Georgia Medicaid Cost Sharing and Copays: A Complete Guide to Section 1916, 42 CFR 447, Exempt Populations, QMB Protections, and the 5% Cap

Georgia Medicaid cost sharing is tightly regulated by federal law and is far lower than commercial insurance copays. This guide walks through what enrollees actually owe at the doctor or pharmacy, who is exempt, how the 5 percent household income cap works, why Qualified Medicare Beneficiaries cannot be balance billed, how Part D Extra Help affects dually eligible enrollees, and how to dispute incorrect charges.

Audience: Georgia Medicaid enrollees and applicants confused about what they owe at the doctor or pharmacy; parents enrolling children in Medicaid or PeachCare for Kids; pregnant women navigating coverage; dual eligibles facing balance billing; Georgia Pathways to Coverage participants asked to pay a premium; community workers and SHIP counselors helping clients understand their financial protections.

What this guide covers: What cost sharing is in Medicaid and why it is tightly limited. The federal framework: Section 1916 of the Social Security Act, Section 1916A (added by the Deficit Reduction Act of 2005), 42 CFR Part 447 Subpart A (sections 447.50 through 447.90), and the May 31, 2013 CMS Final Rule (78 FR 32646). The maximum allowable cost sharing schedule by income tier. The populations exempt from any cost sharing: children under 21, pregnant women, hospice patients, Indian Health Service-eligible individuals, recipients of family planning, recipients of emergency services, and the medically frail in long-term care. The services exempt for all enrollees: emergency, family planning, pregnancy-related, preventive, hospice. The 5 percent aggregate household income cap. The QMB lesser-of rule and the federal prohibition on balance billing Qualified Medicare Beneficiaries under Sections 1902(n)(3)(B), 1905(p), and 1866(a)(1)(A). The Part D Low-Income Subsidy (Extra Help) copay caps under Section 1860D-14, expanded to 150 percent FPL by the Inflation Reduction Act of 2022. CHIP cost sharing under 42 CFR Part 457 Subpart E for PeachCare for Kids. Managed care cost-sharing compliance under 42 CFR 438.108. The Georgia copay schedule for pharmacy, outpatient, inpatient, and ED. The Pathways to Coverage Section 1115 premium framework and consequences of non-payment. Six worked examples covering pregnant women, dual eligibles, ABD adults, CHIP families, exempt children, and Pathways enrollees. A 14-question FAQ. And contact lists for DCH, the three CMOs, legal aid, and federal oversight.

Last verified: May 12, 2026

By Brevy Care Team · Last verified May 12, 2026

When a person with commercial health insurance goes to the doctor, she typically pays a copay, a deductible, or coinsurance: a portion of the cost of care that comes out of her own pocket before insurance pays the rest. This is cost sharing, and it is the financial mechanism by which most American health insurance shifts some of the cost of care to the patient. Cost sharing has two purposes: it generates revenue for the insurer, and it discourages unnecessary utilization by giving the patient a financial stake in the decision to seek care.

Medicaid is fundamentally different. Because Medicaid covers low-income people, including children, pregnant women, the elderly, and the disabled, the program has always been designed with very limited cost sharing. The original Medicaid statute in 1965 contained no cost sharing at all. Section 1916 of the Social Security Act, added by the Social Security Amendments of 1972, permits nominal cost sharing for adult enrollees in narrow circumstances, but explicitly exempts children under 21, pregnancy-related services, family planning, emergency services, services to terminally ill in hospice, and Indian Health Service-eligible individuals. This baseline reflects a policy judgment: charging poor people for healthcare creates an access barrier that pushes them out of preventive care, into emergency rooms, and ultimately drives up total system cost.

The Deficit Reduction Act of 2005 added Section 1916A, which gave states more flexibility to impose higher cost sharing on certain non-mandatory populations and on enrollees above 100 percent of the federal poverty level. But §1916A retained the core exemptions and added a critical backstop: the 5 percent aggregate household income cap. Total Medicaid cost sharing and premiums for all members of a household cannot exceed 5 percent of family income per quarter. When the cap is reached, further cost sharing must be waived.

The May 31, 2013 CMS Final Rule (78 FR 32646) modernized the implementing regulations at 42 CFR Part 447 Subpart A. It set maximum allowable cost sharing levels indexed annually to inflation, reaffirmed the exempt populations and services, restructured the rules for non-emergency ED use, and confirmed the 5 percent cap.

In Georgia, the result is a copay schedule that most enrollees find surprisingly low: small dollar amounts for prescriptions and outpatient visits, a modest inpatient copay, $0 for emergencies, $0 for FQHCs and RHCs, $0 for behavioral health, and $0 for many other services. CMOs (Amerigroup, CareSource, Peach State) must follow the same schedule. Children pay nothing. Pregnant women pay nothing for pregnancy-related care. Hospice enrollees pay nothing.

This guide explains the cost-sharing framework in detail, identifies the exemptions, walks through the Georgia schedule, and shows how to dispute incorrect charges. It is informational and does not constitute legal, financial, or medical advice. Cost sharing rules and amounts can change; always verify with DCH Member Services or qualified counsel before acting.

The federal framework

Three statutory provisions, two implementing regulations, and one major CMS rule define the federal cost-sharing framework for Medicaid.

Section 1916 of the Social Security Act (42 USC 1396o). Enacted by the Social Security Amendments of 1972, §1916 is the original Medicaid cost-sharing statute. It permits states to impose "nominal" deductibles, coinsurance, copays, or similar charges on Medicaid enrollees, but with significant restrictions:

• Children under 18 (later expanded by CMS regulation to under 21) are exempt
• Pregnancy-related services are exempt
• Family planning services are exempt
• Emergency services are exempt
• Services to terminally ill in hospice are exempt
• Indian Health Service-eligible individuals are exempt

Section 1916(f) reaffirms the emergency services exemption with specific reference. Section 1916(g), added later, permits states to impose higher cost sharing for non-emergency use of the emergency department, but only when the hospital provides an EMTALA-mandated screening, determines the condition is not an emergency, and offers the enrollee an alternative non-emergency provider.

Section 1916A of the Social Security Act. Added by the Deficit Reduction Act of 2005 (§6041 of P.L. 109-171), §1916A gives states more flexibility for cost sharing on non-mandatory Medicaid populations (medically needy, optional adults under §1115, expansion adults). Higher cost sharing is permitted, but with structural caps:

• Cost sharing capped at 10 percent of cost for enrollees at or below 100 percent FPL
• Capped at 20 percent for enrollees 101 to 150 percent FPL
• Up to the full Medicaid payment amount for some services for enrollees above 150 percent FPL
• 5 percent aggregate household income cap applies regardless of population

Section 1916A retains the exemptions of §1916: children, pregnancy, family planning, emergency, hospice, IHS.

42 CFR Part 447 Subpart A (§§447.50 through 447.90). Implementing regulations:

• 447.50: basis and purpose
• 447.51: applicability
• 447.52: premium standards
• 447.53: out-of-pocket spending limits (the 5 percent cap)
• 447.54: maximum allowable cost sharing (the dollar caps)
• 447.55: medically needy
• 447.56: exemptions (the key provision listing exempt populations and services)
• 447.60: sliding-scale premiums
• 447.68: services subject to copay
• 447.70: enforcement limits
• 447.78, 447.80: copay specifics
• 447.82: termination for premium nonpayment

The May 31, 2013 CMS Final Rule (78 FR 32646). Titled "Medicaid and CHIP: Increase in Cost Sharing and Premiums," this rule modernized the implementing regulations, set the maximum allowable cost sharing levels (indexed annually since), and reaffirmed the 5 percent cap. Effective January 1, 2014.

Section 1860D-14 (Part D Low-Income Subsidy). Caps drug copays for low-income Medicare beneficiaries. Important for duals.

Section 1902(n)(3)(B), 1905(p), 1866(a)(1)(A) (QMB billing prohibition). Prohibits any Medicare provider from balance billing a Qualified Medicare Beneficiary for Medicare cost sharing.

Federal caps on Georgia Medicaid cost sharing

For Medicaid categorically needy enrollees, 42 CFR 447.54 sets maximum allowable cost sharing levels that CMS adjusts annually for inflation. The structure works in tiers:

Outpatient services (per visit):

• At or below 100 percent FPL: a small fixed dollar maximum
• 101 to 150 percent FPL: 10 percent of cost
• More than 150 percent FPL: 20 percent of cost

Non-emergency use of the ED (per visit):

• At or below 100 percent FPL: a higher fixed dollar maximum than outpatient, permitted only after EMTALA screening and alternative provider notice
• 101 to 150 percent FPL: no statutory dollar maximum, but 5 percent cumulative cap applies
• More than 150 percent FPL: similar

Prescription drugs:

• Preferred drugs (at or below 150 percent FPL): a small fixed dollar maximum
• Non-preferred drugs (at or below 150 percent FPL): a higher fixed dollar maximum than preferred
• Preferred and non-preferred drugs (more than 150 percent FPL): up to 20 percent of cost

Inpatient hospital (per admission):

• At or below 100 percent FPL: a fixed dollar maximum
• 101 to 150 percent FPL: 10 percent of inpatient cost
• More than 150 percent FPL: 20 percent of inpatient cost

Premiums:

• At or below 150 percent FPL: generally prohibited (except in CHIP and certain demonstrations)
• 151 to 200 percent FPL: limited

These are federal maximums; pull the current CMS Informational Bulletin on cost sharing for this year's dollar figures. Georgia, like most states, sets its actual copay schedule far below these maximums for most services, as discussed below.

Exempt populations under federal law

42 CFR 447.56(a) identifies populations that cannot be charged any Medicaid cost sharing:

Children under 21. Federal exemption applies to all children up to age 21 in mandatory Medicaid categories. This includes children enrolled through Family Medicaid (low-income family pathway), Katie Beckett, GAPP, foster care, and SSI. Note that children in CHIP (PeachCare for Kids in Georgia) follow CHIP rules at 42 CFR Part 457 Subpart E, which permits some cost sharing.

Pregnant women. Pregnant women are exempt from cost sharing for pregnancy-related services. Georgia's 12-month postpartum coverage expansion (effective 2022 through the Consolidated Appropriations Act of 2023 §5112) extends this through the year after delivery for the pregnant women's coverage category.

Terminally ill in hospice. Medicaid hospice enrollees are exempt for hospice-related services. Most Medicaid hospice enrollees are also long-term care residents, with their care funded through patient liability (not cost sharing).

Individuals receiving inpatient long-term care services. Nursing facility residents and ICF/IID residents are exempt because their care is funded through patient liability arrangements.

IHS-eligible individuals. People eligible to receive services from the Indian Health Service or a tribal health program are exempt. Georgia has no federally recognized tribes within its borders, but IHS-eligible individuals living in Georgia are protected.

Medicaid Buy-In for Working People with Disabilities. Enrollees in §1902(a)(10)(A)(ii)(XV) or §1902(a)(10)(A)(ii)(XVI) Buy-In categories are exempt (where Georgia operates such categories; Georgia has not operated a robust Buy-In to date).

Family planning recipients. Anyone receiving family planning services is exempt for those services, regardless of population.

Emergency services recipients. Anyone receiving emergency medical services is exempt for those services.

Exempt services for all enrollees

42 CFR 447.56(b) identifies services that cannot be subject to cost sharing for any enrollee:

Emergency services. Section 1916(f) and 42 CFR 447.56(b)(1). No copay for an actual emergency medical condition. Hospital must screen under EMTALA; if the condition is an emergency, no copay regardless of provider.

Family planning services and supplies. Section 1916 and 42 CFR 447.56(b)(2). Contraception, sterilization, related counseling, and family planning preventive care are all exempt.

Pregnancy-related services. 42 CFR 447.56(b)(3). Prenatal care, labor and delivery, postpartum visits, breastfeeding support, and pregnancy-related conditions are exempt for pregnant women and during the postpartum coverage period.

Preventive services for children. Children under 21 are exempt for all services, but the Affordable Care Act and Medicaid policy specifically reaffirm preventive services as a priority.

Preventive services (USPSTF A and B) under ACA expansion. For Medicaid expansion adults (those eligible under the ACA expansion category), preventive services that the U.S. Preventive Services Task Force has graded A or B are exempt. Georgia has not adopted Medicaid expansion through §1902(a)(10)(A)(i)(VIII), but Pathways enrollees may benefit from similar exemptions.

Hospice services. 42 CFR 447.56(b)(4). All hospice services are exempt.

Refugee services in specified circumstances. Per 42 CFR 447.56(b).

Tobacco cessation for pregnant women. Specifically required by ACA §4107 and implementing rules.

The non-emergency emergency room rule

One of the most-discussed federal rules is 42 CFR 447.56(c), which governs cost sharing for non-emergency use of the ED. The rule reflects a policy tension: states want to discourage Medicaid enrollees from using the ED for non-emergencies (which is expensive and inefficient), but federal law strictly prohibits cost sharing for actual emergencies and limits cost sharing for non-emergencies.

Under 42 CFR 447.56(c), a hospital may impose a non-emergency ED copay only when ALL of the following conditions are met:

1. The hospital provides the initial EMTALA-mandated medical screening examination
2. The screening determines that the patient does NOT have an emergency medical condition
3. The hospital informs the patient that the condition is not an emergency
4. The hospital identifies an alternative non-emergency provider (FQHC, urgent care, primary care clinic) reasonably available
5. The hospital informs the patient that the alternative provider will not charge the copay or will charge a lower copay
6. The patient is given a clear choice to seek care at the alternative provider or to proceed in the ED with the copay

If ANY of these steps is missed, the copay is invalid. If the EMTALA screening reveals an emergency medical condition, no copay can be charged regardless of the underlying condition.

In Georgia, the non-emergency ED copay under the current state schedule is a small dollar amount, well below the federal maximum for the at-or-below 100 percent FPL tier.

Common violations include:

• Imposing a copay without performing the EMTALA screening
• Imposing a copay without identifying or offering an alternative
• Imposing a copay for an actual emergency (chest pain that turns out to be MI is still emergent)
• Charging more than the state schedule

Enrollees who receive such bills should refuse, cite 42 CFR 447.56(c), and report to DCH Member Services at 1-866-211-0950.

The 5 percent aggregate household income cap

The 5 percent cap at 42 CFR 447.56(f) is a structural backstop against the cumulative burden of Medicaid cost sharing. Specifically:

Mechanics. Total Medicaid cost sharing PLUS premiums for ALL members of a household, cumulative within a calendar quarter, cannot exceed 5 percent of family income. The state must track this and waive further cost sharing once the cap is reached for the remainder of the quarter.

Who's covered. All members of the household enrolled in Medicaid. If only some are enrolled, the cap applies based on the enrolled members' utilization but as a share of the FAMILY's income (not just the enrollees').

What counts. Cost sharing for non-exempt services and premiums (where charged). Cost sharing for exempt services or to exempt populations doesn't count, because none should be charged.

Tracking in Georgia. DCH tracks cost sharing through provider claims data and member self-report. Members can request a 5 percent cap review by calling Member Services at 1-866-211-0950 or contacting their CMO. If the member has paid cost sharing above the 5 percent cap, the state must refund the excess.

Practical impact. Most Georgia Medicaid households never reach the cap because Georgia's copay schedule is so low. The cap is most likely to bind for ABD households with high prescription utilization or for pregnant women's households with significant non-pregnancy utilization. The cap also binds more quickly for Pathways to Coverage enrollees who pay a percentage-of-income premium plus cost sharing. To estimate a household's quarterly cap, multiply annual family income by 5 percent and divide by four; check the current HHS Federal Poverty Level guidelines for the dollar value of 100 percent FPL at the relevant household size.

QMB lesser-of and the billing prohibition

For Qualified Medicare Beneficiaries (QMB), the cost-sharing rules work differently because the focus shifts to Medicare cost sharing rather than Medicaid cost sharing.

Lesser-of rule (Section 1905(p)). When a QMB receives a Medicare-covered service, the provider bills Medicare first. Medicare pays 80 percent of the approved amount (for most Part B services) or the full Part A rate after deductibles. The remaining patient responsibility (the 20 percent coinsurance, the Part A deductible, etc.) would normally fall to the QMB. But under §1905(p), the state pays the LESSER of:

• The actual Medicare cost-sharing amount, OR
• The Medicaid rate for the service minus what Medicare paid

In practice, the Medicaid rate is usually less than the Medicare payment, so the state pays $0 in lesser-of mode. This generates significant savings for state Medicaid programs but creates a billing tension: providers receive less from the combined Medicare + Medicaid payment than they would have under Medicare + private secondary insurance.

Balance billing prohibition (Sections 1902(n)(3)(B), 1905(p), 1866(a)(1)(A)). Even though the provider may receive less, the provider is federally prohibited from billing the QMB for the difference. Section 1866(a)(1)(A) requires every Medicare-participating provider to accept Medicare payment plus any state Medicaid payment (or denial) as payment in full for a QMB. Section 1902(n)(3)(B) explicitly prohibits states from reducing Medicaid payments to providers based on the QMB billing prohibition (preventing states from using §1905(p) to shift costs to providers). The combined effect: providers cannot recoup the lesser-of-rule shortfall from QMB patients.

In practice, this means many QMB enrollees pay $0 for Medicare services even though, on paper, they "owed" the 20 percent coinsurance. Common violations include:

• ED bills sent to QMBs for the Part A deductible
• Ambulance services billing for the 20 percent coinsurance
• Specialty office bills for the 20 percent Part B coinsurance
• Collection agencies pursuing former QMB patients for old Medicare cost-sharing balances

QMB enrollees should cite §1902(n)(3)(B) in writing, identify themselves as QMB, and request rescission. Unresolved violations should be reported to CMS Region IV in Atlanta at 404-562-7500. GeorgiaCares SHIP at 1-866-552-4464 can help.

Part D Low-Income Subsidy and Inflation Reduction Act

For dual eligibles, prescription drug cost sharing comes through Medicare Part D, with the Low-Income Subsidy (Extra Help) covering most of the patient cost.

Section 1860D-14. The Part D Low-Income Subsidy, also called Extra Help, pays for premiums, deductibles, and cost sharing for low-income Medicare beneficiaries. Until January 2024, Extra Help had two tiers: full Extra Help (≤135 percent FPL) and partial Extra Help (135 to 150 percent FPL).

Inflation Reduction Act 2022 §11404. Effective January 1, 2024, full Extra Help is available to all eligible Medicare beneficiaries at or below 150 percent FPL. Resource limits are updated annually; check the current CMS LIS Resource Limit memo for the current year's individual and couple thresholds.

Full Extra Help benefits.

• $0 Part D premium in benchmark plans
• $0 Part D deductible
• Nominal generic and brand copays capped at the levels published in the current-year CMS LIS copay memo
• $0 for institutionalized or HCBS waiver enrollees
• No coverage gap (donut hole) cost sharing
• IRA 2022 also introduced an annual out-of-pocket cap for all Part D enrollees; refer to medicare.gov for the current-year cap dollar amount

Auto-deemed for duals. Full-benefit duals, QMB, SLMB, and QI enrollees are automatically "deemed" eligible for full Extra Help without a separate application. CMS confirms in writing and assigns a benchmark plan if needed.

Application for others. Non-deemed individuals at or below 150 percent FPL can apply through SSA (Form SSA-1020) or through DCH.

CHIP cost sharing for PeachCare for Kids

The Children's Health Insurance Program operates under its own cost-sharing framework, separate from regular Medicaid, codified at 42 CFR Part 457 Subpart E (§§457.500 through 457.560).

Premium and cost sharing limits. Total CHIP premiums plus cost sharing cannot exceed 5 percent of family income per year. This is an annual cap, in contrast to the Medicaid quarterly 5 percent cap.

Exempt services. Preventive services, immunizations, well-baby visits, well-child visits, and tobacco cessation are exempt from any cost sharing.

Income tiering. States may impose premiums and cost sharing scaled to family income.

PeachCare for Kids (Georgia CHIP) structure (verify exact thresholds and premium amounts in the current PeachCare for Kids handbook at dch.georgia.gov):

• Lowest income tier (up to 100 percent FPL): no premium
• Middle income tier: small monthly family premium
• Top income tier (up to PeachCare's income ceiling): tiered family premium
• Copays for non-preventive services: nominal amounts that vary by tier
• All preventive services free at any income tier

Managed care compliance

Georgia operates most non-ABD Medicaid through three Care Management Organizations: Amerigroup Community Care, CareSource Georgia, and Peach State Health Plan. CMO cost-sharing compliance is governed by 42 CFR 438.108 and the DCH CMO contracts.

Pass-through requirement. Each CMO must apply the same cost-sharing schedule as Georgia's fee-for-service Medicaid. The CMO cannot impose its own different copays.

Track to 5 percent cap. Each CMO must track cumulative member cost sharing toward the 5 percent cap and waive cost sharing once the cap is reached. Members enrolled in multiple plans (e.g., a child in PeachCare and a parent in Pathways) may need to consolidate tracking with DCH.

Exempt populations and services. Each CMO must waive cost sharing for exempt populations and services. CMO member materials must clearly explain the exemptions.

Member services number. Each CMO has a Member Services line for cost-sharing disputes:

• Amerigroup: 1-800-454-3730
• CareSource: 1-855-202-1058
• Peach State: 1-800-704-1484

The Georgia copay schedule

Georgia's actual copay schedule is published in the DCH Member Handbook and the DCH Provider Manual, with the same schedule applied by both fee-for-service Medicaid and the three CMOs. The structure below summarizes the categories of services with copays; pull the current DCH Member Handbook (dch.georgia.gov) for the specific dollar amount tied to each line, as nominal amounts can be updated.

Pharmacy:

• Preferred generic drug: nominal copay
• Preferred brand drug: nominal copay (higher than generic)
• Non-preferred drug: nominal copay
• Some categories (specialty): may vary
• Children under 21: $0
• Pregnancy-related drugs: $0
• Family planning drugs: $0
• Hospice enrollees: $0

Outpatient services:

• Physician office visit: nominal copay
• Outpatient hospital visit: nominal copay
• FQHC or RHC visit: $0 (PPS encounter rate exempt)
• Behavioral health visit: $0
• Dental visit (limited adult): nominal copay
• Vision visit (limited adult): nominal copay
• Preventive service: $0
• Children under 21: $0
• Pregnancy-related: $0

Inpatient services:

• Inpatient hospital admission: nominal copay per admission
• Inpatient psychiatric (under IMD exclusion limits): nominal copay
• Nursing facility: $0 (patient liability applies separately)
• Hospice: $0
• Children under 21: $0

Emergency services:

• Emergency department for emergency medical condition: $0
• Non-emergency ED (after EMTALA screening + alternative provider notice + member choice): nominal copay
• Emergency ambulance: $0

Transportation:

• NEMT (non-emergency medical transport via MTM/Modivcare): $0

Long-term care residents:

• Patient liability applies (income above the Personal Needs Allowance, after deductions; verify the current PNA dollar amount in the current DCH Member Handbook)
• Not technically cost sharing under §1916

Most Georgia Medicaid enrollees pay very little in cumulative cost sharing each year. A child pays $0. A pregnant woman pays $0 for pregnancy-related care. A QMB+ full Medicaid dual pays $0 for nearly everything (Medicare cost sharing protected by lesser-of, Medicaid cost sharing exempt for many services).

Pathways to Coverage premium framework

Georgia Pathways to Coverage, launched in 2023 under a Section 1115 demonstration, covers adults 19 to 64 up to 100 percent FPL with a work or community engagement requirement. Pathways introduces a premium structure that does not apply to other Georgia Medicaid categories. Verify the specific demonstration number, launch date, and current Special Terms and Conditions at dch.georgia.gov or on CMS's §1115 demonstration page.

Premium amounts.

• Adults between 50 percent and 100 percent FPL: a small premium calculated as a percentage of family income under the demonstration's Special Terms and Conditions
• Below 50 percent FPL: $0 (CMS regulatory limit)
• Premium must be paid monthly to maintain eligibility

Grace period and termination.

• 42 CFR 447.82 governs termination for premium nonpayment
• The Pathways §1115 demonstration sets a grace period from the missed payment (verify the current duration in the current STCs)
• Failure to pay within grace period: termination
• A reconsideration window applies after termination; verify the current duration in the Pathways STCs

Lockout history. Georgia's original Pathways implementation included a 6-month lockout period after termination for non-payment, during which the individual could not re-enroll. CMS has scrutinized lockout provisions; the current status of the Georgia lockout may vary based on ongoing CMS dialogue.

Cost sharing. Pathways enrollees follow the standard ABD-equivalent copay schedule.

Provider obligations and limits

Cannot deny service for inability to pay (42 CFR 447.15). With narrow exceptions, a provider must serve a Medicaid enrollee even if the enrollee cannot pay the copay at the point of service. The provider can attempt to collect later. This is critical: a Medicaid enrollee who shows up without the copay cash is still entitled to treatment. The exceptions under §1916A are for non-preferred drugs (some states only) and non-emergency ED (where the alternative-provider procedure has been followed).

Cannot charge more than the state schedule. A provider who charges more than the state-specified copay is committing Medicaid fraud and can be terminated from Medicaid enrollment, prosecuted criminally, and pursued civilly under federal and state false claims acts.

Must accept Medicaid as payment in full. Combined with the state-specified copay, Medicaid payment is payment in full. The provider cannot bill the enrollee for the difference between the Medicaid rate and the provider's usual charge.

QMB balance billing prohibition. For QMB enrollees specifically, no Medicare cost sharing can ever be billed, regardless of what Medicaid pays under the lesser-of rule.

Provider remedies for member. If a provider overcharges or demands payment for an exempt service, the member should:

• Decline to pay
• Cite the federal regulation (e.g., 42 CFR 447.56)
• Report to DCH Member Services at 1-866-211-0950
• Report to the CMO if applicable
• Escalate to the state AG Medicaid Fraud Control Unit
• File a complaint with CMS Region IV at 404-562-7500
• File a complaint with HHS OCR at 1-800-368-1019 for civil rights/disability discrimination

Worked example: Tasha, age 26, Atlanta, pregnant, no copays for pregnancy-related services

Tasha is 26, pregnant (24 weeks), and enrolled in Georgia Medicaid under the pregnant women's category (income up to 220 percent FPL). Her household income is $24,000 per year (about 156 percent FPL), well within the pregnant women's eligibility threshold.

Her cost-sharing experience over a month:

• Prenatal OB visit: $0 copay. Pregnancy-related service exempt under 42 CFR 447.56(b)(3).
• Prenatal blood work at outpatient hospital lab: $0. Part of pregnancy-related services.
• Pharmacy fill for prenatal vitamins: $0. Pregnancy-related drug.
• ED visit for ankle sprain (not pregnancy-related): EMTALA screening identifies non-emergency (no break, no neurovascular compromise). Hospital offers alternative provider (urgent care across the street). Tasha chooses to remain in ED. Standard non-emergency ED copay would apply. But Tasha is pregnant, and the federal regulation exempts pregnant women from cost sharing for services in the pregnancy coverage category in Georgia. So copay should be $0.
• Dental cleaning (not pregnancy-related): Adult dental is limited in Georgia. Under the pregnancy exemption, $0. Standard adult dental copay would otherwise apply.
• Postpartum visit 6 weeks after delivery: $0. Pregnancy-related and within 12-month postpartum coverage.
• Routine well-woman exam 10 months after delivery (still in 12-month postpartum): $0. Within postpartum coverage period.

Net cost sharing for the month and the postpartum year: $0.

Tasha's experience reflects the comprehensive protection pregnant women receive under federal and Georgia Medicaid law. The 12-month postpartum coverage expansion (CAA 2023 §5112) extends this through her first year after delivery.

Worked example: Eleanor, age 78, Macon, QMB plus full Medicaid, lesser-of rule

Eleanor is 78, full-benefit dual eligible (QMB plus full Medicaid), and lives in Macon. Her income is $1,100 per month Social Security ($13,200 annual, about 88 percent FPL).

Her cost-sharing experience over a month:

• Medicare-covered cardiology visit (illustrative numbers: Medicare approves an amount, pays 80 percent, leaves 20 percent coinsurance as patient responsibility under traditional Medicare):

  • Under lesser-of rule (Section 1905(p)): Georgia Medicaid pays the lesser of (a) the actual Medicare cost-sharing amount or (b) the Medicaid rate for the service minus Medicare payment. Because the Medicaid rate is typically below the Medicare payment, the calculation usually yields $0 Medicaid payment.
  • Result: Medicaid pays $0 to cardiologist
  • QMB balance billing prohibition (Section 1902(n)(3)(B)): cardiologist CANNOT bill Eleanor for the coinsurance
  • Eleanor pays: $0

• Medicare inpatient hospital stay (Part A deductible would normally apply):

  • Under lesser-of: Medicaid pays $0 (Medicaid rate for hospital stay ≤ Medicare payment)
  • QMB prohibition: hospital cannot bill Eleanor
  • Eleanor pays: $0

• Medicaid-only NEMT to specialist: $0 (federally exempt)

• Medicaid-only adult dental cleaning: Standard adult dental copay applies (Eleanor is not in long-term care; she lives independently). She may also be exempt if she's enrolled in CCSP or a similar HCBS waiver and considered functionally equivalent.

• Medicaid pharmacy fill (Part D Excluded drug for which Medicaid covers): Standard Georgia Medicaid pharmacy nominal copay, OR $0 if covered through Extra Help via Part D for a Part D-included drug. Mostly $0 in practice.

• Part D drug fill (most prescriptions): Through full Extra Help (Eleanor is deemed via QMB+ status). She pays the nominal generic and brand copays published in the current-year CMS LIS copay memo, or $0 if institutionalized/HCBS.

Net month: Eleanor pays essentially $0 for all Medicare cost sharing and most Medicaid services. Total monthly out-of-pocket is minimal even with multiple drug fills, capped by Extra Help and Georgia's nominal copay schedule.

Worked example: Marcus, age 45, Albany, ABD Medicaid, standard adult copay schedule

Marcus is 45 and on ABD Medicaid for multiple sclerosis. His income is a modest monthly SSDI benefit (roughly above 100 percent FPL); he's actually enrolled through the institutional eligibility pathway because of his planned ICWP application, which uses the 300 percent SSI standard. He has standard adult copay exposure.

His cost-sharing experience over a year, using Georgia's nominal copay structure (verify exact amounts in the current DCH Member Handbook):

• Pharmacy (5 medications, monthly fills): Nominal generic and brand copays per fill; modest monthly subtotal.
• Physician visits (8 per year): Nominal copay per visit.
• Neurologist visits (6 per year): Nominal copay per visit.
• Outpatient hospital MRI (4 per year): Nominal copay per visit.
• Annual labs and tests: $0 (often bundled with office visits; sometimes $0 for labs).
• One ED visit for emergency (suspected stroke that resolved): $0 (emergency exempt).
• One ED visit for non-emergency (urinary tract infection): EMTALA screening, alternative provider offered, Marcus chose to remain in ED: nominal non-emergency ED copay.

Annual total: a low-three-figure dollar amount, well under any 5 percent cap.

5 percent cap check: Marcus's total annual copay exposure is well under 5 percent of his family income. No waiver triggered.

If Marcus had a significantly more expensive year (e.g., 20 medications, 30 visits), he might approach but rarely exceed the 5 percent cap given Georgia's nominal copay structure.

Worked example: Aisha, age 32, Savannah, PeachCare for Kids for her son

Aisha is 32, lives in Savannah with her partner and two children (ages 9 and 4). Family income is $32,000 per year (about 130 percent FPL). The 9-year-old has asthma; the 4-year-old is healthy.

Both children are enrolled in PeachCare for Kids. Aisha's family is in the middle income tier where PeachCare charges a small monthly family premium plus nominal copays for some non-preventive services; pull the current PeachCare for Kids premium schedule from dch.georgia.gov for the dollar amounts at each tier.

Her cost-sharing experience over a year:

• PeachCare premium: Small monthly family premium tied to the 101-150 percent FPL tier.
• Pediatrician visits (well-child for both kids): $0 (preventive)
• Immunizations: $0 (preventive)
• 9-year-old asthma specialist visits (4 per year): Nominal copay per visit at this tier
• Asthma pharmacy (inhaler refills, monthly): Nominal generic copay per fill
• ED visit for asthma exacerbation (emergency): $0
• Vision screening at school for 9-year-old: $0
• Dental cleanings for both kids (2 per year each): $0 (preventive)
• One ED visit for ear infection (non-emergency, but kids exempt anyway): $0

Annual total: a low-three-figure dollar amount.

5 percent annual cap check: PeachCare premium + cost sharing cannot exceed 5 percent of annual family income. Aisha's total stays well under that cap.

Note: CHIP cost sharing follows 42 CFR Part 457 Subpart E, which applies annual 5 percent (not quarterly as in Medicaid). Same arithmetic outcome here.

Worked example: Jamil, age 8, Columbus, child fully exempt from all copays

Jamil is 8 years old, enrolled in regular Medicaid through Family Medicaid (his mother is a low-income working parent). Federal exemption under 42 CFR 447.56(a)(1) applies: children under 21 are exempt from all Medicaid cost sharing.

His cost-sharing experience over a year:

• Annual well-child visit (EPSDT comprehensive): $0
• Immunizations: $0
• Pediatrician sick visits (6 per year for various): $0
• Pharmacy (asthma inhaler refills, antibiotic courses, vitamins): $0
• Dental cleanings and fillings (EPSDT-covered for children): $0
• Vision screening and glasses (EPSDT): $0
• Speech therapy (EPSDT-covered for developmental delay): $0
• ED visits (2, both for ear infections and one wrist injury): $0
• Lab work and X-rays: $0
• Specialist consultation (pediatric pulmonologist): $0

Annual total: $0.

Note: Jamil's family's $0 cost sharing for him does not count toward any 5 percent cap because there's nothing to count.

Worked example: Diana, age 60, rural Georgia, Pathways to Coverage premium and cost sharing

Diana is 60, single, lives in rural Georgia, and is enrolled in Georgia Pathways to Coverage. Her income is $11,500 per year (95 percent FPL), and she works 80 hours per month at a gas station, meeting Pathways' work/community engagement requirement.

Premium: A small percentage of annual family income, billed monthly under the Pathways §1115 demonstration. Pull the current Pathways Special Terms and Conditions for the premium formula tied to her income tier.

Cost sharing schedule: Standard ABD-equivalent.

Her year:

• Pathways premium: Small monthly amount tied to her income
• Pharmacy (3 medications per month, all generic preferred): Nominal generic copay per fill
• Physician visits (6/year): Nominal copay per visit
• Outpatient hospital (1 MRI): Nominal copay
• ED visit (chest pain, EMTALA emergency determined): $0
• Annual labs: $0 (often bundled)

Annual total: premium plus a low-three-figure amount in copays, well under the 5 percent cap.

5 percent annual cap check: Diana's premium + copay total stays under 5 percent of her annual family income.

Premium nonpayment scenario: If Diana misses a monthly premium:

• Month 1: missed payment
• Grace period: Diana can pay back-premium during a grace period (verify the current Pathways grace-period duration in the §1115 STCs) to avoid termination
• After grace period ends: termination notice issued
• After termination: reconsideration window per the demonstration's terms
• Historically: a lockout period was applied after termination; the current status of the Georgia lockout may vary based on ongoing CMS dialogue

To avoid termination, Diana sets up automatic monthly payment from her bank account or uses the Gateway portal for online payment.

Practical guidance for Georgia families

Know what you owe. Most Georgia Medicaid cost sharing is $0 for exempt services and a nominal copay (small dollar amount) for non-exempt services. If a provider quotes you a higher amount, ask why. The DCH Provider Manual or Member Handbook contains the schedule.

Refuse to pay for exempt services. If you're pregnant and asked for a pregnancy-related copay, refuse. If you're under 21 and asked for a copay, refuse. If the service is emergency, refuse the copay. Cite 42 CFR 447.56 or §1916.

Refuse to be denied for inability to pay. Under 42 CFR 447.15, a provider must serve you even if you can't pay the copay at the point of service. The provider can bill you later, but cannot turn you away.

Track your cost sharing if you have high utilization. If your household is paying significant cost sharing across multiple enrollees, track receipts. If you approach 5 percent of family income, contact DCH Member Services at 1-866-211-0950 to request the 5 percent cap waiver.

If you're a QMB, never accept a Medicare cost-sharing bill. Section 1902(n)(3)(B) prohibits balance billing. Identify yourself as QMB in writing, cite the federal prohibition, request rescission. Escalate to CMS Region IV at 404-562-7500 if unresolved.

If you're a dual, get Extra Help. Full-benefit duals, QMB, SLMB, and QI enrollees are automatically deemed eligible. The Inflation Reduction Act 2022 expanded full Extra Help to 150 percent FPL effective January 2024, so more people qualify than before.

If you're in Pathways, never miss a premium payment. Set up auto-pay. 60-day grace period seems generous but disappears quickly. Termination triggers a complicated reinstatement process and (historically) a lockout.

Appeal denials or improper cost sharing. You have the right to a fair hearing under 42 CFR 431.220 if Medicaid denies a service, terminates your coverage, or improperly charges cost sharing. File within 90 days; aid pending available if you file within 10 days of the notice.

Get free help. DCH Member Services 1-866-211-0950; CMO Member Services lines; GeorgiaCares SHIP 1-866-552-4464 for Medicare-Medicaid issues; Georgia Legal Services 1-833-457-7529; Atlanta Legal Aid 404-377-0701; Disability Rights Georgia 404-885-1234.

Ask Polaris if you have questions about Medicaid cost sharing, dual coverage, or how to navigate billing disputes.

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