Georgia Medicaid Eligibility Quality Control: PERM and MEQC

Georgia Medicaid eligibility quality control means every eligibility decision the state makes is checked for accuracy by two federal programs. The first is the Payment Error Rate Measurement (PERM) program, which the Centers for Medicare & Medicaid Services (CMS) runs in every state on a three-year cycle. The second is the Medicaid Eligibility Quality Control (MEQC) program, which Georgia runs itself in the two years between PERM cycles. In Fiscal Year 2025, the national Medicaid improper payment rate measured through PERM was 6.12 percent, and more than three-quarters of those errors came from missing paperwork, which CMS says is generally not a sign of fraud.1,2 This guide explains how these accuracy programs work in Georgia, why they shape your application and renewal, and exactly what to do if you believe your Medicaid case was decided wrong.

What Georgia Medicaid eligibility quality control means for your case

For most families, the honest answer is: nothing you will notice directly. The Payment Error Rate Measurement (PERM) program and the Medicaid Eligibility Quality Control (MEQC) program are accuracy checks on how Georgia's Medicaid agencies do their jobs. They sample a small set of cases each cycle to measure how often eligibility and payment decisions were made correctly. Your case is very unlikely to be sampled, and even if it is, the review is done on documentation, so you would not normally be contacted.1

What these programs do affect is the system around your case. The federal accuracy standards decide what documents Georgia must collect, how income is verified, and how renewals are processed. When PERM finds a pattern of errors, the state has to fix what caused them, and those fixes change day-to-day operations at the Division of Family and Children Services (DFCS) and inside the Georgia Gateway eligibility system. That is why a renewal that felt simple one year can ask for more paperwork the next.

The most important thing to know: if an error affects your eligibility, you keep your normal rights. You can request a fair hearing, and an error caught by quality control can also be corrected in your favor. The numbered steps near the end of this guide walk through what to do.

If you were wrongly denied or terminated in Georgia

Quality control exists partly to catch wrong denials, but you do not have to wait for an audit to find your case. If you believe Georgia denied, reduced, or ended your Medicaid in error, act on your own appeal rights right away.

• Read the notice. Georgia must send a written notice with the reason for the action and an appeal deadline. Common errors include miscounting household income, including a person who should not be in your Modified Adjusted Gross Income (MAGI) household, or terminating a case for a renewal packet that was sent to an old address.
• Request a fair hearing through DFCS. Call the Department of Human Services Customer Contact Center at 1-877-423-4746 (Monday through Friday, 8 a.m. to 5 p.m.) or follow the appeal instructions on your notice. To keep your benefits while a closure is appealed, you must ask to keep them within 12 days of the notice date, and you may have to repay them if the hearing does not go your way.4
• Get free legal help if you need it. The Georgia Legal Services Program offers free civil legal help to lower-income residents in the 154 counties outside metro Atlanta at 1-833-457-7529 (1-833-GLSPLAW).4

A wrongly denied case is exactly the kind of error MEQC's "negative case review" is built to find, but the fair-hearing process gives you a faster, individual path to a fix.

How accuracy is measured: PERM in plain terms

The Payment Error Rate Measurement (PERM) program is the federal program CMS uses to estimate improper payments in Medicaid and the Children's Health Insurance Program (CHIP). PERM measures three parts of the program separately.1

• Eligibility accuracy. Were people enrolled (or denied) based on correct income, household, and verification? Georgia does not grade itself on this one. Since the July 2017 PERM final rule moved the eligibility-review responsibility from the states to a federal contractor, the eligibility component is reviewed by a federal Eligibility Review Contractor (ERC) working for CMS, and the sample is drawn from beneficiaries.1
• Fee-for-service payment accuracy. Were directly billed Medicaid claims paid correctly, for covered, medically necessary services from eligible providers?
• Managed care payment accuracy. Were the monthly capitation payments to managed care plans correct for the right enrollees?

CMS uses what it calls a "17 or 18 state rotational approach," so each state is reviewed once every three years and about one-third of states are measured each cycle. The national Medicaid and CHIP improper payment rates combine the three most recent cycles. The PERM rules are codified at 42 CFR Part 431 Subpart Q.1

What "improper payment" really means

An improper payment is not the same as fraud. In Fiscal Year 2025, the national Medicaid improper payment rate measured through PERM was 6.12 percent, or about $37.39 billion, up from 5.09 percent ($31.10 billion) the year before. CMS reported that 77.17 percent of those Medicaid errors came from insufficient documentation, which it states is generally not indicative of fraud or abuse. The companion CHIP rate was 7.05 percent. CMS attributes much of the recent increase to the post-pandemic "unwinding," when eligibility redeterminations resumed in April 2023.2 Those are national figures. CMS publishes each state's own rate separately, on the PERM rotation described below.

Georgia's most recent PERM result

Georgia's most recent state-specific PERM measurement is Cycle 2, reporting year 2023, covering claims from July 2021 through June 2022. CMS estimated Georgia's overall Medicaid improper payment rate at 1.8 percent, with a 90 percent confidence interval of 0.4 percent to 3.1 percent. Broken into components, the fee-for-service rate was 3.2 percent, the eligibility rate was 0 percent, and the managed care rate was 0 percent. That overall figure sits well below the corresponding national Medicaid improper payment rate for the 2023 cycle, which was 6.26 percent. Because each state is measured once every three years under PERM's rotation, Georgia's next measurement falls in the 2026 audit cycle.3

How Georgia checks itself: MEQC in the off years

The Medicaid Eligibility Quality Control (MEQC) program is codified at 42 CFR Part 431 Subpart P. Under 42 CFR 431.800, MEQC is a program designed to reduce erroneous expenditures by monitoring eligibility determinations, and it works in conjunction with PERM. In a year Georgia is in its PERM cycle, the state runs only PERM; in the two years between PERM cycles, Georgia must run an MEQC pilot. The state develops its own pilot planning proposal and must submit it to CMS, which has to approve the plan before Georgia can put it in place.5

MEQC uses two kinds of review, and they belong to MEQC alone. Active-case and negative-case reviews are the state-run half of this system, defined in Subpart P; they are not how PERM measures eligibility, which is the federal contractor's job described above.1

• Active case review samples people who are currently enrolled to confirm they were correctly approved and still qualify. This catches over-enrollment.
• Negative case review samples applications that were denied or terminated to confirm those decisions were correct. This catches wrongly denied families, which is why it matters most for readers who feel they lost coverage unfairly.

A typical Georgia MEQC pilot might focus on renewal accuracy. For example, the state could sample cases where an automatic ("ex parte") renewal was used and cases where a renewal failed and the family was terminated for not returning a packet, then check whether each decision followed federal rules. Where reviewers find a packet sent to a stale address or a renewal that should have auto-completed, the state corrects the case and fixes the underlying process.

The federal rules behind the programs

Two layers of federal law create this accountability.6

• Section 1903(u) of the Social Security Act (42 U.S.C. 1396b(u)) defines a state's "erroneous excess payments," sets an allowable error rate of 3 percent, and lets CMS reduce federal Medicaid funding for errors above that level.6
• The federal improper-payments statutes require agencies to measure and report improper payments. The Payment Integrity Information Act of 2019 (PIIA) replaced three earlier laws, the Improper Payments Information Act of 2002, the Improper Payments Elimination and Recovery Act of 2010, and the Improper Payments Elimination and Recovery Improvement Act of 2012, and now governs how CMS measures and reports Medicaid improper payments.6

PERM eligibility reviews also check whether Georgia followed the federal verification rules, which cover electronic verification of income, citizenship, identity, and immigration status through sources such as the Internal Revenue Service, the Social Security Administration (SSA), and the Department of Homeland Security SAVE system.1

Who runs Georgia Medicaid eligibility quality control

Several agencies share the work, and knowing who does what helps you reach the right office.

• Georgia Department of Community Health (DCH). DCH is the single state Medicaid agency. It coordinates Georgia's participation in PERM and MEQC and develops the state's MEQC pilot proposal for CMS approval.5 It also runs Georgia Families, the Medicaid managed care program, in partnership with private care management organizations.4
• Division of Family and Children Services (DFCS). DFCS, within the Department of Human Services, makes most eligibility decisions at the county level and handles applications, renewals, and fair-hearing requests.
• Georgia Gateway. Georgia Gateway (gateway.ga.gov) is the online system that processes Medicaid, SNAP, and TANF eligibility. PERM and MEQC reviews evaluate how Gateway determines eligibility and runs electronic verification.
• CMS. The federal agency runs PERM through its own contractors, including the Eligibility Review Contractor that handles the eligibility component, and it must approve Georgia's MEQC pilot plan before the state can put it in place.1,5

How this connects to Georgia's managed care plans

Most Georgia Medicaid members are enrolled with one of the state's managed care plans, and PERM's managed care component checks that the monthly capitation payments to those plans are correct. As of 2026, Georgia Families contracts with three Care Management Organizations (CMOs): Amerigroup Community Care, CareSource, and Peach State Health Plan. A 2024 reprocurement named a different proposed slate of plans for the next contract period, but DCH extended the current three-CMO contracts through June 30, 2027 while the procurement worked through its protest phase.7

How a Georgia PERM cycle plays out

When Georgia is selected for a PERM cycle, CMS's federal contractors and the state work through the review together: a sample is drawn across the three components, Georgia produces the case files and verification records for the sampled cases, the contractors review each case against federal standards, and the findings are finalized into the state's error rate.1

That sample is small by design. CMS sets a fixed cycle sample size each year and distributes it across the states measured in that cycle, so a single state's audit reviews only hundreds to a few thousand payments rather than every claim. In KFF's analysis of the most recent audit cycles, covering 2023 through 2025, the number of claims or payments sampled for one state's Medicaid audit ranged between 288 and 1,782 fee-for-service claims, between 38 and 200 managed care payments, and between 97 and 644 eligibility determinations. The component results are then weighted by expenditures and projected to estimate the state's improper payment rate.8

Where the review finds errors, the state's response is a corrective action plan: it works back to what caused the errors and then sets the fixes, which is how an audit finding turns into a change in policy, worker training, or the Gateway system.

How accuracy rules shape your application and renewal

Because PERM measures whether verification was done correctly, Georgia has a strong incentive to verify thoroughly. For your family, that can mean:

• Documentation requests for income, identity, citizenship, or immigration status when electronic checks do not confirm a fact.
• Electronic verification that is usually invisible and actually reduces your paperwork when it works.
• Current-income checks, not just last year's tax data, because federal rules require verifying income at the time of the decision.
• Renewal rules, including automatic ("ex parte") renewals when Georgia already has the information it needs.

The continuing tension in this system is between accuracy (preventing wrong decisions) and access (not burying families in paperwork). PERM and MEQC findings inform where Georgia lands on that line.

How PERM differs from fraud investigation

PERM and MEQC measure accuracy; they are not fraud investigations. Suspected provider fraud and patient abuse are handled separately by Georgia's Medicaid Fraud Control Unit, housed in the Office of the Attorney General as the Medicaid Fraud and Patient Protection Division, which takes complaints at (404) 458-2878, extension 664, Monday through Friday from 8:30 a.m. to 5:00 p.m.9 A PERM "error" is usually a rule applied incorrectly or a missing document, not intentional wrongdoing.

What to do if you think your Medicaid case is wrong

If you believe a Georgia Medicaid decision was made in error, take these steps in order.4

Where to get help in Georgia

Learn More

Find personalized help navigating Georgia Medicaid eligibility quality control at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.