Pending cuts to Georgia Medicaid payments could affect children who need therapy

ATLANTA — Therapists who help children with disabilities learn how to hold a crayon, walk and talk say their services to low-income families could be sharply reduced by proposed Medicaid rate cuts.

The government is not directly reducing payments. But two of the three contractors who manage Medicaid for Georgia sent letters to therapists recently to alert them to pending 20% reductions.

Providers say they can either absorb the cuts or leave the Medicaid managed care organization networks of those two companies.

The cuts would reduce rates to what therapists were being paid a decade ago, said Ben Braxley, president of the Georgia chapter of the American Physical Therapy Association.

"I don't know any business who could roll the clock back that far and feel that they will be in a sustainable situation," he said.

CareSource, one of the managed care companies, sent letters in late March that said it was cutting reimbursements to 80% of the Medicaid fee schedule effective May 11. The cut is "part of our broader effort to support sustainable program operations that ensure continued access to medically necessary services" by Medicaid recipients, said one letter reviewed by Capitol Beat.

A second company, Peach State Health Plan, sent letters in April with the same rate cut effective May 15.

Both companies said in responses to queries from Capitol Beat that their moves were intended to contain rising costs.

"These updates align with actions being taken by Medicaid programs nationwide to responsibly manage public resources as demand for these services grows," a statement from CareSource said.

Peach State said it was responsible for ensuring recipients get care "in an affordable way" and that the company was negotiating with providers.

"These conversations are ongoing and we are committed to ensuring uninterrupted access to care for our members," the company said.

The cuts follow news about inflated billing in other states.

The Wall Street Journal published several recent articles about excessive billing for autism therapy. In 2023, a provider in Indiana was charging $1,600 an hour and getting paid $640, according to the Journal. Federal investigators documented cases where therapy purportedly was performed while patients were napping or watching videos, such as the 2013 film "The Smurfs 2," the publication reported.

Reported rates of autism in young children have risen rapidly over the past two decades, increasing pressure on Medicaid.

But the cutbacks contemplated by CareSource and Peach State would affect thousands of children who do not have autism but still require therapy to move, manage pain and perform daily tasks, such as getting dressed. The cuts would also affect children who need help learning to speak.

Only those with severe chronic conditions, such as cerebral palsy, Down syndrome and spina bifida are unaffected. The state manages their care directly. Two years ago, state lawmakers increased reimbursement rates for providers who treat those children.

That was a nod to rising costs, said Kimberly Oviedo, who provides therapy services in Acworth.

Her staff of 25 at Beyond Limits Pediatric Therapy Center serves about 500 children a week, she said. More than half are on Medicaid, so if she opts out of those companies' networks, many might have to find another provider.

"My heart doesn't want these kids to not have services, but I also have a business to run," Oviedo said.

If she accepts the rate cuts, she said, it could bankrupt her clinic, affecting her patients who are not on Medicaid.

The vast majority of Shalli Lewis' patients are on Medicaid. Her Word of Mouth Therapy clinic in Statesboro sees about 900 children enrolled with one of Georgia's three managed care organizations. She has 16 therapists, and their advanced degrees cost money to obtain. She faces a tough decision: if she leaves the networks, it could crush her business. But if she stays, the rate cuts would probably drive her younger therapists to employers that do not rely on Medicaid. They still have student loans to pay.

"We can't continue to take a cut on what was already bottom of the barrel rates when inflation is higher than what it's ever been," Lewis said.

She said her clinic is one of two within 50 miles. Their patients effectively have nowhere else to go.

If these therapists leave the networks, the Medicaid managed care contractors are still obliged to serve the children on their rosters. Their contracts with the state require it. Further, Medicaid requires that patients have access to providers within a certain time and distance.

If too many providers leave the networks, the companies could wind up paying even more for out-of-network rates.

"I think it's a poor gamble," Braxley said, "but I do think it's a gamble that they think that providers and businesses will accept."

Roland Behm, a health policy advocate, said the Medicaid management companies won't necessarily be in a tough spot even if many of their partnering practitioners head for the exits.

It basically falls on patients to enforce their rights to service, he said, and that can be difficult for someone who is unfamiliar with the system. There are rights to appeal, but people must know how to do it, and they must adhere to strict deadlines, said Behm, co-founder of the Georgia Mental Health Policy Partnership.

Behm said the state agency that contracts with the Medicaid management companies does not aggressively enforce so-called "network adequacy." He illustrated that with a description of the directories given to patients who need to find an in-network provider.

"If you would just start going through that and calling them, you would find that many of them, sometimes over half, are not in network," he said. "They're not taking new patients. They're not taking that insurance. They've retired. They've died."

A spokesperson for the responsible state agency, the Department of Community Health, said by email that the state was not involved with the decision by CareSource and Peach State to negotiate down rates with their providers.

"That being said, DCH is responsible for oversight of our managed care contracts and ensuring the adequacy of the provider networks each CMO develops," the statement said.

The agency will increase the frequency of monitoring provider networks "to ensure the plans meet network adequacy and each network supports Medicaid members' access to services," the statement said. "Should any CMO fail to meet network adequacy standards established in its contract, appropriate actions will be taken."

Beyond that, it's unclear what, if anything, the state might do.

"I don't think this is the last we've heard of this, and I know that a lot of legislators are getting calls about it," state Rep. Matthew Gambill, R-Cartersville, said last week.

Oviedo is one of his constituents, and she had called him for help.

Gambill said CareSource told him they were reacting to an increase in demand for pediatric therapy.

"I think it's just kind of overwhelmed the system," he said. "So they're looking at ways to try to manage that and unfortunately it's manifested in the way that it has."