Georgia Medicaid Covered Services (2026): Mandatory Benefits, Optional Benefits, Adult vs Pediatric, EPSDT, and CMO Carve-Outs

Georgia Medicaid covers a broad range of medical services for the populations it serves, but the precise list of what is covered depends on three federal layers and several Georgia-specific choices. Federal law sets a mandatory benefit floor that every state Medicaid program must include. On top of that floor, federal law offers a menu of optional benefits that states may elect; Georgia has elected most of them but with adult-versus-pediatric distinctions that matter substantially for what an individual member can actually receive. For children under 21, federal law adds a third layer through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which can override state-plan limits when a medical need is identified through pediatric screening.

This guide explains what Georgia Medicaid actually covers in 2026 across all of those layers. It identifies the mandatory federal services under 42 USC 1396d(a), the optional services Georgia has elected, the comprehensive pediatric coverage under EPSDT in 42 USC 1396d(r), the IMD exclusion that limits inpatient psychiatric coverage for adults 21 to 64, and the services that are carved out of Georgia Families CMO capitation and delivered through fee-for-service arrangements (pharmacy through Gainwell, NEMT through regional brokers, nursing facility care, and most HCBS waivers).

By Brevy Care Team · Last verified May 12, 2026

The federal benefit framework

Title XIX of the Social Security Act, codified at 42 USC 1396 et seq., establishes Medicaid as a federal-state partnership. The federal government sets minimum standards; states administer the program within those standards. Section 1905(a) of the Act, codified at 42 USC 1396d(a), lists 30+ categories of services that may be covered. Some are mandatory; the rest are optional.

The mandatory categories define what every state must cover for the categorically needy population. States that elect to extend coverage to medically needy populations may impose somewhat different rules for the medically needy package, but Georgia does not have a medically needy program for ABD adults, so this distinction does not apply in Georgia.

The optional categories are made available to states. Each state decides which optional categories to add and may impose amount, duration, and scope limits that differ between adults and children, subject to certain federal anti-discrimination and EPSDT rules.

For children under 21, the EPSDT benefit at 42 USC 1396d(r) overrides state-level optional choices. EPSDT requires the state to provide any service in 1396d(a) that is medically necessary to correct or ameliorate a condition discovered through pediatric screening, even if the service is otherwise optional and not covered for adults.

Mandatory services Georgia covers

The following are mandatory under federal law and covered by Georgia Medicaid.

Inpatient hospital services. Acute care admissions, surgical care, inpatient psychiatric care for under 21, inpatient psychiatric care for over 65 if in an IMD, rehabilitation hospital admissions. Authorization is through the CMO for managed-care members or through DCH for fee-for-service members. Concurrent review during the stay manages length of stay.

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

FQHC and RHC services. Comprehensive primary care delivered at federally qualified health centers or rural health clinics. FQHCs and RHCs are paid a prospective payment system rate that covers the encounter and supporting services. Georgia has a robust FQHC network particularly important in rural and underserved areas.

Laboratory and x-ray services. All Medicaid-enrolled CLIA-certified labs and imaging providers. Covers a wide range of diagnostic tests.

Nursing facility services for individuals 21+. For individuals who meet NF level of care and the LTC financial eligibility (SIL pathway or Miller Trust). See the Georgia long-term care Medicaid guide.

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+, STI screening and treatment, and pregnancy testing. Confidentiality protections apply.

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

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

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

Home health services. Skilled nursing on an intermittent basis, home health aide, physical therapy at home, occupational therapy at home, speech-language pathology at home, medical supplies, and DME furnished at home. Federal regulation at 42 CFR 440.70 governs the scope.

Non-emergency medical transportation. Codified as mandatory by the Bipartisan Budget Act of 2018. Delivered through regional broker contracts. See the Georgia NEMT guide.

Tobacco cessation services for pregnant women. Counseling and pharmacotherapy.

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

Optional services Georgia has elected

Georgia has elected most of the optional services available under 42 USC 1396d(a), with adult-versus-pediatric distinctions.

Prescription drugs. Every state has elected drugs, and Georgia is no exception. Georgia operates a single statewide pharmacy benefit manager: Gainwell Technologies as the State Pharmacy Benefit Manager (SPBM). All Georgia Medicaid pharmacy claims (including for Georgia Families CMO members) flow through Gainwell. The state maintains a Preferred Drug List, prior authorization tiers, and DUR processes.

Dental services. Adult dental is limited to emergency services in Georgia: extractions, urgent infection treatment, and trauma. Routine cleanings, fillings, crowns, and dentures are NOT covered for adults 21+ except in limited circumstances. Pediatric dental is fully covered under EPSDT, including preventive cleanings, sealants, fillings, orthodontia when medically necessary, and oral surgery.

Vision services. Adult vision benefits are limited; contact DCH or your CMO for current frequency limits on eye exams and eyeglasses. Replacement eyeglasses require medical necessity justification. Pediatric vision is fully covered under EPSDT, including frequent screenings, exams, and corrective lenses.

Hearing services. Adult hearing exams are covered, but hearing aids are not generally covered for adults 21+ except in narrow circumstances. Pediatric hearing exams and hearing aids are covered under EPSDT.

Durable medical equipment. Wheelchairs (manual and power), walkers, canes, hospital beds, oxygen and oxygen accessories, CPAP and BiPAP, ostomy supplies, diabetes supplies (glucose meters, test strips, insulin pumps), prosthetics, orthotics, and a long list of other devices. Most DME requires prior authorization with the DCH or CMO DME unit. Higher-cost items require additional medical justification.

Physical therapy, occupational therapy, and speech-language pathology. Outpatient therapy services 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.

Behavioral health services. Outpatient mental health (individual therapy, group therapy, family therapy), substance use disorder treatment (counseling, MAT with methadone and buprenorphine), intensive outpatient programs (IOP), partial hospitalization programs (PHP), case management, and inpatient psychiatric services (with the IMD exclusion limiting coverage for adults 21 to 64 except for SUD residential treatment under the GA SUD 1115 demonstration). CCBHCs (Certified Community Behavioral Health Clinics) provide integrated behavioral health and primary care.

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

Prosthetics. Artificial limbs, ocular prostheses, breast prostheses post-mastectomy, and related devices.

Eyeglasses. As described under vision.

Dentures. Limited adult coverage.

Inpatient psychiatric services for under 21. Covered in psychiatric residential treatment facilities and inpatient psychiatric units.

ICF/IID. Intermediate Care Facility for Individuals with Intellectual Disabilities. Limited statewide.

Respiratory care services. For ventilator-dependent individuals.

Home and community-based services (HCBS) under 1915(c) waivers. Georgia operates several waivers including the Community Care Services Program (CCSP), the SOURCE waiver, the Independent Care Waiver Program (ICWP), the NOW waiver, and the COMP waiver. Each is described in its own guide.

Primary care case management. Through Georgia Families CMO assignment.

Personal care services. Delivered through HCBS waivers.

TB-related services. Standard public health benefit.

Podiatry. Routine foot care is limited; medical foot care for diabetes and other conditions with vascular or neuropathic risk is covered.

Chiropractic services. Limited adult coverage with medical necessity.

Private duty nursing. For medically complex individuals with continuous skilled nursing needs at home. Prior authorization required and provided in narrow circumstances.

EPSDT: the comprehensive pediatric benefit

The Early and Periodic Screening, Diagnostic, and Treatment benefit, codified at 42 USC 1396d(r), is the most important federal protection for children in Medicaid. EPSDT entitles every Medicaid-enrolled child under 21 to:

1. Screening services at periodic intervals using the Bright Futures periodicity schedule from the American Academy of Pediatrics. Screening components include comprehensive health and developmental history, physical examination, age-appropriate immunizations per the ACIP schedule, laboratory tests including lead screening at 12 and 24 months, blood pressure screening, hemoglobin and hematocrit testing, and health education and anticipatory guidance.

2. Vision services at periodic intervals, including vision screening at every well-child visit and full eye exams as indicated.

3. Hearing services including newborn hearing screening, age-appropriate audiometric testing, and treatment for identified hearing problems.

4. Dental services including a first dental visit by age one or eruption of the first tooth, periodic preventive dental visits, treatment of cavities, sealants, fluoride treatment, orthodontia when medically necessary, and oral surgery when needed.

5. Other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) of the Social Security Act to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan.

Item 5 is the "EPSDT trump card." If a child is identified as needing a service during EPSDT screening, the state must provide that service even if it is otherwise optional and not in the state plan, even if it is not covered for adults, and even if it would be subject to limits for adults. The only constraint is medical necessity. Examples in Georgia:

• A child identified with severe hearing loss is entitled to hearing aids and audiologic services, even though adult hearing aids are not covered.
• A child identified with developmental delay is entitled to physical, occupational, and speech therapy without the adult visit limits.
• A child identified with autism spectrum disorder is entitled to applied behavior analysis (ABA) therapy and related services if medically necessary.
• A child identified with a chronic dental problem is entitled to comprehensive dental services, including orthodontia if medically necessary.

EPSDT also includes outreach and informing requirements: states must inform Medicaid-eligible families about EPSDT and make appointment scheduling and transportation available.

The IMD exclusion

The federal IMD exclusion at 42 USC 1396d(a) prohibits federal Medicaid payment for services provided to individuals 21 to 64 residing in an Institution for Mental Diseases (IMD), defined at 42 USC 1396d(i) as a hospital, nursing facility, or other institution of more than 16 beds primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases.

The exclusion has existed since the 1965 Medicaid statute and reflects historical preferences for community-based mental health care. Its practical effect is to limit Medicaid coverage of long-term inpatient psychiatric care for working-age adults.

Exceptions:

• Individuals under 21 are NOT subject to the exclusion; inpatient psychiatric services are covered for children and adolescents in psychiatric residential treatment facilities (PRTFs) under 42 USC 1396d(a)(16).
• Individuals 65+ are NOT subject to the exclusion; IMD services may be covered.
• The 21 to 64 exclusion remains the binding rule.
• CMS has approved Section 1115 demonstrations permitting time-limited IMD coverage for substance use disorder (SUD) residential treatment under specific conditions: length-of-stay limits, MAT availability, integrated physical and behavioral health, and quality reporting. Georgia operates a SUD 1115 demonstration that permits this coverage.
• CMS has also approved limited serious mental illness (SMI) IMD 1115 demonstrations in some states (not currently in Georgia).

The practical effect for Georgia members 21 to 64 with severe mental illness is that long-term residential psychiatric treatment in an IMD is generally not Medicaid-covered, although shorter-term hospitalization and community-based treatment are covered. SUD residential treatment in an IMD is covered under the 1115 demonstration up to demonstration limits.

Services carved out of Georgia Families managed care

Georgia Families is Georgia's mandatory Medicaid managed care program for most members. The four CMOs are Amerigroup (Elevance), CareSource, Peach State (Centene), and Wellcare (Centene). Georgia Families 360° serves foster children, adoption assistance recipients, and former foster youth.

The CMO capitation includes most acute services: primary care, specialty care, hospital inpatient and outpatient, emergency, lab and x-ray, and EPSDT for children. Several services are carved out and delivered through separate fee-for-service arrangements:

Pharmacy is delivered through a single statewide SPBM, Gainwell Technologies. Every Medicaid prescription claim flows through Gainwell, regardless of whether the member is enrolled in a CMO. The state maintains the PDL and PA tiers centrally.

Non-emergency medical transportation is delivered through regional broker contracts. Members book NEMT through the regional broker, not through the CMO.

Nursing facility services are fee-for-service. CMO members enter NF care via the SIL pathway or Miller Trust and are paid through DCH FFS while in NF.

Most HCBS waivers (CCSP, SOURCE, ICWP, NOW, COMP) are fee-for-service through DCH and DBHDD waiver administration. The CMO is not involved in waiver service delivery, though the member's underlying acute care remains through the CMO.

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

Dental for adults is limited and delivered through DCH-contracted dental providers, separate from the CMO. Pediatric dental under EPSDT is through CMO networks.

The carve-out structure means a Georgia Families member typically has three different points of contact: the CMO for primary and specialty care, the regional broker for NEMT, and (for pharmacy) any Medicaid-enrolled pharmacy via Gainwell. For more on the CMO structure, see the Georgia managed care plans guide.

Prior authorization landscape

Many services require prior authorization (PA) before they will be paid. PA is a clinical review to determine medical necessity and coverage. The timing standards are governed by 42 CFR 438.210 for managed care and parallel state rules for fee-for-service.

Standard PA timing. For managed care, the CMO must issue a decision on a standard PA request within the timeframes required under 42 CFR 438.210, with possible extension if the member benefits. For fee-for-service, federal standards similarly apply.

Expedited PA timing. When the standard timeframe could seriously jeopardize the member's life, health, or ability to attain or maintain maximum function, an expedited PA process applies with a shorter required decision window.

Hospital concurrent review. Hospital admissions are subject to concurrent review during the stay, with continued-stay decisions issued within one business day of receipt of clinical information.

Pharmacy PA. Non-preferred drugs on the PDL require PA through Gainwell. Decisions are typically issued within 24 hours of receipt of required clinical information.

Appeal rights. A PA denial triggers appeal rights. Managed care members must exhaust the CMO internal appeal first: file within the deadlines stated in the CMO's member handbook, and the CMO must decide within the federally required timeframe. After internal appeal exhaustion, the member may appeal externally 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.

Member cost-sharing

Georgia Medicaid is largely $0 cost-sharing for members. Limited nominal copays exist for some services:

• Outpatient hospital services: nominal copay per visit for certain non-exempt categories
• Pharmacy: nominal copay per prescription depending on drug tier
• Non-emergency use of the emergency department: nominal copay
• Inpatient hospital: $0
• Nursing facility: patient liability calculated post-eligibility (see PNA guide)

Federal law at 42 CFR 447 caps total cost-sharing at 5% of household income. Exempted populations have $0 cost-sharing:

• Children under 18
• Pregnant women (pregnancy-related and 60-day postpartum, plus extended postpartum coverage)
• Institutionalized individuals (NF residents)
• Hospice patients
• Members receiving emergency services
• American Indians and Alaska Natives in certain contexts

Worked example 1: Mrs. Roberts, 67, dual-eligible, knee replacement

Mrs. Roberts is 67, on Medicare and Georgia Medicaid (QMB-Plus dual-eligible). She needs a knee replacement.

Her care plan:

• Pre-surgical consultations with orthopedic surgeon: Medicare primary, Medicaid secondary
• Inpatient knee replacement at Medicaid-enrolled hospital: Medicare primary, Medicaid pays Part A deductible if applicable
• Post-acute rehabilitation: Medicare home health or short SNF stay; Medicaid wraparound
• Physical therapy outpatient (after Medicare home health ends): adult PT covered with PA, limited visits
• DME: walker, raised toilet seat, shower chair, durable hospital bed if needed; covered with PA
• Pain medications: pharmacy via Gainwell SPBM
• Cost to Mrs. Roberts: $0 (QMB covers Medicare cost-sharing; Medicaid covers wraparound; pharmacy nominal copay)

This is the typical dual-eligible flow for surgery and recovery.

Worked example 2: Mr. Diaz, 8 years old, ADHD

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

EPSDT applies. Coverage:

• Behavioral health evaluation: EPSDT covers
• Diagnostic testing if needed (psychological assessment): EPSDT covers
• Stimulant medication if prescribed: pharmacy via Gainwell
• 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 family: $0. EPSDT ensures comprehensive coverage even where adult coverage would be more restrictive.

Worked example 3: Mrs. Lee, 30, pregnant

Mrs. Lee is 30, pregnant, and qualifies for Georgia Medicaid pregnancy coverage.

Coverage:

• Prenatal visits at FQHC and OB-GYN: covered
• Ultrasounds, lab work: covered
• Labor and delivery at Medicaid-enrolled hospital: covered
• Postpartum coverage: extended postpartum Medicaid (Georgia has adopted extended coverage)
• Family planning post-pregnancy: covered
• Tobacco cessation: covered for pregnant women (and now for all members under ACA)
• Cost to Mrs. Lee: $0

Worked example 4: Mr. Chen, 45, SUD residential treatment

Mr. Chen is 45, has opioid use disorder, and is enrolled in Pathways to Coverage.

Coverage:

• SUD residential treatment at IMD facility under Georgia SUD 1115 demonstration: covered up to demonstration limits (length-of-stay average)
• MAT (buprenorphine or methadone): pharmacy via Gainwell or methadone clinic
• Outpatient counseling post-residential: covered
• Behavioral health case management: covered
• Cost to Mr. Chen: varies; Pathways may impose monthly premiums based on income tier

How to find a Georgia Medicaid provider

Several resources help members find covered providers:

• DCH provider directory at dch.georgia.gov/medicaid
• CMO provider directories for Georgia Families members (Amerigroup, CareSource, Peach State, Wellcare each maintain their own)
• Gainwell pharmacy locator for pharmacy network
• NEMT broker directories for transportation
• DCH dental and vision contractor directories for those services
• DBHDD provider directories for behavioral health and waiver services

Members can call DCH at 1-866-211-0950 or their CMO for provider referrals.

Common mistakes Georgia members make

A few patterns recur.

Assuming adult dental is the same as pediatric. Adult dental is emergency-only; pediatric is comprehensive under EPSDT.

Filling a prescription at a non-Gainwell pharmacy. Since July 2022, every Georgia Medicaid pharmacy claim goes through Gainwell. Pharmacies not in the Gainwell network cannot process Medicaid claims.

Calling the CMO for NEMT. NEMT is carved out. Call the regional broker for transportation needs.

Going to a non-Medicaid-enrolled provider. Services from non-enrolled providers are generally not covered.

Not understanding EPSDT trump. For children, services not in the state plan or not covered for adults can still be covered under EPSDT when medically necessary.

Believing adult hearing aids are covered. With limited exceptions, they are not for adults 21+.

Believing experimental treatments are covered. They are generally not.

Missing CMO internal appeal deadline. Late appeals are dismissed. Check the CMO member handbook for the applicable timeframe.

Missing OSAH external appeal deadline. Late appeals are dismissed. Check with OSAH or your CMO for applicable deadlines.

Missing OSAH deadline for fee-for-service denials.

Treating Pathways to Coverage as full Medicaid. Pathways has narrower eligibility and may have premiums.

Believing PACE participants use Gainwell for pharmacy. PACE provides all drugs through the PACE pharmacy, not Gainwell.

Believing PACE participants use the NEMT broker. PACE provides its own transportation.

Believing all behavioral health levels are covered for adults. IMD exclusion limits long-term residential psychiatric for adults 21 to 64 except SUD under 1115.

Believing copays are the same across populations. Pregnant women, children, NF residents, and hospice patients have $0 cost-sharing; other categories have nominal copays.

Get help with Georgia Medicaid covered services

If you have questions about whether a specific service is covered, start with the Georgia Department of Community Health or your CMO. For pharmacy, the SPBM is Gainwell. For NEMT, contact your regional broker. For appeals, the Office of State Administrative Hearings handles external review. For more about how Brevy researches and updates these guides, visit brevy.com.

Related Georgia Medicaid guides

• Georgia Medicaid hub
• Georgia Medicaid eligibility and income limits
• Georgia Medicaid managed care plans
• Georgia Medicaid non-emergency medical transportation
• Georgia long-term care Medicaid
• Georgia PACE program
• Georgia Medicare Savings Programs
• Georgia how to apply

This guide is informational and does not constitute legal or medical advice. Georgia Medicaid covered services, prior authorization rules, and cost-sharing change periodically. For current information, contact the Georgia Department of Community Health or your CMO. Find personalized help navigating Georgia Medicaid covered services at brevy.com.