Caresource Georgia Co

TO MAKE A LASTING DIFFERENCE IN OUR MEMBERS' LIVES BY IMPROVING THEIR HEALTH AND WELL-BEING. CARESOURCE GEORGIA CO. IS A NONPROFIT HMO LICENSED BY THE STATE OF GEORGIA.

CARESOURCE GEORGIA ("CSGA") IS A NONPROFIT CORPORATION ESTABLISHED UNDER THE STATE LAWS OF GEORGIA. ON JULY 18, 2017, CSGA RECEIVED A DETERMINATION LETTER FROM THE INTERNAL REVENUE SERVICE, RECOGNIZING CSGA AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, EFFECTIVE AS OF THE DATE OF CSGA'S FORMATION. CSGA IS A MEMBER OF THE CARESOURCE GROUP OF NONPROFIT ORGANIZATIONS (THE "CARESOURCE GROUP"). THE PARENT OF THE CARESOURCE GROUP IS CARESOURCE, AN OHIO NONPROFIT CORPORATION THAT IS TAX-EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986 (THE "CODE"). THE CARESOURCE GROUP'S PRIMARY ACTIVITY FOR THE LAST THIRTY-ONE YEARS HAS BEEN TO PROVIDE NONPROFIT MEDICAID HEALTH MAINTENANCE ORGANIZATION ("HMO") SERVICES. THE MISSION OF THE CARESOURCE GROUP IS TO MAKE A LASTING DIFFERENCE IN ITS MEMBERS' LIVES BY IMPROVING THEIR HEALTH AND WELL-BEING. THE CARESOURCE GROUP FIRMLY ADHERES TO THIS MISSION, WHICH IT TERMS AS THE ORGANIZATION'S "HEARTBEAT," BY PROVIDING SERVICES THAT GO BEYOND THE DELIVERY OF MEDICAL BENEFITS. CSGA BEGAN PROVIDING CARE TO PARTICIPANTS IN ITS MEDICAID HMO PLAN ON JULY 1, 2017. CSGA SERVES INDIVIDUALS MEETING THE LOW-INCOME THRESHOLDS FOR MEDICAID ELIGIBILITY. CSGA PARTICIPATES IN THE STATE OF GEORGIA'S PLANNING FOR HEALTHY BABIES PROGRAM, OR P4HB, WHICH IS A DEMONSTRATION WAIVER PROGRAM FOR WOMEN MEETING MEDICAID INCOME THRESHOLDS DESIGNED TO HELP REDUCE THE NUMBER OF LOW-BIRTH-WEIGHT BABIES BORN EACH YEAR. THROUGH THE P4HB PROGRAM, CSGA OFFERS FAMILY PLANNING SERVICES, HEALTHCARE COVERAGE FOR CERTAIN PREGNANCY-RELATED CHRONIC CONDITIONS, AND CASE MANAGEMENT SERVICES TO WOMEN AT RISK FOR A LOW-BIRTH-WEIGHT DELIVERY. CSGA LAUNCHED A MARKETPLACE PLAN IN 2020, OFFERING AFFORDABLE INDIVIDUAL AND FAMILY PLANS TAILORED FOR ANY BUDGET, AS WELL AS A DUAL ELIGIBLE SPECIAL NEEDS PLANS IN 2021. IN ACCORDANCE WITH THE CARESOURCE GROUP'S CHARITABLE MISSION, CSGA PROVIDES NUMEROUS PROGRAMS AND POLICIES THAT ENCOURAGE ITS MEMBERS TO OBTAIN PREVENTATIVE AND NECESSARY MEDICAL CARE. MANY OF THESE PROGRAMS ARE EDUCATIONAL IN NATURE AND INTENDED TO MAKE EACH MEMBER AWARE OF THEIR BENEFITS. FOR EXAMPLE, UPON ENROLLMENT, EACH MEMBER RECEIVES A HANDBOOK WITH AN OVERALL EXPLANATION OF BENEFITS. MEMBERS ALSO RECEIVE PERIODIC NEWSLETTERS WHICH INCLUDE ADDITIONAL INFORMATION ON MEMBER BENEFITS AND REMINDERS CONCERNING PREVENTATIVE CARE. ADDITIONALLY, CSGA CONTACTS MEMBERS THROUGHOUT THE YEAR TO FURTHER ASSIST MEMBERS IN UNDERSTANDING THEIR BENEFITS. FINALLY, UPON ENROLLMENT, EACH MEMBER WILL BE AUTOMATICALLY ASSIGNED BOTH A PRIMARY CARE PHYSICIAN ("PCP") AND PRIMARY DENTAL PROVIDER ("PDP"). ASSIGNING A PCP REPRESENTS THE FIRST STEP IN ENCOURAGING MEMBERS TO UTILIZE THEIR BENEFITS. ALSO, BECAUSE EACH PCP WILL BE REQUIRED TO CONTACT MEMBERS TO SCHEDULE EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT ("EPSDT") APPOINTMENTS FOR CHILDREN COVERED BY CSGA, IT INCREASES THE LIKELIHOOD THAT CSGA'S YOUNGEST MEMBERS RECEIVE THE PREVENTATIVE CARE THEY NEED. ENSURING MEMBERS HAVE ACCESS TO QUALITY DENTAL CARE IS ALSO ESSENTIAL, AS ORAL HEALTH CARE IS CLOSELY LINKED TO THE OVERALL HEALTH AND WELL-BEING OF MEMBERS. CARESOURCE SEEKS INPUT FROM MEMBERS ABOUT THE SERVICES THEY RECEIVE AND THE IMPACT OF THE ENHANCED BENEFITS WE OFFER THROUGH A MEMBER ADVISORY COMMITTEE. THE MEMBER ADVISORY COMMITTEE IS CONVENED FOR IN-PERSON AND VIRTUAL MEETINGS. THE COMMITTEE MEETS QUARTERLY AND IS COMPRISED OF MEMBERS FROM ACROSS THE STATE. THEY REPRESENT SPECIAL POPULATIONS THAT ARE SERVED BY THE HEALTH PLAN. THEIR FEEDBACK SUPPORTS THE CONTINUOUS IMPROVEMENT OF BENEFITS AND SERVICES. CSGA LEVERAGES THIS COMMITTEE TO SEEK FEEDBACK ABOUT MEDICAL AND ENHANCED BENEFITS, PROGRAMS LIKE CARESOURCE JOBCONNECT OR OTHER SOCIAL DETERMINANT INITIATIVES, UNDERSTANDING THE CONSUMER EXPERIENCE, AND HOW TO IMPROVE MARKETING AND COMMUNICATION. IMPORTANTLY, CSGA OPERATES UNDER THE CARESOURCE GROUP'S UNIQUE CARE COORDINATION MODELS. CSGA HAS CREATED AN INTEGRATED CARE MANAGEMENT INFRASTRUCTURE THAT CONSISTS OF THREE LEVELS OF MEMBER CARE TO ACCELERATE CARE TRANSFORMATION FOR EACH AND EVERY MEMBER. MEMBERS ARE ASSIGNED TO SELF-MANAGEMENT, RISING RISK, OR HIGH-RISK BASED ON THEIR UNIQUE MEMBER RISK STRATIFICATION. CARESOURCE CAN THEN TAILOR THE CARE COORDINATION PROGRAM TO MEET THOSE MEMBERS' NEEDS. MEMBERS RECEIVE ENHANCED CARE COORDINATION SERVICES BASED ON THEIR COMPLEX PHYSICAL, BEHAVIORAL AND SOCIAL HEALTH NEEDS. THE FLUIDITY OF THIS DESIGN ALLOWS CSGA TO FOCUS ON PREVENTING LOWER-RISK AND RISING RISK MEMBERS FROM ESCALATING TO HIGH-RISK OVER TIME, WHILE STILL TENDING TO THE ONE-TO-ONE CARE MANAGEMENT NEEDS OF HIGH-RISK POPULATIONS. IN CONJUNCTION WITH OUR INTEGRATED CARE MANAGEMENT MODEL, CSGA RELIES ON MTMPATH TO COORDINATE ITS MEMBERS' MEDICATION USAGE. CSGA'S MTMPATH WILL COLLECT DATA ON ALL MEDICATIONS THAT A MEMBER IS CURRENTLY TAKING. CSGA RUNS THIS DATA THROUGH SEVERAL CLINICAL ALGORITHMS TO IDENTIFY POSSIBLE ISSUES RELATED TO COST, SAFETY, AND OVER-UTILIZATION. ANY ISSUES THAT ARE IDENTIFIED ARE SHARED WITH PHARMACISTS, WHO THEN PROVIDE MEMBERS WITH FACE-TO-FACE AND TELEPHONIC COUNSELING. MTMPATH ALSO HAS DIRECT TO PRESCRIBER REQUESTS AND NOTIFICATIONS THAT AIDE IN IMPROVING MEDICATION SAFETY, ADHERENCE, AND UTILIZATION. THIS INDIVIDUALIZED REVIEW OF EACH MEMBER'S MEDICATION USAGE HAS BEEN INSTRUMENTAL IN IMPROVING MEMBER HEALTH, AS EVIDENCED BY A REDUCED NUMBER OF HOSPITALIZATIONS AND EMERGENCY DEPARTMENT VISITS. CSGA, ALONG WITH OTHER MEMBERS OF THE CARESOURCE GROUP, ARE STILL AMONG THE FEW MEDICAID MANAGED CARE ORGANIZATIONS IN THE COUNTRY THAT VOLUNTARILY PROVIDE SUCH A COMPREHENSIVE REVIEW OF MEMBERS' PRESCRIPTION MEDICATIONS. TO OPERATE ITS PLAN, CSGA CONTINUES TO BUILD A HIGH-PERFORMING NETWORK THAT YIELDS EFFICIENCIES IN THE DELIVERY OF CARE. THIS PROVIDER NETWORK RELIES HEAVILY UPON FEDERALLY QUALIFIED HEALTH CENTERS ("FQHC"). FQHCS ARE GENERALLY HEALTH CARE PROVIDERS THAT HAVE BEEN RECOGNIZED BY THE FEDERAL GOVERNMENT AS PROVIDING CARE TO POPULATIONS THAT HAVE LIMITED ACCESS TO MEDICAL TREATMENT DUE TO CONDITIONS SUCH AS POVERTY AND GEOGRAPHIC LOCATION. THE MAIN PURPOSE OF THE FQHC PROGRAM IS TO ENHANCE THE PROVISION OF PRIMARY CARE SERVICES IN UNDERSERVED URBAN AND RURAL COMMUNITIES. CSGA IS ACCREDITED THROUGH NATIONAL COMMITTEE FOR QUALITY ASSURANCE ("NCQA") FOR ITS MEDICAID PLAN AND ITS QUALIFIED HEALTH PLAN ("QHP"). NCQA ACCREDITATION IS THE MOST COMPREHENSIVE EVALUATION IN THE INDUSTRY AND THE ONLY ASSESSMENT THAT BASES RESULTS ON CLINICAL PERFORMANCE AND CONSUMER EXPERIENCE. CSGA FOCUSES ON PREVENTION WITH A GOAL OF IMPROVING MEMBER HEALTH, THE QUALITY OF HEALTH CARE SERVICES RECEIVED, AND ACCESSIBILITY OF HEALTH CARE SERVICES FOR ITS MEMBERS. MANY OF CSGA'S ACTIVITIES IMPROVE EFFICIENCY IN THE DELIVERY OF MEDICAID BENEFITS, RESULTING IN AN IMPROVEMENT OF ITS MEMBERS' OVERALL HEALTH. CSGA PLACES A CONSIDERABLE EMPHASIS ON MEMBERSHIP EDUCATION THROUGH WELLNESS PLANS AND OTHER INDIVIDUAL COMMUNICATIONS. WELLNESS REWARDS ARE AVAILABLE FOR KIDS, ADULTS, AND PREGNANT WOMEN AND BABIES. CSGA PROVIDES DENTAL AND VISION BENEFITS TO ALL MEMBERS, INCLUDING THOSE OVER THE AGE OF TWENTY-ONE. ADDITIONALLY, CSGA PROVIDES MEMBERS WITH FREE ACCESS TO A NURSING HOTLINE TWENTY-FOUR HOURS A DAY, SEVEN DAYS A WEEK. THESE NURSES REVIEW A MEMBER'S SYMPTOMS, OFFER GUIDANCE ON WHEN TO SEEK MEDICAL CARE, EXPLAIN ANY CONDITIONS WITH WHICH A MEMBER HAS BEEN RECENTLY DIAGNOSED, PROVIDE EDUCATION ON OVER-THE-COUNTER MEDICATIONS, AND HELP MEMBERS PREPARE A LIST OF QUESTIONS PRIOR TO A VISIT WITH THEIR DOCTOR. THIS TRIAGING OF CARE BOTH IMPROVES THE EFFICIENCY OF THE MEDICAID PROGRAM AND REDUCES UNNECESSARY HOSPITALIZATIONS AND EMERGENCY DEPARTMENT VISITS. CSGA AIMS TO REMOVE POVERTY AS A BARRIER TO ACHIEVING GOOD HEALTH, AND CSGA PROVIDES A NUMBER OF PROGRAMS DESIGNED TO MEET CHALLENGES THAT ARE SPECIFIC TO INDIVIDUALS WITH LOW INCOMES. ONE PROGRAM IS TRANSPORTATION. BECAUSE LOW-INCOME INDIVIDUALS FREQUENTLY HAVE DIFFICULTY KEEPING MEDICAL APPOINTMENTS DUE TO A LACK OF TRANSPORTATION, CSGA WILL AUGMENT THEIR TRANSPORTATION BENEFIT. TRANSPORTATION ASSISTANCE IS A VALUE-ADDED BENEFIT TO THE CARESOURCE LIFE SERVICES PROGRAM. CSGA WILL PROVIDE RIDES TO EMPLOYMENT AND EDUCATION RELATED ACTIVITIES. IN 2021, CSGA OFFERED RIDES TO LOCAL GROCERY RETAILERS FOR CURBSIDE PICKUP AND TO COMMUNITY ORGANIZATIONS FOR FOOD DISTRIBUTION EVENTS. CSGA PROVIDES ADDITIONAL ENHANCED BENEFITS TO MEMBERS THAT ARE ABOVE AND BEYOND REQUIRED BENEFITS DEFINED BY STATE OR FEDERAL AGENCIES. THESE BENEFITS INCLUDE CLUB MEMBERSHIPS, HEALTH AND WELLNESS ITEMS, REWARDS PROGRAMS, AND SOCIAL DETERMINANT SUPPORT. TOGETHER, THESE ENHANCED BENEFITS PROVIDE CSGA MEMBERS ADDITIONAL PROGRAM BENEFITS IN ORDER TO MAKE A LASTING DIFFERENCE IN MEMBERS' LIVES BY IMPROVING THEIR HEALTH AND WELL-BEING. IN 2016, THE CARESOURCE GROUP IMPLEMENTED CARESOURCE LIFE SERVICES, A