Under Georgia Medicaid, every enrolled child under 21 has a right their parents often do not: coverage for any medically necessary service, even care the state will not pay for in adults. That guarantee is called EPSDT.

EPSDT, short for Early and Periodic Screening, Diagnostic, and Treatment, is the federal Medicaid benefit for children, and it is the broadest coverage anywhere in the program.

In This Guide

What EPSDT Is and Why Georgia Medicaid Children Get More Than Adults

Adult Medicaid coverage runs on a benefit list: the state plan names what is covered, what is excluded, and what limits apply. If a service is not on the adult list, Georgia Medicaid generally will not pay for it.

EPSDT works differently. It is not a benefit list but a federal mandate. For every child under 21 enrolled in Medicaid, Georgia must cover all medically necessary health care, regardless of what the adult state plan says. The benefit is defined in Social Security Act Section 1905(r), codified at 42 U.S.C. 1396d(r), and it has five parts: screening, vision, dental, hearing, and a fifth catch-all.

That fifth part is the engine. Section 1905(r)(5) requires states to cover, for a child, any service listed in Section 1905(a) that is needed to correct or improve a condition found by a screening, "whether or not such services are covered under the State plan." In plain terms: if a service is medically necessary for a child and federal Medicaid is allowed to pay for it at all, Georgia must cover it for that child, even if it caps or excludes the same service for adults.

This is why pediatric Medicaid coverage is so much wider than adult coverage. Applied behavior analysis for autism, hearing aids, augmentative communication devices, private duty nursing, residential behavioral health, and durable medical equipment can all be required for a child under EPSDT when they are medically necessary, even where the adult program would never pay.

How Georgia Children Qualify for Medicaid and PeachCare

Georgia covers children through several pathways. Most families qualify on income through Right from the Start Medicaid (RSM) or, just above those limits, through PeachCare for Kids, Georgia's Children's Health Insurance Program (CHIP). Which one your child lands in matters for this guide: EPSDT is defined in the Medicaid statute and Section 1902(a)(43) makes it a mandatory Medicaid state-plan requirement, so the entitlement described below attaches to Medicaid enrollment. PeachCare for Kids is a separate CHIP program with its own benefit package, so if your child is on PeachCare, confirm a specific service with the plan rather than assuming the EPSDT rule reaches it.

Age Medicaid income limit (% FPL, 2026) PeachCare for Kids (above Medicaid, up to)
Under 1 220% FPL 247% FPL
1 to 5 149% FPL 247% FPL
6 to 18 205% FPL 247% FPL

One wrinkle worth knowing before you rule your family out: Georgia's own eligibility page states the 205% limit as covering "children under age 19," not just ages 6 and up, while separately naming 149% for ages 1 to 5. If your child is between 1 and 5 and your income sits between those two figures, apply anyway and let the agency assign the pathway rather than assuming you are over. PeachCare for Kids is for uninsured children age 18 and under, so a child who already has other health coverage is not eligible for it.

The other pathways matter for specific families:

  • Newborn deemed Medicaid. A baby born to a mother enrolled in Medicaid on the date of birth is automatically covered for the first 12 months with no separate application, under 42 U.S.C. 1396a(e)(4). The hospital notifies Georgia so the newborn gets a Medicaid ID.
  • Katie Beckett (TEFRA). A child who needs an institutional level of care but can be served at home can qualify on the child's own income and resources, with the parents' income and resources not deemed to the child, even when the family is over the income limits above. Note the age bound: Katie Beckett is a class of assistance available to children 18 years of age and younger, whose age "does not extend past the month she or he turns age 19," so it reaches further than most families expect but still does not carry a child to 21. In the month after the child turns 18, Georgia must advise the family to apply for SSI, but nothing happens to the Katie Beckett case either way: whether or not proof of an SSI application is provided, and whether Social Security approves the claim or finds the child not disabled, no action is taken to change eligibility. The case stays open through the month the child turns 19 and closes the month after, and before it closes Georgia reviews the child's eligibility under every other Medicaid class of assistance.
  • HCBS waivers, but only two of the four reach children. Georgia runs four Section 1915(c) Home and Community-Based Services waivers. The New Options Waiver (NOW) and Comprehensive Supports Waiver Program (COMP) serve people with an intellectual disability or a closely related developmental disability that originated at birth or during the developmental years, so a child can qualify. The other two do not serve children: the Elderly and Disabled Waiver Program (EDWP) serves frail elderly and disabled adults, and the Independent Care Waiver Program (ICWP) takes applicants only between the ages of 21 and 64, so no one under 21 can apply. Separately from the waivers, the Georgia Pediatric Program (GAPP) covers in-home skilled nursing for medically complex children.
  • SSI. A child who receives Supplemental Security Income (SSI) is automatically Medicaid-eligible.
  • Former Foster Care Medicaid. A young adult who was in foster care the month of their 18th birthday and was receiving Medicaid then keeps coverage through the last day of the month they turn 26. There are no income or resource limits, and an applicant cannot be found ineligible based on a diagnosis or pre-existing condition. Foster care in any state counts, not only Georgia, and the case is reviewed annually until the recipient turns 26 (see our guide on foster care and youth aging out).

PeachCare for Kids charges a monthly premium on a six-tier sliding scale for households from 134% to 247% FPL: $11 per child at the bottom bracket rising to $36 per child at the top, with a monthly family cap that runs from $16 to $72 depending on the bracket. There is no premium and no copayment for children under age 6, children in foster care, or American Indian and Alaska Native children. Medicaid itself charges no premium.

What Georgia Medicaid Must Cover for Children Under EPSDT

For each service below, adult Georgia Medicaid is limited but pediatric Medicaid must cover whatever is medically necessary.

Dental

Georgia expanded adult Medicaid dental effective July 1, 2024, removing the covered-procedure limitations that had applied to people 21 and older; adult dental services now require prior authorization except in an emergency. Children's coverage is still broader, because for a child the test is medical necessity rather than a state-set list. Under EPSDT, children are entitled to the full range of medically necessary dental care: exams and cleanings, fluoride and sealants, fillings and crowns, root canals, periodontal care, oral surgery, sedation when a child cannot cooperate, and orthodontia when it is medically necessary (for example, cleft palate or a severe bite problem that impairs function). The first dental visit should happen by age 1.

Vision and eyeglasses

EPSDT requires vision services that, by statute, must include "diagnosis and treatment for defects in vision, including eyeglasses" under Section 1905(r)(2), and the implementing rule at 42 CFR 441.56(c) requires them "even if the services are not included in the plan." For a child, none of that is bound by the frequency or scope limits Georgia places on its optional adult eyeglasses benefit: exams as often as medically needed, glasses when prescribed, and replacement glasses when replacement is medically necessary, such as a changed prescription or a pair that is lost, broken, or outgrown. The replacement interval is set by medical necessity rather than a fixed federal number.

Hearing

EPSDT's hearing element requires diagnosis and treatment for hearing defects, including hearing aids, for children. Georgia has not elected the optional adult hearing-aid benefit, so an adult cannot get a hearing aid through Georgia Medicaid itself and is pointed instead to the Georgia Hearing Aid Distribution Program run by the Georgia Lions Lighthouse Foundation. That includes audiology evaluations, hearing aids and replacements, cochlear implants when indicated, and assistive listening devices, when medically necessary.

Behavioral health, including ABA for autism

Because EPSDT's catch-all reaches any medically necessary Section 1905(a) service, Georgia must cover the behavioral health a child needs, including Applied Behavior Analysis (ABA) for autism, outpatient therapy without arbitrary visit limits, intensive outpatient and partial hospitalization, and Psychiatric Residential Treatment Facility (PRTF) care. CMS has said this about autism specifically. In a July 7, 2014 informational bulletin, "Clarification of Medicaid Coverage of Services to Children with Autism," the Center for Medicaid and CHIP Services told states they "are required to arrange for and cover for individuals eligible for the EPSDT benefit any Medicaid coverable service listed in section 1905(a) of the Act that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions." Note the bound on that: the bulletin names ABA as the modality dominating the national discussion, but it does not make ABA the only autism treatment a state must consider, noting that other recognized and emerging treatment modalities exist as well. The bulletin also lays out the authorities a state can use to cover autism services, from section 1905(a) state-plan categories such as Other Licensed Practitioner services at 42 CFR 440.60 to section 1915(i) state-plan home and community-based services, section 1915(c) waivers, and section 1115 demonstrations. ABA is delivered through the managed care plans after a confirmed autism diagnosis and a treatment plan; the number of hours is driven by medical necessity, not a fixed cap.

Home health, private duty nursing, and equipment

EPSDT covers skilled nursing, home health aide services, and private duty nursing for medically complex children, such as those who depend on a ventilator or a feeding tube, at the level that is medically necessary rather than a state-set limit. It also covers durable medical equipment, including wheelchairs, communication devices, feeding pumps, continuous glucose monitors and insulin pumps, and medically necessary incontinence supplies. Medically necessary prescription drugs are covered for children even when a drug falls outside the limits Georgia places on the adult drug benefit.

Getting to care

Georgia Medicaid covers non-emergency medical transportation (NEMT) to any Medicaid-reimbursable service, including EPSDT screening and treatment visits, for an eligible member who has no other means of transportation available. That last condition is part of the benefit definition, not a formality. Since April 1, 2026, DCH uses Verida as the statewide NEMT broker for all five Georgia regions. Because your child is almost certainly enrolled with one of the managed care plans, ask the plan directly how it wants a ride arranged; DCH's published NEMT pages do not spell out the managed care split.

Well-Child Visits: The Bright Futures Schedule

EPSDT screenings are the front door to everything else: a treatment is easiest to authorize when it traces back to a need found at a checkup. Under 42 CFR 441.58 each state sets its own periodicity schedule, which must meet reasonable standards of medical and dental practice determined after consultation with recognized child-health organizations, and states most commonly adopt the Bright Futures/American Academy of Pediatrics (AAP) schedule, which the federal government has also adopted as a HRSA-supported preventive-services guideline. The Bright Futures schedule calls for visits shortly after birth, then at roughly 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months, and once a year from age 3 through 20; ask your child's pediatrician or plan to confirm the exact schedule they follow.

Each visit includes a physical exam, developmental and behavioral screening, immunizations, and vision and hearing checks, with autism screening at 18 and 24 months and depression screening yearly from age 12. Childhood vaccines on the schedule recommended by the CDC's Advisory Committee on Immunization Practices (ACIP) are available at no cost for the vaccine through the federal Vaccines for Children (VFC) program. A concern that comes up between visits triggers an inter-periodic screening; families do not have to wait for the next scheduled checkup.

How EPSDT Works in Real Situations

These examples are illustrative composites, not real individuals, but each shows a pattern Georgia families meet.

Example 1: ABA hours for a child with autism

A 6-year-old in Atlanta is diagnosed with autism, and the treatment plan recommends 40 hours a week of ABA. The managed care plan first authorizes only 20 hours, citing an internal severity guideline. The family appeals. Because EPSDT requires services in the amount and scope that is medically necessary rather than what an internal guideline allows, the higher number is the kind of decision routinely reversed on appeal when the clinical record supports it.

Example 2: A monthly cap on diabetes supplies

An 8-year-old with type 1 diabetes is prescribed a continuous glucose monitor. The plan tries to limit sensors to one box a month, borrowing an adult policy. For a child, EPSDT does not allow an arbitrary monthly cap on a medically necessary supply, so the limit is appealable and the continuous supply can be restored.

Example 3: Residential treatment after a crisis

A 16-year-old with severe depression and repeated hospitalizations needs Psychiatric Residential Treatment Facility care. Adult Medicaid would not cover it, but PRTF is covered for a child under EPSDT, which is a specific federal exception for people under 21. With documented medical necessity, the plan authorizes the admission and a step-down plan to community services.

Common Mistakes Families Make

  1. Accepting an adult-coverage denial for a child. A denial that cites adult state-plan limits is not valid for an EPSDT request. The answer is to escalate and cite Section 1905(r)(5).
  2. Not knowing EPSDT exists. Families are often told a service "is not covered" without anyone checking whether EPSDT requires it for a child.
  3. Skipping well-child visits. Missed visits mean missed screenings, which weakens the link between a need and the treatment that EPSDT authorizes.
  4. Missing 12-month continuous coverage. A child under 19 stays covered for the full year even if income rises; some families drop coverage they still have.
  5. Overlooking Katie Beckett, or missing its age limit. A family over the income limits with a medically complex child may still qualify because the child's own income is what counts, but the pathway closes the month after the child turns 19, so plan the transition before then rather than counting on it to carry a child to 21 the way EPSDT does.
  6. Not asking for transportation. NEMT to Medicaid-covered visits is available to a member with no other way to get there, and it is underused.
  7. Not escalating to a State Fair Hearing. EPSDT denials are often reversed because the standard is medical necessity for a child, not whether the service sits on an adult benefit list.

How to Get EPSDT Coverage and Appeal a Denial

1
Step 1

Enroll

Apply through Georgia Gateway or call the Division of Family and Children Services (DFCS) at 1-877-423-4746. For PeachCare for Kids, call 1-877-427-3224. For a newborn, make sure the hospital notifies the state.

2
Step 2

Choose a plan

Children in Medicaid or PeachCare are assigned to one of three managed care plans, Amerigroup Community Care, CareSource, or Peach State Health Plan. A new member is enrolled into a plan automatically and then has 90 days from that plan's start date to change to a different one, through Georgia Families at 1-888-423-6765 (TDD 1-877-889-4424) or georgia-families.com.

3
Step 3

Keep up with well-child visits

They anchor most EPSDT authorizations.

4
Step 4

Work the prior authorization with your provider

Specialized services need clinical documentation of medical necessity.

5
Step 5

Appeal if denied

Exhaust the plan's internal appeal first, then request a State Fair Hearing through the Georgia Department of Community Health (DCH), which transmits Medicaid hearing requests to the Georgia Office of State Administrative Hearings (OSAH) at 1-877-809-0007. Under the federal managed care appeal rules the windows are 60 calendar days from the plan's adverse benefit determination notice to file the internal appeal and 120 calendar days from the plan's notice of resolution to request the hearing, but read the deadline printed on your own notice and treat that date as the one that governs. Cite EPSDT under Section 1905(r)(5), ask the plan for the specific clinical criteria its denial relied on, and back the request with letters from the treating clinician.

For complex cases, the Atlanta Legal Aid Society and the Georgia Advocacy Office handle Medicaid denials, and the Georgia Legal Services Program serves families outside metro Atlanta.

The mandate has teeth in court

EPSDT is not just an administrative rule. Federal courts have repeatedly enforced the EPSDT mandate against states in class-action litigation. In Rosie D. v. Romney, a class action in the U.S. District Court for the District of Massachusetts brought on behalf of 30,000 Massachusetts children with serious emotional disturbance who were seeking intensive home-based services under EPSDT, the court found the Commonwealth in violation of federal law after a five-week trial in 2005 for failing to provide home-based services; the remedial judgment led Massachusetts to create the Children's Behavioral Health Initiative under MassHealth, with the remedy services implemented in summer 2009. In O.B. v. Norwood, a class of Illinois children with disabilities and complex medical needs challenged the state Medicaid agency's failure to provide or arrange the medically necessary in-home nursing services required by EPSDT and the Americans with Disabilities Act, and obtained a preliminary injunction that was upheld on appeal to the Seventh Circuit. Neither case was brought against Georgia and neither decides your child's claim, but the mandate they enforce is the same federal one that binds Georgia.

Who to Call in Georgia

DCH Member Services Georgia Medicaid and PeachCare coverage and member questions. 1-866-211-0950https://www.gabar.org/about-the-bar/contact-us
Division of Family and Children Services (DFCS) Medicaid eligibility and enrollment. 1-877-423-4746https://dhs.georgia.gov/contact
PeachCare for Kids Enrollment Enroll a child in Georgia's CHIP program. 1-877-427-3224
Georgia Gateway Apply for Medicaid or PeachCare online. gateway.ga.gov
Georgia Pediatric Program (GAPP) In-home skilled nursing for medically complex children. dch.georgia.gov
Babies Can't Wait Early intervention for children birth to 3. 1-800-229-2038
Marcus Autism Center Autism diagnosis and ABA therapy referrals. 1-404-785-9444
Amerigroup Community Care One of Georgia's three current Medicaid managed care plans; member and prior-authorization questions. 1-800-600-4441
CareSource Managed care plan member and prior-authorization questions. 1-855-202-0729
Peach State Health Plan Managed care plan member and prior-authorization questions. 1-800-704-1484
Atlanta Legal Aid Society Free legal help with Medicaid and EPSDT denials. 1-404-524-5811
Georgia Advocacy Office Advocacy for people with disabilities on Medicaid denials. 1-404-885-1234

Frequently Asked Questions

What is EPSDT and why does it matter for my child?

EPSDT, Early and Periodic Screening, Diagnostic, and Treatment, is the federal Medicaid benefit for every enrolled child under 21. It entitles your child to well-child screenings, the diagnostics to find what is wrong, and all medically necessary treatment, including services Georgia does not cover for adults. If a child needs a hearing aid, ABA therapy, a wheelchair, a feeding pump, or residential behavioral health care, EPSDT requires Georgia Medicaid to cover it when it is medically necessary.

What is the "any other necessary care" rule?

It is the fifth part of EPSDT, Section 1905(r)(5). It requires Georgia to cover any medically necessary service that federal Medicaid is allowed to pay for, to correct or improve a condition found by a screening, "whether or not such services are covered under the State plan." That phrase is why a child's coverage is broader than an adult's.

How long does my child stay on Medicaid once enrolled?

A child under 19 stays covered for 12 continuous months even if family income rises, under the federal continuous-eligibility rule effective January 1, 2024. The period ends early if the child turns 19, moves out of state, withdraws, or dies. A renewal is due after 12 months. The 12-month guarantee is written for children under 19, so a 19 or 20 year old who is still Medicaid-eligible keeps EPSDT but is not covered by that particular protection.

Learn More

MedicaidHow to Apply for Georgia MedicaidHow to apply for Georgia Medicaid in 2026: Georgia Gateway, your local DFCS office, Form 700, the documents you need, processing timelines, and how to appeal. MedicaidPeachCare for Kids (Georgia CHIP)Raising a grandchild in Georgia? PeachCare for Kids covers children up to 247% FPL. See 2026 income limits, premiums, benefits, and how to apply. MedicaidKatie Beckett (TEFRA) PathwayGeorgia's Katie Beckett Deeming Waiver (TEFRA) covers a child with a significant disability on the child's own income, through the month the child turns 19. MedicaidGeorgia Medicaid Dental CoverageGeorgia Medicaid dental coverage in 2026: comprehensive adult dental since July 1, 2024, pediatric dental under EPSDT, and how to find a Medicaid dentist. MedicaidGeorgia Medicaid Vision CoverageGeorgia Medicaid vision coverage in 2026: how adult eye exams and glasses work through the CMOs, the EPSDT pediatric benefit, medical eye care, and contacts. MedicaidGeorgia Medicaid Hearing Aid CoverageGeorgia Medicaid hearing aid coverage is guaranteed for children under 21 through EPSDT but optional for adults. Here is how to check your own coverage. MedicaidGeorgia Medicaid Behavioral Health CoverageGeorgia Medicaid behavioral health coverage in 2026: mental health and substance use services, the CMO and community service board system, and how to get care. MedicaidFoster Care and Youth Aging OutGeorgia foster care Medicaid covers children in care automatically with no income test and keeps former foster youth enrolled to age 26. Here is how it works.

Find personalized help navigating Georgia Medicaid children's coverage and EPSDT 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.

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