Archive for the ‘Medicare/Medicaid News’ Category

Medicaid Banner Message: September Physician Services Webinars

The Department of Community Health (DCH) and Gainwell Technologies invite you to participate in one of the Physician Services webinars scheduled during the month of September 2022. There will be ten online webinars available. Providers are encouraged to send their practice managers and billing staff, as well as business associates, including billing/service agents that submit Medicaid claims. The webinars will provide important information you will need to know on the following topics including, but not limited to:

  • Eligibility Verification
  • Procedure Search
  • Common Denials
  • +More

To ensure all Georgia Medicaid providers can attend at least one webinar, there will be ten webinars on the dates below:

  • Wednesday, September 14, 2022
  • Tuesday, September 20, 2022
  • Thursday, September 22, 2022
  • Monday, September 26, 2022
  • Friday, September 30, 2022

Each date will have two webinars: 10:00 AM and 1:00 PM for a total of ten webinars. The webinars will be open to all territories throughout the state of Georgia. Attendees must individually register to reserve a seat. The registration must be completed online.

To register online, visit – Upon completion of your registration, a confirmation notice will be sent via e-mail to the address provided during registration. Please review the confirmation e-mail for accuracy.

The webinar confirmation e-mail will include:

  1. Date and time of the webinar workshop
  2. Conference phone number and pass code 
  3. Teams Meeting hyperlink

Should you have any questions regarding the Physician Services webinars for the month of September 2022, please contact Gainwell Technologies via e-mail at

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

Medicaid Banner Message: Preparing for the End of the Federal Public Health Emergency

Dear Georgia Medicaid Providers,

The Georgia Department of Human Services (DHS) is preparing for the end of the Public Health Emergency (PHE) and the upcoming redeterminations of Medicaid member eligibility.

We are seeking your assistance with this effort. When you meet with Medicaid and PeachCare for Kids members, please remind them to update their account information. This is the first step in the process to ensure eligible members keep their coverage when the federal Public Health Emergency ends.

Since the start of the Public Health Emergency, we have maintained all members on the Medicaid rolls with certain exceptions. Only members who died, moved out of state, were incarcerated, or asked for their coverage to end had their cases closed.

It is important for Georgia Medicaid members to begin preparing by making sure their correct account details are listed in the Georgia Gateway customer portal.

Georgia Medicaid members can quickly and easily report any information that has changed from their last application or renewal by logging in or signing up for an account at

Supplemental Security Income (SSI) Members must contact the Social Security Administration (SSA).

This includes changes to their phone numbers (mobile or land line), email addresses, physical addresses, job or income, as well as a change in the number of people in their household.

Georgia Academy Responds to Request for Medicaid Innovation and Improvement Suggestions

Current contract holders are Anthem, CareSource, and Centene (PeachState), serving more than 1.9 million beneficiaries as of May 2022. Existing contracts run through June 30, 2024. The request for proposals is expected to be released in late 2022 or early 2023. The Georgia Academy responded to the RFI submitting over seven pages of how Georgia’s Medicaid system could be improved.  Chapter President Dr. Susana Ajoy Alfonso noted in our cover page the following:

On behalf of the 3,200 members of the Georgia Academy of Family Physicians, we are submitting suggested recommendations for consideration by the Department as you craft the new (and anticipated) request for proposals for insurance companies focusing on the Medicaid population.  Thank you for allowing us to compile suggestions for quality improvement that help our patients and brings savings to the state of Georgia.

While we are submitting separate information through your RFI process, note that we work closely with our primary care physician and OB Gyn society partners through the Patient-Centered Physician Coalition of Georgia which represents over 10,000 family physicians, pediatricians, internal medicine physicians, obstetricians/gynecologists, and physicians of osteopathic medicine.

We look forward to providing continuous feedback and collaboration through this process. 

Some of the suggestions that were submitted to Georgia’s Medicaid include the following:

  • The Georgia Medicaid program should encourage innovative ideas as medicine and technology are constantly changing.
  • DCH should consider a forum whereby clinicians and/or patients and families can propose innovative ideas and best practices such as-
  • Automatic Behavior medicine assessment for all patients with uncontrolled chronic diseases
  • Coverage for standalone pharmacy services such as for uncontrolled diabetics
  • Community grants which address novel ways to combat SDoH challenges
  • Prior authorization reform needs to occur both for behavioral and physical health– similar to what has occurred in Ohio. Ohio is implementing a fiscal intermediary that will serve as a single point of entry for prior authorization requests.  

Additional information can be found here:

Uniform Preferred Drug Lists

States can establish a uniform PDL (or single PDL) across both managed care organizations and FFS. This is a strategy that states are employing for administrative efficiency and ease, to increase transparency, and maximize drug rebates.

States with a Uniform PDL

The most recent state-by-state analysis that was conducted of state policies regarding uniform PDLs was in 2019 by the Kaiser Family Foundation with support from HMA. In that survey, 16 states reported having a uniform PDL for some or all drug classes as of July 2019. Those states are:

Uniform PDL for all drug classes:








North Dakota


Uniform PDL for some drug classes:





South Carolina



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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

In its letter, the Georgia Academy said in part:

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

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

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

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

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

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

To read the entire letter click here:

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

CMS Study on Burdens Associated with Reporting Quality Measures

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

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

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

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

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

Save the Date: Georgia Medicaid Fair

Dear Georgia Medicaid Providers and Stakeholders:

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

Wednesday, April 25, 2018
UGA Tifton Campus Conference Center

15 RDC Road

Tifton, Georgia 31794

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

Do you want to help shape our agenda?

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

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

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

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

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


Georgia Department of Community Health

DXC Technology

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

Dear Providers:

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

Existing/Open Prior Authorizations:

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

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

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

Pharmacy-Related Prior Authorizations:

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


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

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

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

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



Department of Community Health

View Georgia Families® Frequently Asked Questions & Answers

New Medicare cards offer greater protection to more than 57.7 million Americans

New cards will no longer contain Social Security numbers, to combat fraud and illegal use.

The Centers for Medicare & Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. The new cards will use a unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI), to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card. CMS will begin mailing new cards in April 2018 and will meet the congressional deadline for replacing all Medicare cards by April 2019. Today, CMS kicks-off a multi-faceted outreach campaign to help providers get ready for the new MBI.

Providers and beneficiaries will both be able to use secure look up tools that will support quick access to MBIs when they need them. There will also be a 21-month transition period where providers will be able to use either the MBI or the HICN further easing the transition

Personal identity theft affects a large and growing number of seniors. People age 65 or older are increasingly the victims of this type of crime. Incidents among seniors increased to 2.6 million from 2.1 million between 2012 and 2014, according to the most current statistics from the Department of Justice. Identity theft can take not only an emotional toll on those who experience it, but also a financial one: two-thirds of all identity theft victims reported a direct financial loss. It can also disrupt lives, damage credit ratings and result in inaccuracies in medical records and costly false claims.

CMS is committed to a successful transition to the MBI for people with Medicare and for the health care provider community. CMS has a website dedicated to the Social Security Removal Initiative (SSNRI) where providers can find the latest information and sign-up for newsletters. CMS is also planning regular calls as a way to share updates and answer provider questions before and after new cards are mailed beginning in April 2018.

For more information, please visit:

MACRA Bytes: Payment Primer Helps Family Physicians Digest MACRA Implementation Details

MACRA_ArticleOpener.jpg.daijpg.380Sometimes, when an upcoming project seems overwhelmingly complicated, it’s nice to be presented with a simple step-by-step plan in this format: “Do this now, then do that.”

That clearly was the idea behind the latest Family Practice Management supplement created by the AAFP as a resource for family physicians whose brains are bursting with an excess of information from CMS about how the Medicare Access and CHIP Reauthorization Act (MACRA) is being implemented.

The long-term goal of MACRA is commendable: building a creative new Medicare payment system that focuses on the value of health care provided to patients. And with a huge focus on the value of care — and elements such as team-based care, chronic care management and quality measurement — family physicians stand to benefit.

Unfortunately, too many physicians currently are mired in the muck of endless detail.

Family physicians, do yourselves a huge favor and check out the new supplement available in the July/August Family Practice Management that is available at no charge to all AAFP members and FPM subscribers.

The title says it all: “Making Sense of MACRA: Start Today, Prepare for Tomorrow.” Pull it up online, print it out it, post it in a prominent spot in the office, and then use the supplement as a guide through the next couple of years of Medicare payment reform.

The article starts with a quick overview of current Medicare payment and quality programs — think Physician Quality Reporting System (PQRS), the valued-based payment modifier (VBPM) initiative, and the Medicare and Medicaid Electronic Health Records Incentive programs that hatched meaningful use (MU) — and then outlines what happens to those programs in the coming years.

At this point, it’s time to become familiar with a new term — the Quality Payment Program (QPP) — that HHS introduced in April when the massive MACRA implementation proposed rule rolled out. Everything MACRA-related now falls under this giant payment program umbrella.

From there, the article launches into an explanation about how each of the current payment and quality programs will be assimilated into one of two new payment pathways created as part of the QPP — namely, the Merit-based Incentive Payment System.

The MACRA preparedness supplement is written in an easy-to-understand format that first explains topic areas related to PQRS, VBPM and MU and then answers two basic questions for each that family physicians across the country are likely struggling with:

What can I do now?

What comes next?

The supplement includes colorful charts and graphics that help make sense of the various programs and that point out those definitely-need-to-know dates and timelines, as well as highlight potentials for additional earnings or penalties.

2016 Family Medicine Legislative Champions of the Year


The Georgia Academy of Family Physicians each year recognizes legislative leaders in the Georgia General Assembly. This year, Rep, Terry England (R-116) and Sen. Jack Hill (R-4) were selected for their support of Georgia health initiatives and their stewardship as the chairpersons of the Appropriations Committee for their respective legislative bodies.

Chairpersons England and Hill shepherded in an increase in payment for 32 primary care codes for Medicaid, a major victory for family physicians, including their pediatric, internal medicine, and obstetrics/gynecological colleagues. Victories also include tax credits for rural hospitals and the Prescription Drug Monitoring Bill, which allows clinicians to better identify patients who may have prescription drug addiction.

“Both chairpersons England and Hill have really made the health of Georgians their priority and the Georgia Academy of Family Physicians wants to recognize those legislators who are fighting for a healthier and better future for Georgia residents”, said Mitzi Rubin, M.D. Dr. Rubin is the president of the GAFP and a family physician in the Atlanta area.

Both Chairmen Hill and England were extremely grateful to win the award and demonstrated a continuing commitment to family medicine. “It is an honor to be named GAFPs 2016 Legislative Champion of the Year, along with my esteemed colleague, Jack Hill,” said Rep. England.  “Family medicine plays a large role in the overall health and wellness of our families and the citizens of this state, and investing in family medicine is ultimately and investment in the well-being of all Georgian.”

CMS Opens Door to Possible Delay of MACRA Implementation

During Senate proceedings on July 13, CMS Acting Administrator Andy Slavitt and senators showed that they have heard and understand the AAFP’s sharp call to slow down plans for implementing the Medicare Access and CHIP Reauthorization Act (MACRA).
Speaking before the Senate Finance Committee(, Slavitt said he knows small physician practices might not have enough time to prepare for the important changes in Medicare payment if they go into effect on Jan. 1 as planned.
A final rule on new payment models under MACRA is expected to be announced in November. Sen. Orrin Hatch, R-Utah, chairman of the committee, noted the short period between then and the planned implementation date.
“Physicians will only have about two months before the program goes live,” Hatch said. “This seems to be a legitimate concern. What options is CMS considering to make sure this program gets started on the right foot?”
Slavitt responded that CMS is open to alternatives that include postponing implementation and establishing shorter reporting periods. He acknowledged several times during the hearing that the more time physicians have to spend reporting data, the less time they can devote to patient care.
“We’re putting in an awful lot of change,” Slavitt told the committee. “Too much change on top of an already burdened physician practice is not where we should be going.”
Slavitt’s stance is a good start for family physicians. The AAFP sent CMS a detailed letter on June 24 that called on the agency to, among other changes, delay implementation of MACRA until 2018 and set aside 2017 as a preparation year. The AAFP was also critical of the agency’s decision to delay formation of virtual groups until 2018; the groups would be a crucial support tool for smaller physician practices.
Slavitt also suggested that reporting requirements could be adjusted to ease the burden on physicians. For instance, CMS could obtain data through an automated database such as a registry. He also said practices that demonstrate strength in a particular area of care might not have to report those data and that physicians who do not see a high volume of Medicare patients might not be required to report data.