Annual report, 1990

GEORGIA DEPARTMENT OF MEDICAL ASSISTANCE
Annual Report 1990
Aaron J. Johnson Commissioner

Aaron J. Johnson Commiuioner

State of Georgia
- Department of ~ e d i c aAl ssistance Floyd Veterans Memorial Bldg. West Tower 2 Martin Luther King, Jr. Drive, S.E. Atlanta, Georgia 30334

The Honorable Joe Frank H a r r i s Governor of Georgia
Members o f t h e General Assembly o f Georgia Citizens o f the State o f 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 Report of t h e Department o f Medical Assistance. This r e p o r t summarizes agency a c t i v i t y through t h e f i s c a l y e a r ending June 30, 1990. D u r i n g t h i s y e a r we made h e a l t h c a r e a r e a l i t y f o r more than 600,000 c i t i z e n s .
I w i s h t o express my a p p r e c i a t i o n , and t h a t o f my s t a f f , f o r your support and assistance.

An Equal Opportunity Employer

TABLE OF CONTENTS

Abstract and Covered Services................................................ 1

Who Is . Eligible .............................................................2

Board of Medical Assistance..................................................3

Organization Chart...........................................................4

Highlights of the Year.......................................................5

Table and . Charts ........................................................... 19

A History of Medicaid Benefits Expenditures........................... 20

FY90 Benefits and Recipients by Category of . Service ..................21

Where the Medicaid Dollar Comes From..................................22

Where the Medicaid Dollar Goes........................................23

........... FY90 Administrative Expenditures and FY90 Medicare Premiums

24

Collections and Measurable Cost Avoidance, . FY87-90 ...................25

Recipients and Payments by Aid Category, Sex. Race....................26

Recipients and Payments by Age, Rural/Urban...........................27

Change in Recipients and Payments . 1987-1990 ..........................27

Recipients by Aid Category by Type of Service. FY90...................28

Benefits by Aid Category by Type of Service, FY90.....................29

Percentage of Expenditures. Percentage of Recipients. and Average
Yearly Payment per Recipient by Aid Category. FY90..............30

Number of Visits and Prescriptions by Aid Category. FY90..............30

Average Payment for Services per Recipient. . FY87-FY90 ................31

...... Percentage of Total Recipients Utilizing Each Service. FY87-FY90

32

......... Percentage of Total Expenditures for Each Category of Service

33

Claim Documents Processed by Category of Service. FY90................34

.... Providers with Paid Claims During FY87-FY90 by Category of Service 35

...... Comparison of Eligibles. Recipients. and Expenditures. FY87-FY90

36

... Analysis of Recipients and Expenditures by Recipient's County. FY90 37

Department of Medical Assistance Advisory . Committee ........................42

ABSTRACT OF FISCAL YEAR 1990

Expenditures Benefits Medicare Premiums Administration
Number of Medicaid claim details processed
Enrolled Providers (as of June 3 0 , 1 9 9 0 )
Average number of monthly eligibles
Unduplicated count of recipients served
Average yearly benefit per recipient

$ 1,385,905,937

$

45,427,184

$

65,549,613

19,549,371

26,833

525,310

624,257

$

2,220.09

COVERED SERVICES
Ambulance and Non-Emergency Transportation Ambulatory Surgical Services Community Care Services Dental Services Dialysis Services Durable Medical Equipment Services Early and Periodic Screening, Diagnosis and Treatment
(under age 2 1 ) Services Family Planning Services Home Health Services Hospice Services Inpatient and Outpatient ~ o s p i t a lservices Intermediate Care Facility services Intermediate Care for the Mentally Retarded ~acilityservices Laboratory and Radiological Services Mental Health Case Management Services Mental Health Clinic Services Mental Retardation Community Services Nurse Midwifery Services Orthotic and Prosthetic Services Physician Services Pediatric Services Prescribed Drugs Psychological Services Rural Health Clinic Services Skilled Nursing Facility Services Swing Bed Services Vision Services

Who is Eligible-
I. CATEGORICALLY NEEDY
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) ~ecipients. These individuals are aged, blind or disabled and have less than $386 net income per month.
C. Pregnant women who would be eligible for AFDC if their children were born and living with them; pregnant women in intact families (including unemployed parent households); children under age 1 8 in deprived or intact households; foster care and Itspecial needs" (adoption supplement) children; families who are no longer receiving cash public assistance due to increased earnings or loss of certain work-related deductions.
D. Aged, blind and disabled individuals who have lost their SSI benefits because their Social Security payments have increased as a result of cost-of-living income adjustments or certain changes in disabled adult child or widow(er) benefits. Also included in this group are individuals residing in nursing homes whose income exceeds the SSI income limit. These individuals retain $30 income monthly for their personal needs and contribute the remainder toward the cost of nursing home care.
11. MEDICALLY NEEDY
Pregnant women and children in deprived or intact households and aged, blind or disabled persons in their own homes or in nursing homes who meet the categorically needy qualifications except for income or resources. Incomes in excess of 133 113 percent of the AFDC payment standard may be spent down by application of incurred medical expenses.
111. RIGHT FROM THE START MEDICAID (RSM)
Children under age six and pregnant women whose net family income does not exceed 133 percent of the federal poverty level. Resource limitations are not imposed on this group.
IV. QUALIFIED MEDICARE BENEFICIARIES
Individuals who are eligible to be enrolled in Medicare Part A whose income does not exceed 90 percent of the federal poverty level or twice the SSI resource limits.

BOARD OF MEDICAL ASSISTANCE As of June 30, 1990

The Board of ~edical~ssistancies 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
Ms. Ann McKee Parker, Chairperson Atlanta, Georgia
Joseph H. Patterson, M.D., Secretary Atlanta, Georgia
Ms. Beauty P. Baldwin Lawrenceville, Georgia
Mr. Richard T. De Mayo Atlanta, Georgia
Mr. Charles H. Wilson Atlanta, Georgia

TERM OF OFFICE Through June 30, 1992 Through June 30, 1992 Through June 30, 1993 Through June 30, 1991 Through June 30, 1990

DEPARTMENT OF MEDICAL ASSISTANCE ORGANIZATION CHART
Board of Medical Assistance
I
commissioner

Advisory Committees

I
Deputy Commissioner

I
Assistant
Commissioner

/F T i v i s i o n o f Administration

--
I
Division of Program

- Office of Personnel

Office of /special Services !

Division of Institutional Policy 8 Reimbursement
Office of Special lnitiatives
Administration Unit

HIGHLIGHTS OF THE YEAR
During State Fiscal Year 1990 (July 1, 1989 to June 30, 1990), almost $1.4 billion was paid by the Department for medical care for 624,257 recipients. The cost of administration of the program
remained low - only 3.9 percent of the total Medicaid budget.
In the following summary we have included highlights of major Fiscal Year 1990 (FY90) activities within the Department.
INSTITUTIONAL POLICY AND REIMBURSEMENT
This Division houses the Nursing Home, Hospice, Swing-Bed and Hospital programs.
Hospital, Hospice and Swins Bed Services
1. The Department reimbursed 360 providers for 687,967 days of inpatient hospital care for 120,526 admissions during FY90. This represented an increase of 32,508 days and 12,759 admissions from FY89.
2. Audits Under the auspices of the Department's common audit agreement with Blue Cross and Blue Shield of Georgia, Inc., there were 146 audits of hospital cost reports performed during FY90. These were mainly audits of hospitals' cost reports for FY87 and FY88. As a result of the audits, the Department saved $2,524,340.
Reimbursement Rate Effective January 1, 1990, the Department used each hospital's fiscal period 1987 cost report to determine its prospective per case rate. Effective April 1, 1990, the trend factor used to inflate base year operating costs to the reimbursement year was changed from 4 percent per year to the sum of 3.9, 5.1, 6.1, 5.8 and 1.5 percent for calendar years 1987, 1988, 1989, 1990 and the first quarter of 1991, respectively.
4. Hospital Utilization Allowance Effective January 1, 1990, the Department no longer assigned a utilization allowance for each hospital for the calendar year. The utilization allowance was replaced with a Hospital Preadmission Review Program which began March 1, 1990.
5. Outliers Hospitals were paid $4,102,138 in FY90 for 101 inpatient claims with unusually high charges (cost outliers), or exceptionally long lengths of stay (day outliers).
6. Recoveries The Department identified net overpayments due in the amount of $1,935,136, which represented 115 cost settlements under

the Alternative Reimbursement System. In addition, the Department identified overpayments to 20 hospitals in the amount of $403,535, which represented excess of payments over charges for inpatient services.
7. H o s p i c e Services The Department reimbursed 12 providers for services provided to 98 recipients in the amount of $418,760.
8. Swing-Bed Services The Department began coverage of swing-bed services on January 1, 1990. Reimbursement for swing-bed services is based on the statewide average per diem rate paid to skilled nursing facilities for routine services furnished during the previous calendar year.
9. S t a f f C l a i m R e v i e w Review of out-of-state claims resulted in a savings of $261,880.
Nursinq Home Services
The Department reimbursed 344 providers for 10,032,237 days of nursing home care for 40,974 recipients.
1. A u d i t s Pursuant to its contract with the Department, the State Department of Audits performed on-site audits on 109 facilities during FY90. As a result of the audits, the Department saved $5,869,919.
2. R e i m b u r s e m e n t R a t e s The Department implemented the following changes effective April 1, 1990:
a. the 1989 cost report was used as the basis for computing reimbursement rates for nursing homes;
b. the overall growth allowance used as the basis for computing reimbursement rates was 9.1 percent; and
c. the allowance paid to facilities reimbursed under the Dodge Property Index for equipmentwas increased from $ . 7 5 to $1.02.
3. Effective October 1, 1989, the Department provided an allowance to increase the salaries of non-administrative staff in nursing homes. In June 1990, the Department reimbursed nursing homes for nurse aide training and testing costs which had been incurred to meet the OBRA requirements during the fiscal year.

4. R e v i e w s Pursuant to its contract with the Department, the ~eorgia Medical Care Foundation (GMCF) completed 730 on-site reviews and 57,887 recipient reviews of care in nursing facilities during FY90. A total of 53,697 pre-admission certifications for level of care were completed during FY90, an increase of 12,800 for the year.
PROGRAM MANAGEMENT
The Division of Program Management develops and implements reimbursement, coverage and other policies based on federal laws and regulations, state laws, and directives of the Board of ~edical Assistance. The Division also conducts training for providers in program service areas. The four units within the ~ivisionof Program Management are Individual practitioner services, ~ncillary services, ~ommunity'~erviceasnd Waivered Services.
Individual practitioners services
1. P s y c h o 1 o g y Service On January 1, 1990, covered psychology service hours for children were increased from nine to 41. Psychology rates were increased to be equal to psychiatry rates.
2. P r o v i d e r T r a i n i n g seventy-eight formal policy workshops were held for 2,643 practitioners and billing staff members. Additional assistance in resolving claims payment problems was provided to physicians and other providers statewide on an individual basis by eight field representatives located throughout the State.
3 . New Programs I n i t i a t e d i n FY90 A. On October 1, 1989, the Department implemented the ~ialysis Services Program to monitor and control expenditures for End Stage Renal Disease (ESRD) services for recipients not eligible for Medicare and for services provided during the ninety (90) day waiting period required for Medicare eligibility determination. This service was previously covered under the Physician program.
B. On April 1, 1990, in compliance with the Omnibus Reconciliation Act of 1989, the Department implemented the Community Health Center Services program. This program was designed to reimburse Federally Qualified Health Centers (FQHCs) at an all inclusive rate which represented 100 percent of reasonable cost for I1coreta1nd other ambulatory services covered in the State plan.

C. The Individual Practitioners Section completed all the preliminary tasks in FY90 to begin coverage of services rendered by certified family and pediatric nurse practitioners on July 1, 1990.
4. M u l t i p l e S u r g e r y and P r e p a y m e n t R e v i e w Prepayment review of sterilizations, hysterectomies, and multiple surgery claims resulted in estimated savings of $6,202,738. The Department saved approximately $1,540,035 through its review of certain medical procedures prior to surgery.
5. Claims Inquiry The Individual Practitioners Inquiry Unit received and responded to approximately 39,100 telephone and written inquiries during the year.
6. B i l l i n g P a t t e r n s Sixty-three individual practitioners were referred to the Surveillance and Utilization Review Section because of aberrant billing patterns. Refunds of $182,356 were associated with these referrals.
Ancillary services
1. D e n t a l Services Payments were made to approximately 1,470 providers for 166,389 recipients of dental care, 63 percent of whom were children. Pretreatment review by dental consultants resulted in a savings of $186,794 during FY90.
2 . E a r l y and P e r i o d i c Screening & Diagnosis, and Treatment (EPSDT) The EPSDT program provides periodic examinations and treatment of identified problems in children and youth from birth through age 20. The Department paid for 129,030 complete screens and 209,277 immunizations in FY90, an increase of 21,248 and 102,366 respectively from the previous year. On January 1,1990, Lead Screening was added to the program.
3. D u r a b l e M e d i c a l E q u i p m e n t The Department reimbursed 412 providers for 31,858 recipients of durable medical equipment items during FY90. The Department saved approximately $1,409,800 as a result of its prior approval review process, a 51 percent increase over FY89.
4. O r t h o t i c s and P r o s t h e t i c s The Department reimbursed 142 providers for 8,800 recipients who received orthotic and prosthetic devices, including hearing aids. The Department saved an estimated $163,080 as a result of its prior approval process.

5. Claims Inquiry The Ancillary Services Inquiry Unit received and responded to more than 20,000 telephone and written inquiries during the year.
Community Services Proqram
1. Home Health Services The Department paid 86 providers for 607,954 visits to 12,315 recipients. Effective January 1, 1990, each home health agency's cost per visit was based on the 1988 cost report adjusted for inflation. In January 1990 the Department began to add to its claims payment system data on authorization for home health services. This has resulted in savings of approximately $1,000,000 in the first six months of implementation.
Pharmacy Services The Department paid 1,895 providers for 7,850,080 prescriptions for 484,252 recipients during FY90. A total of 198 generic drugs have either a state or federal Maximum Allowable Cost (MAC) limit. Limitations on length of therapy were placed on anti-ulcer preparations.and single source antiarthritic drugs. Savings generated for the first six months of implementation were estimated at $3.5 million. Effective January 1, 1990, the dispensing fee for proprietary and nonprofit pharmacies was increased to $4.41 and $4.11, respectively. There were 33,272 requests for prior approval, including requests for exceptions to the monthly six prescription limit; 88 percent of these were approved. To reduce drug cost, the Department negotiated drug rebates with pharmaceutical manufacturers. Contracts were signed with seven companies granting formulary exclusivity for specific drugs.
.3 Non-Emergency Transportation (NET)
During FY90 payments were made to 549 providers for services to 121,514 recipients. The number of recipients served increased by 44,284. Effective July 1, 1989, the base rates paid for services were lowered and the minibus mileage rate was changed from $.50 per recipient mile to $.70 per vehicle mile. Rates were adjusted again effective July 1, 1990, and limitations were placed on certain services.
4. Emergency Ambulance Services The Department paid 193 providers for services to 37,755 recipients.
5. Case Management Payments were made to 12 providers for services to 1,203 recipients. This program expanded community-based services in targeted areas as an alternative to institutionalization

for the chronically mentally ill. During FY90, Dekalb, Gwinnett, ~ichmondand Emanuel counties were added to the 48 counties in which case management services were previously available.
6. Mental Health C l i n i c Services Payment was made to 45 providers for services to 26,993 recipients. Effective January 1, 1990, certain mental health service code reimbursement rates were adjusted to discontinue payment for transportation costs. This change resulted in a savings of $402,700.
7 . Claims Inquiry The Community Services Inquiry Unit received and responded to approximately 42,540 telephone and written inquiries in FY90.
Waivered Services
1. Community Care Services The Department paid 214 providers for services to 8,373 Community Care service recipients during FY90, allowing the recipients to avoid institutionalization. Utilization reviews were conducted for 85 Community Care providers. A total of 1,600 clinical records were reviewed and 1,400 recipients were visited. A total of 131 recipients were recommended for discharge. As a result of the reviews, recoveries of $193,294 were identified.
2 . Mental Retardation Waiver Services There are 79 enrolled providers providing an array of home and community-based services designed to assist persons with mental retardation to live in community settings. The Department paid 25 providers for services to 314 recipients during FY90.
3 . Model Waiver The Model Waiver program is a home and community-based program designed to meet the needs of children under 12 years of age who are ventilator or oxygen dependent and who without the assistance of in-home nursing services, would otherwise be institutionalized. In FY90, 28 recipients were approved to receive in-home nursing services.
Effective September 1, 1989, reimbursement rates for services provided by Model Waivered Home Care providers were increased by 10 percent. In March 1990 the age limit for receipt of services was increased from 10 years of age to 12.

PROGRAM INTEGRITY

The Division of Program Integrity is 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 and identify program overpayments.

~nvestiqationsand Compliance

The Investigations and Compliance (I&C) Section is responsible
for the prevention, detection and investigation of provider fraud and abuse in the Georgia Medicaid program. I&C also enforces Title VI of the civil Rights Act of 1964 and section 504 of ~ i t l eV of the Rehabilitation Act of 1973.
In FY 1990, the Section initiated 995 preliminary investigations. Of these, there were 371 Integrity Review (IR) investigations of 153 physicians, 99 non-emergency transporters and 49 dentists and 70 other providers. ~hirty-eight of the IR investigations concluded in fraud investigations; 21were submitted to local district attorneys for prosecution. Of those submitted, one resulted in successful conviction and 20 are still pending final disposition.
The I&C section identified $1,010,364 in provider overpayments, of which $286,759 was collected during the year. ~uring SFY90, I&C issued 35 termination and 33 suspension notices to providers.
The Section initiated a "Targeted Provider Program1' which identifies potential fraud and abuse patterns through computer data analyses. The program to date has resulted in the recovery of $136,000 and 11 criminal indictments.

Surveillance and Utilization Review

The Surveillance and Utilization Review (SUR) section:

-

provides safeguards against unnecessary or inappropriate

use of Medicaid services and against excessive payments;

- assesses the quality of services provided to Medicaid

recipients; and

- controls the utilization of services in both institu-
tional and ambulatory settings.

1. Audits In FY90, SUR completed 348 provider audits, identifying $1,677,574 in funds to be paid back to Medicaid. Over 462 recipients were reviewed, prompting 104 fraud cases. Fortyfive recipients were added to the Department's uLock-In~ program restricting them to one physician and pharmacy for

non-emergency care. I1Lock-Inv1is instituted when program abuse has been substantiated.
2. H o s p i t a l U t i l i z a t i o n Review The SUR section monitored ~edicaid enrolled hospitals1 compliance with federal and state requirements for utilization control through a structured delegated hospital review program. One hundred and sixty-five hospitals perform reviews for the Department; six hospitals had 100 percent of their inpatient claims reviewed retrospectively by Section staff.
3. Data R e p o r t s The SUR data reports were used successfully in enhancing Departmental monitoring of statewide health issues. special studies were initiated on child abuse, birth defects and drug and alcohol dependent infants in the Medicaid population.
Third Party Liability
The Third Party Liability (TPL) Section is responsible for identifying coverage for medical care through insurance or other liability sources in order to ensure that Medicaid is the payor of last resort. The Third Party Liability Section administered the cost avoidance program, saving the Department $391,308,967, including amounts paid by Medicare. It also managed the direct recovery program, resulting in total recoveries of $8,632,666.
1. Health Insurance Unit The Health Insurance Unit is responsible for developing leads regarding insurance coverage. As of June 30, 11 percent of the Medicaid population had been identified as having third party resources for medical care. Once resources were verified and added to the TPL data base, claims payment was deferred until a claim was made against the private insurance coverage. Use of this process allowed Medicaid to avoid paying claims until all other resources were exhausted.
2. C a s u a l t y and L i a b i l i t y U n i t The Casualty and Liability unit investigated and developed cases involving accidental injuries which resulted from negligence and for which a third party was liable. In FY90, this Unit developed cases resulting in direct recovery of $938,337, an 85 percent increase from FY89.
3. F i e l d R e v i e w U n i t The primary responsibility of the Third Party ~iabilityField Review staff is to promote third party liability awareness through on-site provider audits. The staff also assisted caseworkers in the Department of Family and children services (DFCS) by providing on-going training and technical assistance relating to identification of third party resources. The staff served as liaison between the other units in the TPL

Section and the provider community, insurance industry and recipients in identifying, analyzing and resolving problems relating to the TPL recovery effort.
During FY90 the Field Review staff conducted 44 provider audits and 27 DFCS reviews. Direct recoveries of $90,771 from providers and $26,134 from recipients were attributed to Field Review activities.
Medicaid Eliqibility and Ouality Control
1. Q u a l i t y Control U n i t a. Monitoring Eligibility Determinations The Quality Control Unit is responsible for monitoring
. ~edicaid eligibility determinations performed by the
Department of Human Resources (DHR) During FY90, the eligibility status of 1,857 Medicaid cases was reviewed. As errors were detected, referrals were made for corrective action. The Department and DHR conducted an in-depth analysis of error trends and developed an extensive Corrective Action Plan (CAP) addressing error conditions and implementing measures to correct errors in the eligibility determination process. The error rate remained below the federal three.percent tolerance level for the third consecutive year because of the State's aggressive corrective action work.
b. Corrective Action Strategy The Department continued to conduct Case ~ c t i o nRecord Reviews (CARR) as part of the Department's efforts to reduce errors occurring in the eligibility process. Through this review process deficiencies were identified much sooner, allowing correction before possible selection in a Quality Control sample. In the past fiscal year, CARRs were conducted in 96 county departments and approximately 1,600 cases were reviewed.
Q u a l i t y Control C l a i m s R e v i e w U n i t This unit reviewed claims related to the Quality Control (QC) samples and those claims included in the monthly samples for the Claims Processing Assessme~t System (CPAS). The error rate for claims processing was well below the one percent tolerance rate. The Unit also reviewed claims selected in the Quality Control sampling process. The error rate for FY90 was sufficiently low so that the State was not subject to federal fiscal sanctions.
3. Eligibility Policy Unit The Medicaid Eligibility Unit was responsible for making or recommending certain state Medicaid eligibility policy decisions and developing eligibility policies for implementation by DHR. Activities during FY90 included:

a. "Right from the Start Medicaidt1(RSM) Beginning April 1, 1990, coverage was expanded to include children under age six and pregnant women with income up to 133 percent of the federal poverty level. The income limits for RSM are much higher than those of other coverage options, enabling many more poor Georgians to receive early preventive health care and prenatal care. Application procedures for RSM were simplified to facilitate access to coverage, and in some counties, eligibility workers were stationed in public health departments and hospitals to speed up the application process. As of June 30, 1990, approximately 14,000 pregnant woman and 23,400 children under age six were eligible for Medicaid under the RSM coverage.
b. Qualified Medicare Beneficiaries (QMB) Beginning January 1, 1990, the income limit was increased to cover individuals with income below 90 percent of the federal poverty level. Medicaid pays the Medicare costsharing expenses for eligible individuals. This includes the payment of Medicare Part A and Part B insurance premiums, coinsurance and deductibles.
c. Effective January 1, 1990, the Department increased the maximum allowable monthly income "capl1 for eligibility of nursing home, community care, and hospice care for recipients to $1,158 for an individual and $2,316 for a couple. This increase constitutes a change from a net maximum allowable to a gross maximum allowable set at 300 percent of the Supplemental security Income (SSI) federal benefit rate.
d. Beginning April 1, 1990, the Department extended Medically Needy coverage to aged, blind or disabled persons who are not otherwise eligible because personal income exceeds existing income eligibility limits. Medically Needy Medicaid allows a person to achieve eligibility based on the amount of incurred medical expenses. Incurred medical expenses are used to offset personal income in excess of the Medically Needy income limits of $308 for an individual and $367 for a couple. These limits are by law based on 133 113 percent of the highest payment based on family size made under the Aid to Families with Dependent Children (AFDC) program.
e. Effective April 1, 1990, the Department implemented an extension of Medicaid coverage for families who lost their AFDC check due to the receipt of or increase in earned income of the caretaker or due to the loss of one of the allowable earned income disregards of a family member who receives AFDC. This extension can continue for a maximum of six months after the AFDC check has

stopped. The caretaker is the adult family member who receives the AFDC check for himself or herself and the family. This extension of Medicaid is mandated by the Family Support Act of 1988 as a support service to families to facilitate their transition to the work force and self-sufficiency.
4. Recipient I n q u i r y Unit The Recipient Inquiry Unit is responsible for responding to correspondence, telephone inquiries, and office visits related to Medicaid recipient issues. During FY90 the unit responded to over 8,500 telephone calls, 980 letters, and 1,000 walkins. The activities ranged from ordering replacement Medicaid cards and changing addresses to researching claim denials and rejections and providing general information regarding the Medicaid program.
ADMINISTRATION
The Division of Administration performs those functions necessary to support the day-to-day operation of the Department, including financial services, provider enrollment, purchasing and support services.
The Financial Services section includes Budget, ~enefits Recovery and Accounting units. The Benefits Recovery unit collected $10,351,234 through voluntary refunds and accounts receivable during FY90.
The Provider Enrollment section enrolled 2,980 providers during FY90. ~pproximately 47,200 transactional update changes were made to the provider files during FY90. In addition, approximately 6,700 rate changes were made to the usual and customary file, which stores rates for providers. The Section also processed 3,950 out-of-state hospital and physician claims. Finally, the Section reviewed and resolved approximately 3,800 claims, responded to 47,000 phone and 100,000 written inquiries, and mailed provider enrollment material to 2,950 potential providers.
SPECIAL SERVICES
The Office of Special Services is responsible for handling all mandated provider, recipient, and applicant hearings, rendering legal assistance to all divisions, and acting as official liaison with the Department of Law.
During FY90, the Office handled 199 requests for provider hearings, the largest volume of requests ever received by the Department. In order to handle the increased caseload, the Office hired an additional attorney in the fall and installed three personal computers to accommodate its word processing and technical recordkeeping requirements.

SPECIAL INITIATIVES
The Office of Special Initiatives is responsible for planning, implementing and evaluating major changes in the ~edicaidprogram in Georgia. In FY90, the Office established or coordinated implementation of certain federal nursing home requirements as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. One of the principal efforts involved the testing and training of nurse aides who are working or wish to work in nursing homes.
1. Nurse Aide Testing Certification The Office arranged and coordinated state-wide testing through a contract with The Psychological Corporation. Over 15,000 nurse aides were tested between November 1989 and February 1990; approximately 87 percent passed and were certified as meeting federal and state competency requirements.
Deemed Nurse Aides Using the federal criteria for "grandfatheringI1(deeming), the Office certified an additional 600-800 nurse aides as meeting federal and state competency requirements.
Nurse Aide Training, Testing and Certification Seventy-three nurse aide training programs (including all the Adult Technical Education schools) were approved by the Department based upon the federal criteria and State curriculum guidelines.
The Office recruited high schools with Health Occupations programs to provide nursing facilities with an ongoing source of certified nurse aides to an industry with an average employee turnover rate of 149 percent.
4. Intermediate Sanctions In the fall of 1989, the Department's Board established administrative rules which permit the Department to implement federally mandated intermediate sanctions on nursing facilities which do not comply with the requirements for conditions of participation in the Medicaid program. These sanctions allow the Department to try other remedies to improve the care in a facility before termination (decertification) of the facility from the Medicaid program and relocation of residents. The rules take effect October 1, 1990.
5. - Pre-screening for Mental Illness and Mental Retardation
As required by federal law (OBRA), all applicants for nursing facility (home) admission were required to be screened for diagnoses of mental illness or retardation. By April 1, 1990, the Georgia Medical Care Foundation and the Department of Human Resource's contractors completed reviews of all residents in nursing facilities for these diagnoses.

The Program Evaluation section conducted statistical analyses on the effects of Medicaid policy changes, made expenditure and recipient projections, edited the Annual Report, and planned and developed new programs. The section continued its role as the clearinghouse for Georgia Medicaid data. In FY90 Program Evaluation staff evaluated the expenditures for inpatient hospital services by type of facility and conducted a similar evaluation of home health services, comparing free-standing to hospital-based facilities. The Section completed an evaluation of cost containment measures taken during FY89 in various categories of service, including physician services, optometrics and prescribed drugs. The Section studied Medicaid AIDS expenditures and generated initial findings of an evaluation of Medicaid financed prenatal care and delivery. Staff evaluated inpatient expenditures for infants in order to develop an approach for day "outlier1' payments, conducted a study of expenditures for different types of cancer, and studied trends in physician participation in the Medicaid program by specialty. The section planned the new inpatient Preadmission ~ e v i e wprogram and conducted a preliminary evaluation of its effects. Staff prepared estimates of recipients and expenditures for various aid groups, including expansions for pregnant women and children and for Qualified Medicare Beneficiaries. In response to approximately 270 data requests, the Section provided information to both Department staff and other interested parties.
SYSTEMS MANAGEMENT
The Division of Systems Management coordinates and serves as the liaison for all Departmental Medicaid Management ~nformation
. System (MMIS) activities with the Department's fiscal agent,
Electronic Data Systems (EDS) Systems is responsible for ~ecipient Data Base maintenance and inquiry. The Nursing Home Inquiry Unit also is a component of the Systems Management Division. Systems Management responsibilities are divided into two sections, claims Systems and Support Systems.
1. System Tests, Updates and Corrections During FY90, the Division prepared and verified 4,545 test claims through the Parallel Systems Test (PST) and Model office module to validate the accuracy of the MMIS payment methodology. Also, specifications for 182 system changes were developed. The Division reviewed and approved over 460,000 MMIS reference file updates.
2. Data Base Changes The Recipient Data Base Unit processed 496,000 recipient updates, inquiries and claims resolutions. Over 20,000 retroactive eligibility records were entered. Claims payment on 5,800 claims was researched where a date of death was received after claims were paid. The unit documented $1,500,000 in

benefits to be recouped. ~ u r i n gFY90, 166,800 new client records were added to the system. The MMIS processed 7,500,000 recipient updates.
Inquiry The Recipient Card Control Unit resolved over 186,600 provider inquiries. Eighty-eight thousand requests for emergency eligibility cards, address, date of birth, case number and client Medicaid number changes were completed. The Nursing Home Inquiry staff responded to and resolved 6,383 Nursing Home provider requests concerning payment of nursing home claims, and reviewed over 71,000 claims for adjudication.
4. Reporting and Pended Claims During FY90, the ~ivisionreceived, logged and distributed over 775 MMIS reports and several thousand pended claims for DMA analysis. The Systems Management analysts coordinated 977 Ad Hoc report requests, a 64 percent increase over FY89.
PERSONNEL SERVICES
The Office of Personnel Services functions as a centralized personnel office providing services to over 300 on-site employees and those located in 14 field offices. In FY90 the Office received over 2,100 visitors and processed over 837 job applications. It conducted 746 interviews and filled 54 positions. A total of 433 applications were reviewed and rated for vacant positions, and recruitment activities were conducted at eight colleges. There were 976 participants who received training in several categories, including orientation, employee development, management development and skills development. Over 1,000 personnel transactions were processed and entered.
CONTRACT ADMINISTRATION
The Contract Administration Office is responsible for developing Advanced Planning Documents for federal funds, Requests for Proposals and Contracts and for conducting the related monitoring activities. The Office conducted on-site systems performance reviews for the Medicaid Management Information System (MMIS) Contractor and the Department to ensure compliance with legal, financial and performance standards. In addition, the Office assumed responsibility for control of all written policy and billing communication to providers.
During FY90, the Office issued 14 contract or consultant agreements, including Hospital Preadmission certification and Nurse Aide Testing; developed nine Contract Amendments; developed three Advanced Planning Documents; developed and reviewed four Requests for Proposal; completed one Request for ~nformation;appointed 60 Administrative Law Judges and handled 170 written provider communications.

TABLES AND
CHARTS

A HISTORY OF * MEDICAID BENEFITS EXPENDITURES

Fiscal Year

Cash * * Benefit Payments

Percentage Change

Payments * * * By Date of Service

Percentage Change

1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

$28,698,677 $60,907,769 $73,766,763 $1 28,527,366 $141,138,792 $1 87,774,982 $1 82,989,393 $266,136,883 $268,858,408 $31 8,029,162 $343,319,187 $375,653,922 $435,292,735 $519,934,060 $542,306,612 $61 3,392,777 $624,861,133 $694,279,055 $785,486,760 $900,119,766 $1,039,092,121 $1,202,158,160 $1,385,905,937

-
112% 21Oo/ 74 010 10% 3 3 O/o
- 3 O/O
4 5 O/o 1 010
1 8 010 8 010 9Oo/
16 % 1 9 O/o
4 O/o 13 %
2 010 1 1 010 13Oo/ 1 5 O/o 1 5 O/o 16Oo/ 15%

$308,142,782 $338,228,610 $377,658,055 $444,155,517 $536,560,178 $545,307,185 $608,309,046 $649,043,985 $71 7,861,935 $795,950,535 $909,883,869 $1,087,103,291 $1,202,824,264 $1,486,684,310 (est.)

-
10 010 12% 18 % 21 O/o
2 O/o 12%
7Oo/ 1 1 010 1 1 010 14Oo/ 19Oo/ 1 1 O/o 24%

* The figures on this table include Medicare copayments and deductibles but exclude Medicare premium payments.
* * 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 service."

* * * Expenditures for services provided 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 month of service to file a claim. Date of service figures are expenditures as of June 30, 1990, for FY 87-FY 89; FY 90 is an estimate. Note that the figures for fiscal years before 1987 were revised in 1987 to exclude Medicare premium payments.

FY 90 BENEFITS AND RECIPIENTS BY CATEGORY OF SERVICE

Category of Service

Amount

Recipients

Ambulance Ambulatory Surgical Community Care Dental Dialysis Durable Medical Equipment Early & Periodic Screening,
Diagnosis and Treatment Family Planning Home Health Hospice Hospital, Inpatient Hospital, Outpatient LaboratoryIRadiology Mental Health Case Management Mental Health Clinic Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care- MR Nursing Home lntermediate Care-Other Nursing Home Skilled Care Optometric-Eyeglasses Optometry OrthoticslProsthetics Other Coinsurance and Deductibles * * Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic
TOTAL

$1,385,905,937

624,257

Source: Annual Statistical Report on Medical Care ("HCFA 2082") for SFY9O and estimates from Medical Expenditures by Recipient County of Residence for SFY9O. Medicare copayments and deductibles are included, but Medicare premiums are not.
* Includes "Model Waiver" for children under 12 years of age ($772,578 for 25 recipients).
* * Other Coinsurance and Deductibles includes Chiropractor, Physical, Rehabilitation, and Speech therapies.

WHERE THE MEDICAID DOLLAR COMES FROM...
Georgia's Medicaid program receives different levels of federal reimbursement for different types of activity. Reimbursement levels for benefits, family planning, the Medicaid Management Information System (MMIS) and for administ ration of the program are determined each fiscal year by the federal government.

Most Benefits
FEDERAL FUNDS

Medicaid Management Information
8 Systems Management Division

Family Planning Benefits

Most Other Administration

Medical Assistance Only
Medicare Premiuns

Total Benefits, Premiums
8. Administration

Sources of
Federal Funds State Funds Total Revenue

Medicaid Benefits Revenue
FY90 $ 865,732,95 1 $ 520,172,986 $1,385,905,937

WHERE THE MEDICAID DOLLAR GOES...
1990

PHYSICIANS

OTHER CARE

DRUGS

HOSPITAL

NURSING HOME CARE

BENEFITS $1,385,905,937

I

FISCAL
46.4% HUMAN RESOURCES

19.9% OTHER
- - - _ _- -.-

4 5%

INSTIT POLICY GA MED CARE ADMINISTRATION SYSTEMS COMM OFFICE

1 A D M I N I S T R A T I O N $59,839,79 1

6 +:------ 1 BENEFITS

._ --

NURSE AIDE TAAlNlNG 0 4%
PAADMEMEINDIUISIWMTS\RRAE3T.1IO%N 3.8%

OTAL E X P E N D I T U R E $1,496,882,734

FY 90 ADMINISTRATIVE EXPENDITURES

Function

Percent of Total

Administration Division Commissioner's Office Department of Human Resources
Interagency Contract Fiscal Agent Computer Services Georgia Medical Care
Foundation Contract Institutional Policies and
Reimbursement Division Program Integrity Division Program Management Division Systems Management Division

4,173,793 2,764,680 2,309,325

6.97% 4.62% 3.86%

TOTAL * *

$59,839,791

100.0%

* Federal funds only. State matching funds appear in the Department of Human Resources budget. Services provided through this contract include eligibility determination, administration and case management for the community care program, recipient appeal hearings, and certification of facilities for participation in Medicaid.

* The total figure does not include the cost associated with first year implementation of the Nurse Aide Training program mandated by Congress. In FY90, the cost of the program was $5,709,822. These funds were paid directly to nursing homes but not matched at the normal federal financial
participation rate.

FY 90 MEDICARE PREMIUMS

Type of Premium

Expenditures

Percent of Total

100% State Premium

$1 1,368,448

25.03%

State-Federal Premiums State Share Federal Share

$34,058,736 $1 2,848,724 $21,210,012

74.97% 28.28% 46.69%

TOTAL MEDICARE PREMIUMS

$45,427,184

100.00%

The State pays the Medicare premiums for those individuals who are eligible for both Medicare and Medicaid. The State is required to pay the total Medicare premium for a Medicare-Medicaid eligible who lives in an institution and has an income above the SSI Standard.

COLLECTIONS AND MEASURABLE COST AVOIDANCE

COLLECTIONS Third Party Liability * Hospital Cost Settlement Other Collections * *
Total Collections

MEASURABLE COST AVOIDANCE
Nursing Home Audits '* *
Hospital Audits
Prior Approval and Prepayment or Pretreatment Review
Third Party Claim Cost AvoidanceMedicare
Third Party Claim Cost Avoidance-Other
Total Measurable Cost Avoidance

$7,360,000
-
4,748,078 107,892,064
$1 49,445,928

GRAND TOTAL

$1 69,043,545

$6,876,000 8,979,865

$4,664,000 3,187,109 + 8,509,853

$5,869,919 2,524,340 9,764,327

264,905,513 ++ 315,593,760

336,614,291

$325,825,700 $341,631,798

$384,853,605

$409,467,553

$400,552,740

$428,451,453

* Includes "voluntary recoveries" with third party liability. * * Includes collections originating from Investigations and Compliance, Surveillance and Utilization Review, audits
of providers, special situation recovery efforts and voluntary refunds. * * * Estimated from audited base year cost reports. Reductions in allowed costs result in cost avoidance through
prospective future reimbursement rates.
+ Information was not reported prior to FY89.
++ Beginning in SFY88, Medicare Part A is included. Part A is $111,743,045 and Part B is $224,871,246 in SFY9O.

RECIPIENTS AND PAYMENTS BY AID CATEGORY, SEX, AND RACE

RECIPIENTS
AFDC

PAYMENTS
DISABLED

INCLUDES ALL MEDICALLY 8 OPTIONALLY NEEDY INDIVIDUALS
FEMALE 70 8 7 %

RECIPIENTS AND PAYMENTS BY AGE GROUP AND RURAL/URBAN

RECIPIENTS

PAYMENTS

Change in Recipients & Payments
From Fiscal Years 1987 t o 1990
Percent

FY 87

FY 88

F Y 89

FY 90

RECIPEXTS

PAYMENTS

L

RECIPIENTS BY AID CATEGORY BY TYPE OF SERVICE FY 90

TYPE OF MEDICAL SERVICE
Community Health Services * Dental Early & Periodic Screening,
Diagnosis & Treatment Family Planning Hospital, Inpatient Hospital, Outpatient ++ LaboratoryIRadiology Mental Health Case Management + Mental Health Clinic Nursing Home Intermediate Care-MR Nursing Home Intermediate Care-Other Nursing Home Skilled Care
Other Care * '
Other Practitioners * * ' Physician ++ Prescribed Drugs Rural Health Clinic

Age 65 or Over
9,892
9 20,258
463

Blind 291

Disabled 8,994

Other Adults
31 9

Other Unduplicated

Children

Totals

434

19,930

7

1,743

0

1

1,760

161

4,441

1

3

24,864

23

976

1,092

2,723

5,277

TOTAL RECIPIENTS

89,058

2,861

116,695

144,587

271,056

624,257

Source: Annual Statistical Report on Medical Care ("HCFA 2082") for SFY9O. Medicare copayments and deductibles are included, but Medicare premiums are not. There were 73,699 "medically and optional categorically needy" recipients included in the AFDC subtotals: 36,450 pregnant women ("Other Adults") and 37,249 children ("Other Children"). There were 264,467 cash assistance and 77,477 non-cash assistance AFDC recipients of which 233,807 were children and 108,137 were adults.
* lncludes home health and community care, mental retardation and model waiver programs. See table "Benefits and Recipients by Category of Service."
* * lncludes ambulance, ambulatory surgical, durable medical equipment, hospice, non-emergency transportation, optometricseyeglasses, orthotics/prosthetics and therapists programs. See table "Benefits and Recipients by Category of Service."
* * * lncludes chiropractors, nurse midwives, optometrists, podiatrists and psychologists. See table "Benefits and Recipients by Category of Service."
+ Source: Ad hoc AM21 19.
++ lncludes dialysis recipients. Facility and laboratory recipients are under outpatient hospital and professional fees are under physician.

BENEFITS PAID BY AID CATEGORY BY TYPE OF SERVICE FY 90

TYPE OF MEDICAL SERVICE
Community Health Services Dental Early & Periodic Screening,
Diagnosis & Treatment Family Planning Hospital, Inpatient Hospital, Outpatient ++ LaboratorylRadiology Mental Health Case Management + Mental Health Clinic Nursing Home lntermediate Care-MR Nursing Home lntermediate Care-Other Nursing Home Skilled Care Other Care * * Other Practitioners Physician ++ Prescribed Drugs Rural Health Clinic

Age 65 or Over

Blind

Disabled

Other Adults

Other Children

Total Payment

TOTAL PAYMENTS

$377,629,607 $9,447,321 $518,093,143 $280,127,015 $200,608,851 $1,385,905,937

Source: Annual Statistical Report on Medical Care ("HCFA 2082") for SFY9O. Medicare copayments and deductibles are included, but not Medicare premiums, which were $45,427,184 in FY90. Payments of $152,259,243 made for "medically and optional categorically needy" recipients are included in the AFDC subtotals: $104,504,253 for pregnant women ("Other Adults") and $47,754,990 for children ("Other Children"). There were $256,313,200 in payments for cash assistance and $72,268,461 in payments for non-cash assistance AFDC recipients of which $152,920,629 were for children and $175,661,032 were for adults.
lncludes home health and community care, mental retardation and model waiver programs. See table "Benefits and Recipients by Category of Service."
* * lncludes ambulance, ambulatory surgical, durable medical equipment, hospice, non-emergency transportation, optometricseyeglasses, orthoticslprosthetics and therapist programs. See table "Benefits and Recipients by Category of Service."
* * ' lncludes chiropractors, nurse midwives, optometrists, podiatrists and psychologists. See table "Benefits and Recipients by Category of Service."
+ Source: Ad hoc ~ ~ 2 1 1 9 .
++ lncludes dialysis expenditures. Facility and laboratory expenditures are under outpatient hospital and professional fees are under physician.

PERCENTAGE OF EXPENDITURES, PERCENTAGE OF RECIPIENTS AND AVERAGE YEARLY PAYMENT PER RECIPIENT BY AID CATEGORY, FY 90

Basis of Eligibility

Expenditures

Percentage

Percentage Average Paid

of Total Recipients

of Total Per Recipient

Aged *
Blind '
Disabled * AFDC Adult * * AFDC Child "

$377,614,338 $9,447,321
$518,093,143 $1 75,637,817 $152,854,075

27.2% 0.7%
37.4% 12.7% 1 1 .OO/o

89,024 2,861
1 16,695 108,169 233,809

14.3% 0.5%
18.7% 17.3% 37.5%

$4,241.71 $3,302.10 $4,439.72 $1,623.74
$653.76

Medically & Optionally Needy Adult Medically & Optionally Needy Child

$104,504,253 $47,754,990

7.5% 3.4%

36,450 37,249

5.8% 6.0%

$2,867.06 $1,282.05

Total

$1,385,905,937

1OO.O0/o

624,257

100.0%

$2,220.09

Source: Tables "Recipients by Aid Category by Type of Service" and "Benefits Paid by Aid Category by Type of Service."
* 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. Medicare coinsurance and deductibles are included.
' * Includes cash and non-cash AFDC recipients.

NUMBER OF VISITS FOR SELECTED TYPES OF SERVICE AND NUMBER OF PRESCRIPTIONS BY AID CATEGORY
FOR FISCAL YEAR 1990

TYPE OF MEDICAL SERVICE

Phvsician

Outpatient Hos~ital

Community & Rural

Drug

Clinic ' Home Care Health Clinic Prescri~tions .

Aged

Blind

Disabled

486,990

100,790 2,136,507

AFDC Adult "

356,943

110,790

106,410

AFDC Child ' *

575,733

163,408

175,671

Medically & Optionally Needy Adult

69,512

28,564

5,818

Medically & Optionally Needy Child

160,104

25,259

1,995

Unduplicated Totals

1,665,890

431,109 2,546,878

Source: Annual Statistical Report on Medical Care ("HCFA 2082") for SFYSO. * Number of visits to mental health clinics. * * Includes cash and non-cash AFDC recipients.

544,293 6,908 4,728 41 4 1,405
1,298,208

7,439 5,936 7,937
315 1,507 25,644

3,064,489 960,943 91 0,616 138,739 144,309
7,850,080

AVERAGE PAYMENT FOR SERVICES PER RECIPIENT FOR FlSCAL YEARS 1987-1 990

Type of Service

FY 87

FY 88

FY 89

FY 90

Ambulance Ambulatory Surgical Community Care * * Dental Dialysis Durable Medical Equipment Early & Periodic Screening,
Diagnosis and Treatment Family Planning Home Health * * Hospice Hospital, Inpatient Hospital, Outpatient , LaboratoryIRadiology Mental Health Case Management Mental Health Clinic Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care-MR Nursing Home lntermediate Care-Other Nursing Home Skilled Care Optometrics-Eyeglasses Optometry OrthoticslProsthetics Other Coinsurance and Deductibles Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic
Average Payment Per Recipient for All Services
Annual Percent Change

$1,799.89 $1,994.48

8.90%

10.81 010

$2,179.25 $2,220.09

9.26%

1.87%

Source: Table "Benefits and Recipients by Category of Service" and previous Annual Reports. Payments and recipients include Medicare copayments and deductibles. * The definition of "family planning" was changed in FY88, causing the average payment to be lower.
* * Corrections made to FY89 figures.

PERCENTAGE OF TOTAL RECIPIENTS UTILIZING EACH SERVICE FOR FISCAL YEARS 1987-1 990

Cateaorv of Service
Ambulance Ambulatory Surgical Community Care Dental Dialysis Durable Medical Equipment Early & Periodic Screening
Diagnosis and Treatment Family Planning Home Health Hospice Hospital, Inpatient Hospital, Outpatient LaboratorylRadiology Mental Health Case Management Mental Health Clinic Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care-MR Nursing Home Intermediate Care-Other Nursing Home Skilled Care Optometrics-Eyeglasses Optometry OrthoticslProsthetics Other Coinsurance and Deductibles * Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic

FY87

Source: Table "Benefits and Recipients by Category of Service" and previous Annual Reports.
* Other Coinsurance and Deductibles includes Physical, Rehabilitation, and Speech therapies, and Chiropractor.

PERCENTAGE OF TOTAL EXPENDITURES FOR EACH CATEGORY OF SERVICE FOR FISCAL YEARS 1987-1 990

Cateaorv of Service
Ambulance Ambulatory Surgical Community Care Dental Dialysis Durable Medical Equipment Early & Periodic Screening
Diagnosis and Treatment Family Planning Home Health Hospice Hospital, Inpatient Hospital, Outpatient Laboratory/Radiology Mental Health Case Management Mental Health Clinic Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care-MR Nursing Home lntermediate Care-Other Nursing Home Skilled Care Optometric-Eyeglasses OrthoticslProsthetics Other Coinsurance and Deductibles * Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic
TOTAL

FY87

FY88

FY89

FY90

-
24.9% 6.100' 0.2% NIA 1.7%

100.0%

100.0%

100.0%

100.0%

Source: Benefit expenditures (by date of payment) are as reported in the SFY9O Annual Statistical Report on Medical Care ("HCFA 2082") and estimated from the SFY9O Medicaid Expenditures by Recipient County of Residence. "Total Expenditures" include copayments and deductibles for persons eligible for Medicare and Medicaid, but not Medicare premiums.
* Other Coinsurance and Deductibles includes Physical, Rehabilitation, and Speech therapies, and Chiropractor.

CLAIM DOCUMENTS PROCESSED BY CATEGORY OF SERVICE FY90

Category of Service

Number of Documents Processed

Percent

Ambulance Ambulatory Surgical Community Care Dental Dialysis Durable Medical Equipment Early & Periodic Screening
Diagnosis and Treatment Family Planning Home Health Hospice Hospital, Inpatient Hospital, Outpatient LaboratoryIRadiology Medicare Coinsurance and Deductible Mental Health Clinic Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care-MR Nursing Home lntermediate Care-Other Nursing Home Skilled Care Optometry OrthoticslProsthetics Other Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic
TOTAL CLAIM DOCUMENTS

18.809.105

100.00%

Source: Operational Performance Summary Report except for Medicare coinsurance and deductible (Claims Processing Performance). The number of claim documents, rather than details ("line items") are reported by category of service. Medicare coinsurance and deductible documents are reported separately. The total number of claims details in FY90 was 19,549,371, a decrease of 2.54% from total details processed in FY89. The number of claim documents processed in FY90 increased by 8.8% from claims processed in FY89. Source of claims details processed is At-04 report.
Adjustments are included for all categories of service. The Mental Health Clinic numbers include mental health case management.

PROVIDERS WITH PAID CLAIMS DURING FY87-FY90
BY CATEGORY OF SERVICE

Category of Service
Ambulance Ambulatory Surgical Community Care Dental, Adult Dental, Child Dialysis Durable Medical Equipment Early & Periodic Screening,
Diagnosis and Treatment (EPSDT) Family Planning Home Health * Hospice Hospital, Inpatient Hospital, Outpatient Independent LaboratorylRadiology Mental Health Clinic * * Mental Retardation Waiver Non-Emergency Transportation Nurse Midwife Nursing Home lntermediate Care-MR Nursing Home Intermediate Care-Other Nursing Home Skilled Care Optometry Orthotics/Prosthetics Physician Podiatry Prescribed Drugs Psychology Rural Health Clinic

FY87 193

Number of Providers

FY88

FY89

Claims for Medicare coinsurance and deductible and for adjustments are excluded.
NOTE: 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 FY90 was 543; for intermediate care nursing home, 315; for pharmacy, 2,202; for physicians, 15,994; and for child dental, 1,917. The total number of providers enrolled at the end of FY90 was 26,883. Out-of-state providers are included for all years. If a provider had more than one location this year, the provider was only counted once. Source: Provider Participation Summary.
* Includes "model waiver" recipients. There were 70 providers of home health excluding providers of waiver service only.
* * Includes Mental Health Case Management.

COMPARISON OF ELIGIBLES, RECIPIENTS AND EXPENDITURES FY87-FY90
July August September October November December January February March April May June
Average Monthly Eligibles Annual Percent Change
Average Monthly Recipients Annual Percent Change
Average Monthly Expenditures (millions) Annual Percent Change
Average Monthly Expenditure per Monthly Eligible Annual Percent Change
Average Monthly Expenditure per Monthly Recipient Annual Percent Change
Note: Source for eligibles is Medical Eligibles Statewide-End of Month Report. Not all of those eligible are recipients of services. Source for FY87 recipients was Provider Participation Analysis; FY88-90 are based on change in Provider Participation Analysis after Medicare coinsurance and deductible were excluded from report.

County

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY RECIPIENT'S COUNTY FOR FISCAL YEAR 1990

Benefits Paid

a
Estimated 1990 Unduplicated
Population Recipients

OO/ of Population Receiving Medicaid

OO/ of Total State
Recipients

Expenditures Per
Recipient

APPLING ATKINSON BACON BAKER BALDWIN BANKS BARROW BARTOW BEN HILL BERRIEN BIBS BLECKLEY BRANTLEY BROOKS BRYAN BULLOCH BURKE BUTTS CALHOUN CAMDEN CANDLER CARROLL CATOOSA CHARLTON CHATHAM CHATTAHOOCHEE CHATTOOGA CHEROKEE CLARKE CLAY CLAYTON CLINCH COBB COFFEE COLQUlm COLUMBIA COOK COWETA

County

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY RECIPIENT'S COUNTY FOR FISCAL YEAR 1990

Benefits Paid

a
Estimated 1990 Unduplicated
Population Recipients

010 of Population Receiving Medicaid

O/O of Total State
Recipients

Expenditures Per
Recipient

CRAWFORD CRISP DADE DAWSON DECATUR DEKALB DODGE DOOLY DOUGHERTY DOUGLAS EARLY ECHOLS EFFINGHAM ELBERT EMANUEL EVANS FANNIN FAY ETTE FLOYD FORSYTH FRANKLIN FULTON GILMER GLASCOCK GLYNN GORDON GRADY GREENE GWINNETT HABERSHAM HALL HANCOCK HARALSON HARRIS HART HEARD HENRY HOUSTON

County

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY RECIPIENT'S COUNTY FOR FISCAL YEAR 1990

Benefits Paid

Estimated 1990
Population

a
Unduplicated Recipients

O/O of Population Receiving Medicaid

O/O of Total State
Recipients

Expenditures Per
Recipient

IRWIN JACKSON JASPER JEFF DAVIS JEFFERSON JENKINS JOHNSON JONES LAMAR LANIER LAURENS LEE LIBERTY LINCOLN LONG LOWNDES LUMPKIN MACON MADISON MARION MCDUFFIE MCINTOSH MERIWETHER MILLER MITCHELL MONROE MONTGOMERY MORGAN MURRAY MUSCOGEE NEWTON OCONEE OGLETHORPE PAULDING PEACH PICKENS PIERCE PIKE

County

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY RECIPIENT'S COUNTY FOR FISCAL YEAR 1990

Benefits Paid

Estimated 1990
Population

a
Unduplicated Recipients

010 of Population Receiving Medicaid

O/O of Total State
Recipients

Expenditures Per
Recipient

POLK PULASKI PUTNAM QUITMAN RABUN RANDOLPH RICHMOND ROCKDALE SCHLEY SCREVEN SEMINOLE SPALDING STEPHENS STEWART SUMTER TALBOT TALIAFERRO TATNALL TAYLOR TELFAIR TERRELL THOMAS TI FT TOOM BS TOWNS TREUTLEN TROUP TURNER TWIGGS UNION UPSON WALKER WALTON WARE WARREN WASHINGTON WAYNE WEBSTER

County

ANALYSIS OF RECIPIENTS AND EXPENDITURES BY RECIPIENT'S COUNTY FOR FISCAL YEAR 1990

Benefits Paid

a Estimated
1990 Unduplicated Population Recipients

010 of Population Receiving Medicaid

010 of Total State
Recipients

Expenditures Per
Recipient

153 WHEELER 154 WHITE 155 WHITFIELD 156 WlLCOX 157 WILKES 158 WlLKlNSON 159 WORTH
STATEWIDE

Estimated population for 1990 based on 1990 estimates from Governor's Office of Planning and Budget. b
Statewide expenditures and recipients differ from figures shown elsewhere in this report due to exclusion of expenditures and recipients for unspecified counties. Sum of " % of Total State Recipients" exceeds 100% since a recipient can reside in more than one county during a year. Statewide recipients are unduplicated for the State.

DEPARTMENT OF MEDICAL ASSISTANCE ADVISORY COMMITTEE AS OF JUNE 30, 1990

A Medical Assistance Advisory Committee was created to give technical advice to the Department and to provide liaison between the Department and the provider community. Subcommittees of this group, seventeen 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
Ms. Joyce D. Barlow Ms. Betty Bartling Mr. H. Dean Beasley Ms. Betty Belcher Sister Diane Brin Mr. Carl Evans
Vice Chairperson Mr. Charles K. Hecht, I11 Ms. Leanna M. Hogan Ms. Jane McCombs, R.N. Fred McGinnis, Ph.D. Mr. Martin Miller
Chairperson Ms. Margery W. Ponder Ms. Pattie S. Pearson Ms. Carol Robinson
Consumer
Ms. Beatrice Berry Ms. Annette T. Bowling Mr. Otis Burgess
Chairperson Ms. Karen Geiger Mr. Roy Herzbach Ms. Ethel Mae Mathews Mr. Calvin E. Peterson Ms. Patsy Sherrod Ms. Sonya P. Smith Ms. Cindy Wade
Vice Chairperson
Dental
Frank Arnold, D.D.S. Randall R. Benner, D.D.S. Ben Blackburn, D.D.S.

Albany Tucker Augusta Covington
Rome
Winder Columbus
Athens Atlanta Atlanta
Valdosta Atlanta Rome Atlanta
Atlanta Albany
Albany Atlanta Atlanta Atlanta Atlanta Waycross Atlanta
Dalton
Covington Moultrie Atlanta

Roy Brooks, D.D.S.

East Point

F. Marion Durst, 111, D.M.D.

Augusta

Janet H. Harrison, D.D.S.

Vice Chairperson

Milledgeville

E. Douglas Henson, D.D.S.

Chairperson

Atlanta

R.H. Sasser, D.D.S.

Swainsboro

James S. Soteres, D.M.D.

Atlanta

Dewitt T. Walton, D.D.S.

Macon

Alton J. Whiddon, Jr., D.D.S. Moultrie

Durable Medical Equipment

Ms. Linda Childers Mr. Jim Douglas Mr. Larry Ezzard Mr. David Hicks Eric Holgate, R.Ph.
Vice Chairperson James Parkinson, R.R.T.
Chairperson Mr. David Petsch Richard Smith, R.Ph. Phillip Stone, R.Ph.

Athens Atlanta Atlanta Eastman
Augusta
Dalton Augusta Atlanta Covington

Early and Periodic Screening, Diagnosis and Treatment

Melody Carter, M.D. Chairperson
B.T. Elliott, Jr., M.D. Linda Hubbard, R.N. Winton G. King, M.D. Booker Poe, M.D. Carol Smith, R.N. Barbara Sweeney, R.N. Sherilyn Walker, R.N.
Vice Chairperson

Atlanta Atlanta
Macon Decatur Atlanta Decatur Atlanta
College Park

Formulary

Nevron S. Askari, M.D.

Atlanta

Mr. W. Fred Blackmon, Jr.

Norcross

Barbara S. Bruner, M.D.

Atlanta

E. Clyde Buchanan, R.Ph.

Atlanta

Mr. Seymour Inkles

Copiagne

Mr. Luther W. Livingston

Duluth

Jeff Lurey, R.Ph.

Norcross

J. Russell May, Pharm.D.

Augusta

George McFarland, R.Ph.

Atlanta

James S. McWilliams, R.Ph.

Cedartown

Joseph N. Micelli, Ph.D.

Chairperson

Atlanta

Reuben S. Roberts, Jr., M.D.

Hawkinsvil le

George W. Shannon, M.D.

Columbus

Danny Toth, R.Ph.

LaGrange

Earl S. Ward, Pharm-D.

Lilburn

Robert R. Warnock, R. Ph.

Marietta

James R. Wilhoite, M.D.

Nashville

Richard A. Wherry, M.D.

Vice Chairperson

Dahlonega

Benjamin E. Woods, M.D.

Atlanta

Home Health
Ms. Mary Lord Argo Janet Berhang-Doggett, R.N.
Vice Chairperson Ms. Denise Letterbush Ms. Barbara Maxedon Nelle B. Ramage, R.N. Mr. Hal Smith, Jr.
Chairperson Ms. Pat Szucs Ms. Jo Thurmond

Athens
Aiken Valdosta
Atlanta Augusta
Eastman Atlanta
Jasper

Hospice

Mr. George Cussel Ms. Ruth Lee Carl Schneider, M.D. Sister Linda Smith Ms. Sharon Smith
Vice Chairperson Ms. Anne Stewart
Chairperson Ms. Cathy Wiggins

Columbus Tifton
Atlanta Augusta
Marietta
Savannah LaGrange

Hospital Mr. Jerry W. Adams Mr. Weston Bergman

Americus Vidalia

Mr. Ken Beverly Vice Chairperson
Mr. John G. Calhoun Mr. Virgil E. Cooper, Jr. Mr. Andrew L. Galloway Mr. Morton Ganeles Mr. Alexis Klamke Mr. J. David Lawrence, Jr. Mr. Ed Ollie Mr. William T. Richardson Mr. Stephen Shepherd Mr. J. Mike Sims
Chairperson Mr. Richard G. Stovall

Thomasville Augusta Macon Atlanta Atlanta Atlanta
Commerce Albany Tifton
Statesboro
Columbus Marietta

Nursing Home

Ms. Rachel Athon Mr. Larry Baird Ms. Deborah Beards Mr. Ray Brees Ms. C. Lyn Burnette Ms. Jewel1 S. Clifton Mr. Francis M. Feltham Ms. Rosalyn M. Harbuck Mr. Gene Harrison
Chairperson Mr. Bobby Johnson
Vice Chairperson Ms. Jean Morgan Mr. Frank Shaw Ms. Myrtle Vickers

Conyers Toccoa
Atlanta Dallas
Cordele Savannah
Augusta Griffin
Dalton
Atlanta Milledgeville
Atlanta Douglas

Optometric

Sherri L. Becker, O.D. Hamp L. Burney, O.D.
Vice Chairperson William L. Dobbs, O.D. Larry E. Forth, O.D. Daniel D. Gottlieb, O.D. Edwin K. Porter, O.D.
Chairperson

Statesboro
Atlanta Cov ington
Douglas Stone Mountain
Dublin

Orthotics and Prosthetics

James M. Barnes, C.O. Hanif Chaudhary, C.P. Ms. Laura Dennison Ted L. Hyde, C.O. Grover Jeffcoat, C.O.
Chairperson John McNeill, C.P.O.

Atlanta Decatur Lawrenceville
Macon
Savannah Marietta

4 3

Carol Walsh, M.A.T., CC-A Vice Chairperson

Atlanta

Outpatient Mental Health

Mr. James Baird Ms. Patricia Brown Ms. Joann Colwell Mr. Jerry Garber Cynthia A. Luke, R.N.
Vice Chairperson Mr. Bill C. Mahaffey Ms. Annette Maxey
Chairperson Mr. Billy Warden Mrs. Martha J. Williams

Dalton Atlanta Atlanta Atlanta
Columbus Lawrenceville
Decatur Austell Americus

Pharmacy

Milton C. Bowling, Jr., R.Ph.

Gainesville

Jean Courson, R.Ph.

Tifton

Carlos T. Dyer, R.Ph.

Acworth

Stephen Gay, R.Ph.

Statesboro

Harold Jones, R.Ph.

Chairperson

Augusta

Diane Nykamp, Pharm.D.

Atlanta

Michael J. O'Neill, R.Ph.

Marietta

Neil L. Pruitt, R.Ph.

Vice Chairperson

Toccoa

Evan Ward, Sr., R.Ph.

Atlanta

Susan Whitworth, R.Ph.

LaGrange

Patricia Zeigler, R.Ph.

Atlanta

Physician

Bipin Agrawal, Ph.D., M.D. William H. Borders, Jr., M.D.
Chairperson Larry Boss, M.D. Norman L. Elliott, M.D. Shelley Griffin, M.D. Hamilton Holmes, M.D. Charlie Humphries, Jr., M.D. Frank Isele, M.D. William Kanto, M.D.

Columbus
Atlanta Villa Rica
Atlanta Waynesboro
Atlanta Albany Albany
Augusta

Robert F. Long, M.D. Clyde Lord, M.D. Wallace D. Mays, M.D.
Vice Chairperson G. Randall McNair, M.D. Richard A. Wherry, M.D.

Savannah Atlanta
Americus Thomasville
Dahlonega

Podiatry

Robert Cushner, D.P.M. Vice Chairperson
Glen A. Dowling, D.P.M. Gary S. Fields, D.P.M. Norm Kornblatt, D.P.M.
Chairperson

Statesboro Albany
Atlanta
Douglasville

Psychology

Ralph Allsopp, Ph.D. Marcelo De La Serna, Ph.D. Gary Dudley, Ph.D. Donald C. Kent, Ph.D. Nancy A. McGarrah, Ph.D.
Chairperson A. Bartow Ray, Jr., Ph.D.
Vice Chairperson Sylvia Shellenberger, Ph.D.

Atlanta Decatur Marietta Atlanta
Atlanta
Americus Macon

Transportation

Mr. Ken Duke

Forsyth

Mr. Bennie Hinson, Jr.

Vice Chairperson

Macon

Mr. John Cooley Hobdy

Valdosta

Ms. Jan Law

Eastman

Mr. Don Lindsey

Fitzgerald

Ms. June Allen Merritt

Blakely

Mr. Marshall Newsome

Morrow

Mr. Mickey Reeves

Brunswick

Mr. Charles N. Sims, Jr.

Douglas

Ms. Virginia Tankersley

Statesboro

Mr. Richard Tibbetts, A.E.M.T.

Chairperson

LaGrange

Mr. Mitch Turner

Douglasville

Mr. Steve Widener

Thomasville

We wish 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, andfor dignity inworkare equally availableto all. Employeesandapplicants are evaluated on the basis of performance,skill and experiencewithout regardto race, color, sex, age, religion, national origin or physical disability.

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