The repayments are known as clawbacks: When an organization believes it has overpaid for services, it takes steps to get back the money. These insurers continued to receive those payments from Medicaid while there was a dropoff in patient visits. “Clawbacks mean people did not get health care,’’ said Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group.
“It was surprising in terms of timing and the amount,” Weathington said. He added that the three Medicaid insurers were not given detailed breakdowns of how the state actuary arrived at the numbers. The insurers were told the reduction was due to many Medicaid patients skipping medical care during the COVID-19 pandemic, along with other adjustments, said Weathington.
The Georgia Medicaid insurers – Peach State, Amerigroup and CareSource – are paid a per-member, per-month rate to care for Medicaid members. The half-billion-dollar payout will come from two separate Medicaid recoveries, said Jesse Weathington, the executive director of the Georgia Quality Healthcare Association. Due to the federal role in financing Medicaid, much of the returned money would likely go to the U.S. government.
Medicaid, jointly financed by the federal government and individual state governments, covers low-income and disabled residents. Georgia pays the Medicaid insurers over $4 billion each year to provide care to low-income children and other vulnerable populations. The state covers about one-third of those costs, with the feds funding the rest. It’s unclear how much of the recovered funds will go to the feds and how much to Georgia’s coffers. But if it’s split by the normal funding formula, the state would gain more than $165 million. The $202 million retrospective rate adjustment for 2020 is now awaiting approval from the federal Centers for Medicare & Medicaid Services, Weathington said. Another $300 million midyear adjustment for 2021 is currently under negotiation, he added.
The Department of Community Health, which runs Medicaid in the state, did not respond to GHN’s requests for comment. “Essentially, people may have missed services they needed last year. That’s no fault of the because we saw that happen access the board regardless of the type of insurance. The state still has a right to address that based on their contract,” added Colbert.
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