Georgia Medicaid Copays & Cost Sharing 2026

In 2026, Georgia Medicaid copays are small: $0.50 for a preferred prescription, $3 for a non-emergency ER visit, and $12.50 for a hospital stay, and many members pay nothing at all. 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. This guide gives the actual Georgia copay amounts, who owes nothing, and how to dispute a charge that breaks the rules.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 portion of a medical bill a patient pays out of pocket, through a copay, deductible, or coinsurance. In Georgia Medicaid it is deliberately small, and for most people most of the time it is zero. The same schedule applies whether a member is in fee-for-service Medicaid or in one of the three Georgia Families Care Management Organizations (CMOs), Amerigroup Community Care, CareSource, and Peach State Health Plan, because federal rule requires each CMO to apply the state's cost-sharing schedule.5

For a Georgia Medicaid member, only a few services carry a copay at all. There is no copay for preventive care, family planning, emergencies, or dialysis. The figures below are the current Georgia Medicaid member copays.1

There is no copay for an inpatient stay 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," meaning the amount depends on what the care costs. The cost-based scale tops out at $3.1

Adult dental is a covered Georgia Medicaid benefit since the state expanded it on July 1, 2024, and a non-preventive adult dental visit carries the cost-based copay.6,1

Who pays no Georgia Medicaid copays

Federal and Georgia rules exempt whole groups of members from any cost sharing. These Georgia Medicaid and PeachCare for Kids members have no copays for covered care: members under age 21 (Medicaid) or under age six (PeachCare for Kids), pregnant women, nursing facility residents, children in foster care, members in hospice care, members in the Breast and Cervical Cancer program, and American Indians or Alaska Natives.1

Two of those exemptions sit directly in federal law. Pregnancy-related Medicaid services are exempt from cost sharing under Social Security Act Section 1916 and 42 CFR 447.56; in Georgia, the pregnant women's Medicaid pathway covers income up to 220 percent of the Federal Poverty Level (FPL) and runs through 12 months after the end of pregnancy, so that protection holds through the full postpartum year.7,8

American Indians and Alaska Natives are exempt from Medicaid premiums and all cost sharing if they are eligible to receive, or have ever received, an item or service from an Indian health care provider, under 42 CFR 447.56(a)(1)(x).2

Nursing facility residents do not pay copays either, but their income is applied to the cost of care a different way, through "patient liability." A Georgia nursing-home resident keeps a Personal Needs Allowance of $70 per month, and the rest of their income, after allowed deductions, goes toward the facility bill. That is not cost sharing under the copay rules.9

The federal limits behind Georgia Medicaid copays

Georgia sets its copays far below the ceiling federal law allows. Under 42 CFR 447.52, 447.53, and 447.54, a state may charge no more than the maximum allowable cost sharing in the table below, and those nominal dollar maximums rise each October by the medical-care component of the Consumer Price Index. For members above 100 percent FPL, some caps switch from a flat dollar amount to a percentage of what the agency pays.3

The point of the table is the gap: Georgia's $0.50 preferred-drug copay sits well under the $4 federal maximum, and its $12.50 inpatient copay is a fraction of the $75 ceiling. The federal rule is a cap, not a target.3,1

The 5 percent household income cap

Federal rule sets a hard backstop on the cumulative burden of cost sharing. Under 42 CFR 447.56(f), total Medicaid premiums and cost sharing for all members of a household may not exceed an aggregate limit of 5 percent of the family's income, measured on a quarterly or monthly basis. Once the household reaches that cap, the state must waive further cost sharing for the rest of the period.3

Most Georgia households never approach the cap, because Georgia's copays are so low. The cap is most likely to matter for a household with very heavy prescription or hospital use. To estimate a quarterly cap, multiply annual family income by 5 percent and divide by four. If you think you have paid more than the cap, call Georgia Medicaid Member Services at 1-866-211-0950 or your CMO and ask for a 5 percent cap review; the state must refund cost sharing collected above the limit.3

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 a specific federal procedure under 42 CFR 447.54. Before billing the copay, the hospital must conduct an appropriate medical screening that determines the patient does not need emergency services, tell the patient the copay amount, give the name and location of an available alternative non-emergency provider (such as a Federally Qualified Health Center (FQHC) or urgent care), and offer a referral.1,3

If any of those steps is skipped, the copay is invalid. And if the screening shows an actual emergency, no copay can be charged regardless of the final diagnosis. A bill that ignores this process should be refused; cite 42 CFR 447.54 and report it to DCH Member Services at 1-866-211-0950.3

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, including deductibles, coinsurance, and copayments, even when Medicaid pays nothing toward that bill. The provider must accept Medicare's payment (and any Medicaid payment) as payment in full and may instead bill the state. The authority is Social Security Act Sections 1902(n)(3)(B), 1905(p)(3), and 1866(a)(1)(A). QMB is one of the Medicare Savings Programs.4

If you are billed anyway, tell the provider in writing that you are in the QMB program, cite the prohibition, and ask for the charge to be rescinded. If it is not resolved, report it to CMS Region IV in Atlanta at 404-562-7500, and GeorgiaCares SHIP at 1-866-552-4464 can help. Our improper QMB billing guide walks through the full dispute process step by step.4

For prescription drugs, dual eligibles get help through Medicare Part D and the Low-Income Subsidy (Extra Help). In 2026, full Extra Help enrollees pay no more than $5.10 for a generic and $12.65 for a brand-name covered drug, and $0 once their out-of-pocket drug costs reach the $2,100 catastrophic threshold. Full-benefit duals, including QMBs, are automatically deemed eligible for full Extra Help, which now reaches everyone at or below 150 percent FPL.10

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. PeachCare members age six and over pay per-service copays that, combined with premiums, total no more than 5 percent of family income per year.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. No premium or copay is charged for children under age six, children in foster care, or American Indian and Alaska Native children.11

Georgia Pathways to Coverage copays

Georgia Pathways to Coverage is the state's Section 1115 demonstration covering adults ages 19 to 64 with income up to 100 percent FPL who complete at least 80 hours per month of qualifying activities. Pathways members are required to pay a copayment for certain services under the standard Medicaid schedule, except that copayments are not required for members under age 21.12

So a Pathways enrollee pays the same nominal copays as other adult Georgia Medicaid members, $0.50 for a preferred drug, $3 for a non-emergency ER visit, and $12.50 for an inpatient stay, with the same exemptions and the same 5 percent cap.1

What providers can and cannot do

A few provider rules protect Georgia Medicaid members at the point of care. A provider may not deny a service because the member cannot pay the cost sharing at the visit; the state plan must specify that no provider may deny services to an eligible individual on account of inability to pay, though the provider may bill the copay later. A provider may never charge more than the state-specified copay, and must accept Medicaid's payment plus the copay as payment in full.3

If a provider overcharges, bills for an exempt service, or refuses care over an unpaid copay, decline to pay, get the bill in writing, cite the federal rule (42 CFR 447.52 or 447.56), and report it to DCH Member Services at 1-866-211-0950 and to your CMO. Unresolved Medicaid-fraud concerns go to the Georgia Attorney General's Medicaid Fraud Control Unit.3

Real situations: what families actually pay

The scenarios below are hypothetical illustrations of how the Georgia rules apply. Your own costs depend on your eligibility category, income, and services.

A pregnant woman in her postpartum year pays nothing

Tasha is 26, enrolled in Georgia's pregnant women's Medicaid, and her household income is about 156 percent FPL. Prenatal visits, labor and delivery, prenatal vitamins, and postpartum visits are all pregnancy-related and exempt. Because the pregnancy exemption runs through 12 months after delivery, even a routine visit 10 months postpartum is $0. Her total cost sharing for the year is zero.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 generic drugs a month. Each fill is the $0.50 preferred-drug copay, so his pharmacy cost is about $2.50 a month, or roughly $30 a year. A non-emergency ER visit would add $3; an inpatient stay would add $12.50. His annual cost sharing stays well under 5 percent of his income, so the cap never triggers.1,3

A dual eligible billed for Medicare coinsurance

Eleanor, 78, is a full-benefit dual and a QMB. After a Medicare cardiology visit, the office sends her a bill for the 20 percent Part B coinsurance. That bill is unlawful: as a QMB, she cannot be billed for Medicare cost sharing. She writes the office citing her QMB status and the federal prohibition, and the charge is rescinded. Her Part D drugs run through full Extra Help, capped at $5.10 generic and $12.65 brand.4,10

A Pathways to Coverage enrollee

Diana, 60, is enrolled in Georgia Pathways to Coverage at 95 percent FPL and meets the 80-hour monthly work requirement. She pays the standard adult Medicaid copays, $0.50 per preferred drug and $3 for a non-emergency ER visit, but her emergency ER visit for chest pain is $0 because true emergencies are never charged. Like every member, she is protected by the 5 percent cap.12,1

Who to Call

Learn More

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.