House Bill 1502
By: Representatives Kelley of the 16th, Williamson of the 112th, and Douglas of the 78th
A BILL TO BE ENTITLED
AN ACT
To amend Article 7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated,
relating to medical assistance generally, so as to establish requirements for the Department
of Community Health relative to contracts with care management organizations for the
provision of healthcare services for Medicaid or PeachCare for Kids recipients; to provide
for definitions; to provide for an effective date and applicability; to provide for related
matters; to repeal conflicting laws; and for other purposes.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION 1.
Article 7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating to
medical assistance generally, is amended by adding a new Code section to read as follows:
"49-4-159.5.
(a) As used in this Code section, the term:
(1) 'Care management organization' shall have the same meaning as set forth in Code
Section 33-21A-2.
(2) 'Existing contracts' means all contracts in effect on the effective date of this Code
section, between the department and one or more care management organizations to
provide or arrange healthcare services on a prepaid, capitated basis to a member.
(3) 'Member' means a Medicaid or PeachCare for Kids recipient who is currently
enrolled in a care management organization plan.
(b)(1) Upon the expiration of the existing contracts and subject to the requirements set
forth in paragraphs (2) and (3) of this subsection, the department shall publish on its
website a request for applications from care management organizations to contract with
the department to provide or arrange healthcare services to members. The department
shall contract with each care management organization that submits an application in
response to such request and meets the minimum standards established by the department
pursuant to subsection (d) of this Code section.
(2) Not later than 60 days before the department issues a request for applications in
accordance with paragraph (1) of this subsection, the department shall publish notice of
and make available for public review and comment such request for applications and any
related, nonprivileged documents, including, but not limited to, the proposed contract.
The department shall provide interested persons a reasonable opportunity to submit
comments on such request for applications in writing or orally at one or more public
forums.
(3) Not later than 30 days before the department issues a request for applications, the
department shall post on its website:
(A) A summary of comments received from interested persons under paragraph (2) of
this subsection; and
(B) The department's response to such comments.
(4) The department shall take all steps reasonably necessary to extend existing contracts
as needed until new contracts are entered into in accordance with this subsection.
(c) Any procurement for a care management organization pending without a final contract
with the department on the effective date of this Code section shall be automatically
cancelled.
(d) The department shall establish minimum quality and performance standards to evaluate
the applications of care management organizations submitted pursuant to subsection (b) of
this Code section. In adopting such standards, the department shall consider:
(1) Cost efficiency, quality of care, and experience of care;
(2) The size and quality of a care management organization's provider network; and
(3) The care management organization's past experience in providing similar services in
this or other states.
(e) Each member shall be permitted to select from any plan offered by a care management
organization which the department has contracted with and which offers healthcare services
in the member's region for which the member is eligible.
(f) The department shall:
(1) Evaluate by July 1, 2027, and annually thereafter, each care management
organization by region against the quality and performance standards established pursuant
to subsection (d) of this Code section;
(2) Publish on its public website and in a format that is easily understood by a member
of the general public the results of such evaluations;
(3) Establish and publish an aggregate benchmark under which a care management
organization may not be recertified until corrective actions are taken;
(4) Reevaluate and recertify that a care management organization is reasonably capable
of fulfilling the terms of its contract in accordance with all applicable federal and state
laws for the regions under which the department has entered into a contract:
(A) Five years after a care management organization initially enters into a contract
with the department to provide healthcare services in a region; and
(B) Every three years thereafter.
(g)(1) A care management organization who, pursuant to this Code section, either has
not been awarded a contract with the department for failure to meet to the minimum
standards established by the department pursuant to subsection (d) of this Code section
or whose contract has been terminated shall be entitled to a hearing before the
department. In such cases, the department shall give written notice of either the denial
of application or termination of contract to the affected care management organization,
including the reasons of the department for denial or termination. Should the care
management organization desire to contest the initial decision of the department, it must
give written notice of appeal to the commissioner of community health within 14 days
after the date on which the notice of denial or notice of termination was transmitted to
such care management organization. A hearing shall be scheduled and commenced
within 20 days after the date on which the commissioner receives the notice of appeal;
and the commissioner or his or her designee or designees shall render a final
administrative decision as soon as practicable thereafter.
(2) Any care management organization which is aggrieved or adversely affected by a
final decision of the commissioner may seek judicial review thereof by filing a petition
within 30 days after the service of the final decision of the commissioner or, if a
rehearing is requested, within 30 days after the decision thereon. Copies of the petition
shall be served upon the commissioner and all parties of record. The petition shall state
the nature of the petitioner's interest, the facts showing that the petitioner is aggrieved by
the decision, and any grounds upon which the petitioner contends that the decision should
be reversed or modified. Judicial review of the commissioner's decision shall be
reviewable in the Superior Court of Fulton County in the same manner and under the
same standards as are applicable to those contested cases which are reviewable pursuant
to Code Section 50-13-19.
(h) If a care management organization that has contracted with the department pursuant
to subsection (b) of this Code section fails to comply with the terms of the contract or with
any requirement set forth in this Code section and to make substantial efforts to mitigate
or cure such noncompliance, as determined by the department, in addition to any remedies
available under the contract, the department may:
(1) Require that the care management organization submit and comply with a corrected
action plan;
(2) Suspend default enrollment of members to the care management organization in one
or more regions; or
(3) Terminate the contract.
(i) This Code section shall be the exclusive means by which the department may enter into
contracts with a care management organization to provide or arrange healthcare services
for a member."
SECTION 2.
This Act shall become effective upon its approval by the Governor or upon its becoming law
without such approval, and shall apply to all contracts entered into by the department with
a care management organization to provide or arrange healthcare services to a member.
SECTION 3.
All laws and parts of laws in conflict with this Act are repealed.