Georgia Medicaid Copays & Cost Sharing 2026

In 2026, Georgia Medicaid copays are small: as little as $0.50 for a prescription, $3 for a non-emergency ER visit, and $12.50 for a hospital stay, and many members pay nothing at all. Which other services carry a copay depends on which Georgia Families plan you are in, because the published CMO schedules are not identical. Children, pregnant women, nursing-home residents, and several other groups are exempt entirely, and federal law caps total cost sharing at 5 percent of family income.1

In This Guide

• What Georgia Medicaid copays actually cost
• Who pays no Georgia Medicaid copays
• The federal limits behind Georgia Medicaid copays
• The 5 percent household income cap
• Non-emergency ER copays and the EMTALA rule
• If you have Medicare and Medicaid
• PeachCare for Kids copays
• Georgia Pathways to Coverage copays
• What providers can and cannot do
• Real situations: what families actually pay
• Frequently Asked Questions
• Learn More

What Georgia Medicaid copays actually cost

Cost sharing is the part of a medical bill you pay yourself. In Georgia Medicaid it is small, and which services carry a copay depends on your plan. Georgia Families has three Care Management Organizations (CMOs), Amerigroup Community Care, CareSource, and Peach State Health Plan. The two plan schedules read here, CareSource's and Peach State's, are the plans' own restatements rather than state policy, and they don't match each other or the state's list. Check your own plan's copay page.4,1

The state's own schedule comes from the Georgia Department of Community Health (DCH), in its announcement that Pathways copayments took effect October 1, 2025, which says they match every other Medicaid class under the state plan: $12.50 for an entire inpatient stay, $3 per outpatient hospital visit, $3 for non-emergency use of the ER, $0 for primary care, $2 for a specialist, $3 for durable medical equipment ($1 for rentals and supplies), and pharmacy on the cost-based scale below.1

The table below combines both plan schedules and marks which plan carries each charge.1

On CareSource's schedule an inpatient stay carries no copay when the member was admitted or transferred from an ER, urgent care, another hospital, or a nursing or other health facility.1

Some Georgia copays are "cost-based": the amount depends on what the care costs, on a scale topping out at $3.1 There is a route back from the non-preferred rate: under 42 CFR 447.53(e), if your prescriber determines a preferred drug in the same class would be less effective or cause adverse effects, the agency must have a timely process limiting your cost sharing to the preferred-drug amount. CareSource calls it asking for an exception.5,1

Adult dental has been a covered Georgia Medicaid benefit for recipients 21 and over since July 1, 2024, when the state removed the covered-procedure limits that applied to adults. Whether a dental service carries a copay depends on your plan: Peach State lists oral maxillofacial services at the cost-based copay, and CareSource's schedule lists no dental copay at all. Ask your plan before the visit, and note that every adult dental service except emergency care needs prior authorization.6,1

Who pays no Georgia Medicaid copays

Both plan schedules list no copays for members under 21, pregnant women, nursing facility residents, hospice members, Breast and Cervical Cancer program members, and American Indians or Alaska Natives; CareSource adds children in foster care. That is the plans' list, not DCH's, so confirm an exemption with your plan or DCH. PeachCare's state-set list is shorter: children under six, children in foster care, and American Indians and Alaskan Natives.1

Two of those exemptions sit in federal law. Pregnancy-related services are exempt under Social Security Act Section 1916 and 42 CFR 447.56, and every service given to a pregnant woman counts as pregnancy-related unless the state plan names it otherwise. In Georgia, the pregnant women's Medicaid pathway covers income up to 220 percent of the Federal Poverty Level (FPL), and coverage runs 12 months past the end of pregnancy. The federal exemption for pregnant women themselves is shorter, ending with the month in which the 60-day postpartum period ends, so later in that year ask your plan whether a copay applies.7,8

The American Indian and Alaska Native exemption turns on use of Indian health care, not on tribal membership by itself. Under 42 CFR 447.56(a)(1)(x), an Indian who is currently receiving or has ever received an item or service from an Indian health care provider, or through a referral under contract health services, is exempt from all cost sharing; the parallel premium exemption is broader, reaching anyone merely eligible for such care. The statutory basis is Section 1916(j) of the Social Security Act (42 U.S.C. 1396o(j)), which also bars the agency from cutting its payment to the Indian health provider by the waived amount.9

Nursing facility residents pay no copays either, but their income reaches the cost of care another way, through "patient liability." A Georgia nursing-home resident keeps a Personal Needs Allowance of $70 a month; the rest of their income, after allowed deductions, goes to the facility bill. That is not cost sharing under the copay rules.10

The federal limits behind Georgia Medicaid copays

Georgia sets its copays far below the federal ceiling. Under 42 CFR 447.52, 447.53, and 447.54, a state may charge no more than the maximum allowable cost sharing, and above 100 percent FPL some caps switch from a flat dollar amount to a percentage of what the agency pays.5

One caveat: the dollar figures below are base amounts codified in the CFR, not a 2026 ceiling. Each rises every October with the medical-care component of the CPI-U, so the operative maximum is higher. The percentage-of-cost caps are not indexed.5

The point of the table is the gap: Georgia's top drug copay, $3, sits under the $4 codified maximum, and its $12.50 inpatient copay is a fraction of the $75 figure. In no case may a state's cost sharing equal or exceed what the agency itself pays for the service. Nor may the state impose more than one type of cost sharing on the same service.5,1

The 5 percent household income cap

Federal rule sets a hard backstop on the cumulative burden. Under 42 CFR 447.56(f)(1), premiums and cost sharing incurred by everyone in the Medicaid household "may not exceed an aggregate limit of 5 percent of the family's income," applied quarterly or monthly as the state agency specifies. Once the household reaches it, no further cost sharing may be imposed that period.2

The tracking is not entirely on you: under 42 CFR 447.56(f)(3)-(4) the agency must notify you and your providers when you reach the limit, and must let you ask for the family limit to be reassessed after your circumstances change. Which period Georgia uses, quarterly or monthly, is the state's choice and is not on the CMO copay pages, so ask DCH. To estimate the cap, multiply annual family income by 5 percent, then divide by four for a quarterly limit or twelve for a monthly one. If you think you have paid more, call Georgia Medicaid Member Services at 1-866-211-0950 or your CMO and ask for a 5 percent cap review.2,11

Non-emergency ER copays and the EMTALA rule

A true emergency is always free. The non-emergency ER copay, $3 in Georgia, can only be charged after the hospital follows the procedure at 42 CFR 447.54: an appropriate medical screening finding you do not need emergency services, notice of the copay amount, the name and location of an available alternative non-emergency provider (such as a Federally Qualified Health Center (FQHC) or urgent care) that can treat you in a timely way at lower or no cost sharing, and a referral to schedule it. None of this cuts into EMTALA.1,5

If the hospital skipped a step, the copay was not charged the way the rule requires, and both Georgia plan schedules charge no copay for a real emergency. Question a bill that ignores the process, cite 42 CFR 447.54, and call DCH Member Services at 1-866-211-0950.5,11

If you have Medicare and Medicaid

If you have both Medicare and Medicaid as a Qualified Medicare Beneficiary (QMB), the protection is stronger than a low copay. It is against federal law for any Medicare provider or supplier, including pharmacies, to bill a QMB for Medicare Part A or Part B cost sharing, even when Medicaid pays nothing toward that bill. Medicare's payment plus any state Medicaid payment counts as payment in full, and the provider may bill the state Medicaid program for the cost sharing. You cannot waive the protection by agreeing to pay, and it follows you across state lines. QMB is one of the Medicare Savings Programs.3

If you are billed anyway, show both your Medicare and Medicaid cards, tell the provider in writing that you are in the QMB program, and ask for the charge to be rescinded. If you already paid, you have the right to a refund; CMS tells providers to recall bills sent to collections and refund what they collected. Call 1-800-MEDICARE (1-800-633-4227) and Medicare will confirm your QMB status and ask the provider to stop billing and refund you.3 If a debt collector keeps calling about the bill, file a complaint with the Consumer Financial Protection Bureau at consumerfinance.gov/complaint or 1-855-411-2372.3 For free help sorting through the bills, call a GeorgiaCares SHIP counselor at 1-866-552-4464, option 4. Our improper QMB billing guide walks through the full dispute process step by step.3,12

For prescription drugs, dual eligibles get help through Medicare Part D and the Low-Income Subsidy (Extra Help). In 2026, $5.10 generic and $12.65 brand is the ceiling, not what everyone pays: a full-benefit dual at or below 100 percent FPL pays $1.60 and $4.90, and one who is institutionalized or on home and community-based services pays $0. Everyone pays $0 once out-of-pocket drug costs reach $2,100. A full-benefit dual or a QMB doesn't have to apply: Medicare automatically treats them as eligible. For anyone else, the income limit sits just below 150 percent FPL, about $1,995 a month for one person and $2,705 for a married couple in the contiguous 48 and DC, and it is higher for a larger household. Since the Inflation Reduction Act ended the partial-subsidy tier in 2024, everyone who qualifies gets the full subsidy.13

PeachCare for Kids copays

PeachCare for Kids is Georgia's Children's Health Insurance Program (CHIP), and it has its own cost-sharing rules. Children under age six pay nothing, and under the state's rule that exemption ends at the sixth birthday. Peach State's PeachCare page alone says "age six and under," a more generous reading than the state's, so the family of a six-year-old Peach State member can ask whether the plan waives the copay but shouldn't assume it does. PeachCare members age six and over pay per-service copays. DCH says they can range from $0.50 to $12.50, with most at $2 or $3, and there is no copay for emergency services, routine check-ups, immunizations, or routine preventive and diagnostic dental care.1

CareSource lists the PeachCare amounts this way:1

Cost-based copays follow the same $0.50-to-$3 scale shown above.1

PeachCare for Kids also charges a monthly premium on a six-tier sliding scale by income, from $11.00 per child (with a $16.00 family cap) at 134 to 158 percent FPL up to $36.00 per child (with a $72.00 family cap) at 232 to 247 percent FPL. Two premium rules matter: coverage does not start until the first premium is paid, and Georgia allows new applicants 45 days and renewing families 30 days to pay it. After that, a missed premium no longer ends coverage, though unpaid amounts accrue and DCH sends a quarterly statement. Premiums and copays together are capped at 5 percent of your yearly income, and a family that reaches the cap owes neither for the rest of the year.14

Georgia Pathways to Coverage copays

Georgia Pathways to Coverage is the state's Section 1115 demonstration for adults 19 through 64 with household income up to 95 percent FPL, effectively 100 percent once the 5 percent disregard is applied, who complete at least 80 hours a month of qualifying activities. Its beneficiaries owe the same copayments as state plan Medicaid beneficiaries, with none for members under age 21 and none for beneficiaries enrolled in HIPP.15

So a Pathways enrollee pays the same small copays as any other adult Georgia Medicaid member; DCH's announcement that Pathways copayments took effect October 1, 2025 printed the same state schedule shown above.1 The demonstration itself is only temporarily extended, through December 31, 2026, and its rules change on January 1, 2027 under federal law, with current members unaffected until their 2027 renewal.15

What providers can and cannot do

Under 42 CFR 447.52(e)(2), the state plan must bar providers from denying services because you can't pay the cost sharing. A provider may still bill the copay later, and you can be held liable for it. The narrow exception at 447.52(e)(1) reaches only non-exempt members above 100 percent FPL. A provider may always choose to reduce or waive a copay case by case.2 Both Georgia plans say the same in their own words: CareSource says it cannot deny treatment if you cannot pay, and Peach State says you will not be denied care for a covered service.1

If a provider overcharges, bills an exempt service, or refuses care over an unpaid copay, get the bill in writing, cite 42 CFR 447.52 or 447.56, and call DCH Member Services at 1-866-211-0950 and your CMO.2,11

Real situations: what families actually pay

These are hypothetical illustrations. Your own costs depend on your eligibility category, income, and services.

A pregnant woman through delivery and recovery

Tasha is 26, on Georgia's pregnant women's Medicaid at about 156 percent FPL. Prenatal visits, labor and delivery, and prenatal vitamins are pregnancy-related and carry no cost sharing, and her exemption runs through the month her 60-day postpartum period ends. Her coverage lasts 12 months, so for a routine visit later in that year she should ask her plan about a copay.7,8

An adult on Aged, Blind, and Disabled Medicaid with several prescriptions

Marcus, 45, has Aged, Blind, and Disabled (ABD) Medicaid and fills five preferred generics a month at CareSource's $0.50 each: about $2.50 a month, or $30 a year. A non-emergency ER visit would add $3, an inpatient stay $12.50. He stays well under 5 percent of income, so the cap never triggers.1,2

A dual eligible billed for Medicare coinsurance

Eleanor, 78, is a full-benefit dual and a QMB. After a Medicare cardiology visit, the office bills her the Part B coinsurance. That bill is unlawful, and when she writes citing her QMB status it is rescinded. Her Part D drugs run through full Extra Help at $1.60 generic and $4.90 brand if her income is at or below 100 percent FPL, $5.10 and $12.65 above it.3,13

A Pathways to Coverage enrollee

Diana, 60, is on Georgia Pathways at 95 percent FPL and meets the 80-hour requirement. She pays the standard adult copays, but her ER visit for chest pain is $0 because a real emergency carries no copay.15,1

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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.