Georgia Medicaid Managed Care Quality (2026): HEDIS, CAHPS, Appeals

Georgia rates its three Medicaid managed care plans on quality using clinical scores, member surveys, independent reviews, and a five percent capitation withhold written into the plans' contracts. This guide shows Georgia families how to use that data to choose a plan, file a grievance, and appeal a denial.

Most Georgia Medicaid beneficiaries get their coverage through a Care Management Organization (CMO), the term Georgia uses for a Medicaid Managed Care Organization (MCO).1 The three current Georgia CMOs are Amerigroup Community Care of Georgia, CareSource Georgia, and Peach State Health Plan. The Georgia Department of Community Health contracts with these three organizations to deliver benefits, manage provider networks, authorize services, pay providers, and coordinate care. The state pays each CMO a capitated monthly payment per enrolled member, and the CMO bears the financial risk if costs exceed that capitation.2 Understanding Georgia Medicaid managed care quality means tracing both the federal law that sets the rules and the state framework that enforces them.

That payment model creates a built-in tension. A CMO has a financial incentive to limit utilization, which can show up as service denials, narrow networks, slow appeals, and underinvestment in prevention. To counter those incentives, federal Medicaid law and Georgia rules build a quality framework on top of the contract. Federal regulations at 42 CFR Part 438 require each CMO to run a Quality Assessment and Performance Improvement program, undergo an annual independent External Quality Review, meet network adequacy and access standards, and operate a grievance and appeal system that includes continuation of benefits during an appeal and the right to a State Fair Hearing.3 Georgia adds quality withholds tied to performance, Performance Improvement Projects on priority topics, annual member experience surveys, and secret-shopper network validation.

For a Georgia family, this framework is the practical machinery behind real outcomes. It is how a parent gets a delayed mental health appointment scheduled, how a pregnant woman with a denied ultrasound gets that denial overturned on appeal, how a member can compare quality data before switching plans, and how a CMO that underperforms loses money.

How Georgia rates Medicaid managed care quality

The federal framework: 42 CFR Part 438

Section 1932 of the Social Security Act, codified at 42 USC 1396u-2, lets states require most Medicaid beneficiaries to enroll in managed care while guaranteeing choice of plans, grievance and appeal rights, and quality measurement. The Centers for Medicare and Medicaid Services (CMS) implemented that authority through 42 CFR Part 438, the comprehensive federal regulation governing Medicaid managed care.

Part 438 anchors the quality framework in a handful of subparts. 42 CFR 438.330 requires each CMO to run a Quality Assessment and Performance Improvement program, including Performance Improvement Projects, performance measurement using HEDIS measures, and mechanisms to detect both underutilization and overutilization.3 Under Section 1932(c)(2) of the Social Security Act and the External Quality Review subpart at 42 CFR 438.350 through 438.364, the state must contract with a qualified External Quality Review Organization (EQRO) to conduct an annual independent review of each CMO and publish an Annual Technical Report. 42 CFR 438.402 through 438.424 establish the grievance and appeal system. 42 CFR 438.6 is the basis for the quality withhold structure Georgia uses.

The framework was last overhauled by the 2024 Medicaid and CHIP Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F), published in the Federal Register on May 10, 2024 and effective July 9, 2024, which strengthened enforceable access standards, including maximum appointment wait time standards and independent secret-shopper surveys, and established a Medicaid and CHIP managed care Quality Rating System.5

HEDIS, CAHPS, and the EQRO report

Two measurement instruments drive the public quality picture. The National Committee for Quality Assurance (NCQA), a nonprofit accreditation and measurement organization, publishes HEDIS, a standardized set of clinical quality measures covering well-child visits, prenatal and postpartum care, diabetes care, blood pressure control, behavioral health follow-up, cancer screening, immunizations, and asthma management. The Agency for Healthcare Research and Quality (AHRQ), a federal agency, develops the CAHPS member experience surveys, which ask members to rate their personal doctor, their plan, customer service, getting needed care, and getting care quickly.

The EQRO Annual Technical Report is the single best source for comparing the three Georgia CMOs. Produced annually by an independent organization under contract to DCH, it validates each CMO's HEDIS measures, validates its Performance Improvement Projects, presents CAHPS results, assesses information systems, reviews network adequacy, and identifies areas for improvement. The report is publicly posted on the DCH website and presents each CMO's scores against national Medicaid benchmarks.3

Quality withholds and performance incentives

The Georgia Families contract's Value-Based Purchasing (VBP) provision states that "DCH will withhold five percent (5%) of the Contractor's Capitation Payments for the Value-Based Purchasing program," and that DCH "may return all, part or none of the withheld funds to the Contractor as incentive payments" based on the CMO achieving the VBP performance metrics, which are defined in Attachment U of the contract and are "primarily related to Healthcare Effectiveness Data and Information Sets (HEDIS) measures."6

Read that as leverage written into the contract, not as a guarantee that quality is being bought. Georgia's own Office of Health Strategy and Coordination reviewed the managed care contracts in October 2022 and reported that "the financial withhold has not been implemented as described in the contract," and that Georgia's CMOs were "performing at or below the HEDIS 25th percentile benchmark" on several chronic-condition measures.6 So the 5 percent withhold tells you what DCH may do, and the state's own reviewers have questioned whether it does it. For a family comparing plans, the EQRO Annual Technical Report is the more reliable signal.

NCQA Health Plan Accreditation

NCQA also offers voluntary Health Plan Accreditation, a plan-level certification covering quality management, utilization management, credentialing, members' rights, member experience, and population health management. Because it is voluntary and a plan's status can change, check it rather than assume it. Each CMO's current accreditation status is public at ncqa.org and can be looked up by a prospective enrollee before choosing or switching. The National Committee for Quality Assurance maintains that lookup.

Who runs Georgia Families and the three CMOs

The Georgia Families program is the state's mandatory Medicaid managed care program for most beneficiaries.1 It is administered by DCH under contracts with three current Care Management Organizations:

• Amerigroup Community Care of Georgia, a subsidiary of Elevance Health, member services 1-800-600-4441. Amerigroup also operates the Georgia Families 360 program for children in foster care and former foster youth. (Elevance has rebranded some Amerigroup plans nationally as Wellpoint, but the Georgia plan remains branded Amerigroup; Wellpoint is not a separate Georgia Families CMO.)
• CareSource Georgia, the Georgia operation of CareSource, a not-for-profit plan headquartered in Dayton, Ohio, member services 1-855-202-0729.
• Peach State Health Plan, a subsidiary of Centene Corporation, member services 1-800-704-1484.

In December 2024, DCH issued a Notice of Intent to Award under a reprocurement of the Georgia Families contracts naming a different proposed slate of CMOs.1 As of 2026, that procurement is in the bid-protest phase with no DCH-confirmed go-live date, and the current three-CMO contracts have been extended through June 30, 2027. Until any new slate goes live, the three CMOs above remain the current Georgia Families plans.

Georgia Families covers most beneficiaries, including children, parents, pregnant women, and Pathways to Coverage adults. Several groups are not in it. DCH's own Georgia Families Frequently Asked Questions answers the question "Who is NOT eligible for Georgia Families?" with four categories: individuals in a nursing home, individuals in hospice, Aged, Blind, and Disabled beneficiaries (with certain exceptions), and children enrolled in the Georgia Pediatric Program (GAPP). PACE (Program of All-Inclusive Care for the Elderly) participants are likewise outside the program.

That exclusion matters most to the readers this guide is otherwise written for. If you are an older or disabled Georgia Medicaid beneficiary, do not assume you are in a CMO. Check your Medicaid card or call the DCH Medicaid Member Services line at 1-866-211-09507 and confirm which track you are on before you rely on anything below, because the CMO grievance and appeal steps in this guide govern managed care denials, and a denial under Georgia's fee-for-service program follows a different route to a state fair hearing.

Two specialized arrangements run alongside the main program. The Planning for Healthy Babies (P4HB) Section 1115 demonstration provides family planning and interpregnancy care to women in a specified income range, administered through the CMOs. The Pathways to Coverage Section 1115 demonstration, which launched July 1, 2023 and is temporarily extended through December 31, 2026, covers adults ages 19 through 64 with household income up to 100 percent of the Federal Poverty Level who complete at least 80 hours per month of qualifying activities; Pathways enrollees receive coverage through the three Georgia Families CMOs.8

How to choose or switch your CMO

A new Georgia Families beneficiary can choose any of the three CMOs at enrollment. If the member does not choose, DCH auto-assigns based on prior plan enrollment, family enrollment, geographic factors, and CMO performance.

After enrollment, members can switch CMOs in three situations:

• Within 90 days of the start date of your health plan, for any reason and with no cause required.4
• During the annual open enrollment period, for any reason.
• For cause at any time, including a service quality issue, a provider network gap, a move outside the service area, or a religious or cultural reason. The member files the request with Georgia Families Enrollment, which evaluates the cause.

To compare the three CMOs before choosing, use the EQRO Annual Technical Report on the DCH website for HEDIS and CAHPS scores, the NCQA accreditation status at ncqa.org, and each CMO's provider directory to confirm your doctors and specialists are in network. Georgia Families Enrollment at 1-888-423-6765, or georgia-families.com, provides choice counseling.4

How to file a grievance, appeal, or fair hearing

Grievance versus appeal

Under 42 CFR 438.400, a grievance is a complaint about any matter other than an adverse benefit determination, such as rude staff, long clinic waits, provider directory errors, billing problems, or transportation issues. An appeal is a request to review an adverse benefit determination, which includes a denial or limited authorization of a service, a reduction or termination of a previously authorized service, a denial of payment, or a failure to act within required timeframes. Grievances do not carry continuation of benefits or a right to a State Fair Hearing; appeals do.

The Notice of Adverse Benefit Determination

Under 42 CFR 438.404, when a CMO makes an adverse benefit determination, it must send the member timely, adequate written notice explaining the action and the reason for it (including the right to free copies of the documents and medical-necessity criteria used), the right to appeal and how to exhaust the CMO's one level of appeal, the right to request a State Fair Hearing, when an appeal can be expedited, and the right to free interpretation services and to appoint a representative.9 Read this notice carefully and note the filing deadline.

Filing an internal CMO appeal

Under 42 CFR 438.402, the member files the appeal with the CMO within 60 calendar days of the date on the Notice of Adverse Benefit Determination.10 The appeal can be filed orally or in writing, and the member can appoint a representative such as a family member, advocate, or attorney. A managed care plan may have only one level of appeal.

Under 42 CFR 438.408, the CMO must resolve a standard appeal within a state-set timeframe no longer than 30 calendar days, and an expedited appeal within no longer than 72 hours.11 Either timeframe may be extended by up to 14 calendar days if the member requests the extension or the plan shows that more information is needed and the delay is in the member's interest. The appeal must be reviewed by someone not involved in the original decision, and a medical-necessity appeal must be reviewed by a clinical peer. If the CMO upholds the denial, it sends a Notice of Appeal Resolution explaining the member's right to a State Fair Hearing.

Expedited appeals

If the standard 30-day timeframe could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function, the member can request an expedited appeal, which the CMO must resolve within 72 hours.11 Expedited review is typically appropriate for denials of urgent medical or behavioral health services, denials of medications needed for ongoing treatment, or terminations of ongoing services where interruption would cause acute harm. The member can request expedited review when filing.

Continuation of benefits during an appeal

If the appeal involves a termination, suspension, or reduction of a previously authorized service, and the member files the appeal before the action takes effect and requests continuation of benefits, federal law requires the service to continue until a decision is rendered, unless the sole issue is one of federal or state law or policy. Federal rules at 42 CFR 431.230 tie this continuation to a hearing or appeal requested before the date of action; a request made after the action's effective date does not trigger continuation, though 42 CFR 431.231 separately lets the agency reinstate services when the request comes no more than 10 days after the date of action.12

If the CMO's decision is ultimately sustained, what the agency may claw back is bounded. 42 CFR 431.230(b) permits recovery only of the cost of services furnished solely by reason of the continuation, not of everything the member received while the appeal was pending.12 And under 42 CFR 438.404(b)(6), the notice the plan sends must spell out the circumstances, consistent with state policy, under which a member may be required to pay those costs, so read that paragraph of your notice rather than guessing at your exposure.9

Requesting a State Fair Hearing

After the CMO appeal is resolved, the member can request a State Fair Hearing. A missed deadline opens a second route: under 42 CFR 438.408(f)(1)(i), if the CMO fails to follow its own notice and timing rules, the appeal is deemed exhausted and the member can request a fair hearing without waiting for a resolution that never came.11 Under 42 CFR 438.408(f), the member must request the hearing within the window the state sets, which federal law requires to be no fewer than 90 and no more than 120 calendar days from the date of the CMO's notice of appeal resolution.11 The hearing is a formal proceeding before an Administrative Law Judge of the Georgia Office of State Administrative Hearings (OSAH). It is typically held by phone or video, and the member can attend with a representative, present evidence, and cross-examine the CMO's witnesses. The ALJ issues a written decision that DCH adopts as final agency action, after which the member can seek review in superior court.

How often appeals are overturned

The EQRO Annual Technical Report and DCH public reports publish appeal volumes, dispositions, and overturn rates by CMO. Overturn rates vary by CMO and by category of denial, with behavioral health and pharmacy denials sometimes overturned at higher rates than medical and surgical denials. A high overturn rate can signal inappropriate utilization management, and DCH uses appeal data as one input to identify CMOs that need added oversight.

What network adequacy and wait-time standards require

Federal and Georgia standards

42 CFR 438.206 and 438.207 require the state to ensure that each CMO maintains a provider network sufficient to deliver all covered services, addressing time and distance to providers, appointment wait times, specialty access, and accessibility for members with disabilities.13 Georgia sets its own quantitative network time-and-distance standards in the Georgia Families Contract rather than relying on CMS-set figures: each CMO must conduct a geographic access analysis of its network against the standards in Figure 1 of that contract. The federal rule at 42 CFR 438.68 sets the framework but requires the state to develop and enforce the actual quantitative standards.

Those Figure 1 numbers are public on DCH's network adequacy page, so you do not have to ask anyone for them. Urban members must have two PCPs or pediatricians within eight miles, rural members two within fifteen miles. Obstetric providers: two within thirty minutes or thirty miles urban, forty-five minutes or forty-five miles rural. Specialists, hospitals, mental health providers, general and subspecialty dental providers, therapy (PT/OT/ST) and vision providers: one within thirty minutes or thirty miles urban, forty-five minutes or forty-five miles rural. Pharmacies: one open 24 hours a day, seven days a week within fifteen minutes or fifteen miles urban and thirty minutes or thirty miles rural, and in the rural cell only, a pharmacy with an after-hours emergency phone number and a pharmacist on call also counts. Georgia's compliance bar is that at least 90 percent of the members in each county have access to a provider when the contractual access standards are applied, reported through quarterly CMO Network Adequacy Reports.14

The 2024 CMS appointment wait time standards

Under 42 CFR 438.68(e), added by CMS-2439-F, states must establish and enforce maximum appointment wait time standards: no longer than 10 business days for outpatient mental health and substance use disorder services, 15 business days for primary care, and 15 business days for obstetric and gynecological services. A plan is deemed compliant when independent secret-shopper results show appointment availability meeting those standards at least 90 percent of the time.15 These appointment wait time standards are not yet in force: under 42 CFR 438.68(h), they apply to the first managed care rating period beginning on or after July 9, 2027, and the secret-shopper survey requirement applies on or after July 9, 2028. The network adequacy standard in 42 CFR 438.68(d)(1)(iii) applies to the first rating period beginning on or after July 9, 2026.16

That federal phase-in does not leave Georgia members without an appointment wait-time standard in the meantime. Figure 2 of the Georgia Families Contract already sets contractual waiting times by provider type: routine PCP visits not to exceed fourteen calendar days; adult and pediatric sick visits not to exceed twenty-four clock hours; specialists not to exceed thirty calendar days; mental health providers fourteen calendar days; routine dental visits not to exceed twenty-one calendar days; urgent care not to exceed twenty-four clock hours; and emergency care immediately, twenty-four hours a day.14 If your CMO cannot offer you an appointment inside those windows, that is a standard in your plan's contract with the state and you can cite it in a grievance now, without waiting for the 2027 federal date.

The sixty-minute cap on waiting inside the provider's office is a separate standard, and it is not in Figure 2. It sits in Figure 3 of the Georgia Families model contract, Waiting Times by Appointment Type, which caps office waits at sixty minutes for a scheduled appointment and ninety minutes for a work-in or walk-in visit, and requires that after thirty minutes, or forty-five minutes for a work-in or walk-in, the patient be given an update on the wait with the option of waiting or rescheduling. DCH does not republish Figure 3 on its network adequacy page, so it is confirmable only against 2017-generation model contract text: cite the sixty-minute limit to Figure 3, and confirm it with your CMO before relying on it.14

Behavioral health parity

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that financial requirements and treatment limitations for mental health and substance use disorder benefits be no more restrictive than those for medical and surgical benefits, covering prior authorization, medical-necessity rules, and network access.17 Parity applies to Medicaid managed care, but a 2024 HHS Office of Inspector General report found that none of the eight states it reviewed had built the required parity terms into their MCO contracts by the October 2, 2017 compliance date. OIG recommended that CMS improve its oversight of states' compliance with parity requirements and require states to improve their own monitoring of MCOs' ongoing compliance; CMS concurred.18 Members who believe a behavioral health benefit is being managed more restrictively than a comparable medical benefit can raise a parity complaint with their CMO and with DCH.

Service authorization timeframes

Under 42 CFR 438.210, a CMO must make a standard prior-authorization decision within a state-set timeframe that may not exceed 7 calendar days for rating periods starting on or after January 1, 2026 (down from the prior 14-day cap), with a possible extension of up to 14 calendar days.19 For an expedited decision, when the standard timeframe could seriously jeopardize the member's life, health, or function, the CMO must decide no later than 72 hours after receiving the request.

How DCH enforces Georgia Medicaid managed care quality

DCH has multiple tools to enforce CMO compliance:

• Liquidated damages: contractually specified penalties for defined performance failures.
• Corrective Action Plans: required remediation with deadlines and DCH-approved steps.
• Civil money penalties: financial penalties for certain violations under federal Medicaid managed care law.
• Enrollment freezes: the CMO cannot accept new members until problems are corrected.
• Suspension of capitation payments: DCH stops paying the CMO pending correction.
• Auto-assignment changes: DCH steers new auto-assignments away from a noncompliant CMO.
• Contract termination: the ultimate sanction, with members transferred to other CMOs.

CMS has concurrent authority and can impose sanctions independently.

How the framework plays out: real situations

Diabetes management and HEDIS-driven care

Marcus, 42, lives in southwest Atlanta with uncontrolled type 2 diabetes, hypertension, and early kidney disease, enrolled in Amerigroup. Diabetes care sits among the HEDIS measures the Georgia Families contract ties to the VBP withhold, and Amerigroup's care management team identifies Marcus, assigns a care manager, and schedules a retinal eye exam, a primary care follow-up for blood pressure and medication, and enrollment in a diabetes self-management program. Over the next several months his control improves and he completes his eye exam. Marcus can also compare diabetes-care performance across the three CMOs in the EQRO Annual Technical Report on the DCH website, and switch during annual open enrollment if another plan performs substantially better.

Prenatal care timeliness

Aisha, 28, in Macon, enrolls in pregnancy coverage at nine weeks and selects Peach State Health Plan because her OB is in network.20 Georgia Medicaid covers pregnant women through the Right from the Start Medicaid pathway at or below 220 percent of the Federal Poverty Level and extends postpartum coverage to a full 12 months after the end of pregnancy. The HEDIS Prenatal and Postpartum Care measure tracks timeliness of the first prenatal visit and a postpartum visit. Peach State's maternal care team calls within days of enrollment to confirm her OB, schedule her first visit, and arrange transportation; Aisha attends her first prenatal visit at week 11 and her postpartum visit within the standard window, counting toward Peach State's measure performance.

Behavioral health appeal and fair hearing

Jamil, 14, in Savannah, has ADHD and major depression and is enrolled in CareSource Georgia. After an inpatient psychiatric stay, CareSource's discharge team schedules his follow-up appointment before discharge to meet the HEDIS follow-up-after-hospitalization measure, using telehealth because the nearest in-person opening is weeks out. When his family later requests a partial hospitalization program, CareSource denies it as not medically necessary. Jamil's mother files an appeal within the 60-day window, requests expedited review, and requests continuation of benefits. After CareSource upholds the denial, she files a State Fair Hearing request with OSAH; the ALJ finds the medical-necessity criteria were misapplied and orders CareSource to approve the program.

Network adequacy and the secret-shopper survey

Sarah, 45, in a rural county near Augusta, needs ongoing endocrinology care and is enrolled in CareSource Georgia. The three in-network endocrinologists the directory lists are either closed to new patients or carry a six-month wait. Sarah files a grievance with CareSource about the directory inaccuracy. DCH requires a Corrective Action Plan, and CareSource contracts an additional endocrinologist, offers telehealth endocrinology, and reimburses transportation for in-person visits. Once the federal secret-shopper survey requirement takes effect, this kind of directory gap is independently validated and feeds DCH's annual access oversight.

Practical guidance for Georgia families

How to file a grievance

You can file a grievance with your CMO at any time. Call your CMO's member services line (Amerigroup 1-800-600-4441, CareSource 1-855-202-0729, Peach State 1-800-704-1484) and say you want to file a grievance, or file in writing. Keep a record of the date, the staff member, and what was said. If the grievance is not resolved to your satisfaction, escalate to DCH Medicaid Member Services at 1-866-211-0950, file a complaint with the Georgia Office of the Commissioner of Insurance and Safety Fire at 1-800-656-2298, or seek free legal help from the Georgia Legal Services Program at 1-833-457-7529.21,7

How to file an appeal

When you receive a Notice of Adverse Benefit Determination, note the action, the reason, and the deadline. File the appeal with your CMO by phone (to start the clock) and in writing within 60 calendar days. Request expedited review if the standard timeframe could harm your health, and request continuation of benefits if the CMO is ending a service you already receive. If the CMO upholds the denial, request a State Fair Hearing with OSAH within the required window. For complex appeals (especially behavioral health, durable medical equipment, or denied surgeries), consider a free legal advocate at the Georgia Legal Services Program, whose statewide intake line is 1-833-457-7529 (1-833-GLSPLAW),7 or, in metro Atlanta, Atlanta Legal Aid Society (404-524-5811).21

How to switch CMOs

Within 90 days of your health plan's start date, call Georgia Families Enrollment at 1-888-423-6765 (TDD 1-877-889-4424) to switch with no cause required.4 During annual open enrollment, call the same number to change plans. At any time for cause, call to file a cause-based switch request and be prepared to document the cause.

Where to get help with Georgia Medicaid managed care quality

The offices below can help you compare CMOs, file a grievance, appeal a denial, request a State Fair Hearing, or escalate a complaint. Free legal help is available for Medicaid members.

Learn More

Find personalized help navigating Georgia Medicaid managed care quality 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.