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 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.

Table 2-1 — Care Management Organizations (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. Accredited* through 9/22/2025
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 9/22/2025
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 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

*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 annual enrollment by program.

Table 2-2 — Medicaid Enrollment Numbers for CMO, FFS, and PeachCare for Kids® for April 2023
Program April 2023
Medicaid CMO 2,184,084
Medicaid FFS 642,561
Medicaid Total Enrollment 2,826,645
PeachCare for Kids® 207,162

Source: Advantage Suite, 6/1/2023, HD; This report is based on Medicaid and Peachcare for Kids® members in April 2023.

 

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.

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).

Medical Loss Ratio (MLR) Reports

The Department of Community Health must ensure, through its contracts starting on or after July 1, 2017, that each Care Management Organization calculate and report a MLR in accordance with 42 CFR 438.8.

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).

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.

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.

Care Management Organization Resources

Amerigroup

CareSource

PeachState