The 11-year-old entered foster care in crisis. Within hours of being released from a psychiatric unit and arriving at her foster home, she smeared feces all over a bathroom and attempted to jump out of a window. Even so, the company that manages the Medicaid health plan for every foster child in Georgia turned down a request that she be admitted to a 24-hour psychiatric residential treatment facility.
Amerigroup, the managed care company, only approved residential services months later, after the girl tried to both drown and electrocute herself, according to the state’s foster care agency. At that point, no facility would accept her.
Amerigroup also denied a medical provider’s request that a 13-year-old in state custody be admitted to residential treatment. The girl had gone back into crisis soon after a previous admission, starting to hurt herself and becoming aggressive toward others. While the state appealed the company’s decision, she tried to overdose on lithium pills and cut herself with glass.
In hundreds of similar cases involving children in state custody, case workers end up in daily battles, as they try to get appointments and placements for seriously ill children. Over and over again, they fail. “This work is high cost and very low success,” Audrey Brannen, a 21-year veteran of the state’s foster care agency, told Georgia lawmakers in January. “It’s tireless. It’s days filled with begging for somebody to ensure a child’s needs are met. And everyone’s saying no, we don’t have a bed. We won’t approve that service. We cannot accept that kid.”
Georgia has pre-paid Amerigroup billions in state and federal Medicaid dollars to set up networks of providers and cover and coordinate the care of the state’s most vulnerable children.
Yet, the delays, denials and suffering play out as Georgia’s Department of Community Health, which oversees the state’s Medicaid contracts, fails to hold the managed care company accountable while also stonewalling and thwarting officials who have tried to investigate the issue, an Atlanta Journal-Constitution investigation has found.
The AJC’s investigation determined that DCH doesn’t routinely track and analyze denials of mental health services by its managed care contractors, even though this is an especially critical issue for children in foster care.
Clues of a breakdown started to emerge years ago. Foster kids with mental health issues were locked in hotels when they couldn’t get treatment. Hospital ERs kept seeing the same kids in crisis, over and over again. Georgia’s lieutenant governor was blocked as his office tried to investigate. Somehow, the state agency in charge of Medicaid got away with not answering questions about its oversight of one of the state government’s biggest contracts.
Advocates say the failures don’t end with the 11,000 kids in state custody. In Georgia, 1.7 million children get health coverage through Medicaid care management organizations. “This is a problem that far exceeds foster care,” said Melissa Carter, executive director of the Barton Child Law and Policy Center at Emory University. “The fact of the matter is, many of those children who are currently in foster care may not need to be if parents were able to access services to meet their children’s needs in the community.”
Children covered by Medicaid in Georgia have struggled for years to get mental and behavioral health services even though they have a right to receive care that will allow them to stay out of institutions, said Joe Sarra of the Georgia Advocacy Office, a federally mandated organization that protects and works on behalf of people with disabilities.
Without support and treatment, children routinely cycle in and out of a crisis. While some end up in foster care as their symptoms escalate, others are sent out of state or end up in the juvenile justice system. “It’s just absolutely unacceptable,” Sarra said.
As Georgia prepares this year to negotiate and award new, multi-billion dollar Medicaid managed care contracts, elected officials and advocates say it’s critical for state lawmakers to insist on change.
“The failure to deliver decent mental health services for children is everybody under Gold Dome’s responsibility, and we have not delivered the services that Georgia’s children need or are entitled to,” said Rep. Mary Margaret Oliver, D-Decatur, a co-sponsor of the Mental Health Parity Act that was signed into law last year.
It wasn’t supposed to be this way.
Georgia moved its foster children into a Medicaid managed care system about a decade ago with the promise that the change would vastly improve access to services and coordinate the care of high-needs kids in the state’s custody. The switch was supposed to save the state money, too.
The system works like this: The state pays Amerigroup and its other contractors a monthly fee to cover and coordinate the care a child needs, whether it’s an annual check-up, treatment for cancer, or care and services for serious mental health conditions. But the contractors make higher profits if they spend less on care.
Private managed care organizations operating in Georgia
In 2006, Georgia began using managed care companies for its Medicaid program. It added foster care to its managed care system in 2014. About 2 million adults and children in Georgia have their care managed through a Medicaid CMO. Here are the private managed care organizations currently operating in Georgia. The state is in the midst of extended process to consider new vendors and establish new contract requirements for its Medicaid program.
Operating in Georgia since 2006, Peach State Health Plan is a subsidiary of Centene Corporation.
Members as of August 2022: 1,028, 421 adults and children
Amerigroup and Amerigroup 360
Operating in Georgia since 2006, Amerigroup Community Care is a subsidiary of insurance giant Elevance, formerly Anthem. In 2014, Amerigroup 360 was added as the single, statewide care management organization for children in foster care, adoption assistance and some children in the juvenile justice system.
Members as of August 2022: 610,322 adults and children
Operating in Georgia since 2017, CareSource is a nonprofit managed care provider.
Members as of August 2022: 451, 717 adults and children
“Coverage denials are one way in which managed care organizations can profit at the expense of the health of millions of Georgians enrolled in their plans,” said Roland Behm, an advocate and co-founder of the Georgia Mental Health Policy Partnership.
The state’s foster care agency has complained repeatedly about children in state custody being denied care. Pediatricians, psychologists and other providers say they face barriers, too, when they seek approvals for services. “The denials we get are almost breathtakingly cruel,” said Shannon Mullen, a psychologist who practices in South Georgia, where providers are hard to find.
She said the network of care providers is limited because a lot of psychologists and therapists stop taking Medicaid after they get established due to both low payment rates and the difficulties with getting care approved.
Advocates say that the state of Georgia has neither enforced the requirement that Amerigroup establish a network filled with enough providers nor has it done the work to make sure the state has a comprehensive mental health system.
Nor has DCH ensured that Amerigroup has policies in place for several other key contract requirements. A recent independent assessment of contract oversight conducted for DCH found that Amerigroup’s policies didn’t reference requirements that behavioral health services and supports be provided for Medicaid youth suffering from serious emotional disturbances.
“The state is not doing its duty,” Sarra said.
The switch to managed care hasn’t provided the services that could help high-needs children avoid bouncing from crisis to crisis, said Tom Rawlings, who has served as a juvenile court judge, child advocate and director of the Georgia Division of Family and Children Services.
“Managed care can provide the coordination that is desperately needed to address the needs of complex cases, but right now it appears the system remains too fragmented among different agencies to effectively achieve that goal,” he said.
Credit: Georgia House of Representatives
Credit: Georgia House of Representatives
The picture painted by Amerigroup and DCH is much rosier.
The company, a subsidiary of national insurance giant Elevance Health, told lawmakers at a General Assembly committee meeting in January that it always places the needs of children above its bottom line. “I’ve never made a decision about how to treat anyone, particularly a foster care kid, that was related to cost and I never will,” Amerigroup Georgia President Melvin Lindsey said. “We will get people the right services at the right time, all the time.”
And a DCH report presented to the Georgia General Assembly in January claimed that fewer than 100 psychotherapy requests were denied in calendar year 2019 and the 2021 and 2022 fiscal years by the state’s Medicaid managed care contractors, including AmeriGroup.
But DCH’s numbers aren’t supported by state records. The Atlanta Journal-Constitution found that Amerigroup denied or partially denied more than 6,500 prior authorization requests for individual and group psychotherapy for children and teens covered by Medicaid between 2019 and mid-2022. Many of the requests were for kids in foster care.
The Journal-Constitution also found that Amerigroup denied hundreds of authorization requests for psychiatric residential treatment, something DCH didn’t include in its report to lawmakers. Amerigroup also denied thousands of requests for evaluations related to mental or behavioral health issues and hundreds of requests for autism-related services.
Email correspondence and denial letters from Amerigroup obtained by the AJC through the Georgia Open Records Act show the details of cases where children couldn’t get services or medications their doctors requested. Over and over, Amerigroup denied services by citing a lack of records they wanted to prove medical necessity. Frequently, kids were blocked from entering or staying longer at Psychiatric Residential Treatment Facilities. These were kids with aggressive behaviors, self-harm or serious psychiatric conditions. Amerigroup’s rejection of the stays used boiler-plate language and cite medical necessity, frequently saying, “Records no longer show you have these issues.”
The Georgia Department of Human Services, which handles the state foster care system, has warned repeatedly that Amerigroup has failed to approve and arrange the right services in a timely fashion, and it has said that DCH hasn’t forced the company to abide by its contract.
The insurer’s contract with the state requires it to have inpatient substance abuse treatment options for kids in foster care — but it doesn’t, Brian Pettersson, a DHS attorney and assistant deputy commissioner, told lawmakers in January at the committee hearing. More than 2,500 children in foster care haven’t even gotten basic medical checks and screenings that are required for every child in state custody, he said.
As part of the state’s process of gathering written comments in advance of re-bidding the Medicaid contracts, DHS Commissioner Candice Broce last year wrote a strongly-worded letter to DCH Commissioner Caylee Noggle, saying Amerigroup failed to give foster children access to physical, mental and behavioral health services. Children must wait weeks or months for an appointment, are rejected for services based on a narrow definition of “medical necessity” and are deprived of care coordination for their complex needs, Broce wrote.
Broce and Noggle both worked in Gov. Brian Kemp’s office before he appointed them to lead large, critical state agencies. Noggle was Kemp’s deputy chief of staff for operations; Broce was Kemp’s chief operating officer.
Broce told Noggle that DCH was doing little to hold Amerigroup to account for its failures. “To our knowledge, DCH has never levied financial penalties against Amerigroup for non-compliance with any of their contractual provisions,” Broce says in the letter.
DCH has said little, publicly, in response.
Last August, Noggle denied an interview request from the Journal-Constitution related to access to mental health services for children and teens and the agency’s oversight of psychiatric hospitals and the Medicaid CMOs.
In February, when the newspaper sought information about DCH’s oversight of managed-care organizations, spokeswoman Fiona Roberts said in an email that the procurement process precluded it from commenting on the issues of denials and access to care, but she said DCH planned to prioritize behavioral health in its new contracts.
Asked about why the agency reported that fewer than 100 psychotherapy requests were denied, while records show thousands, Roberts said the report, prepared by a consulting firm, included just one category of denials — medical necessity — and didn’t include young children under age 12. Also, DCH said, the formal report covered a slightly different time frame and relied on “category of service” instead of codes used for the Journal-Constitution’s request. “The two data sets were not extracted using the same methodology,” Roberts responded.
The Journal-Constitution also asked if DCH had ever fined Amerigroup for noncompliance.
DCH said it had not, adding “when issues are brought to our attention, DCH and Amerigroup work to resolve, including use of corrective action plans when required.”
Amerigroup told the AJC that it approves, in full or at least partially, the majority of the requests it receives for behavioral health services. The company said denials may happen because providers making requests don’t supply enough information to show medical necessity, or the services requested don’t fit with Amerigroup’s policies that it says are based on research.
“This process is not meant to create barriers but is necessary to ensure that the appropriate care is made available so that individuals can live their healthiest lives,” said Amerigroup spokesman Michael Perry.
Yet facing many Amerigroup denials, DHS set up a special unit to file appeals. In a series of such cases at the Georgia Office of State Administrative Hearings, records obtained by the Journal-Constitution show that Amerigroup agreed to cover the services only after the agency got its lawyers involved.
Meanwhile, the foster care agency resorts to tapping its own budget to pay for care that Amerigroup denies. With no option to place the kids who have serious mental health conditions and disruptive behavior in therapeutic settings to get health care, it has placed hundreds in hotel rooms with ultra-expensive, around-the-clock staffing.
The irony of the situation isn’t lost on policy wonks: A state agency responsible for foster children has gone to war with the private insurer Georgia hired to handle health care, even though the state paid that insurer taxpayer funds to cover all the care that abused, neglected and abandoned kids would need.
Other state officials also have tried to force DCH’s hand.
Mike Dudgeon had clout and credibility in 2019 when he raised questions about Amerigroup and where the money goes that it is paid.
Dudgeon, a former state representative who became the policy director for former Lt. Gov. Geoff Duncan, became concerned that Georgia’s kids weren’t getting care they needed. He based that not only on foster kids being housed in hotels, but also on what he and his wife had experienced as foster parents themselves trying to get services for children in their care.
He started asking questions about spending and how often care was being denied. He struggled to get answers.
“It was just a total stonewall,” Dudgeon testified during January’s hearing at the General Assembly, “and this is with the weight of the Lieutenant Governor’s office and the weight of the Senate Budget Office behind it . . . months and months of stonewalling.”
Dudgeon, a tech entrepreneur, said the information he eventually received raised concerns that Amerigroup was bolstering profits by denying care that doctors had requested.
“All I can tell you,” he told lawmakers, “is there’s a lot of smoke there that this money is not being appropriately spent.”
Dudgeon urged lawmakers to step up oversight and insist on transparency so they can finally understand what’s actually happening with the state’s outsourced Medicaid system and address the failings.
“It’s time to do something for real,” he said.
DCH also took months to provide records the Journal-Constitution requested under the Georgia Open Records Act on how often the Medicaid insurers deny requests for mental health services for children and teens.
It took more than two months alone for the agency to determine that it had no internal records related to denials. At a General Assembly hearing in January, Noggle told lawmakers that DCH has brought in an independent third party to start monitoring the Medicaid contracts for compliance and performance standards.
How we got the story
As part of its ongoing coverage of the state’s mental health system and the availability of services for children and teens, the Atlanta Journal-Constitution began seeking records last year related to Georgia’s Medicaid care managed care companies. The Journal-Constitution collected data from a state agency, often waiting months for responses under the Georgia Open Records Act. In spite of delays and limited responses, the newspaper continued to ask questions and request information. The reporter reviewed hundreds of pages of documents and interviewed state officials, advocates, care providers, families and experts to examine the Medicaid system that serves as the health plan for every child in foster care and low-income children across Georgia
This story is part of the AJC’s coverage of Georgia’s failure to create a comprehensive and safe mental and behavioral health system to serve Georgia’s children and teens. Read the AJC’s Children in Crisis series here.
Now, Georgia is moving ahead with its plans to rebid its managed care program with new Medicaid contracts. It’s a procurement process that is expected to take months.
But advocates and providers worry that a new contract won’t improve the lives of Georgia’s most vulnerable kids without significant changes by state agencies and the Medicaid contractors.
After hearing frank testimony in January about breakdowns in the system and Amerigroup’s take on its role, Sen. Kay Kirkpatrick, R-Marietta, an orthopedic surgeon, said it was clear that “this is a front-burner issue.”
“These kids didn’t ask for this and they should be going to the front of the line, however we can get them there,” Kirkpatrick told lawmakers. “I don’t think there’s any disagreement about that.”