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Every Medicaid beneficiary in Georgia receives services through one of two fundamentally different delivery systems. The first is fee-for-service (FFS), in which the beneficiary uses the Department of Community Health's directly enrolled provider network and DCH pays each provider based on the published Medicaid fee schedule. The second is managed care, in which the beneficiary is enrolled with one of four Care Management Organizations (Amerigroup, CareSource, Peach State, or Wellpoint) and the CMO uses its negotiated contracted provider network to deliver services, with DCH paying the CMO a monthly capitation amount per enrolled member rather than per service. The choice of delivery system is determined by federal law (Section 1932 of the Social Security Act and the populations it excludes from mandatory managed care under Section 1932(a)(2)), state implementation (DCH's specific choices about which Georgia populations are in managed care, voluntary, or excluded), and individual circumstances (eligibility group, service needs, geographic location). Understanding which delivery system applies is one of the most consequential operational facts in Medicaid because it shapes the provider network, payment methodology, prior authorization processes, appeals procedures, care coordination, and value-added services that determine the practical experience of receiving care. This guide translates the dual delivery system framework so families, advocates, and providers can understand which system applies to which beneficiary, how transitions between systems operate, and why the distinction matters for the day-to-day reality of Medicaid in Georgia. :::
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Key takeaways
- Federal law under Section 1902(a)(23) of the Social Security Act establishes freedom of choice as the default rule in Medicaid, but Section 1932 (added by the Balanced Budget Act of 1997) authorizes states to require managed care enrollment for most populations through state plan amendments rather than waivers.
- Section 1932(a)(2) excludes certain populations from mandatory managed care enrollment including dual-eligibles in some scenarios, American Indian and Alaska Native populations with opt-out rights under Section 1932(h), special needs children meeting specific criteria, children in foster care or out-of-home placement, and children receiving Adoption Assistance under Title IV-E.
- 42 CFR Part 438 provides the comprehensive federal regulatory framework governing Medicaid managed care including enrollment, disenrollment, network adequacy, quality, beneficiary protections, rate-setting, and the Medical Loss Ratio.
- Georgia Families is the program name for Georgia's mandatory managed care arrangement, serving the majority of Georgia Medicaid beneficiaries. The four CMOs are Amerigroup, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia.
- Georgia places most non-disabled adults, children, parents, and pregnant women in mandatory managed care through Georgia Families. Most aged, blind, and disabled adults receiving long-term services and supports remain in fee-for-service, along with some Katie Beckett enrollees, beneficiaries in retroactive or presumptive eligibility, and tribal beneficiaries who exercise opt-out rights.
- Even within managed care, certain services are carved out and delivered through fee-for-service or alternative arrangements. Historically Georgia has had complex carve-out arrangements for behavioral health (involving the Department of Behavioral Health and Developmental Disabilities), and arrangements for dental, vision, and pharmacy have evolved over time.
- In fee-for-service, providers are paid based on DCH's published fee schedules; in managed care, providers are paid based on CMO-negotiated rates, with state-directed payments under 42 CFR 438.6(c) sometimes establishing minimum payment levels.
- Prior authorization is conducted by DCH in fee-for-service and by the CMO in managed care, with different operational processes and appeal pathways.
- Appeals in fee-for-service go through DCH; appeals in managed care go through the CMO first (internal appeal and external review) before reaching state fair hearing under 42 CFR Part 431 Subpart E.
- Care coordination is largely the beneficiary's responsibility in fee-for-service but is actively provided by CMOs in managed care through care managers, disease management programs, transitions of care coordination, and value-added services. :::
What this framework is and why it matters
Medicaid does not deliver care directly. It pays for care delivered by providers. The mechanism by which Medicaid pays for that care defines the delivery system, and the choice of delivery system has profound implications for every aspect of how beneficiaries experience Medicaid.
In fee-for-service, the relationship between the beneficiary and the provider is direct. The beneficiary chooses any provider enrolled with DCH Medicaid. The provider delivers care. The provider bills DCH directly. DCH pays based on the published Medicaid fee schedule. This is a simple, transparent model with broad provider choice but limited care coordination.
In managed care, the relationship is mediated by a Care Management Organization. The beneficiary is enrolled with a specific CMO (one of four in Georgia). The CMO maintains a contracted provider network. The beneficiary chooses a provider from that network. The provider delivers care. The provider bills the CMO. The CMO pays based on negotiated rates. The state pays the CMO a monthly capitation amount per enrolled member rather than per service. This is a more complex model with care coordination, value-added services, and provider network management but constrained provider choice and additional administrative layers.
For Georgia families, the practical difference between these two models is enormous. Beneficiaries in managed care interact with the CMO for member services, prior authorization, care coordination, and value-added services. Beneficiaries in fee-for-service interact with DCH directly. The same eligibility status can mean a completely different experience depending on the delivery system.
For providers, the choice between participating in fee-for-service, contracting with one or more CMOs, or both, shapes their administrative burden, payment, and patient access. For DCH and policy stakeholders, the balance between fee-for-service and managed care shapes total Medicaid spending, quality oversight, and the operational complexity of program administration.
Federal statutory framework
Section 1902(a)(23) freedom of choice
Section 1902(a)(23) of the Social Security Act generally requires that Medicaid beneficiaries have freedom of choice among qualified providers. This is the default rule in Medicaid: any willing and qualified provider must be able to serve any eligible beneficiary.
Mandatory managed care enrollment is an exception to this default rule, requiring specific federal authority.
Section 1932 managed care state plan authority
Section 1932 of the Social Security Act, added by the Balanced Budget Act of 1997, authorizes states to require managed care enrollment for most Medicaid populations through state plan amendments rather than waivers. Before Section 1932, mandatory managed care typically required Section 1915(b) waivers, which involve a more burdensome federal approval process.
Section 1932 was a major modernization of the federal managed care framework, recognizing that managed care had become a mainstream delivery model and that waivers were no longer necessary for most managed care arrangements.
Key Section 1932 provisions include:
Section 1932(a)(1) authorizes mandatory managed care enrollment for most populations through state plan authority.
Section 1932(a)(2) lists excluded populations who cannot be required to enroll in managed care under state plan authority.
Section 1932(a)(3) establishes enrollment and disenrollment procedures including choice periods, auto-assignment, and good-cause disenrollment.
Section 1932(a)(4) allows enrollment broker activities to assist beneficiaries with CMO selection.
Section 1932(b) establishes managed care plan requirements including provider participation, quality, and member services.
Section 1932(h) addresses tribal opt-out rights for American Indian and Alaska Native populations.
Section 1932(a)(2) excluded populations
Section 1932(a)(2) lists populations excluded from mandatory managed care enrollment:
Dual-eligibles in some scenarios. Beneficiaries entitled to Medicare and Medicaid (dual-eligibles) cannot be required to enroll in Medicaid managed care under Section 1932 state plan authority in certain scenarios. Medicare is the primary payer for most dual-eligible health services, which complicates Medicaid managed care.
American Indian and Alaska Native populations. Under Section 1932(h), AI/AN beneficiaries have opt-out rights from mandatory managed care. They may choose to remain in fee-for-service to maintain their relationship with Indian Health Service or Tribal facilities.
Special needs children meeting specific criteria. Certain children with specialized health needs may be excluded from mandatory managed care.
Children in foster care or out-of-home placement. Children under the supervision of state child welfare agencies are excluded.
Children receiving Adoption Assistance under Title IV-E. Adoption-assistance-eligible children are excluded.
States may include these excluded populations in voluntary managed care or in managed care under Section 1115 demonstration authority. Many states have moved excluded populations into managed care through Section 1115 demonstrations to achieve coordination benefits while preserving the underlying federal exclusion.
Section 1903(m) managed care FFP
Section 1903(m) conditions federal financial participation in managed care on actuarially sound capitation rates and compliance with managed care requirements. This is the federal financial authority for managed care payments.
Section 1915(b) waiver authority
Section 1915(b) provides alternative waiver authority for managed care arrangements. Section 1915(b) waivers allow states to:
- Waive freedom of choice (mandatory managed care)
- Use cost savings for additional services
- Limit provider participation
- Use selective contracting
Some states have used 1915(b) waivers; Georgia primarily uses Section 1932 state plan authority for Georgia Families.
Section 1115 demonstration authority
Section 1115 of the Social Security Act allows the Secretary of HHS to approve demonstration projects that test innovative approaches to Medicaid. Many states use Section 1115 demonstrations to:
- Include excluded populations in managed care
- Test innovative payment arrangements
- Implement value-based delivery models
- Expand eligibility or benefits in budget-neutral ways
Section 1937 alternative benefit plans
Section 1937 of the Social Security Act allows states to offer alternative benefit plans (ABPs) for certain populations. ABPs can be delivered through managed care or fee-for-service.
Federal regulations
42 CFR Part 438 managed care framework
42 CFR Part 438 is the comprehensive federal regulation governing Medicaid managed care. Key sections:
- 438.50 mandatory enrollment authority and state plan requirements
- 438.52 enrollment requirements including choice periods
- 438.54 enrollment broker activities
- 438.56 disenrollment procedures including good-cause disenrollment
- 438.70 carve-out services
- 438.71 information requirements for beneficiaries and providers
- 438.114 emergency services requirements
- 438.4-438.8 rate-setting, contract requirements, and MLR
42 CFR 438.70 carve-out services
42 CFR 438.70 allows states to carve out specific services from managed care for delivery through fee-for-service or alternative arrangements. Common carve-outs include:
- Behavioral health (in some states; integrated in others)
- Dental services
- Long-term services and supports
- Pharmacy benefits (in some states)
- Specific specialty services
Carve-outs are a major source of complexity because beneficiaries enrolled in managed care for medical services may simultaneously be in fee-for-service for carve-out services.
42 CFR Part 440 services
42 CFR Part 440 governs Medicaid covered services. Both fee-for-service and managed care must cover the mandatory services and any optional services included in the state plan.
42 CFR 440.230 amount, duration, scope
42 CFR 440.230 requires that services be sufficient in amount, duration, and scope to reasonably achieve their purpose. This applies in both fee-for-service and managed care. CMOs cannot reduce services below what the State Plan would provide in fee-for-service.
42 CFR Part 447 payment
42 CFR Part 447 governs payment in fee-for-service. Managed care payment is governed by 42 CFR Part 438.
Federal guidance
CMS 2016 Medicaid Managed Care Final Rule
The 2016 Managed Care Final Rule (CMS-2390-F) modernized the managed care framework including:
- Network adequacy standards
- Quality requirements
- Beneficiary protections
- Rate setting refinements
- MLR application to Medicaid managed care
CMS 2020 Medicaid Managed Care Final Rule
The 2020 Final Rule (CMS-2408-F) refined certain managed care requirements including:
- Grievance and appeals procedures
- Network adequacy clarifications
- Provider payment arrangements
- Pass-through payment limitations
CMS 2024 Medicaid Managed Care Access Final Rule
The 2024 Access Final Rule strengthened access standards including:
- Appointment wait time standards
- Provider directory accuracy
- Network adequacy enforcement
- Member experience surveys
- Public reporting of access data
CMS State Medicaid Director Letters
Various State Medicaid Director Letters provide guidance on managed care implementation including carve-out arrangements, network adequacy, beneficiary protections, and value-based payment.
Fee-for-Service mechanics
How fee-for-service works
In fee-for-service, services are delivered through a direct relationship between the beneficiary and the provider:
- Beneficiary seeks care from a provider enrolled with DCH Medicaid
- Provider delivers services
- Provider submits claim to DCH or DCH's fiscal agent (the claims processing contractor)
- DCH pays the provider based on the published Medicaid fee schedule
- Beneficiary may have minimal or no cost-sharing depending on eligibility group
DCH fee-for-service provider network
The fee-for-service network consists of all providers enrolled with DCH Medicaid. Providers enroll through DCH's provider enrollment system, which requires:
- Verification of provider credentials and licensure
- Background checks
- Acceptance of Medicaid as payment in full
- Agreement to comply with billing and documentation requirements
- Cooperation with audits and program integrity activities
- Compliance with state and federal Medicaid rules
Providers can be:
- Individual practitioners (physicians, nurse practitioners, mental health professionals)
- Group practices
- Hospitals and health systems
- Federally Qualified Health Centers (FQHCs)
- Rural Health Clinics (RHCs)
- Pharmacies
- Long-term care facilities
- Home health agencies
- Other Medicaid-eligible provider types
DCH fee schedules
DCH publishes fee schedules for each service category. Fee schedules establish the maximum payment for each procedure code. Updates are made periodically based on:
- State budget appropriations
- Federal requirements
- Provider payment access concerns
- Specific policy initiatives
Fee schedules are typically lower than commercial insurance and Medicare rates, which creates payment access concerns for some specialties and creates financial pressure on safety-net providers.
Prior authorization in fee-for-service
DCH conducts prior authorization for fee-for-service services where required. Common PA requirements:
- Inpatient admissions (with concurrent review during the stay)
- Certain surgical procedures
- Durable medical equipment above defined cost thresholds
- Some medications (PA list maintained by DCH pharmacy benefit administration)
- Long-term care services
- Specialty services
Prior authorization decisions can be appealed through DCH processes.
Appeals in fee-for-service
For fee-for-service service denials, beneficiaries can:
- Request reconsideration from DCH
- Request a state fair hearing under 42 CFR Part 431 Subpart E
- Coordinate with DCH Member Services for assistance
State fair hearing rights are robust and provide due process protection for beneficiaries.
Care coordination in fee-for-service
Fee-for-service provides limited care coordination compared to managed care. Beneficiaries are largely responsible for:
- Navigating provider relationships
- Scheduling appointments
- Coordinating across specialists
- Managing transitions of care
- Tracking medication regimens
- Following up on referrals
DCH does not assign a primary care provider or care manager in traditional fee-for-service. Some FFS beneficiaries may receive care coordination through specific programs (LTSS case management, certain demonstration projects), but the default is limited coordination.
Managed Care mechanics
How managed care works
In managed care, services are delivered through the Care Management Organization framework:
- Beneficiary is enrolled with a CMO
- CMO receives a monthly capitation payment from DCH per enrolled member
- Beneficiary seeks care from a provider in the CMO's network
- Provider delivers services
- Provider submits claim to the CMO
- CMO pays the provider based on the CMO's negotiated contract
- CMO operates within federal managed care rules and state contract requirements
Georgia Families program
Georgia Families is the program name for Georgia's mandatory managed care arrangement and serves the majority of Georgia Medicaid beneficiaries.
Four Care Management Organizations
Georgia contracts with four CMOs to deliver Georgia Families:
Amerigroup. Operates statewide.
CareSource Georgia. A nonprofit organization that operates Medicaid and other government-sponsored plans in multiple states. Operates statewide in Georgia.
Peach State Health Plan. Operates statewide.
Wellpoint Georgia. Operates statewide.
Each CMO operates statewide, so most beneficiaries can choose any of the four during enrollment.
CMO network
Each CMO maintains a network of contracted providers. Networks can vary in size and composition between CMOs. Federal network adequacy standards (strengthened by the 2024 Access Final Rule) require CMOs to maintain networks sufficient to:
- Provide timely access to primary care, specialty care, and behavioral health
- Maintain reasonable appointment wait times
- Include providers in geographic proximity to members
- Include providers serving members with limited English proficiency
- Include providers serving members with disabilities
Beneficiaries access in-network providers for most services. Out-of-network services are typically not covered except for emergency services (which must be covered regardless of network status under 42 CFR 438.114) and certain other situations.
CMO provider payment
CMOs negotiate payment rates with network providers. Rates can be:
- Fee-for-service at negotiated amounts (often based on Medicaid fee schedules with modifications)
- Per-diem (for hospital stays)
- Bundled payments (for episodes like maternity care or joint replacement)
- Value-based arrangements (shared savings, episode bundles, performance bonuses)
- Capitation (for primary care medical homes)
State-directed payments under 42 CFR 438.6(c) often require minimum payment levels for hospitals and certain providers, ensuring that CMO negotiation does not drive payment below sustainable levels.
Prior authorization in managed care
CMOs conduct prior authorization within their utilization management framework. PA requirements are CMO-specific but generally similar across CMOs (because all CMOs must cover State Plan services).
PA decisions can be appealed through CMO appeals processes (internal appeal, external review through an independent review organization, and state fair hearing).
Appeals in managed care
For managed care service denials, beneficiaries can:
- Request internal appeal from the CMO (the CMO reconsiders the decision)
- Request external review by an independent review organization (a CMO-independent entity reviews the medical necessity decision)
- Request a state fair hearing (DCH-administered hearing with full due process)
- File grievances about CMO operations (separate from appeals)
The federal grievance and appeals framework under 42 CFR 438.400 et seq. governs these procedures.
Care coordination in managed care
CMOs provide care coordination through:
Care managers. Telephonic and in-person care managers for members with complex needs.
Disease management programs. Programs for chronic conditions including diabetes, asthma, hypertension, heart failure, and chronic kidney disease.
Transitions of care coordination. Coordination of care during transitions between care settings (hospital to home, hospital to skilled nursing facility, nursing facility to home).
Behavioral health integration. Where applicable, integration of behavioral health with physical health.
Social determinants of health programs. Programs addressing housing instability, food insecurity, and other social determinants.
Pharmacy coordination. Medication therapy management, pharmacy lock-in for high-utilization patterns, and other pharmacy-focused coordination.
Value-added services
CMOs typically offer value-added services beyond the State Plan, including:
- Health rewards programs (incentives for healthy behaviors)
- Smoking cessation support
- Weight management programs
- Vision exams beyond State Plan
- Over-the-counter medication allowances
- Transportation beyond NEMT
- Mobile clinics in some communities
- Telehealth platforms
- Member education resources
Value-added services are constrained by federal rules (services must not be billed as medical claims and must comply with MLR rules), but represent a competitive differentiator among CMOs.
Georgia implementation
Mandatory managed care populations
DCH places the following populations 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 covered through an income-based Medicaid eligibility threshold.
TANF Medicaid. Low-income families receiving Temporary Assistance for Needy Families.
PeachCare for Kids. CHIP children in households above Medicaid eligibility but within CHIP limits.
Some categorically eligible populations. Specific eligibility groups designated for mandatory managed care.
Fee-for-service populations
DCH maintains fee-for-service for several populations:
Most aged, blind, and disabled adults receiving long-term services and supports. Adults receiving nursing facility care or extensive home and community-based waiver services are largely fee-for-service.
Most dual-eligibles. Beneficiaries entitled to both Medicare and Medicaid, with Medicare as primary payer.
Some Katie Beckett enrollees. Katie Beckett provides Medicaid for children with significant disabilities living at home. Some enrollees are in managed care; others are in fee-for-service depending on specific circumstances.
Beneficiaries in retroactive eligibility periods. Medicaid coverage can be retroactively granted for the three months prior to application. During the retroactive period, coverage is typically fee-for-service.
Beneficiaries in presumptive eligibility periods. Presumptive eligibility (for pregnant women through hospitals and clinics) operates as fee-for-service until full eligibility is determined.
Beneficiaries during transitional eligibility before managed care enrollment is effective. A brief fee-for-service period typically occurs between eligibility determination and managed care enrollment effective date.
Tribal beneficiaries who exercise opt-out rights under Section 1932(h). AI/AN beneficiaries can opt out of mandatory managed care to maintain relationships with IHS or Tribal facilities.
Some specialized eligibility groups. Including Medicare Savings Programs (which pay Medicare premiums and cost-sharing but do not provide full Medicaid coverage).
Carve-out services
Even for managed care members, certain services are carved out and delivered through fee-for-service or alternative arrangements. Georgia carve-out arrangements have evolved over time:
Behavioral health. Georgia has historically had complex behavioral health arrangements involving the Department of Behavioral Health and Developmental Disabilities (DBHDD). Some services are integrated into managed care; others remain in DBHDD or fee-for-service arrangements. The specific arrangements should be verified through DCH for current configuration.
Pharmacy. Pharmacy services have evolved between fee-for-service and managed care arrangements over time. The arrangement affects how prescription drugs are obtained and how providers and pharmacies interact with the system.
Long-term services and supports. Long-term care services including nursing facility services and home and community-based waiver services are largely fee-for-service for most beneficiaries.
Dental. Dental services are delivered through specific arrangements that may differ from medical managed care.
Vision. Vision services arrangements may differ from medical managed care.
Transitions between fee-for-service and managed care
Beneficiaries can transition between fee-for-service and managed care when:
- Eligibility status changes (e.g., aging into ABD, gaining LTSS needs that move them out of mandatory managed care)
- Geographic relocation between Georgia and other states
- Change in family composition affecting eligibility group
- Tribal opt-out election or revocation
- Loss of Medicare entitlement (changing dual-eligible status)
- Other circumstances triggering eligibility recategorization
Transitions are managed through DCH and DFCS coordination. Continuity of care provisions help reduce disruption during transitions.
Enrollment process
For mandatory managed care populations:
- Eligibility is determined by DFCS through Georgia Gateway (gateway.ga.gov)
- Beneficiary is referred to enrollment in Georgia Families
- DCH enrollment broker provides choice counseling about CMO options
- Beneficiary has a choice period to select a CMO from the four options
- If no choice is made by the end of the choice period, auto-assignment algorithm assigns a CMO
- Enrollment is effective at the next month transition
- Beneficiary has an initial enrollment period after enrollment to change CMOs for any reason
- After the initial change period, annual open enrollment is the primary opportunity to change CMOs (typically once per year)
- Outside open enrollment, good-cause disenrollment is available under 42 CFR 438.56(d)(2) for specific circumstances
Auto-assignment algorithm
The auto-assignment algorithm considers:
- Family member CMO if applicable (keeping families together)
- Previous CMO if recently enrolled (preserving continuity)
- Provider continuity considerations (preserving existing provider relationships when possible)
- Algorithm distribution among the four CMOs (preventing concentration in any one plan)
Continuity of care
When beneficiaries enroll in managed care, DCH and CMOs coordinate to:
- Honor existing provider relationships during transition (typically for at least the first 90 days)
- Continue existing prior authorizations
- Coordinate transitions of care for ongoing services
- Avoid disruption of established medication regimens
- Maintain access to established specialists
CMO contracts with DCH
DCH contracts with each CMO include:
- Capitation rate methodology and rates by rate cell
- Network adequacy requirements
- Quality requirements including HEDIS, CAHPS, and EQRO standards
- Reporting requirements (encounter data, MLR, financial reports)
- Compliance and oversight provisions
- State-directed payment requirements
- MLR requirements under 42 CFR 438.8
CMS Region IV oversight
CMS Region IV (Atlanta) oversees Georgia's managed care implementation including state plan amendments authorizing mandatory managed care, rate certifications by the state actuary, contract reviews, and compliance with federal managed care rules under 42 CFR Part 438.
Practical implications for Georgia families
Knowing which delivery system applies is essential
The first practical question for any Georgia Medicaid beneficiary is: which delivery system applies to me? This determines:
- Which provider network you can use
- Which member services number to call
- Which appeals process to follow
- What care coordination is available
- What value-added services may be available
- How to handle prior authorization
Beneficiaries can verify their delivery system status by:
- Reviewing eligibility correspondence from DFCS
- Checking gateway.ga.gov member portal
- Calling DCH Member Services
- Calling their CMO if they know which CMO they are enrolled with
Fee-for-service provides freedom but limited coordination
In fee-for-service, beneficiaries have access to any DCH-enrolled provider but limited care coordination. This works well for beneficiaries who:
- Have established provider relationships
- Can self-manage their care
- Have specialized needs requiring providers who may not be in any single CMO network
- Prefer maximum provider choice
Managed care provides coordination but network constraints
In managed care, beneficiaries have active care coordination and value-added services but are constrained to the CMO's network. This works well for beneficiaries who:
- Benefit from care management
- Have chronic conditions that benefit from disease management programs
- Value the additional services offered beyond State Plan
- Are willing to use in-network providers
Carve-outs add complexity
Carve-out services mean that even managed care members may interact with fee-for-service or alternative arrangements for specific services. For example, a managed care member may use the CMO for primary and specialty care but receive behavioral health services through DBHDD or fee-for-service arrangements, and long-term care services if applicable through fee-for-service.
Understanding which services are managed care versus carve-out is essential, particularly for beneficiaries with behavioral health, dental, or long-term care needs.
Transitions can disrupt care
Transitions between fee-for-service and managed care, or between CMOs, can disrupt established care if not managed well. Beneficiaries should:
- Notify providers of delivery system changes
- Verify that ongoing prior authorizations are honored
- Coordinate with DCH or CMO care management
- Use the initial choice period strategically when first enrolling
- Use good-cause disenrollment if needed for specific circumstances
Appeals processes differ
Fee-for-service appeals go through DCH directly; managed care appeals go through the CMO first (internal appeal and external review) before reaching state fair hearing. Knowing the appropriate appeals process for your specific service denial is important for preserving rights and meeting deadlines.
For both delivery systems, the state fair hearing right under 42 CFR Part 431 Subpart E provides ultimate due process protection.
Pending policy debates
LTSS managed care expansion
Some states have expanded managed care to include long-term services and supports (often called Managed Long-Term Services and Supports, or MLTSS). Georgia's LTSS is largely fee-for-service. Whether to expand managed care to LTSS is a recurring policy discussion with implications for hundreds of thousands of beneficiaries and a large share of Medicaid spending. Arguments for MLTSS include care coordination benefits and budget predictability; arguments against include disruption of established LTSS arrangements and complexity for vulnerable populations.
Dual-eligible managed care
Coordination of dual-eligible coverage between Medicare and Medicaid is complex. Section 1932 generally excludes duals from mandatory Medicaid managed care, but Medicare Advantage Special Needs Plans (D-SNPs) and integrated care arrangements have evolved. Georgia has explored dual-eligible coordination options.
Behavioral health integration
Whether behavioral health should be carved out (delivered separately from physical health) or integrated (delivered within managed care alongside physical health) is a continuous policy debate. Integration can improve coordination of behavioral and physical health; separation can preserve specialized behavioral health expertise and provider relationships.
Georgia's specific behavioral health arrangements have evolved over time and should be verified through current DCH and DBHDD information.
Pharmacy benefit administration
The administration of pharmacy benefits within or outside managed care is evolving. PBM (pharmacy benefit manager) arrangements, transparency requirements, spread pricing rules, and 340B coordination are continuing policy areas with significant financial implications.
Network adequacy enforcement
The 2024 Access Final Rule strengthened network adequacy standards including specific appointment wait time standards. Enforcement of these standards across the four CMOs is an ongoing focus area for DCH and CMS Region IV.
Value-added services scope
The scope of value-added services CMOs can offer is constrained by federal rules (services must not be billed as medical claims and must comply with MLR rules). CMOs continually expand value-added offerings within these constraints, and the boundary between value-added services and standard managed care is an evolving area.
Worked examples
Example 1: Maria 35 Albany family Medicaid
Maria is a 35-year-old single mother with two children (ages 8 and 11) living in Albany. She works part-time at a retail job and applies for Medicaid for herself and her children through gateway.ga.gov.
DFCS approves her application: Maria qualifies for Family Medicaid based on her income and household composition; both children qualify for Medicaid as well. The family is in the mandatory managed care population.
DCH enrollment broker contacts Maria with information about the four CMOs (Amerigroup, CareSource, Peach State, Wellpoint). Maria reviews the CMO information packets during her choice period, considers which CMOs have her children's pediatrician in network, and selects CareSource Georgia.
Enrollment is effective the following month. Maria and her children are now in managed care through CareSource. They use CareSource's provider network for primary care, specialty care, behavioral health (subject to any carve-out arrangements), and other services. CareSource provides care coordination for the children's pediatric needs.
Maria has an initial enrollment period to change CMOs if she wishes. After that period, she would need to wait for annual open enrollment or qualify for good-cause disenrollment.
Example 2: Eleanor 78 Atlanta dual-eligible LTSS
Eleanor is 78 years old, lives in Atlanta, and is dual-eligible: she has Medicare (primary coverage) and Georgia Medicaid (secondary coverage). Two years ago, her health declined and she moved into a skilled nursing facility for long-term care.
For Eleanor's healthcare:
Medicare is primary. Medicare covers her hospital and physician services, with traditional Medicare fee-for-service payment methodology.
Medicaid is secondary. Georgia Medicaid covers her Medicare cost-sharing (Part A coinsurance, Part B coinsurance) and any benefits not covered by Medicare. Most importantly, Georgia Medicaid covers her nursing facility room-and-board after she has spent down her assets to Medicaid limits.
Eleanor is in fee-for-service for Medicaid. Because she is dual-eligible and receiving long-term services and supports, she is not in mandatory managed care under Section 1932(a)(2). DCH directly pays the nursing facility for Medicaid-covered services using FFS payment methodology.
Eleanor interacts with:
- The nursing facility for daily care
- Her Medicare-participating physicians for ongoing medical care
- DCH for any Medicaid-specific questions or coverage issues
- DFCS for eligibility renewal (annual redetermination)
She does not have a CMO and does not interact with managed care infrastructure for her Medicaid coverage.
Example 3: Jamil 8 Newport Katie Beckett
Jamil is an 8-year-old child with cerebral palsy and complex medical needs. He lives at home with his parents in Newport. He is enrolled in Medicaid through the Katie Beckett pathway, which provides Medicaid for children with significant disabilities living at home without regard to parental income.
Jamil's delivery system depends on his specific circumstances:
For physical health services. Jamil may be in managed care or fee-for-service depending on specific Katie Beckett arrangements. Some Katie Beckett enrollees are in managed care with specialized care coordination; others remain in fee-for-service.
For long-term services and supports. Personal care services, durable medical equipment, and specialized therapies under Katie Beckett may be delivered through fee-for-service with case management.
For Medicaid waiver services. If Jamil receives services through a Medicaid waiver in addition to Katie Beckett, waiver services have their own delivery arrangements.
Jamil's parents interact with multiple entities to coordinate his care, which can be complex. They typically have a case manager who helps navigate the system. The specific delivery system arrangements should be verified through DCH and the Katie Beckett program.
Example 4: Marcus 45 ABD adult
Marcus is 45 years old, has end-stage renal disease requiring dialysis, and is enrolled in Medicaid through the Aged, Blind, and Disabled (ABD) eligibility pathway. He receives dialysis three times per week and has multiple comorbidities.
Marcus's situation depends on several factors:
If Marcus is not receiving extensive long-term services and supports. He may be in managed care through Georgia Families. The CMO would coordinate his care including dialysis (which may be carved out under specific arrangements), specialty care, and primary care.
If Marcus is receiving extensive long-term services and supports. He may be in fee-for-service with DCH directly paying for his services.
If Marcus is dual-eligible (under Medicare). Adults with end-stage renal disease qualify for Medicare. If Marcus has Medicare in addition to Medicaid, Medicare is primary and Medicaid is secondary. He would not be in mandatory Medicaid managed care.
Marcus's specific delivery system arrangements should be verified through DCH or his CMO if applicable. His high-cost care patterns (frequent dialysis, specialty care, hospitalizations) make care coordination particularly important regardless of delivery system.
Example 5: Aisha 32 Savannah pregnancy
Aisha is 32 years old, lives in Savannah, and recently became pregnant. She applies for Medicaid through gateway.ga.gov and qualifies for Right from the Start Medicaid (RSM), which provides Medicaid for pregnant women up to 220 percent of federal poverty level.
Aisha is in the mandatory managed care population. She selects Amerigroup as her CMO and is enrolled effective the following month.
For her pregnancy care:
Prenatal care. Amerigroup coordinates her prenatal visits with an in-network obstetrician. The CMO may provide a pregnancy care manager who supports Aisha through her pregnancy.
Delivery. Aisha delivers at an Amerigroup-contracted hospital. The CMO pays the hospital under their negotiated arrangement, which may include a maternity bundle payment.
Postpartum care. Georgia provides extended postpartum Medicaid coverage for new mothers. Aisha continues with Amerigroup during the postpartum period.
Newborn coverage. Aisha's baby is automatically enrolled in Medicaid as a deemed newborn for the first year. The baby may be enrolled with Amerigroup or assigned to another CMO depending on family member CMO and other auto-assignment factors.
Aisha experiences active care coordination throughout her pregnancy and postpartum period, with the CMO providing maternal health support, transitions of care, and value-added services like over-the-counter medication allowances.
Example 6: Tasha transitioning eligibility status
Tasha is a 22-year-old single mother who has been in Georgia Families for two years through Family Medicaid. She is enrolled with Peach State Health Plan and has established a relationship with her primary care provider in Peach State's network.
Tasha experiences a medical emergency leading to a serious disability that prevents her from working. She applies for SSI through the Social Security Administration and is approved. With SSI eligibility, Tasha's Medicaid category changes from Family Medicaid to Aged, Blind, and Disabled (ABD) Medicaid.
Depending on whether Tasha receives long-term services and supports, her delivery system may change:
If Tasha does not receive extensive LTSS. She may remain in managed care through Peach State, with eligibility category changed but managed care continued.
If Tasha begins receiving LTSS. She may transition from managed care to fee-for-service to align with Georgia's LTSS delivery arrangement.
If Tasha transitions to fee-for-service:
- She loses access to Peach State's care coordination
- She must navigate the FFS provider network directly
- Her established primary care provider may or may not be enrolled with DCH FFS (most providers are, but verification is important)
- She gains the freedom of choice across all DCH-enrolled providers
DCH and DFCS coordinate the transition. Continuity of care provisions help reduce disruption, but Tasha may experience administrative friction during the transition. She may benefit from working with her primary care provider, a social worker, or DCH Member Services to manage the transition effectively.
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Frequently asked questions
What is the difference between fee-for-service and managed care?
In fee-for-service, the beneficiary uses DCH-enrolled providers and DCH pays each provider based on published fee schedules. In managed care, the beneficiary is enrolled with a Care Management Organization (CMO), uses the CMO's contracted network, and the CMO pays providers based on negotiated rates. DCH pays the CMO a monthly capitation amount per enrolled member rather than per service.
Which Georgia Medicaid populations are in managed care?
Most non-disabled adults, children, parents, and pregnant women are in mandatory managed care through Georgia Families. This includes Family Medicaid, Right from the Start Medicaid (pregnancy), TANF Medicaid, and PeachCare for Kids (CHIP).
Which Georgia Medicaid populations are in fee-for-service?
Populations excluded from mandatory managed care under Section 1932(a)(2) and Georgia's specific implementation include most aged, blind, and disabled adults receiving long-term services and supports, most dual-eligibles, some Katie Beckett enrollees, beneficiaries in retroactive or presumptive eligibility, and tribal beneficiaries who exercise opt-out rights under Section 1932(h).
What is Section 1932?
Section 1932 of the Social Security Act, added by the Balanced Budget Act of 1997, authorizes states to require managed care enrollment for most Medicaid populations through state plan amendments rather than waivers. Section 1932(a)(2) excludes certain populations from mandatory managed care.
What are the four CMOs in Georgia?
Amerigroup (Elevance Health), CareSource Georgia, Peach State Health Plan (Centene), and Wellpoint Georgia. Each operates statewide. Beneficiaries can typically choose any of the four during enrollment.
How do I find out which delivery system I'm in?
Check your eligibility correspondence from DFCS, log into your account at gateway.ga.gov, call DCH Member Services, or call the CMO if you know which one you are enrolled with.
How do I choose a CMO?
When you are enrolled in mandatory managed care, DCH's enrollment broker provides choice counseling and information about the four CMOs. You have a choice period to select a CMO. If you don't choose within that period, the auto-assignment algorithm assigns a CMO. You also have an initial enrollment period after enrollment to change CMOs for any reason.
What is a carve-out service?
A carve-out is a service that is delivered through fee-for-service or alternative arrangements even for beneficiaries who are otherwise in managed care. Common carve-outs include behavioral health, dental, vision, long-term services and supports, and (in some arrangements) pharmacy.
Are behavioral health services in managed care?
Georgia has historically had complex behavioral health arrangements involving the Department of Behavioral Health and Developmental Disabilities (DBHDD). Some services are integrated into managed care; others are in DBHDD or fee-for-service arrangements. Specific current arrangements should be verified through DCH.
Can I change CMOs?
Yes, but with restrictions. You have an initial enrollment period to change for any reason. After that, you can change during annual open enrollment (typically once per year) or with good-cause disenrollment under 42 CFR 438.56(d)(2) for specific circumstances.
What is good-cause disenrollment?
Good-cause disenrollment allows beneficiaries to change CMOs outside the open enrollment window for specific federal-defined good-cause reasons including poor quality of care, lack of access to needed providers, lack of access in geographic area, and others. The CMO or DCH evaluates the request.
How does prior authorization differ between systems?
In fee-for-service, DCH conducts prior authorization. In managed care, the CMO conducts prior authorization. PA requirements may differ in specifics but both must cover State Plan services.
How do appeals work in fee-for-service?
For fee-for-service service denials, you can request reconsideration from DCH and request a state fair hearing under 42 CFR Part 431 Subpart E. Contact DCH Member Services for assistance.
How do appeals work in managed care?
For managed care service denials, you first request internal appeal from the CMO. If denied, you can request external review by an independent review organization. You can also request a state fair hearing. The 42 CFR Part 431 Subpart E fair hearing right applies in both delivery systems.
What care coordination is available in fee-for-service?
Care coordination is limited in fee-for-service. Beneficiaries are generally responsible for navigating their own care. Some specialized programs (LTSS case management, demonstration projects) provide care coordination for specific populations.
What care coordination is available in managed care?
CMOs provide care coordination through care managers, disease management programs for chronic conditions, transitions of care coordination, behavioral health coordination, social determinants of health programs, and pharmacy coordination.
What are value-added services?
Value-added services are services or benefits CMOs offer beyond the State Plan. Examples include health rewards programs, smoking cessation support, weight management programs, vision exams, over-the-counter medication allowances, and transportation beyond NEMT. Value-added services are constrained by federal rules but represent a competitive differentiator among CMOs.
How do tribal beneficiaries handle managed care?
Under Section 1932(h), American Indian and Alaska Native beneficiaries have opt-out rights from mandatory managed care. They can choose to remain in fee-for-service to maintain their relationship with Indian Health Service or Tribal facilities. Georgia has a small tribal footprint but the rights apply.
What happens when my eligibility status changes?
When your Medicaid eligibility category changes (e.g., aging into ABD, gaining LTSS needs, becoming dual-eligible), your delivery system may also change. DCH and DFCS coordinate the transition. Continuity of care provisions help reduce disruption.
Where can I get help understanding my delivery system?
Contact DCH Member Services, your CMO if you know which one you are enrolled with, or DFCS Customer Service. For legal assistance with delivery system issues, contact the Georgia Legal Services Program. Brevy at brevy.com provides educational information about Medicaid delivery systems. :::
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Contacts and resources
- DCH Medicaid Member Services: Contact via medicaid.georgia.gov
- Amerigroup Member Services: Contact via plan's official website
- Peach State Health Plan: Contact via plan's official website
- CareSource Georgia: Contact via plan's official website
- Wellpoint Georgia: Contact via plan's official website or DCH enrollment broker
- DCH enrollment broker: Contact through DCH main line
- DFCS Customer Service: Contact via dfcs.georgia.gov
- Georgia Gateway: gateway.ga.gov
- Georgia Department of Behavioral Health and Developmental Disabilities: For behavioral health carve-out services
- DCH Office of Managed Care: Contact through DCH main line
- AARP Georgia: Contact via aarp.org/states/ga
- 211 Georgia: Dial 211 for local resource referrals
- Georgia Legal Services Program: Contact via georgialegalaid.org
- Disability Rights Georgia: Contact via disabilityrightsga.org
- CMS Region IV (Atlanta): For federal oversight inquiries :::
Final notes
The dual delivery system framework is one of the most consequential operational facts in Georgia Medicaid. Whether a beneficiary is in fee-for-service or managed care shapes nearly every aspect of how they experience their coverage: which providers they can see, how prior authorizations are handled, how appeals operate, what care coordination is available, what value-added services may be offered, and how transitions between providers and care settings are managed.
For most Georgia Medicaid beneficiaries, the relevant question is not whether to be in managed care (the federal and state frameworks largely determine this based on eligibility category) but rather which CMO to choose, how to use the initial choice period effectively, when to invoke good-cause disenrollment, and how to navigate carve-out services like behavioral health.
For beneficiaries in fee-for-service, the relevant questions are how to find DCH-enrolled providers willing to accept Medicaid, how to coordinate care across specialists without managed care infrastructure, and how to navigate appeals through DCH directly.
For families with members in both delivery systems (for example, parents in managed care with elderly relatives in fee-for-service LTSS), the framework requires interacting with both DCH and one or more CMOs across different family members.
This guide is educational information about how Georgia's dual delivery system works. For specific questions about your delivery system status, plan options, or coverage, contact DCH Member Services or your CMO directly. For legal assistance with delivery system issues, contact the Georgia Legal Services Program. Brevy is not legal or financial advice; consult qualified professionals for specific situations.
Find personalized help navigating Georgia Medicaid at brevy.com.