In 2006, the state of Georgia implemented the Georgia Families program through which private Medicaid managed care companies arrange for care for enrollees in Peach Care for Kids and the following categories of Medicaid: Low Income Medicaid, Right from the Start, and Breast and Cervical Cancer. A separate program called Georgia Families 306o covers children, youth and young adults in Foster Care, Adoption Assistance and the Juvenile Justice System. The Aged, Blind and Disabled, Dual Eligibles and Nursing Home Medicaid programs are managed directly by the state and are not included in the Georgia Families program.
Initially, the Georgia Families contracts were with Amerigroup, Peach State Health Plan (Centene), and Wellcare. Beginning in 2014 Amerigroup was granted the contract for the Georgia Families 360o program for children in foster care. A lengthy re-procurement for the Georgia Families program was conducted in 2015 and 2016, resulting in the award of contracts to all of the incumbents, as well as a new plan, Caresource. The new Georgia Families and Georgia Families 360 contracts were implemented on July 1, 2017.
Under the CMOs, Georgia Medicaid pays a fixed monthly payment to one of the three CMOs based on the number of Medicaid members enrolled in the CMO’s plan. The CMO is then responsible for paying providers, including hospitals, for covered services provided to the CMO’s enrolled members. The hospital bills the CMO for services based on contractual payment terms that have been negotiated between the hospital and the CMOs in order for the hospital to participate in the CMO’s provider network. The CMOs are required by state law to pay hospitals that do not participate in the CMO’s provider network 100% of the fee for service Medicaid rate for emergency services. However, non-emergency services may be covered at 90% of the fee for service Medicaid rate if there have been three failed attempts by the CMO to negotiate a contract with the hospital. In fact, the CMOs may require authorization for non-emergent services and if it is not obtained may deny the claim entirely.
In 2015, GHA began meeting quarterly with leadership of the Department of Community Health (DCH), the three CMOs and other provider organizations in an effort to improve communications and resolve common issues. See the links below for reports of these meetings.