2933 Georgia Pediatric Program

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Georgia Pediatric Program

Effective Date:

June 2020

Chapter:

2900

Policy Number:

2933

Previous Policy Number(s):

MT 44

Updated or Reviewed in MT:

MT-60

Requirements

The Model Waiver Program (MWP) and the Exceptional Children’s Service were merged into the Georgia Pediatric Program (GAPP) effective 3/30/03. The program provides specialized medical services to a Medicaid recipient who is under age 21 and respirator or oxygen dependent.

Basic Considerations

A request for GAPP services is made when an individual is in need of a particular medical service that is not usually covered by Medicaid. The Prior Authorization (PA) Unit of Georgia Health Partnership (GHP) is responsible for determining appropriateness for these services.

To be eligible for GAPP services, the A/R must meet the following conditions:

  • The A/R is a Medicaid recipient under the most advantageous COA, including SSI, Family Medicaid or ABD Medicaid.

  • The A/R is under the age of 21.

  • The A/R is respirator or oxygen dependent.

  • The A/R is approved for a nursing home level of care (LOC).

  • The A/R is approved by the PA Unit for GAPP services.

The PA Unit is responsible for obtaining the required LOC unless Medicaid eligibility is determined under the Deeming Waiver COA.

Eligibility for GAPP services is approved manually and is not entered on the DFCS system.

Procedures

Medicaid Recipient

Follow the steps below to initiate GAPP services if the individual requesting these services is currently receiving Medicaid.

Step 1

Verify Medicaid eligibility
Step 2

Verify that the A/R is under age 21.
Step 3

Document the PR’s statement that the individual is respirator or oxygen dependent. File any supporting medical documentation in the case record.
Step 4

Inform the PR to have the A/R’s physician or hospital discharge planner contact the PA Unit at the following address to arrange for GAPP services:

Georgia Medical Care Foundation
Prior Authorization (GAPP)
P.O. Box 105406
Atlanta, GA 30348

Or electronically at: www.mmis.georgia.gov.

Explain to the PR that additional information may be required by the PA unit, such as Form DMA-6(A) completed by the physician.

If the A/R is approved for GAPP services, DCH notifies the county DFCS of the approval with a copy of the approval letter that is sent to the PR.
Step 5

Review the income of the GAPP A/R. Contact a state Medicaid consultant regarding calculations of a cost share if the A/R has income in excess of the FBR for LA-A.

Changes in Medicaid or GAPP Eligibility Participating Provider Types

Complete a CMD if an individual has been terminated from ongoing Medicaid and is receiving GAPP services. Refer to Section 2052, Continuing Medicaid Determination.

Medicaid Applicant

Follow the steps below to determine Medicaid eligibility and initiate GAPP services if the individual requesting these services is not currently receiving Medicaid.

Step 1

Accept the A/R’s Medicaid application.
Step 2

Verify that the A/R is under age 21. Document the A/R’s respirator or oxygen dependency in the case record
Step 3

Screen for Medicaid eligibility under all COAs, including SSI, Family Medicaid and ABD Medicaid. Determine eligibility under the COA most advantageous to the A/R.

  • If the A/R is ineligible for Medicaid under all other COAs and is a child under age 19, determine Medicaid eligibility under the Katie Beckett COA.

  • If eligibility is determined under the Katie Beckett COA, forward a copy of the GMCF LOC approval letter to the PA unit as soon as it is returned to DFCS from GMCF.
Step 4

Tell the PR to have the A/R’s physician or hospital discharge planner contact the PA Unit. Refer to Step 4 of the Procedures to initiate GAPP services for an individual who is currently receiving Medicaid listed above.

GAPP services cannot be approved while an application for Medicaid is pending.

Special Considerations

SSI PNA

A disabled child may be eligible for a $30 SSI personal needs allowance from SSA if s/he meets the following criteria:

  • Is disabled

  • Received SSI benefits (limited to PNA) while in a medical treatment facility

  • Is ineligible for SSI solely because of deemed income or resources of the parents

  • Is currently eligible for Medicaid under one of the following COAs:

    • Katie Beckett

    • CCSP

      OR

    • Is receiving services under GAPP

If the child meets the above criteria, refer the parent(s) to SSA to continue the SSI $30 PNA payment and Medicaid. Continue to maintain the child under the COA above unless the child no longer meets the criteria for that program.

Nurse Services

In order for Medicaid to pay for the services of a nurse, the GAPP child must be approved under a skilled LOC and would have to be oxygen or ventilator dependent on a continuing basis.