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:
Network Adequacy
Accreditation Status of Care Management Organizations
The State of Georgia introduced the Georgia Families managed care program in 2006 and contracts with private Care Management Organizations to deliver services to enrolled members. The Department of Community Health 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 fee-for-service and managed care components. The Department of Community Health is the single State agency for Medicaid.
The Department of Community Health 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 Department of Community Health 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 Care Management Organizations that contracted with Department of Community Health during SFY 2022–2023 are displayed in Table 2-1.
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. | Accredited* through 09/22/2025 Health Equity Accredited* through 11/15/2025 |
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. | Accredited* through 09/22/2025 Health Equity Accredited* through 11/15/2025 |
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* through 12/21/2024 |
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. | Accredited* through 06/05/2026 |
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 09/18/2023 |
*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 Department of Community Health monthly enrollment by program.
Program | October 2024 |
---|---|
Medicaid CMO | 1,782,625 |
Medicaid FFS | 882,203 |
Medicaid Total Enrollment | 2,664,828 |
PeachCare for Kids® | 216,373 |
Source: Business Objects, 11/22/2024, SK; This report is based on Medicaid and PeachCare for Kids® members in October 2024.
Managed Care Program Annual Report (MCPAR)
Per federal regulations, the Department of Community Health must post the Managed Care Program Annual Report (MCPAR) for each managed care program that it administers to its website as required under 42 CFR 438.10(c)(3) and 42 CFR § 438.66(e).
- Planning for Healthy Babies (P4HB) MCPAR -2023 - Posted 03/13/24
- Georgia Families 360° (GF360) MCPAR - 2023 - Posted 03/13/24
- Georgia Families (GF) MCPAR - 2023 - Posted 03/13/24
- Planning for Healthy Babies (P4HB) MCPAR - 2022 - Posted 03/13/24
- Non-Emergency Medical Transportation (NEMT) MCPAR - 2022 Posted - 03/13/24
- Georgia Families 360° (GF360) MCPAR - 2022 - Posted 03/13/24
- Georgia Families (GF) MCPAR - 2022 - Posted 03/13/24
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 and post the results of these audits on our website. 42 CFR§ 438.602(e) and (g).
Agreed‐Upon Procedures Reports
These reports are conducted by an independent auditor to evaluate the Care Management Organizations (CMOs) contract compliance, program integrity (PI) oversight, subcontractor oversight, and encounter submissions.
Agreed-Upon Procedures Reports from prior years can be accessed here.
- Peach State Health Plan AUP Report - Posted 11/21/24
Encounter Data Reports
“Encounter data” are claims that have been paid by Care Management Organizations or delegated vendors (e.g., dental, vision, and pharmacy) to health care providers that have rendered health care services to members enrolled with the Care Management Organization (CMO).
Reports from prior years can be accessed here.
-
GA
CMO Encounter Report - Amerigroup Georgia Families and Georgia Families 360° August 2022 thru July 2024
- Posted 10/15/24
- GA CMO Encounter Report - Amerigroup Georgia Families and Georgia Families 360° June 2022 thru May 2024 - Posted 10/15/24
- GA CMO Encounter Report - Amerigroup Georgia Families and Georgia Families 360° April 2022 thru March 2024 - Posted 06/10/24
- GA CMO Encounter Report – Amerigroup Georgia Families and Georgia Families 360° February 2022 thru January 2024 - Posted 04/12/24
- GA CMO Encounter Report - Amerigroup Georgia Families and Georgia Families 360° December 2021 thru November 2023 - Posted 03/22/24
-
GA
CMO Encounter Report - CareSource August 2022 thru July 2024
- Posted 10/15/24
- GA CMO Encounter Report - CareSource June 2022 thru May 2024 - Posted 10/15/24
- GA CMO Encounter Report - CareSource April 2022 thru March 2024 - Posted 06/10/24
- GA CMO Encounter Report – CareSource February 2022 thru January 2024 - Posted 04/12/24
-
GA
CMO Encounter Report - Peach State August 2022 thru July 2024
- Posted 10/15/24
- GA CMO Encounter Report- Peach State June 2022 thru May 2024 - Posted 10/15/24
- GA CMO Encounter Report - Peach State April 2022 thru March 2024 - Posted - 06/10/24
- GA CMO Encounter Report – Peach State February 2022 thru January 2024 - Posted 04/12/24
- GA CMO Encounter Report - Peach State December 2021 thru November 2023 - Posted 03/22/24
Care Management Organization Hospital Statistical and Reimbursement (HS&R) Reports
Care Management Organizations must provide the Hospital Statistical and Reimbursement (HS&R) report for a specific fiscal year as requested by the hospital provider within 30 days of the hospital's request. GA. Code § 33-21-A-11.
HS&R Reports from prior years can be accessed here.
- Amerigroup HS&R Quarter 2, 2024 Report
- Amerigroup HS&R Quarter 1, 2024 Report
- Amerigroup HS&R Quarter 4, 2023 Report
- Amerigroup HS&R Quarter 3, 2023 Report
- Amerigroup HS&R Quarter 2, 2023 Report
- Amerigroup HS&R Quarter 1, 2023 Report
- CareSource HS&R Quarter 2, 2024 Report
- CareSource HS&R Quarter 1, 2024 Report
- CareSource HS&R Quarter 4, 2023 Report
- CareSource HS&R Quarter 3, 2023 Report
- CareSource HS&R Quarter 2, 2023 Report
- CareSource HS&R Quarter 1, 2023 Report
- Peach State Health Plan HS&R Quarter 2, 2024 Report
- Peach State Health Plan HS&R Quarter 1, 2024 Report
- Peach State Health Plan HS&R Quarter 4, 2023 Report
- Peach State Health Plan HS&R Quarter 3, 2023 Report
- Peach State Health Plan HS&R Quarter 2, 2023 Report
- Peach State Health Plan HS&R Quarter 1, 2023 Report
Annual Ownership and Control Interest and Criminal Conviction Information Reports
Annual Ownership and Control Interest and Criminal Conviction Information Reports from prior years can be accessed here.
- Amerigroup - Disclosure of Ownership and Control Interest and Criminal Conviction Information - Posted 09/19/24
- CareSource - Disclosure of Ownership and Control Interest and Criminal Conviction Information - Posted 09/19/24
- Peach State - Disclosure of Ownership and Control Interest and Criminal Conviction Information - Posted 09/19/24
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.
Care Management Organization Resources
Amerigroup
- Drug Formulary
- Provider Directory
- Georgia Families Member Handbook
- Georgia Families 360° Member Handbook
- PeachCare for Kids® Member Handbook
- Planning for Healthy Babies Member Handbook
CareSource
- Drug Formulary
- Georgia Families Member Handbook
- Planning for Healthy Babies Member Handbook
- Provider Directory