Georgia Medicaid for Children

Medicaid is a funded with state and federal funds and is a program for low-income individuals and families without access to health insurance. Each state operates a department that oversees the program, makes decisions on eligibility and administers the program. In Georgia, the Georgia Department of Community Health is this agency. Applicants must meet eligibility requirements in order to receive Medicaid coverage.

Eligibility

• Several groups of families and individuals are covered by Medicaid in the state of Georgia. Within each of the groups, eligibility criteria must be met. These criteria include age, pregnancy, blind, aged, disabled, income level and citizenship status. Undocumented immigrants and non-qualified alien residents may qualify for emergency help in certain circumstances. The Georgia Department of Community Health urges all interested persons to apply for Medicaid even if eligibility is uncertain or if an application has been denied in the past.

Early and Periodic Screening, Diagnosis and Treatment

• The Early and Periodic Screening, Diagnosis and Treatment is part of the Federal Medicaid Act that stipulates the state of Georgia's responsibility to care for all Medicaid-eligible children. Under this section of the law, Georgia is required to provide all necessary health care, treatment and diagnostic services related to treating or correcting physical and mental illness and conditions. According to this law, Medicaid-eligible children are guaranteed coverage for various therapies, nursing care, vision care, dental care and other behavioral support care. The required services are under the discretion of the child's treating physicians or other health care professionals, without artificially determined limits or caps on coverage. The EPSDT law also states these children under the age of 21 are entitled to prompt medical care without administrative delays.

Ensuring Coverage Under EPSDT

• Since EPSDT requires the state of Georgia to ensure all Medicaid-eligible children under the age of 21 are covered for comprehensive health care, coverage should be automatic. During the Early and Periodic Screening, called "Healthcheck" in Georgia, if a physician determines health issues are present and require treatment, he will provide the parent or guardian with a prescription for medication or referral to another Medicaid-approved treating physician. The doctor or health care provider may need to request prior authorization from Georgia Medicaid before treatment can be ordered, but in most situations, the Medicaid provider will treat the child and then bill Medicaid directly.

Denials

• When a Medicaid-eligible minor is denied treatment, or if the amount of services is reduce in terms of length of care, the frequency of treatment or less aggressively than non-Medicaid patients, the parent will receive notification from Georgia Medicaid within 30 days of the denial of treatment or service. By Georgia law, the denial letter must include the precise treatment or service that have been denied including any codes used to describe the treatment or service, additional information necessary from the health care provider that may be needed to change the determination of denial and the reason and facts used to issue the denial. When a claim is denied, the parent has the right to appeal the decision and a decision must be made by the Georgia Department of Community Health within 90 days of the appeal. The denial letter received provides direction on how to appeal a denial, all correspondence regarding the denial appeal should be sent via registered mail with a receipt of delivery.