Medicaid Managed Care

The Medicaid and CHIP Managed Care Final Rule improves transparency by requiring states and managed care plans to provide and maintain specific content on a public website that is accessible to Medicaid and CHIP managed care members. Specifically, the Medicaid and CHIP Managed Care Rule requires states and managed care plans to provide the following information:

Nurse holding tablet wearing stethoscope and scrubs.

Network Adequacy

Accreditation Status of CMOs

The State of Georgia introduced the GF managed care program in 2006 and contracts with private CMOs to deliver services to enrolled members. The DCH is responsible for administering the Medicaid program and CHIP in the State of Georgia. The State refers to its CHIP as PeachCare for Kids®. Both programs include FFS and managed care components. The DCH is the single State agency for Medicaid.

The DCH employs a care management approach to organize its system of care, enhance access, achieve budget predictability, explore possible cost containment opportunities, and focus on systemwide performance improvements. The DCH uses managed care to continuously improve the quality of healthcare and services provided to eligible members and improve efficiency by using both human and material resources more efficiently and effectively.

The CMOs that contracted with DCH during SFY 2020–2021 are displayed in Table 2-1.

Table 2-1 — CMOs in Georgia
CMO Year Operations Began in Georgia as a Medicaid CMO Profile Description CMO NCQA Accreditation Status
Amerigroup 2006 Amerigroup Community Care is a subsidiary of Amerigroup Corporation. Amerigroup is a wholly owned subsidiary of Anthem, Inc., founded in 2004 with the merger of Anthem and WellPoint Health Networks. Product lines include Medicaid, Medicare commercial, federal employees, and specialty services. Commendable*
Accredited through 10/22/2022
Amerigroup 360°*** 2014 Amerigroup 360° is a subsidiary of Amerigroup Corporation. Amerigroup is a wholly owned subsidiary of Anthem, Inc., founded in 2004 with the merger of Anthem and WellPoint Health Networks. Product lines include Medicaid, Medicare commercial, federal employees, and specialty services. Commendable*
Accredited through 10/22/2022
CareSource 2017 CareSource was founded in 1989 and is a nonprofit model of managed care. CareSource product lines include Medicaid, Marketplace, and Medicare Advantage programs. Accredited**
Accredited through 3/1/2022
Peach State 2006 Peach State Health Plan is a subsidiary of the Centene Corporation. Centene was founded in 1984. Product lines include Medicaid, Medicare, and the Exchange plans in some states. Commendable*
Accredited through 5/22/2023
WellCare 2006 WellCare of Georgia, Inc., is a subsidiary of WellCare Health Plans, Inc. WellCare was founded in 1985. Product lines include Medicaid, Medicare Advantage, Medicare Prescription Drug Plans, State Children's Health Insurance Programs, and others. On January 23, 2020, WellCare Health Plans, Inc. became a wholly owned subsidiary of Centene Corporation. The merger with Peach State Health Plan was completed on April 30, 2021. Accredited**
Accredited through 9/18/2023

*Commendable: NCQA has awarded an accreditation status of Commendable for service and clinical quality that meet NCQA’s rigorous requirements for consumer protection and QI.
**Accredited: NCQA has awarded an accreditation status of Accredited for service and clinical quality that meet the basic requirements of NCQA’s rigorous standards for consumer protection and QI.
***Amerigroup 360° is not separately accredited from Amerigroup.

Table 2-2 displays the DCH annual enrollment by program.

Table 2-2 — FY 2022 Annual Program Enrollment
Program Members Average
Medicaid* 2,766,423
PeachCare for Kids® 174,406

Source: IBM Watson Health, DP, based on eligibility for the month of June 2022.

Agreed‐Upon Procedures Reports

These reports are conducted by an independent auditor to evaluate the CMO’s contract compliance, program integrity (PI) oversight, subcontractor oversight, and encounter submissions.

Managed Care Periodic Audit Reports

Per federal regulations, the Department of Community Health must periodically, but no less frequently than once every three years, conduct or contract for an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of each Care Management Organization (CMO) and post the results of these audits on our website. 42 CFR§ 438.602(e) and (g).

Please see below the results of the 2020 periodic audits for each CMO:

Please see below the results of the 2019 periodic audits for each CMO:

Encounter Data Reports

“Encounter data” are claims that have been paid by CMO’s or delegated vendors (e.g., dental, vision, and pharmacy) to health care providers that have rendered health care services to members enrolled with the CMO.

Ownership and Control Interest and Criminal Conviction Information Reports

Medicaid Quality Reports

Review the Medicaid Quality reports page for Quality Strategic Plans, Quality Performance Dashboards, and External Quality Review Organization Reports.

Georgia Families and Georgia Families 360° Contracts

Review current Georgia Families and Georgia Families 360° contracts on the Georgia Families webpage.

CMO Resources

Amerigroup

CareSource

PeachState