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Acute Care Services
Long-Term Care Services


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Benefits by State: Georgia (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes $3/visit Specified surgical procedures Limited to procedures safely performed in ambulatory setting, as approved by CMS Prospective cost based rate per episode of care using Medicare payment rates as ceiling CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes Public Health Clinics not covered Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Federally Qualified Health Center Services
Yes $2/visit Prospective cost based rate/visit CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes $12.50/non-emergency admission Non-emergency admissions except maternity Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered Prospective payment/discharge using DRG CN & MN
Outpatient Hospital Services
Yes $3/non-emergency visit Specified procedures Observation limited to 48 hours Cost based payment using percentage of charge CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Rural Health Clinic Services
Yes $2/visit Prospective cost based rate/visit CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Chiropractor Services
No
Dental Services
Yes Specified services Limited to emergency treatment for relief of pain and infection, limit does not apply to pregnant women Fee for service CN & MN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes $.50-$3 for selected services dependng on payment rate Specified services Fee for service CN & MN
Nurse Midwife Services
Yes Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Nurse Practitioner Services
Yes $.50-$3 for selected services dependng on payment rate 12 office visits/year, 1 inpatient hospital visit/day, 12 nursing facility visits/year Fee for service at 90% of physician fee CN & MN
Optometrist Services
Yes $.50-$3 for selected services dependng on payment rate Limited to diagnosis and treatment of medical eye problems as permitted by law and post-cataract surgery follow-up care, refractive exams covered for nursing facility residents with specific physician order Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Physician Services
Yes $.50-$3 for selected services dependng on payment rate Specified surgical procedures 12 office visits/year, 12 nursing facility visits/year Fee for service at 84.645% of CMS RBRVS rates for 2000, services performed in outpatient hospital rather than office paid lower fees CN & MN
Podiatrist Services
Yes $.50-$3 for selected services dependng on payment rate Specified services including most services for nursing facility residents 12 visits/year, specified services not covered Fee for service, services performed in outpatient hospital rather than office paid lower fees CN & MN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes $1-$3/Rx depending on drug cost and status Specified drugs 5 Rxs or refills/month AWP-11%, plus $4.69 dispensing fee to for profit retail pharmacies, dispensing fee $.33 less to non-profit pharmacies CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
No
Eyeglasses
Yes Adult coverage limited to nursing facility residents with specific physician order, minimum diopter correction required for initial and replacement eyeglasses Products provided by state's volume purchase contractor, dispensing provider paid fee for service CN & MN
Hearing Aids
No
Medical Equipment and Supplies
Yes $3/med equipment item, $1/med supply item or rental of med equipment item per month Specified med equipment and med supply items including enteral formula Coverage for nursing facility residents limited to augmentative communication devices Fee for service at 80% of CMS 2007 rates CN & MN
Prosthetic and Orthotic Devices
Yes $3/service Prosthetics and other specified items Orthopedic shoes must be attached to brace Fee for service at 80% of CMS 2007 rates CN & MN
Transportation Services
Ambulance Services
Yes 2 trips/day Fee for service CN & MN
Non-Emergency Medical Transportation Services
Yes $1/trip See service-specific FN CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes Fee for service at 84.645% of CMS RBRVS rates for 2000 CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Specified high cost tests and services Portable x-ray services not covered Fee for service, based on CMS rates CN & MN
Targeted Case Management
Yes Quantity and frequency limits vary by group served Fee for service or negotiated rate CN & MN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 1, 2, 4, 6 & 8 - See service-specific FN Dependent upon the services provided CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes $3/visit Therapies 50 nursing, home health aide and therapy visits/year; 2 months med equipment rental Prospective cost based rate per visit CN & MN
Hospice Care
Yes Two 90-day periods and one 30-day period with physician certification Prospective regional rates based on Medicare methodology CN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
No
Inpatient Psychiatric Services, under age 21
Yes Cost based payment CN
Intermediate Care Facility Services for the Mentally Retarded
Yes Yes Prospective cost based per diem with limits, leave days paid 95% of per diem CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes For LOC determination upon admission Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year Prospective cost based per diem with limits, leave days paid 95% of per diem CN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: None
 
 
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