Georgia Medicaid: Fee-for-Service vs. Managed Care 2026

Every Georgia Medicaid beneficiary gets care through one of two delivery systems, and which one you are in decides your provider network, your member-services number, and how you appeal a denial. Most non-disabled children, parents, and pregnant women are in managed care through Georgia Families, served by three Care Management Organizations (CMOs). Most aged, blind, and disabled adults on long-term care, and most people who also have Medicare, stay in fee-for-service (FFS) and deal with the state directly. This guide shows which system applies to you and what changes when you move between them.

Am I in Georgia Medicaid fee-for-service or managed care?

Use this quick check to find which delivery system applies to you, then confirm it with DCH or your CMO.

Your situation	Likely delivery system
Child, parent, or pregnant woman on Family Medicaid, Right from the Start Medicaid, TANF Medicaid, or PeachCare for Kids	Managed care (Georgia Families)
Aged, blind, or disabled adult receiving nursing facility care or extensive waiver services	Fee-for-service
Have both Medicare and Medicaid (dual-eligible)	Usually fee-for-service for Medicaid; Medicare is primary
In a retroactive, presumptive, or transitional eligibility period	Fee-for-service until full managed care enrollment takes effect
American Indian or Alaska Native beneficiary who has not chosen managed care	Fee-for-service

To confirm your status, review your eligibility notice from the Division of Family and Children Services (DFCS), log in at gateway.ga.gov, or call the Georgia Department of Human Services Customer Contact Center at 1-877-423-4746, Monday through Friday, 8 a.m. to 5 p.m.

Georgia Medicaid fee-for-service vs managed care: the core difference

In fee-for-service, the relationship is direct. You see any provider enrolled with DCH Medicaid, the provider bills DCH, and DCH pays on its published fee schedule. There is broad provider choice but little care coordination.

In managed care, a Care Management Organization sits in the middle. You enroll with one CMO, use its contracted network, and the provider bills the CMO. DCH pays the CMO a fixed per-member-per-month (PMPM) capitation amount whether or not you use services that month, so the CMO carries the financial risk. In exchange the CMO builds the network, runs prior authorization, and provides care coordination, with a narrower set of in-network providers.

For most Georgia families the practical difference is large. In managed care you call your CMO for member services, authorizations, and care management. In fee-for-service you deal with DCH directly. The same eligibility category can mean a very different day-to-day experience depending on which system you land in.

The federal rules behind the two systems

Freedom of choice is the default

Section 1902(a)(23) of the Social Security Act generally gives Medicaid beneficiaries freedom of choice among qualified providers. Mandatory managed care is an exception to that default and requires specific federal authority.

Section 1932 lets states require managed care

Section 1932 of the Social Security Act, added by the Balanced Budget Act of 1997, lets states require managed care enrollment for most populations through a state plan amendment rather than a waiver. Before Section 1932, mandatory managed care usually needed a Section 1915(b) waiver and a heavier federal approval. Georgia uses Section 1932 state plan authority for Georgia Families.

Key provisions:

Section 1932(a)(1) authorizes mandatory managed care for most populations.
Section 1932(a)(2) lists populations a state cannot force into managed care under state plan authority.
Section 1932(a)(3) sets enrollment and disenrollment procedures, including choice periods and auto-assignment.
Section 1932(a)(2)(C) bars a state from requiring an American Indian or Alaska Native beneficiary to enroll in a managed care entity unless that entity is itself an Indian health entity.

Who federal law keeps out of mandatory managed care

Section 1932(a)(2) excludes these groups from mandatory managed care under state plan authority:

Dual-eligibles in certain scenarios, because Medicare is the primary payer.
American Indian and Alaska Native beneficiaries. Under Section 1932(a)(2)(C), Georgia cannot require enrollment unless the plan is itself an Indian health entity, such as the Indian Health Service, a tribally operated program, or an urban Indian health program. They may still choose managed care voluntarily.
Certain special-needs children meeting specific criteria.
Children in foster care or out-of-home placement.
Children receiving Adoption Assistance under Title IV-E.

A state may still bring these groups into managed care voluntarily or through a Section 1115 demonstration.

The managed care rulebook

42 CFR Part 438 is the comprehensive federal regulation for Medicaid managed care, covering enrollment (438.52), disenrollment (438.56), carve-out services (438.70), emergency services (438.114), and rate-setting and the medical loss ratio (438.4 through 438.8). The rate-setting rules require capitation rates to be developed so a CMO would reasonably achieve a medical loss ratio of at least 85 percent for the rate year. Section 438.70 is the authority that lets a state carve specific services out of managed care and deliver them through fee-for-service or a separate arrangement.

How fee-for-service works in Georgia

In fee-for-service:

You see a provider enrolled with DCH Medicaid.
The provider delivers care and submits the claim to DCH or its fiscal agent.
DCH pays the provider on its published Medicaid fee schedule.

The fee-for-service network is every provider enrolled with DCH, who agree to accept Medicaid as payment in full and to follow billing, documentation, and program-integrity rules. DCH fee schedules are generally lower than commercial and Medicare rates, which creates access pressure for some specialties.

DCH conducts prior authorization for fee-for-service where it is required, for example inpatient admissions, certain procedures, durable medical equipment above set thresholds, and long-term care services. For a denied service, you can ask DCH for reconsideration and request a state fair hearing under 42 CFR Part 431 Subpart E.

Care coordination is limited in fee-for-service. DCH does not assign a primary care provider or care manager in traditional FFS, so you generally manage referrals, scheduling, and transitions yourself. Some programs (long-term care case management, certain demonstrations) add coordination for specific populations.

How managed care works in Georgia

In managed care:

You enroll with one CMO.
DCH pays the CMO a monthly capitation amount per member.
You see a provider in the CMO's network, the provider bills the CMO, and the CMO pays on its negotiated rates.

The three Georgia Families CMOs

Georgia contracts with three CMOs to deliver Georgia Families: Amerigroup Community Care, CareSource, and Peach State Health Plan. Each operates statewide, so most beneficiaries can choose any of the three. WellCare and Wellpoint are not current separate Georgia Families CMOs. A 2024 reprocurement named a different proposed slate (CareSource, Humana, Molina, and UnitedHealthcare), but as of 2026 the current three-CMO contracts are extended through June 30, 2027, with no DCH-confirmed transition date published.

Networks, payment, and authorizations

Each CMO maintains a contracted network and must meet network-adequacy standards. Those time-and-distance standards are set by Georgia in the Georgia Families Contract, not by CMS; under 42 CFR 438.68 the federal rule requires the state to develop and enforce quantitative standards, and DCH publishes the actual figures in Figure 1 of the contract, with each CMO filing a geographic access analysis. Out-of-network care is generally not covered except for emergencies, which must be covered regardless of network status under 42 CFR 438.114.

CMOs negotiate provider rates (negotiated fee-for-service, per-diem, bundled, value-based, or capitated for some primary care). State-directed payments under 42 CFR 438.6(c) can set minimum payment levels for hospitals and certain providers. The CMO runs prior authorization within its own utilization management, and all CMOs must cover State Plan services.

Appeals in managed care

For a managed care denial you generally work through the appeal ladder in order:

Step 1

File the CMO's internal appeal

Start with the Care Management Organization that issued the denial. You have 60 calendar days from the date on the adverse benefit determination notice, and the plan may have only one level of appeal, which you can request orally or in writing.

Step 2

Wait for the plan's decision

The CMO must resolve a standard appeal within 30 calendar days, or within 72 hours if the appeal is expedited; either window can be extended by up to 14 calendar days if you ask or if the plan shows the state that more information is needed and the delay is in your interest.

Step 3

Request a state fair hearing

That single internal appeal is the only step you have to exhaust. Once the plan upholds its denial, the state must give you no less than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing under 42 CFR Part 431 Subpart E, with the exact deadline inside that band set by the state. If the plan misses its own notice or timing rules, your appeal is deemed exhausted and you can go straight to the hearing.

A grievance about CMO operations (customer service, access, or quality) is a separate track from an appeal and can be filed at any point. For step-by-step deadlines, see Georgia Medicaid appeals and fair hearings.

Care coordination and value-added services

CMOs provide care managers, disease-management programs for chronic conditions, transitions-of-care coordination, and pharmacy coordination. They also offer value-added services beyond the State Plan, such as health-rewards programs, over-the-counter allowances, and transportation beyond standard non-emergency medical transportation. Value-added services must follow federal rules (they cannot be billed as medical claims and must comply with medical loss ratio rules).

What "85 percent" actually means

You will see an "85 percent" medical loss ratio (MLR) figure attached to Medicaid managed care. It is a rate-setting standard, not a flat guarantee that every plan spends 85 percent on care or pays money back. Under 42 CFR 438.4(b)(9), capitation rates must be developed so a CMO would reasonably achieve an MLR of at least 85 percent for the rate year, and a minimum-MLR floor with a payback (remittance) is a state option under 42 CFR 438.8, not a universal federal mandate. All plans must still calculate and report their MLR annually. See Georgia Medicaid medical loss ratio for how Georgia applies it.

Who is in each system in Georgia

Mandatory managed care populations

DCH places these groups in mandatory managed care through Georgia Families:

Family Medicaid. Low-income parents and children covered through MAGI eligibility groups.
Right from the Start Medicaid (RSM). Pregnant women with budget-group income at or below 220 percent of the Federal Poverty Level.
TANF Medicaid. Low-income families receiving Temporary Assistance for Needy Families.
PeachCare for Kids. CHIP children above Medicaid limits but within CHIP limits.

Georgia extended postpartum coverage to a full 12 months after the end of pregnancy effective November 1, 2022. Under DFCS continuous-coverage policy, a pregnant woman who becomes or would become ineligible because of a change in her assistance unit or budget group stays eligible for the rest of the pregnancy and through that 12-month postpartum period, ending at the end of the month the twelfth month falls in. One express exception: a woman approved for Emergency Medical Assistance is not automatically eligible for the 12-month extended postpartum period.

Fee-for-service populations

DCH keeps these groups in fee-for-service:

Most aged, blind, and disabled adults receiving nursing facility care or extensive home and community-based waiver services.
Most dual-eligibles, with Medicare as primary payer.
Some Katie Beckett enrollees, depending on circumstances. Georgia's Katie Beckett (TEFRA) pathway waives the deeming of the parents' income and resources so the child qualifies on their own. It is available to children 18 years of age and younger, and eligibility does not extend past the month the child turns 19. In the month after the child turns 18, the child must be advised to apply for SSI, but no action is taken to change eligibility, whether or not proof of that application is provided and whether SSA approves SSI or finds the child not disabled. The Katie Beckett class of assistance stays open through the month the child turns 19 under continuous eligibility and closes the month after, with a continuing Medicaid determination considering all Medicaid classes of assistance completed before it closes.
Beneficiaries in retroactive or presumptive eligibility periods, and in the brief transitional period before managed care enrollment takes effect.
American Indian and Alaska Native beneficiaries who have not voluntarily enrolled with a CMO. See Georgia Medicaid tribal health coverage.

Carve-out services

Some services sit outside the CMO's standard medical network, or are split between the two delivery systems:

Long-term services and supports. Nursing facility care and most home and community-based waiver services are largely fee-for-service. See Georgia Medicaid long-term care.
Behavioral health. Some services run through the Department of Behavioral Health and Developmental Disabilities (DBHDD) rather than the CMO. See Georgia Medicaid behavioral health coverage.
Pharmacy (split, not carved out). For the fee-for-service population, OptumRx is the pharmacy benefits manager and processes FFS outpatient pharmacy claims at the point of sale. CMO members get pharmacy through their own CMO or its subcontracted PBM, not OptumRx, so the drug list that governs you depends on which plan you are in. A 2023 state review counted four different drug lists in Georgia Medicaid: one for each of the three CMOs plus fee-for-service. Check your own plan's formulary rather than assuming a single statewide list.
Non-emergency medical transportation. Effective April 1, 2026, Verida is the sole statewide Medicaid transportation broker for all five Georgia regions.
Dental and vision. Delivered through specific per-CMO arrangements that may differ from medical managed care.

Enrolling and switching plans

For mandatory managed care populations, DFCS determines eligibility through Georgia Gateway, then DCH's enrollment broker provides choice counseling. You select a CMO during your choice period; if you do not choose, an auto-assignment algorithm assigns one, weighing family members' CMO, any recent prior CMO, and provider continuity. You then have an initial period to change CMOs for any reason. After that, you change during annual open enrollment or with good-cause disenrollment under 42 CFR 438.56(d)(2). For the full timeline, see Georgia Medicaid MCO enrollment and disenrollment.

When you enroll in managed care, DCH and the CMO coordinate continuity of care: honoring existing provider relationships during the transition, continuing active prior authorizations, and avoiding disruption of established medication regimens.

When your delivery system changes

You can move between fee-for-service and managed care when your eligibility category changes, for example aging into the aged, blind, and disabled group, gaining long-term care needs that move you out of mandatory managed care, becoming dual-eligible, aging out of the Katie Beckett pathway the month after you turn 19, or electing or revoking tribal opt-out. DCH and DFCS coordinate the transition.

A move can disrupt care if it is not managed. Before and during a transition, notify your providers, confirm that active prior authorizations carry over, and ask DCH or the CMO about care-management support. If you move from managed care to fee-for-service, you lose the CMO's care coordination but gain access to any DCH-enrolled provider; confirm your established providers are enrolled with DCH.

Pending policy debates

Several recurring debates shape the boundary between the two systems in Georgia:

Managed long-term services and supports. Georgia's long-term care is largely fee-for-service. Whether to bring it into managed long-term services and supports (MLTSS) is a recurring debate, weighing care coordination and budget predictability against disruption for vulnerable populations.
Dual-eligible coordination. Section 1932 generally excludes dual-eligibles from mandatory Medicaid managed care, but Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) and integrated arrangements continue to evolve.
Behavioral health integration. Whether behavioral health should be carved out or integrated with physical health remains an open question.
Network adequacy enforcement. Georgia sets its own time-and-distance network standards in the Georgia Families Contract under the framework of 42 CFR 438.68. The 2024 CMS Access Final Rule (CMS-2439-F) added appointment-wait-time standards at 42 CFR 438.68(e), but they do not bind yet: states must apply them from the first managed care rating period beginning on or after July 9, 2027. Enforcing network standards across the CMOs is an ongoing focus for DCH and CMS Region IV.

Worked examples

These examples are illustrative and hypothetical, not real cases. They show how the delivery-system rules apply to common situations.

Example 1: Maria, 35, Albany, Family Medicaid

Maria is a single mother of two who qualifies for Family Medicaid through gateway.ga.gov. The family is in mandatory managed care. DCH's enrollment broker sends her the three CMO options; she checks which plans include her children's pediatrician and selects CareSource. Enrollment is effective the next month, and she uses CareSource's network for primary, specialty, and other care. She can change CMOs during her initial period, then must wait for annual open enrollment or qualify for good-cause disenrollment.

Example 2: Eleanor, 78, Atlanta, dual-eligible in long-term care

Eleanor has Medicare (primary) and Georgia Medicaid (secondary) and lives in a skilled nursing facility. Because she is dual-eligible and receiving long-term services and supports, she is not in mandatory managed care. Medicare covers her hospital and physician care; Georgia Medicaid covers her Medicare cost-sharing and her nursing facility room and board after spend-down. DCH pays the facility directly under fee-for-service. She has no CMO.

Example 3: Aisha, 32, Savannah, pregnancy

Aisha qualifies for Right from the Start Medicaid, which covers pregnant women with budget-group income at or below 220 percent of the Federal Poverty Level. She is in mandatory managed care and selects Amerigroup. The CMO coordinates her prenatal care, delivery at a contracted hospital, and postpartum care. Her coverage continues through a full 12-month postpartum period, and her newborn is enrolled as a deemed newborn.

Example 4: Tasha, 22, transitioning eligibility

Tasha has been in Georgia Families through Family Medicaid, enrolled with Peach State Health Plan. After a disabling injury she is approved for Supplemental Security Income (SSI) through the Social Security Administration, which moves her Medicaid category to aged, blind, and disabled. If she does not receive extensive long-term care, she may stay in managed care with Peach State. If she begins receiving long-term services and supports, she may move to fee-for-service, losing the CMO's coordination but gaining access to all DCH-enrolled providers. DCH and DFCS coordinate the transition and continuity of care.

Frequently Asked Questions

What is the difference between Georgia Medicaid fee-for-service and managed care?

In fee-for-service, you use DCH-enrolled providers and DCH pays each provider on published fee schedules. In managed care, you enroll with a Care Management Organization (CMO), use its contracted network, and the CMO pays providers on negotiated rates while DCH pays the CMO a fixed monthly amount per member.

Which Georgia Medicaid populations are in managed care, and which are in fee-for-service?

Most non-disabled children, parents, and pregnant women are in mandatory managed care through Georgia Families (Family Medicaid, Right from the Start Medicaid, TANF Medicaid, and PeachCare for Kids). Most aged, blind, and disabled adults on long-term services and supports, most dual-eligibles, some Katie Beckett enrollees, people in retroactive or presumptive eligibility, and American Indian and Alaska Native beneficiaries who have not voluntarily enrolled with a CMO are in fee-for-service.

What are the CMOs in Georgia?

As of 2026, Georgia Families has three current CMOs: Amerigroup Community Care, CareSource, and Peach State Health Plan. Each operates statewide. WellCare and Wellpoint are not current separate Georgia Families CMOs.

How do I find out which delivery system I am in?

Review your eligibility notice from DFCS, log in at gateway.ga.gov, or call the Georgia Department of Human Services Customer Contact Center at 1-877-423-4746, Monday through Friday, 8 a.m. to 5 p.m.

What is a carve-out service?

A carve-out is a service delivered through fee-for-service or a separate vendor even for managed care members. In Georgia, carve-outs include long-term services and supports, some behavioral health (through DBHDD), and statewide non-emergency medical transportation (Verida). Pharmacy is not one of them for CMO members: OptumRx is the pharmacy benefits manager for the fee-for-service population, while a CMO member's pharmacy benefit and drug list come from their own plan or its subcontracted PBM.

How do appeals differ between the two systems?

For a fee-for-service denial, request reconsideration from DCH and a state fair hearing under 42 CFR Part 431 Subpart E. For a managed care denial, file the CMO's internal appeal within 60 calendar days of the denial notice. That one internal appeal is the step you must exhaust; after the plan upholds the denial you have the state's 90-to-120-day window to request a state fair hearing. The fair-hearing right applies in both systems.

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References

Cited in this article

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U.S. Government Publishing Office. (n.d.). 42 CFR 438.408(f) — Requirements for State fair hearings (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408
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U.S. Government Publishing Office. (n.d.). 42 CFR 438.402 — General requirements: Grievance and appeal system (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/section-438.402
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Also reviewed

U.S. Government Publishing Office. (n.d.). 42 CFR §438.8 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-A/section-438.8
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