

3,038

97,665

103,039

196,469

454,823

a Source: Annual Statistical Report on Medical Care (sum of unduplicated count by maintenance assistance status and basis of eligibility). Medicare copayments and deductibles included.
bother practitioners include chiropractors (263), nurse midwives (257), optometrists (15,085), podiatrists (16,968), psychologists (4,336) and therapists (1,223). Other care includesambulance (18,376),community care (alternative health; 2,984),durable medical equipment (18,092),non-emergency transportation (28,031) and orthotics1prosthetics (2,436). d Recipients are counted no more than once in each category of service in which service was provided. Recipients also are counted in each aid category in which they were eligible, so the unduplicated total is generally less than the sum across aid categories. There were 498 "medically needy" recipients. The total for "AFDC children" includes 1,396 "Other Title XIX recipients" (AFDC foster care).

BENEFITS PAID BY AID CATEGORY BY TYPE OF SERVICE a
FY 85

Type of Medical Service

Skilled Nursing Facility

Intermediate Care-Other

Intermediate Care for the

Mentally Retarded

Inpatient Hospital

Outpatient Hospital

Physician

Prescribed Drugs

Dental

-

Other Practitioner Clinic (Mental Health)

\O

Family Planning

Home Health

Laboratory/ Radiology

Early & Periodic Screening,

Diagnosis & Treatment

Rural Health Clinic

Other Care

Age 65 or Over

Blind

Disabled

AFDC Adults

AFDC Children

TOTAL PAYMENTS d

$234,219,996 $6,172,973 $277,237,423 $100,579,428 $76,069,235

Total Payment
--
$694,279,055

a Source: Annual Statistical Report on Medical Care (sum of amounts by maintenance assistance status and basis of eligibility).Medicare copayments and deductibles included. Other practitioners include chiropractors ($7,89l), nurse midwives ($95,683), optometrists ($585,279), podiatrists ($740,714),psychologists ($535,727) and therapists ($319,214). Other care includes ambulance ($1,003,488),community care (alternative health; $6,980,830),durable medical equipment ($3,938,039), non-emergency transportation ($2,827,020) and orthoticsl prosthetics ($1,008,176). Total Payments do not include Medicare premiums paid for persons eligiblefor both Medicare and Medicaid. Medicare premiums were $21,908,334 in FY85. Payments of $227,467 were made for "medically needy" recipients. The total for "AFDC Children" includes $550,049 for "Other Title XIX Recipients" (AFDC foster care).

PERCENTAGE OF EXPENDITURES AND OF RECIPIENTS AND AVERAGE YEARLY PAYMENT PER RECIPIENT BY AID CATEGORY FY 85

Basis of Eligibility
Aged a Blind a Disabled a AFDC Children AFDC Adults
TOTAL

Expenditures
$234,2 19,996 6,172,973
277,237,423 76,069,235 100,579,428
$694,279,055

Percentage of Total
33.7% 0.9% 39.9% 1 1 .O% 14.5%
100.0%

Recipients
90,474 3,038 97,665 196,469 103,039
454,823b

Percentage of Total

Average Paid Per Recipient

100.O%

$1,526.48

a Most aged and a portion of the blind and disabled are covered by Medicare, so expenditures do not reflect the total cost of health care.

to4

b Unduplicated count. Percentage of total has been calculated based on sum of recipients within aid categories. This sum is 490,685, since

individuals can be in more than one aid category per year.

PAYMENTS FOR SERVICES PER RECIPIENT a

Type of Service

Average Payment Per Recipient

82

83

84

85

Nursing Home Intermediate Care-MR Intermediate Care-Other Skilled Care
Inpatient Hospital Home Health Clinic (Mental Health) Physician Dental Prescribed Drugs Other Care
Ambulance Community Care (Alt. Health) Durable Medical Equipment Non-Emergency Transportation Orthoticsl Prosthetics Outpatient Hospital Family Planning Other Practitioner Chiropractor Nurse Midwife Optometrist Podiatrist Psychologist Speech, Phys., Rehab. Therapist Laboratory/ Radiology Rural Health Clinic Early & Periodic Screening, Diagnosis and Treatment

$ 26,127.55 5,495.17 4,443.25 1,584.04 1,216.93 525.52 162.32 1 12.26 149.34 133.34
c
c c
c
c
124.75 109.96 66.57
c
C
c c
c
c
19.39 48.04
29.59

Average Payment Per Recipient

for All Services

$ 1,244.21

$ 1,381.27

$ 1,406.91

$ 1,526.48

Payments and recipients include Medicare copayment and deductibles. Recipients by type of service were estimated for FY83 and FY84. Data not available.

PERCENTAGE OF TOTAL RECIPIENTS UTILIZING EACH SERVICE

Type of Service

FY 82

FY83 a

Prescribed Drugs Physician Outpatient Hospital Inpatient Hospital Dental Early & Periodic Screening
Diagnosis & Treatment Other Care
Ambulance Community Care (Alt. Health) Durable Medical Equipment Non-Emergency Transportation Orthotics and Prosthetics Other Practitioner Chiropractor Nurse Midwife Optometrist Podiatrist Psychologist Speech, Phys., Rehab. Therapist Family Planning Laboratory and X-Ray Intermediate Care-Other Mental Health Clinic Skilled Nursing Facility Home Health Intermediate Care-MR Rural Health

a Recipients by type of service estimated for FY83 and FY84. Data not available.

FY84 a

FYSS

CLAIMS PROCESSED BY CATEGORY OF SERVICE FY 85

Category of Service
Prescribed Drugs Physician Outpatient Hospital Nursing Home Inpatient Hospital Other
TOTAL

Number of Claims Processed
6,578,021 4,004,7 10
727,524 350,64 1 184,898 1,89 1,9 10
13.737.704

Percent
47.88% 29.15% 5.30% 2.55%
1.35% 13.77%
100.00%

TOTAL NUMBER OF PHYSICIANS' VISITS BY LOCATION
FOR FISCAL YEAR 1985

Place of Visit
Physician's Office Hospital Inpatient Hospital Outpatient Clinic Skilled Nursing Home Intermediate Care Nursing Home Recipient's Home Elsewhere
TOTAL

Number of Visits 1,035,195

NOTE: "Recipient's home" and "elsewhere" are estimates based on FY84 data.

Percent 100.00%

PROVIDERS WITH PAID CLAIMS a
DURING FY82-FY85 BY TYPE OF SERVICE

Type of Service

FY82

Skilled Nursing Home Intermediate Care-Other Intermediate Care for
Mentally Retarded Inpatient Hospital Outpatient Hospital Physician Prescribed Drugs Dental Adult Dental Other Practitioner
Nurse Midwife Optometrist Podiatrist Psychologist Mental Health Center Family Planning Home Health Independent Laboratory and X-ray Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Rural Health Clinic Other Care Durable Medical Equipment Orthotics/ Prosthetics Ambulance Non-Emergency Transportation Community Care (Alt. Health)

Number of Providers

FY83

FY84

C
FY8S

a The number of providers with paid claims can be considerably less than the number of providers "enrolled." For example, the number of providers enrolled for inpatient hospital during FY85 was 1,421;for intermediatecare nursing home, 307;for pharmacy, 1,855;for physicians, 15,393;and for child dental, 1,510. The total number of providers enrolled at the end of FY85 was 24,211, an increase of 1,404 from FY84.
Most large differences between FY85 and earlier year figures are due to a change in the basis for counting providers in FY85. Unlike counts from previous years, FY85 counts include Medicareonly providers and providers with negative payments only. Physicians and pharmacies are not included as family planning providers in FY85. Each separate facility was counted as a provider of mental health or EPSDT in FY85. Out-of-state providers are included for all years.
Data not available.

APPL IN6 ATKINSOH DACON BAKER BALWlM DAMS BARRW DARTW BEN HILL DERR lEN 1118 DLECKLEY RRANTLEY BROOKS 1RYAN BULLOCH 1URKE Dulls CALHOUN CABDEN CANDLER CARROLL CATOOSA CHARLTON CHATHAM CHATTAHOOCWEE CIATT006A CHEROKEE CLARKE CLAY CLAYTON CL INCH COBB COFFEE COLQUI T 1 COLUMDlA COOK CWETA CRAWFORD CR lSP OAOE OAWSON

ANALYSIS OF RECIPIENTS AND EXPENOITWRES BY CWltTY FOR FISCAL YEAR 1985

1
Est i n t e d
Drmcf itr
Paid

b Prejectrd
1985 Pepmlrtion

Undmplicrtd Recipicmtr

% r f Peplrtimr Rrrririmg Irdicrid

C r f lrtrl State
Deripiemts

E~prditmtes Per
Dcripirmt

DECATUR DEKALB DODGE DOOLY DOU6RhRlY DOU6LAS EARLY EC18iS EFF lN6RAW ELBEIT EWAWUEL EVANS
FAWWl w
FAYETTE FLOYD FORSYTY FRAWKLl W FUlTOW 61 LWEI BLASCOCK GLYWI BORDOI GRAD1 BREEWE GWIWNETT HA8ERSYAW HALL HAICOCK HARALSMl HARRIS HART HEARD HEWRY YOusloW IRWlI JACKSOW JASPER JEFF DAVlS JEFFERSON JEWKIIS JOWISOW JONES

AWALYSIS OF REClPlEWTS AID EIPEMITBRES BY COWIY FOR FISCAL YEAR 1985

a Estimated Beref it s
Paid

L ?rejected
1985 Pnprlat inn

BrCplitrted Recipients

I ef Peprlatier
Retririr# Ikdicail

(i r l t o t a l atate
Reripirnts

EtptJitrres Per
ktipitnt

Count 1
LAMAR LAWlER LAUREMS LEE 1IIERTY L IYCOLM LOWE LWllbES LUlPKlM rAcon MA) ISON MAR ION YCDMFF IE MC IWTOSH YEIlWETHER MILLER MITCIELL MOIOE MOMT6OHERY HOR6AM MURRAY RSCO6EE NEW011 DCMIEE 06LETIIOIPE PAULDIM6 PEACH PlCKEMS PIERCE PIKE POLK PULASKI PUTNAM QUITHAW RABUM RAMOOLPH RlCHNOND ROCIDALE SCHLEY SCREVEM SEMIMOLE SPALOIN6

ANALYSIS OF RECIPIENTS AID EXPENDITURES BY COUMTY FOR FISCAL TEAR 1985

a Est hated I e e t f it s
Paid

b Projected
1985 Pepulatien

Undspli c a t e l Recipients

% of Pepslatien Rcceirieg Medicaid

S of Total State
Recipients

Expenlitsres Per
Recipient

ANALYSIS OF RECIPIENTS AND EXPEIOITURES BY COUNTY FOR FISCAL YEAR 1985

County

a Est imatcd Benef it s
Paid

b Projected
1985 Population

Undup 1icated Recipients

% of Population Receiving Medicaid

% of Total State
Recipients

Expendi t u r e s Pe r
Recipient

STEPHENS STEWART SUMTER TALBOT TAL lAFERRO TATTNALL TAYLOR TELFAIR TERRELL THOMAS TlFT TOMlBS TWWS TREUTLEN TROUP TURNER TW 166s UNlON UPSOI WALEER WALTON WARE WARREN WASI IN6TON WAYNE YEBSTER WHEELER WHITE WHITFIELO Y l LCOX W l LEES W l l l l ISON WORTH
c STATEW l BE
a Benefits payments f o r each cofinty hare been estimated based on recipients from the 'Medicaid Net Expenditure R e p r r t by R e c i p i e n t County o f Residence' f r r SF185 and expenditures per r e c i p i e n t from SFY84. Expenditfires per r e c i p i e n t f o r SFY85 were estimated by i n f l a t i n g SF184 f i g u r e s by 15.339 percent ir order tr be c o n s i s t e n t w i t h s t a t e w i d e t o t a l expenditures. SFY85 e x p e n d i t ~ r e sa r e t h e product o f r e c i p i e n t s by expenJitfires per r e c i p i e n t . b Projected popfilatior f o r 1985 from 6orernor1s Off i c e o f Planning and Budget. c Statewide expenditfires and r e c i p i e n t s d i f f e r from f i g f i r e s shown elsewhere i n t h i s r e p o r t dne t o i n c l u s i r n o f refngces i n t h i s t a b l e . Srm o f '1 o f T o t a l S t a t e Recipients' exceeds 100% s i n c e a r e c i p i e n t can r e s i d e i n more than ore cofirty during a year. Statewide recipient cofint i s unduplicated f o r the State.

COMPARISON OF ELIGIBLES, EXPENDITURES AND EXPENDITURES PER ELIGIBLE, FY82-FY85

July August September October November December January February March April May June
Average Monthly Eligibles
Annual Percent Change

41 1,202

4 12,982 0.43%

426,122 3.18%

--
430,825 1.10%

Annual Expenditures (millions)
Annual Percent Change
Annual Expenditure Per Eligible
Annual Percent Change

$542.307 $1,3 18.83

$613.393

13.11%

--

-

$1,485.28

12.62%

$624.861 1.87%
$1,466.39 -1.27%

$694.279
11.1 1%
--
$1,611.51
9.90%

Note: Source for eligibles is Monthly Statistical Report On Medical Care. Not all of those eligible are recipients of services. The average number of recipients for whom payments were made each month were 210,805 for FY82,218,825 for FY83,218,368 for FY84, and 229,438 for FY85.

DEPARTMENT OF MEDICAL ASSISTANCE ADVISORY COMMITTEE AS OF JUNE 30,1985

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. Subcommittees of this group, sixteen representing medical professional groups and one representing consumers, are appointed by the Commissioner and meet at least quarterly or at the discretion of their respective chairpersons. An important function of these subcommittees is to delineate the effects of proposed policy changes and relay the concerns of their associates to the Department. The subcommittees and their members are listed alphabetically below.

Community Care Mr. Lawrence Besel Ms. Sarah Brownlee Mr. Hunter Hurst, Chairperson Mr. Olan Jones Ms. Julia Mack Ms. Jane McCombs Fred McGinnis, Ph.D. Ms. Rosemary Parker Ms. Patricia Persse Ms. Carol Robinson Mr. Ralph Robinson Ms. Brenda Sanford Mr. Scott Schull

Dalton Atlanta Savannah Waycross Atlanta Atlanta Atlanta Savannah Savannah Atlanta Athens
Tucker

Consumer

Ms. Mary Banks

Ms. Grace Barksdale

Atlanta

Ms. Phyllis J . Holmen, Chairperson Atlanta

Ms. Susan Hutchins

Athens

Ms. Ethel Mae Mathews

Atlanta

Ms. Dora Miles

Atlanta

Mr. Jeff Roulston

Atlanta

Ms. Nancy Scurry

Augusta

Mr. Lewis Sinclair

Atlanta

Ms. Patricia M. Smith

Marietta

Mr. Willie Temple

Darien

Ms. Carol Trails

Atlanta

Mr. William R. Wright

Newnan

Dental

Michael Carr, D . D S

Donalsonville

Janet H. Harrison, D.D.S. Milledgeville

Alston J. McCaslin, D.D.S.,

Chairperson

Savannah

James H. Piper, D.D.S.

Elberton

Linda L. Smith, D.D.S.

Atlanta

James L. Stockslager, D.D.S

Macon

Willis J . Walker, Jr., D.M.D.

Augusta

Dewitt T. Walton, Jr., D.D.S.

Macon

Edward M. Williams, D.D.S.

Atlanta

Durable Medical Equipment

Mr. Wayne Bloodworth

Macon

Mr. H.G. Bowden,

Chairperson

Warm Springs

Mr. Dean Cox

Cartersville

Mr. Eric Holgate

Augusta

Mr. Roy M. Shuman

Waycross

Mr. Steve Stahlman

Marietta

Early and Periodic Screening,

Diagnosis and Treatment

Mr. Willie Barker

Atlanta

Daniel S. Blumenthal, M.D.,

Chairperson

Atlanta

Gunar Bohan, M.D.

Atlanta

Monica Cynthia Greene, M.D. Augusta

Ms. Reba Greenwood

Atlanta

Ms. Donna E. Smith

Atlanta

Ms. Barbara Sweeney, R.N.

Atlanta

Ms. Delphine Young

Atlanta

Home Health Ms. Eileen Bland Captain C. C. Dudley Ms. Lois Hall Mr. Charles Hecht, I11 Mr. Ira Jackson Ms. Wilma Kerr Mr. Robert Mills Mr. Ron Silvers Ms. Patricia Szucs, R.N.,
Chairperson

Jesup Lavonia
Griffin Columbus
Atlanta Atlanta Brunswick Atlanta
Atlanta

Hospital

Mr. Glenn Black

Marietta

Ms. Selena D. Dunn, Chairperson Atlanta

Mr. Charles L. Foster, Jr.

LaGrange

Mr. J.R. Griffith, Jr.

Americus

Mr. William Jackson

Atlanta

Mr. Thomas Kelly, Jr.

Augusta

Mr. Damon D. King

Macon

Mr. Dan S. Maddock

Hawkinsville

Ms. Kay Moses

Atlanta

Mr. Bobby L. Thorneberry

Rome

Mr. Joe Tucker

Swainsboro

Mr. W.H. Woolard

Sylvester

Nursing Home

Mr. Joseph F. Cobis

Columbus

Mr. James Cunningham

Adel

Ms. Edwina Evans

Macon

Mr. Kent Charles Fosha

Tucker

Mr. Bobby Johnson

Ellenwood

Mr. Davis King

Albany

Mr. Doug Moody

Tifton

Mr. Frank Shaw

Atlanta

Mr. Fred Watson, Chairperson Atlanta

Mr. W. Jule Windham

Marshallville

Optometric

Carol William Brown, O.D.

Savannah

William Dobbs, O.D.

Covington

David Dudovitz, O.D.

Duluth

Lorenzo Jones, O.D.

Macon

Stuart R. Tasman, O.D.

Acworth

Allan Wexler, O.D., Chairperson Savannah

Orthotics and Prosthetics

Mr. Lee Claxton

Augusta

Mr. A.M. Hancock

Atlanta

Mr. Grover A. Jeffcoat

Savannah

Mr. Howard Thranhardt,

Chairperson

Atlanta

Mr. Arthur Williams

Dalton

Outpatient Mental Health

Allen Carter, Ph.D.

Atlanta

Mr. Robert (Bob) Lee Hauss Jefferson

Charles (Chuck) P. Kuhn, M.D. Dublin

Ms. Cynthia A. Luke, R.N.

Columbus

Mr. Bill C. Mahaffey

Lawrenceville

Ms. Cathy E. McRae,

Chairperson

Savannah

Ms. Judy E. Nevilles Porter

Atlanta

Ms. Patricia A. Rentrope

Atlanta

Elizabeth Stribling, Ph.D.

Atlanta

Mrs. Sherman K. Whitfield Warner Robins

Ms. Jennie E. Williams

Marietta

Pharmacy Oren H. Harden, Jr., R.Ph., Chairperson Harold Jones, R.Ph. Diane Nykamp, Pharm. D. Neil Pruitt, R.Ph. Sam W. Tolar, 111, R.Ph. Earl S. Ward, Jr., Pharm. D. Evan Ward, Sr., R.Ph. Joe Whaley, R.Ph. Patricia L. Zeigler, R.Ph.

Sylvester Augusta Atlanta Toccoa Sharpsburg Atlanta Atlanta Albany Atlanta

Physicians

Julia V. Ashley, M.D.

Monroe

William H. Borders, Jr., M.D. Atlanta

Mirian E. Chivers, M.D.

Atlanta

William H. Cox, D.O.

Norcross

James M. Crawford, M.D.,

Chairperson

Atlanta

Joel Robert Fountain, M.D.

Forsyth

Judson L. Hawk, Jr., M.D.

Atlanta

Herbert Jones, M.D.

Atlanta

Winton King, M.D.

Decatur

A.A. McNeill, Jr., M.D.

Camilla

William H. Rhodes, Jr., M.D. Union Point

Robert E. Lee Shumate, M.D. Columbus

Podiatry Kermit R. (Ted) Ary, D.P.M. M. Tucker Brawner, D.P.M., Chairperson John R. Cooper, D.P.M. Michael E. Wineburgh, D.P.M.

Albany
Savannah Mableton Riverdale

Psychology Ronald Berlin, Ph.D. Allen Carter, Ph.D. Hugh Christie, Ph.D. Jerry Davis, Ph.D., Chairperson Nick de Filippis, Ph.D. Donald R. Keppner, Ph.D. Sylvia Shellenberger, Ph.D.

Atlanta Atlanta Griffin Atlanta Augusta Athens Macon

Rural Health
Mr. John Carter, Chairperson Mr. Richard Hathaway Guerrant H. Perrow, M.D. Ms. Joan Pettit

Albany Crawford
Jasper Morganton

Transportation

Mr. Michael L. Gallagher

Gainesville

Mr. Paul Genest

Claxton

Ms. Judy Hagebak

Decatur

Mr. Ray Hawkins

Atlanta

Mr. Ben Hinson, Chairperson

Macon

Mr. Hubert Murray

Fairburn

Mr. Wayne Scruggs

Atlanta

Ms. Patricia E. Walker

Milledgeville

It is appropriate in this Annual Report to reaffirm the Department's full commitment to the principles of Equal Employment Opportunity. The Department's policy is to assure that opportunities for employment, advancement, and for dignity in work are equally available to all. Employees and applicants, including handicapped individuals, are evaluated on the basis of performance, attitude, skill and experience without regard to race, color, sex, age, religion or national origin.

STATE OF GEORGIA DEPARTMENT OF MEDICAL ASSISTANCE 2 MARTIN LUTHER KING, JR., DRIVE S.E.
ATLANTA GEORGIA 30334