Georgia Families CMOs and Therapy - Babies Can't Wait Program
Background
The Babies Can’t Wait (BCW) program is administered by the Department of Public Health, under the authority of Part C of the Individuals with Disabilities Education Improvement Act (IDEA). This is a federally funded grant program to assist states in providing early intervention services to infants and toddlers (birth through age 2) with developmental disabilities.
Services provided through Babies Can’t Wait include:
- Multi-disciplinary evaluation
- Service coordination that is required by this federal program for all participants
- Early intervention services (including speech, physical, and occupational therapy) that are identified as necessary, from the multi-disciplinary evaluation
Coverage of Services
- Federal regulation require that other sources of funding such as private insurance or Medicaid are utilized, prior to federal funds. However, there is no requirement that Medicaid pay for services that would not otherwise be covered by Medicaid (e.g. services that are not medically necessary).
- The Care Management Organizations (CMO) are required to cover therapy services that are medically necessary to correct or ameliorate physical illnesses and conditions. Medically necessary means that the treatment is:
- Appropriate and consistent with the diagnosis
- Omission of treatment could adversely affect the member’s condition
- Compatible with the standards of acceptable medical practice
- Provided in a safe, appropriate, and cost-effective setting
- Not provided solely for the convenience of the member or provider
- Not primarily custodial or supportive
- The CMOs are not required to cover services solely because they are part of the child’s Individualized Family Service Plan (IFSP) developed through BCW.
Care Management
- The CMOs are required to provide case management services for infants and toddlers at risk for developmental delay.
- They are not necessarily required to cover the services provided by the BCW service coordinator.
- The CMO requirements for case management, as defined in the contract are:
- Early identification of Members who have or may have special needs;
- Assessment of a Member’s risk factors;
- Development of a plan of care;
- Referrals and assistance to ensure timely access to Providers;
- Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;
- Monitoring;
- Continuity of care; and
- Follow-up and documentation.
Impact on Babies Can’t Wait
- The CMO case managers are not required to provide all of the same types of services either as BCW service coordinators, nor are they required to meet the same schedule of face-to-face contact. Therefore, unless the CMO were to elect to adopt all of the BCW requirements for their case management programs, BCW must still provide a service coordinator for each family.
- Two of the three CMOs have agreed to cover service coordination through BCW.
- One CMO is reimbursing at Medicaid rates ($135 per month), the second is reimbursing at $75 per month.
- BCW must pay the cost of service coordination if the CMO does not cover it.
- BCW does not pay the difference in rates($75 vs. $135), if the CMO does cover service coordination
- BCW must pay for any therapy services that are part of a child’s IFSP, that are determined by a CMO to be not medically necessary and therefore not covered by Medicaid.
- BCW will only reimburse therapists for these services after the member has exhausted all levels of appeal of the medical necessity denial.
