Georgia Medicaid Covered Services 2026: Benefits Overview

Georgia Medicaid covers the medical care most families need, from hospital stays and doctor visits to prescriptions, behavioral health, dental, maternity care, and long-term care. What any one member actually receives turns on three things: the benefits federal law requires every state to cover, the optional benefits Georgia has chosen to add, and whether the member is a child or an adult.

Children under 21 get the broadest coverage. Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, a child is entitled to any medically necessary service, even services Georgia does not cover for adults. Most acute care for both adults and children runs through the Georgia Families managed care plans, but several benefits, including the fee-for-service pharmacy program, non-emergency transportation, nursing facility care, and most waivers, are carved out and delivered separately. This guide explains which services Georgia Medicaid covers in 2026 across all of those layers, run by the Georgia Department of Community Health (DCH).

What decides whether Georgia Medicaid covers a service

Title XIX of the Social Security Act, codified at 42 USC 1396 et seq., runs Medicaid as a federal-state partnership: the federal government sets minimum standards, and states administer the program within them. Section 1905(a), at 42 USC 1396d(a), lists more than 30 categories of service. Some are mandatory for every state. The rest are optional, and each state decides which to add.

Mandatory categories define what Georgia must cover. Optional categories are a menu Georgia may choose from, and the state may set amount, duration, and scope limits that differ between adults and children, within federal anti-discrimination and EPSDT rules.

For anyone under 21, a third layer overrides the first two. EPSDT, at 42 USC 1396d(r), requires Georgia to provide any service in 1396d(a) that is medically necessary to correct or ameliorate a condition found through pediatric screening, even when that service is otherwise optional and not covered for adults.1

Mandatory services Georgia Medicaid covers

Inpatient hospital services. Acute admissions, surgical care, and rehabilitation hospital admissions. Authorization runs through the managed care plan for plan members or through DCH for fee-for-service members, with concurrent review during the stay. Inpatient psychiatric care is a separate, optional benefit category rather than part of this mandatory one.

Outpatient hospital services. Emergency department visits, outpatient surgery, observation stays, diagnostic and treatment services, and hospital-based clinic visits. Some elective procedures require prior authorization.

FQHC and RHC services. Comprehensive primary care at federally qualified health centers and rural health clinics, paid a prospective payment system rate. Georgia has a strong FQHC network, important in rural and underserved areas.

Laboratory and x-ray services. A wide range of diagnostic tests through Medicaid-enrolled, CLIA-certified labs and imaging providers.

Nursing facility services for individuals 21 and over. For people who meet nursing facility level of care and the long-term-care financial limits. For 2026, Georgia's institutional income limit (the Medicaid Cap) is $2,982 a month for an individual and $5,964 for a couple, up from $2,901 and $5,802 in 2025, with countable resources at or below $2,000; income at or above the cap can still qualify by routing through a Qualified Income Trust. The cap is set at 300% of the Supplemental Security Income (SSI) federal benefit rate, and Georgia's own ABD limits chart now carries the same $2,982 figure CMS publishes. See the Georgia long-term care Medicaid guide.2

EPSDT services for under 21. Comprehensive screening, diagnostic, and treatment services, detailed below.

Family planning services and supplies. Contraception (oral, injectable, IUD, implant), sterilization with federal consent forms for individuals 21 and over, STI screening and treatment, and pregnancy testing, with confidentiality protections.

Physician services. Office visits, hospital visits, surgery, anesthesia, and consultations.

Nurse midwife services. Pregnancy care, labor and delivery, and postpartum care from certified nurse midwives.

Certified pediatric and family nurse practitioner services. Independent practice with required collaboration agreements.

Home health services. Intermittent skilled nursing, home health aide visits, physical, occupational, and speech therapy at home, medical supplies, and durable medical equipment furnished at home, under 42 CFR 440.70.

Non-emergency medical transportation. Required of every state: 42 CFR 431.53 obliges the Medicaid agency to ensure necessary transportation to and from providers, and the Consolidated Appropriations Act, 2021 (Division CC, Title II, Section 209) wrote that assurance into Section 1902(a)(4) of the Social Security Act. Georgia delivers it through a statewide broker. See the Georgia NEMT guide.3

Tobacco cessation services for pregnant women. Counseling and pharmacotherapy.

Freestanding birth center services. Available where birth centers are licensed.

Optional services Georgia Medicaid has elected

Prescription drugs and pharmacy

Every state covers drugs, and Georgia is no exception. For fee-for-service members, the outpatient pharmacy benefit is administered by OptumRx, the pharmacy benefits manager for the Georgia Medicaid Fee-For-Service Outpatient Pharmacy Program, which processes claims at point of sale and pays enrolled pharmacies. Georgia Families plan members get their pharmacy benefit through their plan instead. Gainwell Technologies operates GAMMIS, the state's Medicaid Management Information System, as fiscal agent and member contact center. The state maintains a Preferred Drug List, prior authorization tiers, and drug utilization review for the fee-for-service program. There is no single statewide drug list: Georgia's Office of Health Strategy and Coordination has reported that the three plans plus fee-for-service produce four different drug lists, because plans and their subcontracted pharmacy benefit managers generally prefer to manage their own. Check the formulary of the plan you are actually in.4

Dental, vision, and hearing

Dental. Adult dental is now comprehensive. Effective July 1, 2024, Georgia removed the procedure limits that had restricted adult Medicaid dental to a narrow emergency/extraction-only scope. Adults 21 and over now have diagnostic, preventive, restorative, periodontal, prosthodontic, orthodontic, endodontic, and emergency dental services plus oral surgery, furnished when medically necessary and at intervals meeting reasonable standards of dental practice. Prior authorization is required for all adult dental services except emergency services.5

Vision. Adult vision benefits are limited; confirm current frequency limits on eye exams and eyeglasses with DCH or your plan, and note that replacement eyeglasses require medical necessity.

Hearing. Georgia has not elected the optional adult hearing-aid benefit. Its DFCS Medicaid manual provides hearing aids to those under age 18, and adults cannot obtain a hearing aid through Georgia Medicaid itself; the manual points hearing-impaired adults instead to the Georgia Hearing Aid Distribution Program, administered by the Georgia Lions Lighthouse Foundation for people 18 and over with income at or below 200% of the federal poverty guidelines, reachable at 404-325-3630 or 1-800-718-7483 outside metro Atlanta.6

Therapy and rehabilitation

Outpatient physical therapy, occupational therapy, and speech-language pathology are covered for medical necessity. Adult coverage is limited by visit numbers and requires prior authorization for ongoing therapy. Pediatric coverage under EPSDT is broader and is not subject to the same visit caps. Respiratory care services are covered for ventilator-dependent individuals.

Behavioral health and substance use treatment

Coverage includes outpatient mental health (individual, group, and family therapy), substance use disorder treatment (counseling and medication-assisted treatment with methadone and buprenorphine), intensive outpatient programs, partial hospitalization, case management, and inpatient psychiatric services. Certified Community Behavioral Health Clinics provide integrated behavioral health and primary care.

Equipment, supplies, and specialized care

Durable medical equipment and prosthetics. Wheelchairs (manual and power), walkers, canes, hospital beds, oxygen, CPAP and BiPAP, ostomy and diabetes supplies, prosthetics, orthotics, and a long list of other devices. Most items require prior authorization, and higher-cost items require added medical justification.

Hospice. Election of the Medicare or Medicaid hospice benefit for a terminal prognosis of six months or less; election typically waives curative treatment for the terminal condition.

Other covered services. Podiatry (medical foot care for diabetes and vascular or neuropathic conditions; routine foot care is limited), chiropractic (limited adult coverage for medical necessity; Medicare's chiropractic benefit is separate, with its own rules), private duty nursing (for medically complex members needing continuous skilled nursing, with prior authorization), ICF/IID care (limited statewide), inpatient psychiatric care for members under 21, primary care case management, personal care services, and TB-related services.

Home- and community-based services

Georgia operates four Section 1915(c) waivers: the Elderly and Disabled Waiver Program (EDWP) for elderly adults and adults with physical disabilities who need nursing facility level of care, which delivers its services through two models, the Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE); the Independent Care Waiver Program (ICWP) for adults who apply between the ages of 21 and 64 with severe physical disabilities; and the New Options Waiver (NOW) and Comprehensive Supports Waiver (COMP) for individuals with intellectual and developmental disabilities. Each is described in its own guide.7

EPSDT: full coverage for children under 21

The Early and Periodic Screening, Diagnostic, and Treatment benefit, at 42 USC 1396d(r), is the strongest federal protection for children in Medicaid. Every Medicaid-enrolled child under 21 is entitled to:

1. Screening services at periodic intervals on the Bright Futures schedule from the American Academy of Pediatrics, including health and developmental history, physical exam, immunizations on the ACIP schedule, lab tests (including lead screening at 12 and 24 months), blood pressure, hemoglobin and hematocrit testing, and health education.
2. Vision services, including a vision screening at every well-child visit and full eye exams as indicated.
3. Hearing services, including newborn hearing screening, audiometric testing, and treatment for identified hearing problems.
4. Dental services, including a first dental visit by age one or first-tooth eruption, periodic preventive visits, treatment of cavities, sealants, fluoride, medically necessary orthodontia, and oral surgery.
5. Any other necessary care, diagnostic services, treatment, and measures described in section 1905(a) to correct or ameliorate conditions found by screening, whether or not those services are covered under the state plan.1

Item 5 is the "EPSDT trump card." For example:

• A child with severe hearing loss is entitled to hearing aids and audiologic services, even though adult hearing aids are not covered.
• A child with autism spectrum disorder is entitled to applied behavior analysis (ABA) therapy and related services when medically necessary.
• A child with a chronic dental problem is entitled to comprehensive dental care, including medically necessary orthodontia.

EPSDT also carries outreach duties: Georgia must inform families about the benefit and help with appointment scheduling and transportation.

Inpatient psychiatric care for adults: the IMD limit

The federal IMD exclusion bars federal Medicaid payment for services to most individuals under age 65 who are patients in an Institution for Mental Diseases, defined at 42 CFR 435.1010 as a hospital, nursing facility, or other institution of more than 16 beds primarily engaged in the diagnosis, treatment, or care of persons with mental diseases. Its practical effect is to limit Medicaid coverage of long-term inpatient psychiatric care for working-age adults.8

Key exceptions:

• Members under 21 are not subject to the limit; inpatient psychiatric services are covered in psychiatric residential treatment facilities (PRTFs).
• Members 65 and over are not subject to the limit; IMD services may be covered.
• For members 21 to 64, the limit is the binding rule. One narrow pathway sits inside it: under 42 CFR 438.6(e), a state may make its monthly managed-care capitation payment for an enrollee aged 21 to 64 who is receiving inpatient psychiatric or substance use treatment in an IMD, for a short-term stay of no more than 15 days during the period that payment covers.8
• CMS has approved Section 1115 demonstrations that permit time-limited IMD coverage for substance use disorder residential treatment under specific conditions (length-of-stay limits, medication-assisted treatment availability, integrated care, and quality reporting). Georgia operates such a SUD 1115 demonstration. Serious mental illness IMD demonstrations have been approved in some states but not in Georgia.

Which benefits your CMO does not manage

Georgia Families is Georgia's mandatory Medicaid managed care program for most members. As of July 2026 it has three plans: Amerigroup Community Care, CareSource, and Peach State Health Plan. Georgia Families 360 serves foster children, adoption assistance recipients, and former foster youth.9

Plan capitation covers most acute services: primary care, specialty care, hospital inpatient and outpatient, emergency care, lab and x-ray, the member's pharmacy benefit, and EPSDT for children. Several benefits are carved out of that capitation and delivered separately:

Pharmacy (fee-for-service population). Administered by OptumRx; plan members use their plan's pharmacy network instead.4

Non-emergency medical transportation. Verida (formerly Southeastrans) is DCH's statewide Medicaid Transportation Broker, and effective April 1, 2026 it provides NEMT in all five Georgia regions (North, Atlanta, Central, East, and Southwest); Modivcare no longer provides Georgia Medicaid NEMT. DCH contracts and pays the broker directly, at a monthly capitated rate per eligible member in the region. DCH's published NEMT pages do not spell out how a Georgia Families member books a ride, so check your plan handbook alongside the DCH NEMT page before you call.10

Nursing facility services. Paid fee-for-service through DCH while the member is in the facility.

Most HCBS waivers. EDWP, including its CCSP and SOURCE models, along with ICWP, NOW, and COMP, run fee-for-service through DCH and the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD); the member's underlying acute care stays with the plan.

Targeted case management in certain categories (developmental disability, behavioral health) is fee-for-service.

Prior authorization and appeals

Many services require prior authorization, a clinical review of medical necessity, before they are paid. Timing standards come from 42 CFR 438.210 for managed care, with parallel state rules for fee-for-service.

• Standard prior authorization. The plan must decide a standard request within the timeframe required under 42 CFR 438.210, as expeditiously as the member's condition requires, with a possible extension when it benefits the member.
• Expedited prior authorization. When the standard timeframe could seriously jeopardize the member's life, health, or function, a shorter expedited decision window applies.
• Hospital concurrent review. Continued-stay decisions are issued promptly after the plan receives clinical information.
• Pharmacy. Non-preferred drugs require prior authorization, processed through OptumRx in fee-for-service or through the plan for plan members.

A denial triggers appeal rights. Managed care members must first exhaust the plan's internal appeal, filing within the deadline in the plan member handbook, and the plan must decide within the federally required timeframe. After that, the member may appeal to the Office of State Administrative Hearings (OSAH). Fee-for-service denials go directly to OSAH. For more on appeals, see the Georgia managed care plans guide.

What Georgia Medicaid costs members

Georgia Medicaid copays are nominal, but they are not identical from plan to plan: each Georgia Families plan publishes its own schedule, so which services carry a copay depends on which plan you are in. CareSource's Georgia Medicaid schedule lists two: $12.50 for an inpatient hospital stay (no copay if you were admitted or transferred from an emergency room, urgent care, another hospital, or a nursing or other health facility) and $3 for an emergency room visit that is not an emergency. Peach State Health Plan lists a broader set of Georgia Medicaid copays: $12.50 inpatient, $3 for an emergency department visit for a non-emergency condition, $3 for an outpatient non-emergency visit, $3 at an ambulatory surgical center, $2 at a federally qualified health center or rural health clinic, and cost-based copays for oral maxillofacial services. Preferred drugs carry a $0.50 copay; non-preferred drugs are cost-based, scaling from $0.50 when the care costs $10.00 or less to $3 when it costs $50.01 or more. CareSource charges nothing for preventive care, family planning, emergencies, or dialysis. Check your own plan's copay page rather than assuming a service is free, and see the Georgia Medicaid cost sharing and copays guide for the full schedules.11

The following members have no copays for covered care: members under age 21 (Medicaid) or under age 6 (PeachCare for Kids), pregnant women, nursing facility residents, children in foster care, members in hospice, members in the Breast and Cervical Cancer program, and American Indians and Alaska Natives. PeachCare for Kids members age six and over do pay per-service copays, but those copays total no more than five percent of family income; the published plan schedules do not state the period over which that five percent is measured, so confirm it with your plan.11

Frequently Asked Questions

Does Georgia Medicaid cover adult dental?

Yes. Effective July 1, 2024, Georgia expanded adult (21+) dental from a narrow emergency/extraction-only scope to comprehensive coverage. Prior authorization is required for all adult dental services except emergency services, and frequency limits and age rules apply, so confirm specific limits with DCH or your plan. Children under 21 keep full comprehensive dental coverage under EPSDT.5

Does Georgia Medicaid cover nursing home care?

Yes, for individuals who meet nursing facility level of care and the long-term-care financial limits. For 2026, Georgia's Medicaid Cap (300% of the SSI federal benefit rate) is $2,982 a month for an individual and $5,964 for a couple, with countable resources at or below $2,000 for an individual. Income at or above the cap can still qualify by routing through a Qualified Income Trust (Miller Trust). Spousal impoverishment protections apply for a community spouse.2

Coverage in four real situations

The following are illustrative examples, not real individuals, and show how coverage typically works in common situations.

Mrs. Roberts, 67, dual-eligible, knee replacement

Mrs. Roberts has Medicare and Georgia Medicaid (QMB-Plus, one of the Medicare Savings Programs). She needs a knee replacement.

• Pre-surgical consultations with the orthopedic surgeon: Medicare primary, Medicaid secondary.
• Inpatient knee replacement at a Medicaid-enrolled hospital: Medicare primary, Medicaid covers the Part A deductible if applicable.
• Post-acute rehabilitation: Medicare home health or a short SNF stay, with Medicaid wraparound.
• Outpatient physical therapy after Medicare home health ends: covered with prior authorization, limited visits.
• DME (walker, raised toilet seat, shower chair, hospital bed if needed): covered with prior authorization.
• Pain medications: drug coverage, primarily through Medicare Part D for a dual-eligible.
• Cost to Mrs. Roberts: little to nothing out of pocket. Her QMB enrollment is what decides whether she owes Medicare cost-sharing. See the Georgia Medicare Savings Programs guide.11

The Diaz family: an 8-year-old with ADHD

The Diaz family's 8-year-old son is enrolled in Georgia Families through CareSource. His pediatrician identifies symptoms consistent with ADHD at a routine well-child visit. EPSDT applies.

• Behavioral health evaluation and any diagnostic psychological testing: covered under EPSDT.
• Stimulant medication if prescribed: pharmacy benefit through the CareSource plan.
• Behavioral therapy: covered under EPSDT, with no adult-style visit caps.
• School coordination: limited school-based Medicaid coverage.
• Follow-up pediatric visits: covered.
• Cost to the family: $0.1

Mrs. Lee, 30, pregnant

Mrs. Lee is pregnant and qualifies for Georgia pregnancy Medicaid, which covers pregnant women with income at or below 220% of the federal poverty level.12

• Prenatal visits at an FQHC and OB-GYN, ultrasounds, and lab work: covered.
• Labor and delivery at a Medicaid-enrolled hospital: covered.
• Postpartum coverage: 12 months of continuous coverage after pregnancy (Georgia extended postpartum Medicaid effective November 1, 2022).
• Family planning after pregnancy and tobacco cessation: covered.
• Cost to Mrs. Lee: $0.12

Mr. Chen, 45, substance use residential treatment

Mr. Chen has opioid use disorder and is enrolled through Pathways to Coverage.

• SUD residential treatment at an IMD facility under Georgia's SUD 1115 demonstration: covered up to the demonstration's limits.
• Medication-assisted treatment (buprenorphine or methadone): pharmacy benefit through his plan, or dispensed at an opioid treatment program.
• Outpatient counseling after residential treatment and behavioral health case management: covered.
• Cost to Mr. Chen: Pathways members pay copayments for certain services (members under 21 are exempt); Pathways does not charge a monthly premium.13

How to find a Georgia Medicaid provider

Start with the DCH provider directory at dch.georgia.gov/medicaid. Georgia Families members should use their own plan's directory, since Amerigroup, CareSource, and Peach State each maintain one, along with their plan's pharmacy network. DBHDD publishes directories for behavioral health and developmental disability services, and Verida handles non-emergency transportation.

Common mistakes to avoid

• Using a pharmacy that is not Medicaid-enrolled. Prescriptions must be filled at a Georgia Medicaid-enrolled pharmacy; fee-for-service claims process through OptumRx, and plan members use their plan's network.
• Missing an appeal deadline. Late plan internal appeals and late OSAH appeals are dismissed; check your plan handbook and OSAH for the applicable timeframes.
• Treating Pathways to Coverage as full Medicaid. Pathways has narrower eligibility and charges copayments for some services.13
• Assuming PACE members use the regular pharmacy or NEMT benefit. A PACE program provides its own drugs and transportation.

Get help with Georgia Medicaid covered services

For help coordinating Medicare and Medicaid, GeorgiaCares (the State Health Insurance Assistance Program) offers free counseling.14

Learn More

Find personalized help understanding what Georgia Medicaid covers 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.