By Richard D. Sanders*
December 17, 2008
In 2008, Georgia's most significant healthcare reforms included a complete overhaul of the State's Certificate of Need (CON) Program and significant changes to laws related to Care Management Organizations (CMOs), the managed care plans through which Georgia's Medicaid enrollees receive benefits. Although funding for trauma care was a hot-button issue in 2008, the legislature did not ultimately approve a trauma care funding system.
Certificate of Need
The most significant of all healthcare reforms in 2008 came from Senate Bill 433, which the General Assembly passed at the tail end of the legislative session and became effective July 1, 2008.
A much anticipated aspect of Senate Bill 433 was the inclusion of general surgery and physiatrists in the CON exception for single-specialty ambulatory surgery centers. Senate Bill 433 also increased the expenditure threshold of CON-exempt, single-specialty ambulatory surgery centers from $1.7 million to $2.5 million (indexed for inflation). Joint venture ambulatory surgery centers, which are owned jointly by hospitals and physicians, are now also exempt from CON requirements.
Other exceptions include diagnostic and therapeutic cardiac catheterizations, as well as equipment expenditures under $1 million. However, new freestanding imaging centers are required to obtain a CON to purchase diagnostic equipment, regardless of cost. For perinatal services and for destination cancer hospitals located within twenty-five miles of the Atlanta airport, CON requirements have been reduced.
Senate Bill 433 also increased the capital expenditure threshold for healthcare facilities to $2.5 million (and will be adjusted for inflation).
Care Management Organizations
The Georgia General Assembly also passed House Bill 1234, the "Medicaid Care Management Organizations Act," in the late hours on the final day of the legislative session. The bill clarifies that a CMO is required to obtain a certificate of authority as a health maintenance organization (HMO) and is subject to laws relating to HMOs. The bill requires that each CMO program review its automated claims payment systems. Each CMO must pay out-of-network providers the same amount paid by the Georgia Department of Community Health under fee-for-service Medicaid for emergency healthcare services and post-stabilization services.
The bill also requires that each CMO pay interest in the amount of 20% per annum for all claims that are initially denied or underpaid, but eventually determined to have been owed by the CMO.
Although the General Assembly paid significant attention during the legislative session to Georgia's underfunded and overburdened trauma-care network, it failed to pass a bill to address the need for a sustainable funding mechanism related to trauma care.
Upcoming Issues for 2009
Among issues anticipated to arise for the 2009 legislative session are tort liability expansion, trauma care, and behavioral health in Georgia.
*We would like to thank Richard D. Sanders, Esquire (Balch & Bingham LLP, Atlanta, GA) for providing this summary.