Georgia Medicaid Children and EPSDT (2026 Coverage Guide)

Georgia children on Medicaid or PeachCare for Kids have a right adults do not: coverage for every medically necessary service, even ones the state refuses to pay for in adults. This is something extraordinary under federal law.

This guarantee is called EPSDT, which stands for Early and Periodic Screening, Diagnostic, and Treatment. It is codified at 42 USC 1396d(r) and 42 CFR 441 Subpart B. It is, by a wide margin, the most comprehensive federal benefit in Medicaid law and also the most underutilized. Many families never learn that their Medicaid-enrolled child is entitled to hearing aids, ABA therapy, residential behavioral health treatment, private duty nursing, augmentative communication devices, and any other medically necessary service, even when Georgia does not cover those services for adults.

This guide is the canonical Georgia Medicaid EPSDT playbook. It walks through every eligibility pathway for Georgia children, the federal EPSDT statutory and regulatory framework, the Bright Futures periodicity schedule that Georgia adopted for well-child screenings, the broad scope of services that Georgia must cover for children, six worked examples showing how EPSDT applies to real-world clinical situations, 15 common mistakes families and providers make, and a comprehensive FAQ. The intended reader is a parent or guardian of a Georgia child on Medicaid or PeachCare, a clinician trying to authorize a service, or an advocate trying to escalate a denial.

What is EPSDT and why is it different from adult Medicaid

Adult Medicaid coverage in Georgia is shaped by a benefit list. The state plan specifies which services are covered, which are excluded, and what limits apply (for example, 2 routine dental cleanings per year for pregnant women only, no routine vision after age 21 except every 24 months for exams and 3 to 4 years for eyeglasses, no routine hearing aids, etc.). If a service is not on the state plan benefit list for adults, Georgia Medicaid generally will not pay for it.

EPSDT works differently. EPSDT is not a benefit list. It is a statutory mandate that, for every child under 21 enrolled in Medicaid, Georgia must cover ALL medically necessary health care, regardless of what the state plan says about adults. The federal statute defining EPSDT is 42 USC 1396d(r). It identifies five core elements:

(1) Screening services. A periodic comprehensive child health assessment including a comprehensive health and developmental history, a comprehensive unclothed physical exam, appropriate immunizations on the CDC schedule, laboratory tests including lead screening, and health education and anticipatory guidance.

(2) Vision services. Diagnosis and treatment for vision defects including eyeglasses.

(3) Dental services. Maintenance of dental health and relief of pain and infection. Dental services begin at the earliest age recommended by professionals and must include diagnostic, preventive, and emergency services and treatment.

(4) Hearing services. Diagnosis and treatment for hearing defects including hearing aids.

(5) Any other necessary health care, diagnostic services, treatment, and other measures described in section 1396d(a) of this title to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.

The fifth element, the any-other-necessary-care clause, is the statutory override. The phrase "whether or not such services are covered under the State plan" means that a service that is medically necessary for a child must be covered even if Georgia does not cover that service for adults, as long as the service is one that federal Medicaid is authorized to cover under 42 USC 1396d(a). That section lists the universe of services that federal Medicaid can pay for: inpatient hospital, outpatient hospital, physician services, lab and x-ray, nursing facility services, home health, EPSDT itself, family planning, rural health clinic, FQHC, nurse-midwife, certified pediatric and family nurse practitioner, dental, prescription drugs, physical and occupational therapy, speech-language-hearing, prosthetic devices, eyeglasses, intermediate care facility for individuals with intellectual disabilities, inpatient psychiatric services for under 21, hospice, case management, primary care case management, respiratory care, personal care, private duty nursing, religious nonmedical health care institution services, and any other medical care recognized under state law.

The combination is broad: EPSDT covers any service in 1396d(a) that is medically necessary for a child, regardless of state plan limits. It means that any clinically warranted intervention for a Medicaid-enrolled child is covered if it falls anywhere in that federal universe. ABA therapy for autism, hearing aids, cochlear implants, augmentative communication devices, residential psychiatric treatment, intensive home health, private duty nursing, unlimited dental work, vision therapy, low-vision aids, durable medical equipment of all kinds: if it is medically necessary and federally allowable, it is required.

Federal authorities behind EPSDT

EPSDT rests on a layered foundation of statute, regulation, case law, and agency guidance.

Statutory.

• 42 USC 1396d(r) defines the benefit and its five elements
• 42 USC 1396a(a)(43) requires states to inform every Medicaid-eligible child and family of EPSDT, arrange screenings, provide or arrange diagnosis and treatment, and report annually to CMS
• 42 USC 1396a(a)(10)(A)(i)(I) and (VI) and 42 USC 1396a(a)(10)(A)(ii)(VIII) make Medicaid coverage of low-income children mandatory at certain federal income thresholds
• 42 USC 1396a(e)(12) requires 12 months of continuous eligibility for children under 19
• 42 USC 1396a(e)(4) deems newborns born to Medicaid-eligible mothers automatically enrolled for the first 12 months of life
• 42 USC 1396a(e)(3) and the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 create the Katie Beckett pathway for children with significant disabilities living at home
• 42 USC 1397aa et seq. authorizes Title XXI CHIP, which Georgia uses for PeachCare for Kids

Regulatory.

• 42 CFR 441.50 to 441.62 implements EPSDT
• 42 CFR 441.55 defines screening services
• 42 CFR 441.56 defines additional services (diagnostic and treatment)
• 42 CFR 441.57 governs periodicity schedules
• 42 CFR 441.58 governs case management coordination
• 42 CFR 441.60 limits arbitrary service exclusions
• 42 CFR 441.61 requires non-emergency transportation to EPSDT services

Case law.

• Bowen v. Massachusetts: established EPSDT as a comprehensive entitlement
• S.D. v. Hood: incontinence supplies and applied behavior analysis required under EPSDT
• Rosie D. v. Romney: home-based and community behavioral health services required under EPSDT
• O.B. v. Norwood: home health services required under EPSDT, state cannot cap arbitrarily
• Bond v. Stanton: EPSDT requires treatment, not just screening
• Pereira v. Kozlowski: EPSDT must cover services beyond state plan
• Pittman v. Secretary, Florida DCF: state cannot impose arbitrary visit caps on EPSDT services

Agency guidance.

• CMS State Medicaid Manual sections 5010 through 5320 provides operational detail on EPSDT
• CMS guidance confirms autism services including ABA are covered under EPSDT
• CMS EPSDT: A Guide for States (2014) is the canonical CMS guidance document
• CMS Bright Futures-based periodicity schedule is the federal benchmark for well-child visit timing and content

Georgia eligibility pathways for children under 21

Georgia has several distinct pathways through which children become eligible for Medicaid or CHIP. All of these pathways trigger EPSDT entitlement once enrollment is complete.

1. MAGI children under age 1

Federal law mandates Medicaid coverage for infants in families up to 138 percent FPL. Georgia covers infants up to 220 percent FPL. Babies are typically enrolled through the Right from the Start Medicaid (RSM) presumptive eligibility process during the mother's pregnancy or via the newborn deemed Medicaid pathway under 42 USC 1396a(e)(4).

2. MAGI children ages 1 through 5

Georgia covers children ages 1 through 5 up to 149 percent FPL.

3. MAGI children ages 6 through 18

Georgia covers children ages 6 through 18 up to 205 percent FPL under the Right from the Start Medicaid (RSM) program. (The federal mandatory minimum for this age group is 138 percent FPL; Georgia covers well above the floor.)

4. PeachCare for Kids (Title XXI CHIP)

PeachCare for Kids is Georgia's Title XXI CHIP program covering children up to 247 percent FPL whose family income is above the Medicaid ceiling for their age. PeachCare picks up where children's Medicaid leaves off (above 149 percent FPL for ages 1 through 5 and above 205 percent FPL for ages 6 through 18), up to the 247 percent FPL PeachCare limit. PeachCare requires modest monthly premiums for families above 150 percent FPL, and small copays for some services. PeachCare benefits are structured to mirror Medicaid EPSDT for the most part.

5. Newborn deemed Medicaid

Under 42 USC 1396a(e)(4), any newborn born to a mother enrolled in Medicaid at the time of birth is automatically deemed eligible for Medicaid for the first 12 months of life. No separate application is needed. This is automatic. The only step is for the hospital to notify DCH so the newborn receives a Medicaid ID.

6. Former foster care youth under 26

Under 42 USC 1396a(a)(10)(A)(i)(IX), added by ACA section 2004, former foster care youth who aged out of foster care at 18 are entitled to Medicaid through age 25 (until their 26th birthday) regardless of income. Georgia implemented this federal requirement. There is no income limit and no asset test. This is a particularly important pathway because foster care alumni have very high rates of chronic conditions, behavioral health needs, and gaps in continuous coverage.

7. Katie Beckett (TEFRA) pathway

The Katie Beckett pathway under 42 USC 1396a(e)(3) and TEFRA section 134 allows children with significant disabilities to qualify for Medicaid based on the child's own income and resources (not the parents'), regardless of family income. The child must meet an institutional level of care (would otherwise require ICF/IID, nursing facility, or hospital level of care) but can live at home if doing so does not cost more than institutional care. Georgia administers this through the Department of Community Health. This is critical for medically complex children whose families would otherwise be over income.

8. Independent Care Waiver Program (ICWP) and other HCBS waivers

Georgia operates HCBS waivers serving children including the Independent Care Waiver Program (ICWP) for adults and children with severe physical disabilities, the New Options Waiver (NOW) and Comprehensive Supports Waiver (COMP) for individuals with intellectual and developmental disabilities, and the Georgia Pediatric Program (GAPP) for medically complex children. Babies Can't Wait, Georgia's Part C early intervention program for children birth to age 3, coordinates closely with Medicaid and EPSDT to provide therapeutic services during the critical early development window. Each waiver provides additional home and community-based services on top of EPSDT.

9. SSI-related pathway

Children receiving SSI based on disability are automatically Medicaid-eligible in Georgia. This includes children with severe medical or developmental conditions that meet SSA's childhood disability standard.

The Bright Futures periodicity schedule

Georgia adopted the American Academy of Pediatrics Bright Futures periodicity schedule for EPSDT well-child visits. Bright Futures specifies the timing and content of every well-child encounter from birth to age 21. The schedule:

• Newborn (birth to 5 days, typically before hospital discharge)
• By 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months (lead screen, hemoglobin)
• 15 months
• 18 months (autism screen)
• 24 months (lead screen, autism screen)
• 30 months
• Annual visits ages 3 through 20

Each visit must include a comprehensive physical exam, developmental and behavioral screening, immunizations per the CDC schedule, sensory screening (vision and hearing) as age-appropriate, screening for tuberculosis risk and exposure, anticipatory guidance for the family on safety, nutrition, behavior, school readiness, oral health, sexual and reproductive health for adolescents, and screening tools for autism (18 and 24 months), depression and suicide risk (annually starting at age 12), substance use (adolescents), and lead exposure (12 and 24 months at minimum). Inter-periodic screenings can be performed any time a concern arises. For example, if a parent notices a child is not meeting developmental milestones at 14 months, the child should receive an inter-periodic developmental screening even though no Bright Futures visit is scheduled at 14 months.

EPSDT-required services that exceed adult coverage

This is where EPSDT shows its power. For each of these services, Georgia adult Medicaid is restrictive but pediatric Medicaid (EPSDT) must cover anything medically necessary.

Unlimited medically necessary dental

Adult Georgia Medicaid limits dental to emergency-only with no comprehensive routine coverage. EPSDT requires:

• Preventive dental services starting at age 1 or within 6 months of first tooth eruption
• Cleanings, fluoride treatments, sealants
• Diagnostic services including dental x-rays
• Restorative services (fillings, crowns)
• Endodontic services (root canals, pulpotomies)
• Periodontal services
• Orthodontic services when medically necessary (cleft palate, severe malocclusion impairing function, jaw misalignment causing functional problems)
• Oral surgery including extractions
• Sedation when medically necessary for children who cannot cooperate
• Hospital-based dental procedures for medically complex children

Unlimited medically necessary vision

Adult Georgia Medicaid limits vision to one exam every 24 months and eyeglasses every 3 to 4 years. EPSDT requires:

• Vision exams as often as medically necessary
• Eyeglasses when prescribed, with no arbitrary frequency cap
• Replacement glasses when lost, broken, or outgrown
• Contact lenses when medically appropriate
• Vision therapy when medically necessary (for example for amblyopia or convergence insufficiency)
• Low-vision aids and assistive technology
• Treatment for refractive errors, strabismus, amblyopia, and other vision disorders

Hearing aids and audiology services

Adult Georgia Medicaid does not cover routine hearing aids. EPSDT requires:

• Comprehensive audiology evaluations
• Hearing aids (typically bilateral when medically necessary) with no arbitrary cap on cost or frequency
• Cochlear implants when audiologically indicated, including the device, surgical procedure, programming, mapping, and follow-up
• Bone-anchored hearing aids (BAHA) when indicated
• FM systems and assistive listening devices
• Replacement hearing aids when lost, broken, or audiologically outgrown
• Auditory-verbal therapy and aural rehabilitation

Applied Behavior Analysis (ABA) for autism

CMS confirmed in 2014 that medically necessary autism services, including ABA, are covered under EPSDT. Georgia covers ABA through the Medicaid CMOs after a confirmed autism diagnosis from a qualified clinician and a recommended treatment plan. Coverage includes:

• Initial assessment by a Board Certified Behavior Analyst (BCBA)
• Direct ABA therapy hours (often 20 to 40 hours per week for younger children) provided by registered behavior technicians (RBTs) under BCBA supervision
• BCBA supervision and treatment plan oversight
• Parent training
• Reassessment and plan updates
• No statutory cap on hours: medical necessity drives authorization

Other behavioral health services

EPSDT requires comprehensive behavioral health coverage exceeding adult coverage including:

• Outpatient therapy (individual, family, group) without arbitrary visit limits
• Intensive Outpatient Programs (IOP)
• Partial Hospitalization Programs (PHP)
• Inpatient psychiatric services (including under-21 IMD coverage, which is a federal exception to the IMD exclusion under 42 USC 1396d(a))
• Psychiatric Residential Treatment Facility (PRTF) services
• Mobile crisis response
• Crisis Stabilization Unit (CSU) services
• Substance use disorder treatment including medication-assisted treatment

Home health and private duty nursing

Adult Georgia Medicaid limits home health to short-term post-acute services. EPSDT requires:

• Skilled nursing visits as medically necessary
• Home health aide services for ADL support
• Physical, occupational, and speech therapy in the home
• Private duty nursing (PDN) for medically complex children requiring continuous skilled nursing (children on ventilators, with tracheostomies, on TPN, with complex seizure disorders, etc.)
• No arbitrary hour caps. The 7th Circuit in O.B. v. Norwood held that states cannot cap home health for children below what is medically necessary.

Durable medical equipment

EPSDT requires comprehensive DME including:

• Wheelchairs (manual, power, custom-fitted)
• Augmentative and Alternative Communication (AAC) devices
• Standers, gait trainers, adaptive seating
• Feeding pumps and supplies
• Ventilators, CPAP, BiPAP, suction machines
• Apnea monitors
• Hospital beds and pressure-relief mattresses
• Continuous glucose monitors (CGM) and insulin pumps for children with diabetes
• Diabetic supplies including strips and CGM sensors without arbitrary monthly caps
• Hearing aid replacement parts
• Eyeglass replacement when broken or lost
• Incontinence supplies (diapers, pull-ups) for children age 3 and older with medical need

Therapy services

EPSDT requires medically necessary physical, occupational, speech, and feeding therapy without arbitrary visit limits. CMS has consistently held that states cannot impose hard caps (for example 20 visits per year per discipline) on EPSDT therapy services. Therapy must continue as long as it is medically necessary and producing benefit (which under EPSDT explicitly includes "maintenance" therapy to prevent regression for children with chronic conditions).

Non-emergency medical transportation

42 CFR 441.62 requires that states arrange necessary scheduling assistance for EPSDT screening and treatment services and ensure non-emergency medical transportation is available. Georgia provides NEMT through regional transportation brokers. Families can arrange transportation to medical appointments at no cost.

Six worked examples

These illustrate how EPSDT applies in real clinical situations.

Example 1: Mateo, age 6, Atlanta, autism and ABA

Mateo was diagnosed with autism spectrum disorder at age 4 by a developmental pediatrician at the Marcus Autism Center. The BCBA assessment recommended 40 hours per week of direct ABA therapy plus weekly BCBA supervision and monthly parent training. Mateo is enrolled in Medicaid through the MAGI children's pathway (household income at 130 percent FPL).

Under EPSDT, his Medicaid CMO authorized:

• 40 hours per week of direct ABA delivered by RBTs at a community-based ABA center
• 5 hours per week of BCBA supervision
• 2 hours per month of parent training
• Quarterly BCBA reassessment and treatment plan updates
• Coordination with Mateo's IEP team at his elementary school
• Speech therapy 2 hours per week
• Occupational therapy 1 hour per week

The CMO initially authorized only 20 hours per week of ABA citing internal "moderate severity" guidelines. The BCBA submitted a letter explaining that Mateo's severity warranted 40 hours based on the assessment scores. The CMO upheld 20 hours on internal appeal. The family filed a State Fair Hearing. The ALJ ruled in the family's favor, citing that EPSDT requires services in the amount, duration, and scope that is medically necessary, and that internal CMO guidelines cannot impose limits below medical necessity. The CMO authorized 40 hours per week retroactive to the initial request.

Example 2: Aaliyah, age 14, Macon, bilateral cochlear implants

Aaliyah developed bilateral profound sensorineural hearing loss after a viral illness. Audiology evaluation confirmed she was a candidate for bilateral cochlear implants. Aaliyah is enrolled in PeachCare for Kids (household at 175 percent FPL).

Under EPSDT (mirrored in PeachCare), her CMO authorized:

• Bilateral cochlear implant surgery
• Implant devices and surgical procedure
• Programming and mapping sessions
• Auditory-verbal therapy for 24 months post-implant (2 sessions per week)
• Replacement processors when audiologically warranted
• FM system for school use

Total cost of the bilateral implants and related services was substantial. None of this would be covered under Georgia adult Medicaid (which does not cover routine hearing aids at all). Under EPSDT it is mandatory.

Example 3: Sophie, age 8, Athens, type 1 diabetes with CGM and insulin pump

Sophie was diagnosed with type 1 diabetes at age 6. Her endocrinologist at the Children's Healthcare of Atlanta diabetes clinic recommended a continuous glucose monitor (CGM) and insulin pump. Sophie is enrolled in Medicaid via MAGI children's pathway.

Under EPSDT, her Medicaid CMO authorized:

• Insulin pump and supplies (every 90 days)
• CGM and sensors (10-day or 14-day sensors changed continuously)
• All insulin and diabetes medications
• Glucagon emergency kits
• Test strips and lancets as needed
• Quarterly endocrinology visits
• Annual ophthalmology screening
• Diabetes self-management education
• Medical nutrition therapy

The CMO initially limited CGM sensor coverage to "one box per month" citing adult policy. The endocrinologist's letter explained that Sophie required continuous CGM coverage for safety. The CMO upheld the limit on internal appeal. Family filed a State Fair Hearing. The ALJ reversed, holding that EPSDT prohibits arbitrary monthly caps on medically necessary supplies for children. CMO now authorizes continuous CGM coverage without monthly caps.

Example 4: Jayden, age 12, Augusta, severe asthma with biologic

Jayden has severe persistent asthma uncontrolled on inhaled corticosteroids and a long-acting beta agonist. His pulmonologist prescribed dupilumab (a biologic) and a home nebulizer. Jayden is enrolled in Medicaid.

Under EPSDT, his Medicaid CMO authorized:

• Dupilumab biologic (administered subcutaneously every 2 weeks)
• Home nebulizer machine with replacement parts
• Nebulizer solution refills
• Spacer device for inhalers
• Quarterly pulmonology visits
• Spirometry as needed
• Asthma action plan coordination

Biologics for asthma like dupilumab carry high list prices. Under adult Medicaid this would require extensive prior authorization with documented failure of multiple controllers. Under EPSDT the standard is medical necessity for the child. Once the pulmonologist documents that step therapy has failed and biologic is indicated, coverage is required.

Example 5: Lily, age 4, Savannah, amblyopia with comprehensive vision

Lily was diagnosed with amblyopia ("lazy eye") at her 3-year well-child visit. The pediatric ophthalmologist recommended patching therapy and vision therapy. Lily is enrolled in Medicaid via the MAGI children's pathway.

Under EPSDT, her Medicaid CMO authorized:

• Comprehensive vision exams every 6 months during active treatment
• Prescription eyeglasses (replaced after she sat on them; EPSDT covers replacement)
• Patching supplies
• Vision therapy 1 hour per week for 6 months
• Reassessment and ongoing monitoring

Adult Georgia Medicaid does not cover vision therapy at all and limits eyeglasses to every 3 to 4 years with no replacement coverage. Under EPSDT all of this is covered without arbitrary limits.

Example 6: Carlos, age 16, Columbus, psychiatric residential treatment

Carlos has major depressive disorder with severe self-injury, multiple psychiatric hospitalizations, and failed outpatient and intensive outpatient treatment. His psychiatrist recommended Psychiatric Residential Treatment Facility (PRTF) placement. Carlos is enrolled in Medicaid via the MAGI children's pathway.

Under EPSDT, his Medicaid CMO authorized:

• 120-day PRTF admission at an accredited facility
• All medical, psychiatric, nursing, therapeutic, educational, and ancillary services within the PRTF
• Family therapy with parental participation
• Discharge planning to step-down to a community-based wraparound program
• Post-discharge intensive outpatient and case management

PRTF coverage for children is required under EPSDT, and it is a specific federal exception to the Institutions for Mental Diseases (IMD) exclusion under 42 USC 1396d(a) for individuals under 21. Adult Medicaid would not cover this. For Carlos, EPSDT meant the difference between an appropriate level of care and a much longer and more dangerous attempt to manage his condition with insufficient outpatient services.

15 common mistakes families and providers make

1. Not knowing EPSDT exists. The biggest mistake. Families are told a service "is not covered" without anyone checking whether EPSDT requires it.

2. Accepting an adult-Medicaid denial for a pediatric request. A denial that cites adult state plan limits is not valid for an EPSDT request. The right response is to escalate citing 42 USC 1396d(r)(5).

3. Skipping Bright Futures well-child visits. Missed visits mean missed screenings, missed referrals, and missed early intervention windows. They also undermine the "discovered by the screening services" anchor that supports treatment authorization.

4. Failing to document medical necessity. EPSDT requires services that are medically necessary. The provider's clinical documentation is the single most important record. Vague notes do not support appeals.

5. Not requesting inter-periodic screenings when a concern arises. EPSDT covers inter-periodic screenings. Any time a parent, teacher, or provider raises a concern, a screening is authorized. Many families wait until the next scheduled visit.

6. Missing the 12-month continuous eligibility protection. Under 42 USC 1396a(e)(12), kids are guaranteed 12 months of coverage even if family income rises. Some families let coverage drop because they think they are now over income, when they actually have months remaining.

7. Not enrolling newborns automatically. Newborns to Medicaid-enrolled mothers are deemed eligible under 42 USC 1396a(e)(4). The hospital should notify DCH. If the baby does not appear in the Medicaid system within 30 days, parents must follow up.

8. Not exploring the Katie Beckett pathway for medically complex children. Many families with private insurance and a medically complex child are over income for MAGI Medicaid but can qualify under Katie Beckett because the child's own income is used.

9. Not exploring former foster care eligibility under 26. Aged-out youth often do not know they are entitled to Medicaid through 25 regardless of income.

10. Letting hearing aid, eyeglass, or DME denials stand. These are some of the most reversible denials. Adult-style caps applied to children are unlawful under EPSDT.

11. Letting therapy visit caps stand. A CMO's denial of "exceeded annual visit limit" for a child is not valid if therapy remains medically necessary.

12. Letting ABA hour caps stand. A CMO authorization for 20 hours when the BCBA recommends 40 hours is appealable. EPSDT requires services in the amount, duration, and scope necessary.

13. Not requesting Non-Emergency Medical Transportation. NEMT is available for EPSDT screening and treatment visits and is underutilized.

14. Confusing MAGI Medicaid and PeachCare for Kids. These are different programs with different income thresholds and modest cost-sharing differences. Families sometimes lose coverage by mis-categorizing.

15. Not escalating to State Fair Hearing. EPSDT denials are highly reversible at fair hearing because the legal standard (medical necessity for a child) is more favorable than the legal standard for adult denials. Many families accept denials that would be overturned in a hearing.

Putting it together: how to actually access EPSDT

For most families the practical sequence is:

1. Enroll. Apply through Georgia Gateway (gateway.ga.gov) or call DFCS at 1-877-423-4746. For PeachCare specifically call 1-877-427-3224. For newborns, ensure the hospital notifies DCH.

2. Choose a CMO. Children enrolled in MAGI Medicaid or PeachCare are auto-assigned to one of the three Georgia Families Care Management Organizations (Amerigroup Community Care, CareSource, and Peach State Health Plan). Families have 30 days to switch. WellCare of Georgia is no longer a separate Georgia Families Medicaid CMO; a 2024 reprocurement that proposed a new slate is in bid protest with no announced go-live, and the current three-CMO contracts have reportedly been extended through about June 30, 2027.

3. Schedule well-child visits on the Bright Futures schedule. This anchors EPSDT. Most treatments authorized under EPSDT trace back to a finding "discovered by the screening services."

4. For specialized services, work with your provider on prior authorization. Most CMO services beyond basic primary care require prior authorization. The provider submits the request with clinical justification citing medical necessity.

5. If denied, appeal. Internal CMO appeal within 60 days. If denied at the internal appeal, request State Fair Hearing within 120 days. Cite EPSDT under 42 USC 1396d(r)(5). Document medical necessity through the treating clinician.

6. For complex situations get help. Atlanta Legal Aid Society at 1-404-524-5811 and the Georgia Advocacy Office at 1-404-885-1234 handle EPSDT denials. Georgia Legal Services Program serves families outside metro Atlanta.

What Brevy is tracking

We at brevy.com maintain a state-by-state map of pediatric Medicaid coverage including EPSDT case law, CMO authorization patterns, and the specific services most commonly denied that are reversed on appeal. We coordinate with parent advocacy organizations and pediatric clinicians across Georgia and update this guide as new federal guidance issues, as CMO policies evolve, and as state plan amendments take effect.

EPSDT is the most powerful entitlement in Medicaid law. The reason it is underutilized is not that the law is unclear (the law is remarkably clear) but that families and even clinicians do not consistently know to invoke it. We hope this guide helps Georgia families and providers extract the full scope of what federal law already guarantees.

Who to Call in Georgia

• Department of Community Health (DCH) Member Services: 1-866-211-0950
• DFCS (eligibility and enrollment): 1-877-423-4746
• PeachCare for Kids enrollment: 1-877-427-3224
• Georgia Gateway (online application): gateway.ga.gov
• Georgia Pediatric Program (GAPP, medically complex children): 1-404-657-2700
• Babies Can't Wait (Part C early intervention, 0 to 3): 1-800-229-2038
• Marcus Autism Center (autism diagnosis and services): 1-404-785-9444
• Children's Healthcare of Atlanta: 1-404-785-5437
• Amerigroup CMO (children's services): 1-800-600-4441
• CareSource CMO: 1-855-202-0729
• Peach State Health Plan CMO: 1-800-704-1484
• Atlanta Legal Aid Society (Medicaid denials): 1-404-524-5811
• Georgia Advocacy Office (disability rights): 1-404-885-1234

Learn More

• How to Apply for Georgia Medicaid
• PeachCare for Kids (Georgia CHIP)
• Katie Beckett (TEFRA) Pathway
• Georgia Medicaid School-Based Services
• Georgia Medicaid Dental Coverage
• Georgia Medicaid Behavioral Health Coverage
• Georgia Medicaid Hearing Aid Coverage

Brevy.com keeps this guide current as federal EPSDT guidance, Georgia CMO policies, and state plan amendments change.

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.