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Overview

Effective June 1, 2006, the state of Georgia implemented Georgia Families®, a managed care program through which health care services are delivered to members of Medicaid, PeachCare for Kids® and Planning for Healthy Babies®, which serves approximately 1.3 million members. The Georgia Department of Community Health (DCH) contracts with Care Management Organizations (CMOs) to provide benefits and services to Georgia Families® members. DCH currently contracts with the following CMOs: Amerigroup, CareSource, Peach State Health Plan and WellCare. There were 1,390,845 members enrolled in Georgia Families as October 2019.

CareSource provides managed care services to Medicaid and PeachCare for Kids® members and Planning for Healthy Babies® enrollees. As of October 2019, CareSource Georgia covered 225,599 members, which represents roughly 12% of the Medicaid eligible population in Georgia. Enrollment figures from October 2019 for the other Georgia Families CMOs are as follows:

 

Amerigroup: 345,819

Peach State Health Plan: 50,089

WellCare: 469,338

Georgia Families® provides health care services to children enrolled in PeachCare for Kids®, and certain men, women, children, pregnant women and women with breast or cervical cancer covered by Medicaid. The remainder of Georgia’s Medicaid population, which includes aged, blind and disabled citizens, is not included in the Georgia Families® program.

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Eligibility and Exclusions

The following Georgia Families® eligibility categories are required to enroll in Medicaid or PeachCare for Kids®:

  • Parent/caretaker with children Medicaid – Adults and children who meet the standards of the former AFDC (Aid to Families with Dependent Children) program
  • Transitional Medicaid – Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit
  • Pregnant women – Pregnant women with family income at or below 220 percent of the federal poverty level who receive Medicaid through the Right from the Start Medicaid (RSM) program
  • Children (RSM) – Children less than 19 years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family
  • Newborns – A child born to a woman who is eligible for Medicaid on the day the child is born
  • Women eligible due to breast and cervical cancer – Women less than 65 years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer
  • Refugees – Individuals, as defined under O.C.G.A. § 38-3-3, including but not limited to those who have the required Immigration and Naturalization Service (INS) documentation showing they meet a status of asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.

The following recipients are excluded from enrollment in Georgia Families®, and as a result, excluded from coverage by CareSource Georgia:

  • Recipients eligible for Medicare
  • Recipients that are members of a federally recognized Indian Tribe
  • Recipients that are enrolled in fee-for-service Medicaid through Supplemental Security Income (SSI) prior to enrollment in Georgia Families®
  • Medicaid children enrolled in the Children’s Medical Services program administered by the Georgia Department of Public Health
  • Children enrolled in the Georgia Pediatric Program (GAPP)
  • Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act
  • Individuals enrolled in a hospice category of aid
  • Individuals enrolled in a nursing home category of aid
  • Individuals enrolled in Community Based Alternatives for Youths (CBAY)

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Coverage

CareSource Georgia covered services include:

  • Allergy testing and treatment
  • Anesthesia
  • Dental Services
  • Diagnostic Radiology
  • Durable Medical Equipment
  • Emergent/Urgent Care
  • Federally Qualified Health Center/Rural Health Center
  • Hearing Aids
  • Hospice Care
  • Skilled Nursing Facility
  • Oral Maxillofacial Surgery
  • Outpatient Hospital
  • Podiatry
  • Inpatient Facility
  • Ambulatory Surgery Center
  • Vision
  • Ambulance services
  • Behavioral Health: inpatient facility, outpatient facility, psychological testing
  • Diagnostic Surgery
  • Diagnostic Lab/Pathology
  • Emergency Room
  • Family Planning
  • Habilitative Services
  • Home Health Services
  • Inpatient Hospital
  • Office Visits
  • Orthotics/Prosthetics
  • Pharmacy
  • Preventative Services
  • Outpatient Facility
  • Transportation/Non-Emergency

Data Considerations

CareSource Georgia began contracting with the State of Georgia in 2017.  Therefore, claims data was not available for HMS use prior to 2017. HMS receives all claims data from CareSource Georgia except for dental. 

It is important to note that since HMS receives claims data directly from CareSource Georgia, we are receiving actual claims data as opposed to encounter only data. However, providers for this claim population are not paid on a Fee-For-Service basis.  Rather payment is received directly from CareSource, which may pay more or less than the Medicaid FFS rate.

 

 

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