Caresource vs amerigroup

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Due to the federal role in financing Medicaid, much of the returned money would likely go to the U. The insurers were told the reduction was due to many Medicaid patients skipping medical care during the COVID pandemic, along with other adjustments, said Weathington. He added that the three Medicaid insurers were not given detailed breakdowns of how the state actuary arrived at the numbers.

These insurers continued to receive those payments from Medicaid while there was a dropoff in patient visits. The repayments are known as clawbacks: When an organization believes it has overpaid for services, it takes steps to get back the money. Medicaid, jointly financed by the federal government and individual state governments, covers low-income and disabled residents.

The state covers about one-third of those costs, with the feds funding the rest. Before the pandemic, many states had measures in place to limit the profits that state Medicaid insurers could make on their contracts and ensure taxpayer dollars went to patient care. Federal law requires states to update their plans for improving Medicaid health care quality at least every three years.

Georgia, however, published its most recent quality plan in February Georgia, like most other states, contracts with private insurance companies to provide health care services for most Medicaid members and all , or so PeachCare kids. If the companies do not spend all of that on patient care, they keep the money, as in most other state Medicaid systems, she said. Three of the four state CMOs are owned by publicly traded Fortune companies.

The Georgia report said the state would publish a new quality strategy in It is now February — and no new plan is forthcoming. Credit: Georgia Health News. Other Southern states all updated their Medicaid strategies within the three-year-window the federal government requires.

DCH will publish a new quality plan in spring , Roberts added, which will be two years after the deadline. GHN reported in December that after consistently submitting information about how its Medicaid program and PeachCare were delivering care, the state for the last two years reported only a fraction of the quality information that federal health officials request.

Since — when the last quality strategy report was published in Georgia — the Medicaid program has changed in major ways. Georgia partially expanded Medicaid eligibility for low-income adults, provided they meet certain requirements. And, back in , Georgia added CareSource to its Medicaid roster. CareSource, a nonprofit corporation headquartered in Dayton, Ohio, now operates in five states.

Until last week, Georgians lacked data about how CareSource performed on things like postpartum care, childhood immunizations, lead screening, and diabetes treatment. Out of the 45 adult and child health measures GHN analyzed, CareSource performed the worst of the four companies on CareSource went live July 1, , servicing , Medicaid recipients.

Some measures have as much as a two-year window for data to be captured, some of which would precede our [launch]. Additionally, we use the same providers that the other CMOs utilize.

Georgia Health News compared the latest data from with the baseline data from In many cases the state did not meet its goal, and in many other cases performance stagnated. Jesse Weathington, executive director of the Georgia Quality Healthcare Association, an industry trade group, declined to comment on the performance measures. Georgia faces a well-known maternal and infant health crisis, racial disparities in maternal and infant outcomes, and a shortage of specialist health care providers in rural areas of the state.

Rates of timely prenatal care fell for two of the three CMOs that have been in Georgia since Back in , the state said its goal was to decrease the Medicaid low-birth-weight delivery rate to 8. But rates of these baby deliveries actually increased between and Postpartum care rates also dropped. Low-birth-weight deliveries are those where the infant weighs less than five pounds, eight ounces.

CareSource had the highest rate, with 9. Back in , the state centered its plan to reduce health disparities on lowering the disproportionately high rates of low-birth-weight deliveries among African Americans. DCH does not break its data down by race, so there is no way to tell how well CMOs are addressing the racial disparity. As of , DCH stopped publishing data on two maternal health measures: frequency of prenatal care, and mental health screening for pregnant women. Maternal depression and substance abuse during pregnancy can have negative effects on both infant and postpartum maternal health.

Early intervention can help head off these problems. Babies should see a health care provider for a well-child visit at least six times between birth and 15 months, says the American Academy of Pediatrics. But according to the latest state data, only about two-thirds of Amerigroup, Peach State, and WellCare patients met this target.

The rates hovered around rates, showing little to no improvement. The Academy of Pediatrics also recommends that children between ages 3 and 6 see a doctor at least once a year. Checkup rates for improved slightly over for this age group. Amerigroup and Peach State improved by about 1 percentage point. Almost all childhood immunization rates dropped. Only one immunization rate — that of adolescents receiving vaccines for both meningitis and Tdap tetanus, diphtheria, and pertussis — increased.

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