Georgia Medicaid ICF/IID: Active Treatment, NOW & COMP Waivers

A Georgia ICF/IID is a Medicaid-certified residential facility that provides around-the-clock active treatment to people with intellectual disabilities. It is the institutional option for someone whose needs cannot be safely met at home, and it sits alongside Georgia's community-based NOW and COMP waivers.

Most families weighing an ICF/IID are also weighing those waivers, because Georgia's policy strongly favors community placement. This guide covers what an ICF/IID is and the active-treatment rule that defines it, who qualifies and what it costs, the NOW and COMP alternatives and their years-long Planning List, the screening that applies before a nursing-home admission, and how to apply, transition, or appeal.

What is a Georgia ICF/IID?

A Georgia ICF/IID is a Medicaid-certified residential facility that provides active treatment to people with intellectual disabilities or related conditions. The full name is Intermediate Care Facility for Individuals With Intellectual Disabilities (ICF/IID), and the benefit is defined at Section 1905(d) of the Social Security Act.

ICF/IIDs range in size from small group homes of four to eight residents to larger facilities. In Georgia, most ICF/IID capacity is in private community-based group homes; the state-operated institutional system has been substantially scaled down following the 2010 DOJ Olmstead settlement.

The ICF/IID benefit is optional under Section 1905(a)(15) of the Social Security Act. States may choose whether to include ICF/IID services in their Medicaid State Plan, and Georgia has chosen to include it. The Federal Medical Assistance Percentage (FMAP) then applies: for federal fiscal year 2026 (October 1, 2025 through September 30, 2026), the federal government pays 66.40 percent of most Georgia Medicaid expenditures, including ICF/IID care, and Georgia pays the remaining state share of about 33.60 percent.6

The defining feature of an ICF/IID is the active treatment requirement under 42 CFR 483.440. An ICF/IID must provide an active treatment program that is directed toward the acquisition of behaviors necessary for the client to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status. Custodial care alone, or supervision without programming, does not meet the active treatment standard.

Rosa's Law and the change from ICF/MR to ICF/IID

For most of the history of the Medicaid benefit, ICF/IIDs were called "Intermediate Care Facilities for the Mentally Retarded" (ICF/MR). The term "mental retardation" was the federal statutory term.

Rosa's Law (Public Law 111-256), signed October 5, 2010, replaced "mental retardation" with "intellectual disability" and "mentally retarded individuals" with "individuals with intellectual disabilities" throughout federal law. The Medicaid benefit became "Intermediate Care Facility for Individuals With Intellectual Disabilities" (ICF/IID).

Rosa's Law was named after Rosa Marcellino, a child with Down syndrome whose family advocated for the change. The substantive requirements of the benefit (the Conditions of Participation at 42 CFR Part 483 Subpart I) were unchanged. What changed was the terminology used to describe the people the benefit serves.

In Georgia, the terminology shift is reflected in DBHDD's organization (Division of Developmental Disabilities), regulatory references, and provider manuals. Some legacy documents and older citations may still use "ICF/MR"; the meaning is the same.

What rules every ICF/IID must follow (42 CFR Part 483 Subpart I)

The Conditions of Participation for ICF/IIDs are at 42 CFR Part 483 Subpart I, sections 483.400 through 483.480. Every Medicaid-certified ICF/IID must comply with all of these requirements. The Conditions of Participation are among the most detailed in all of federal Medicaid law.

42 CFR 483.400: Basis and scope

This section establishes that Subpart I implements Section 1905(d) and applies to all facilities certified as ICF/IIDs. It is the gateway to the rest of the subpart.

42 CFR 483.410: Governing body and management

Every ICF/IID must have a governing body that is legally responsible for the facility's operation. The governing body must:

• Adopt and implement a written facility plan
• Establish policies governing client services
• Designate a chief executive officer (CEO) or administrator
• Ensure compliance with applicable federal, state, and local laws

The administrator must be qualified by education and experience to operate an ICF/IID.

42 CFR 483.420: Client protections

This is one of the most consequential sections. It establishes that the facility must protect and promote the rights of each client. Rights include:

• The right to privacy and dignity
• The right to freedom from abuse, neglect, and exploitation
• The right to freedom from coercion
• The right to refuse treatment except in limited circumstances
• The right to communicate privately with persons of choice
• The right to participate in decisions affecting one's life
• The right to vote (where eligible)
• The right to manage one's own money or have it managed in trust
• The right to confidentiality of records

Communication of rights to the client must be in a form the client understands. Where the client has a representative (parent, guardian, conservator), rights flow to the client with appropriate involvement of the representative.

42 CFR 483.430: Facility staffing and the QIDP

This section governs the workforce. Every ICF/IID must employ Qualified Intellectual Disability Professionals (QIDPs) and direct care staff sufficient to meet client needs.

A QIDP is defined as a person who has at least one year of experience working directly with persons with intellectual disabilities or related conditions, and is a:

• Doctor of medicine or osteopathy
• Registered nurse
• Person holding at least a bachelor's degree in a professional category specified in the regulation, including social work, psychology, special education, occupational therapy, physical therapy, speech-language pathology, recreation therapy, nursing, or human services

The QIDP is the central professional role in an ICF/IID. Each client must have a designated QIDP responsible for:

• Integrating the work of all professionals contributing to the client's program
• Chairing the interdisciplinary team meetings
• Ensuring the Individual Program Plan (IPP) is developed and implemented
• Monitoring progress and ensuring revisions to the IPP as needed

The QIDP role is substantive, not administrative. A QIDP who only attends meetings and signs documents is non-compliant with the regulation.

Direct care staff ratios under 483.430 must be sufficient to ensure active treatment. The facility cannot have staffing so thin that active treatment is impossible.

42 CFR 483.440: Active treatment, the central requirement

This is the defining requirement of an ICF/IID. Active treatment is defined at 483.440(a):

The facility must ensure that each client receives a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services... that is directed toward (i) The acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible; and (ii) The prevention or deceleration of regression or loss of current optimal functional status.

Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

The active treatment program must be developed and supervised by an interdisciplinary team that includes:

• The client (to the extent of the client's ability to participate)
• The client's parent or guardian or other legal representative, as appropriate
• The QIDP
• Other professionals as needed: physician, psychologist, nurse, social worker, occupational therapist, physical therapist, speech-language pathologist, recreation therapist, dietitian

The interdisciplinary team must:

• Conduct a comprehensive functional assessment within 30 days of admission
• Develop an Individual Program Plan (IPP) within 30 days of admission
• Review the IPP at least annually
• Revise the IPP based on progress
• Document the client's progress toward IPP objectives

The IPP must contain specific objectives, the methods and instructional strategies to achieve them, the staff responsible for implementing the program, and a schedule for review.

Active treatment must be provided on a continuous basis, not just during designated "training time." Activities of daily living, work, recreation, community access, and skill development all become opportunities for active treatment when properly designed and implemented.

CMS surveyors and state surveyors review facility documentation, observe client interactions, and interview clients and staff to evaluate active treatment. A facility that documents an active treatment plan but does not implement it in practice will be cited.

42 CFR 483.450: Client behavior and facility practices

This section governs how the facility responds to inappropriate client behavior and uses behavioral interventions. The standards are strict:

• The facility must develop and implement written policies and procedures for managing inappropriate client behavior
• Behavioral interventions must be designed to teach replacement behaviors and skills
• Restraints (physical and chemical) and time-out procedures are heavily regulated
• Restraints may only be used as part of a written program approved by the interdisciplinary team, the physician, and the human rights committee
• Restraints may not be used as punishment, for staff convenience, or as a substitute for active treatment
• Use of restraints must be documented, monitored, and time-limited
• The least restrictive intervention must be used

Use of restraints in an ICF/IID is a serious matter that triggers reporting requirements, ongoing oversight, and review by the human rights committee.

42 CFR 483.460: Health care services

The facility must provide or arrange for comprehensive health care services:

• Physician services (a designated physician for each client)
• Nursing services (a registered nurse on duty as required for the population served)
• Dental services
• Vision and hearing services
• Pharmacy services
• Emergency medical services
• Mental health services (when needed)
• Therapy services (occupational, physical, speech, as needed)

Medication administration must be supervised by a licensed health professional. Medications must be reviewed periodically for continued appropriateness.

42 CFR 483.470: Physical environment

Sets standards for the facility's physical plant:

• Bedroom size and number of beds per room (typically no more than four beds per room, with movement toward single and double occupancy)
• Bathroom facilities
• Dining areas
• Activity and program areas
• Storage
• Fire safety and emergency procedures
• Sanitation
• Accessibility

42 CFR 483.480: Dietetic services

Requires the facility to provide nutritionally adequate meals and snacks. Special dietary needs must be accommodated. A qualified dietitian must be involved in menu planning and individual nutritional needs.

What screening happens before a nursing-home admission (PASRR Level II)

The Preadmission Screening and Resident Review (PASRR) framework at Section 1919(e)(7) of the Social Security Act and 42 CFR 483.100 through 483.138 requires that before any person is admitted to a Medicaid-certified nursing facility, the state must screen for serious mental illness, intellectual disability, or related conditions.7

PASRR Level I is a basic screening using a standardized form. Any clinician or qualified staff person can perform Level I. If Level I is positive (i.e., indicates possible MI, ID, or related condition), Level II must occur before the person can be admitted to or continue residing in a nursing facility.

PASRR Level II is a comprehensive evaluation performed by a qualified evaluator. For individuals with intellectual disability or related conditions, the Level II evaluator determines:

• Whether the person meets the federal definition of intellectual disability or related condition with onset before age 22
• Whether the person needs the level of services provided by a nursing facility
• Whether the person needs specialized services for intellectual disability
• Whether the nursing facility is an appropriate placement, or whether ICF/IID or community-based services would be more appropriate

In Georgia, DBHDD administers PASRR Level II for individuals with intellectual disability and related conditions. The PASRR Level II report is the basis for the placement decision, the specialized services plan, and any transfer recommendations.

If the PASRR Level II determines that the person should not be in the nursing facility, the state must arrange a transition to a more appropriate setting. This may be ICF/IID, NOW/COMP community placement, or other community options. The PASRR Level II is a powerful tool for moving people out of inappropriate nursing facility placements.

Eligibility for ICF/IID in Georgia

To receive Medicaid coverage for ICF/IID services in Georgia, a person must meet three requirements:

1. Financial eligibility for Medicaid

Common pathways include the following. Each dollar figure below reflects the 2026 federal standards.3,8

• SSI recipient (automatic Medicaid)
• 300 percent SSI special income rule under Section 1902(a)(10)(A)(ii)(VI): monthly income up to $2,982 in 2026, which is 300 percent of the 2026 Supplemental Security Income (SSI) federal benefit rate of $994 per month3
• Section 1924 spousal impoverishment protections where a married applicant has a spouse remaining in the community (the 2026 Community Spouse Resource Allowance, or CSRA, ranges from $32,532 to $162,660; the 2026 Minimum Monthly Maintenance Needs Allowance, or MMMNA, ranges from $2,705.00 to $4,066.50)8
• Medically Needy with patient liability (spend-down)
• Katie Beckett TEFRA, which waives the deeming of parents' income and resources for a child who meets institutional level of care. Georgia's operative age rule runs through age 18: DFCS Medicaid policy 2133 makes Katie Beckett a class of assistance "available to children 18 years of age and younger" and requires that the child's age "does not extend past the month she or he turns age 19," and Georgia Medicaid describes the program as serving certain children 18 years of age or less9
• Other categorical eligibility (for example, children's Medicaid and adult eligibility groups)

The SSI resource (asset) limits that most institutional Medicaid categories follow are $2,000 for an individual and $3,000 for a couple.3 Where one spouse remains in the community, the Section 1924 spousal-impoverishment rules protect a share of the couple's countable resources for that spouse instead.8

2. Federal definition of intellectual disability or related condition

Intellectual disability is defined by:

• Significantly subaverage intellectual functioning (IQ approximately 70 or below)
• Concurrent deficits in adaptive behavior (in conceptual, social, or practical domains)
• Onset before age 22

A "related condition" is a severe, chronic disability attributable to cerebral palsy, epilepsy, or another condition (other than mental illness) that produces impairment similar to that of intellectual disability, with onset before age 22, expected to continue indefinitely, and producing substantial functional limitations in three or more major life activities.

3. ICF/IID level of care (need for active treatment)

The person must have demonstrated need for active treatment. This is the clinical determination that distinguishes ICF/IID-eligible individuals from those who can be served at lower levels of care.

In Georgia, DBHDD administers the ICF/IID LOC determination. The determination considers the diagnosis, adaptive behavior, functional limitations, medical complexity, behavioral needs, and existing support systems.

Patient liability and post-eligibility treatment of income

When a person receives institutional care in an ICF/IID, most of their countable monthly income must be applied to the cost of care, and the resident keeps a Personal Needs Allowance (PNA) for personal items such as clothing, haircuts, and small purchases. Georgia's DFCS Medicaid manual (Appendix A1, Chart A1.9) sets a $70 monthly PNA for a Medicaid member in a nursing home or institutionalized hospice, in effect since July 2019, which sits above the federal floor of at least $30 a month for an aged, blind, or disabled individual under 42 CFR 435.725. Chart A1.9 publishes no separate ICF/IID row, so ask the DFCS caseworker handling the case to confirm the PNA that will apply in your family member's specific setting before you budget around it.10

After deducting the PNA, deductions for health insurance premiums (Medicare Part B, Medicare supplement, etc.), and any deductions for medical expenses not covered by Medicaid, the remaining income is the "patient liability" that the resident pays toward the ICF/IID cost. Medicaid pays the difference between the patient liability and the facility's Medicaid rate.

Spousal impoverishment protections under Section 1924 apply when one spouse is in the ICF/IID and the other remains in the community. In 2026, up to the MMMNA (which ranges from $2,705.00 to $4,066.50) of the institutional spouse's income may be allocated to the community spouse if needed to bring that spouse up to the MMMNA, and the CSRA (which ranges from $32,532 to $162,660 in 2026) protects a share of the couple's countable resources for the community spouse.8

For NOW or COMP waiver participants (the community-based alternative), the post-eligibility treatment of income differs. The participant is living in the community, retains most of their income for living expenses, and may have small cost-sharing depending on services.

The community alternatives: the NOW and COMP waivers

Section 1915(c) of the Social Security Act permits states to operate Home and Community-Based Services (HCBS) waivers that serve people who would otherwise require institutional level of care. For ICF/IID-eligible individuals in Georgia, the relevant waivers are NOW and COMP.11,12

NOW (New Options Waiver)

NOW supports adults and children with developmental disabilities who need community-based supports and can live with family, in a host home, or in their own apartment. Common NOW services include:

• Community living supports (in-home and community-based)
• Supported employment
• Transportation
• Behavior supports
• Respite (planned and emergency)
• Specialized medical equipment
• Adult day services

NOW participants have a capped per-person budget. The cap is set by the tier assignment (Tier 1, 2, 3, or 4) under the Supports Intensity Scale. Higher tiers receive higher budgets to fund more intensive services.

COMP (Comprehensive Supports Waiver)

The Comprehensive Supports Waiver (COMP) provides more intensive supports for adults and children with more complex needs. COMP services include all of the NOW services plus:

• Residential supports (host home, supported living, community living arrangement)
• More intensive supported employment and day programs
• Skilled nursing services
• More intensive behavior supports

COMP participants typically have higher SIS scores and more intensive support needs. The budget under COMP is generally higher than NOW.

Cost neutrality

Under Section 1915(c)(2)(A), the aggregate per-capita cost of NOW or COMP services for waiver participants must not exceed the aggregate per-capita cost of ICF/IID services that those participants would have received had they not been on the waiver. This is the cost-neutrality formula.

The formula is: Factor D + Factor D' (waiver costs and other Medicaid costs for waiver participants) must be less than or equal to Factor G + Factor G' (ICF/IID costs and other Medicaid costs for the institutional comparison group).

Cost neutrality is calculated at the aggregate level, not the individual level. This means individual participants may have services that cost more than what an ICF/IID would cost, as long as the average across all participants is below the institutional comparison.

The Planning List (NOW/COMP waitlist)

Georgia's demand for NOW and COMP far exceeds the slots that DBHDD can fund within the state budget. The result is the Planning List, which is the waitlist for NOW or COMP services.

As of September 2025, approximately 7,900 Georgians were on the planning list, per the Georgia Department of Audits and Accounts' special examination of the two waivers. About 3,000 of them (38 percent) were under age 22 and about 4,900 were age 22 or older, and nearly all of those 4,900 adults were waiting for NOW services. On average, people on the list had been waiting nearly five years, and 43 percent of the adults (2,100 of 4,900) had been waiting at least six years.2

How DBHDD decides who moves off the list first

DBHDD typically prioritizes the individuals with the greatest unmet needs, and those whose circumstances are more urgent under DBHDD's criteria may receive services first. Prioritization is based on need rather than on how long a person has been on the planning list, so waiting longer does not by itself move someone up. Applications are reviewed by DBHDD Regional Field Office Intake and Evaluation staff, and individuals found pre-eligible are placed on the I/DD Planning List for NOW and COMP.2

Apply as soon as a person may eventually need services. Getting on the Planning List is what establishes pre-eligibility and puts the person's documented needs in front of DBHDD, even though position on the list is not what determines who is served next.

The 2010 DOJ Olmstead settlement and Georgia policy

In 1999, the U.S. Supreme Court decided Olmstead v. L.C., 527 U.S. 581. The Court held that the unjustified institutional isolation of people with disabilities is a form of discrimination prohibited by Title II of the Americans with Disabilities Act (42 USC 12132). States must provide services in the most integrated setting appropriate to the needs of individuals with disabilities.

Olmstead created an "integration mandate" that has shaped Medicaid policy for more than two decades. States have entered into multiple settlement agreements with the U.S. Department of Justice (DOJ) to remedy unjustified institutional placement.

In 2010, the United States entered into a comprehensive settlement agreement with Georgia following a DOJ investigation of Georgia's state-operated hospital system. The investigation found that Georgia had unnecessarily institutionalized people with serious mental illness and intellectual and developmental disabilities in state-operated facilities. The settlement (United States v. Georgia, N.D. Ga.) required Georgia to:

• Stop admitting people with developmental disabilities to state-operated hospitals
• Transition all people with developmental disabilities out of state hospitals to community settings
• Expand community-based supports for people with developmental disabilities through NOW and COMP
• Develop Georgia Crisis Response Service (GCRS) for IDD
• Provide supported housing for people with serious mental illness
• Develop Assertive Community Treatment (ACT) teams for SMI
• Maintain ongoing monitoring and reporting to DOJ

The settlement has been extended multiple times. Gracewood State School & Hospital (Augusta), one of Georgia's largest IDD institutions, closed in 2011 as a direct result. Other state hospitals have shifted from primarily IDD residential to primarily SMI acute treatment.

The settlement and Olmstead continue to drive Georgia's policy preference for community-based supports (NOW/COMP) over ICF/IID institutional care. DBHDD's funding decisions, the Planning List prioritization, and the transition supports through Money Follows the Person all reflect this preference. However, ICF/IID remains a legal Medicaid benefit and is appropriate for some individuals, particularly those with complex medical or behavioral needs who cannot be safely supported in less restrictive settings.

Georgia administration: DBHDD, DCH, DPH

DBHDD (Department of Behavioral Health and Developmental Disabilities)

DBHDD is the state agency primarily responsible for Georgia's developmental disability service system.1 DBHDD operates:

• State-operated ICF/IIDs (legacy state hospital system)
• The NOW and COMP Section 1915(c) waivers
• PASRR Level II for IDD
• The Georgia Crisis Response Service (GCRS) for IDD
• Intake and Evaluation (I&E) services

DBHDD has six regional offices that administer services locally:

• Region 1: Rome (Northwest Georgia)
• Region 2: Macon and Dublin (Middle Georgia)
• Region 3: Atlanta (Metro Atlanta and North Georgia)
• Region 4: Albany (Southwest Georgia)
• Region 5: Savannah (Coastal Georgia)
• Region 6: Columbus (West Central Georgia)

Each regional office has IDD coordinators, intake staff, and crisis response capacity. Regional offices are the primary local interface for families seeking ICF/IID, NOW, or COMP services.

DCH (Department of Community Health)

The Georgia Department of Community Health (DCH) is Georgia's single state Medicaid agency. DCH:

• Operates the Medicaid State Plan
• Licenses ICF/IIDs through the Division of Health Care Facilities Regulation (working with DPH)
• Sets ICF/IID Medicaid reimbursement rates
• Operates the Medicaid eligibility system (in coordination with DHS)
• Manages the State Hub and Medicaid Provider Manuals

DPH (Department of Public Health) Healthcare Facility Regulation

DPH operates the Healthcare Facility Regulation Division, which surveys ICF/IIDs under contract with CMS to evaluate compliance with the federal Conditions of Participation at 42 CFR Part 483 Subpart I. Annual surveys, complaint investigations, and follow-up inspections are conducted by DPH.

State-operated ICF/IIDs and the historical Georgia system

For most of the twentieth century, Georgia operated a network of state institutions that included ICF/IID units. The largest facilities historically included:

• Gracewood State School & Hospital (Augusta), closed 2011
• Central State Hospital (Milledgeville), once one of the largest psychiatric hospitals in the U.S., now greatly reduced
• Georgia Regional Hospital Atlanta (GRHA)
• East Central Regional Hospital (Augusta)
• Southwestern State Hospital (Thomasville)
• West Central Georgia Regional Hospital (Columbus)
• Northwest Georgia Regional Hospital (Rome)

Under the 2010 DOJ Olmstead settlement, Georgia stopped admitting people with developmental disabilities to these state hospitals and transitioned existing residents to community settings supported by NOW and COMP. The state hospitals have shifted toward serving people with acute serious mental illness rather than long-term IDD residential care.

The few state-operated facilities that retain any IDD residential capacity now do so primarily for individuals with the most complex needs (significant behavioral challenges, complex medical conditions, dual diagnosis) for whom community placement has not been feasible.

Private ICF/IIDs in Georgia

Most Georgia ICF/IID capacity is in private community-based ICF/IIDs, typically small group homes of four to eight beds. Many are operated by mid-sized provider organizations.

Private ICF/IIDs must comply with all of the federal Conditions of Participation at 42 CFR Part 483 Subpart I, including:

• The active treatment requirement under 483.440
• The QIDP role under 483.430
• Client protections under 483.420
• Behavioral intervention standards under 483.450
• Health care services under 483.460
• Physical environment standards under 483.470
• Dietary services under 483.480

Private ICF/IIDs are licensed by DCH, surveyed by DPH Healthcare Facility Regulation for federal compliance, and reimbursed by Georgia Medicaid.

The Supports Intensity Scale and four-tier resource allocation

DBHDD uses the Supports Intensity Scale (SIS) to assess support needs for individuals seeking NOW or COMP services. The SIS is a standardized assessment that measures support needs across:

• Activities of daily living (eating, dressing, hygiene)
• Instrumental activities of daily living (housework, money management, transportation)
• Medical support needs
• Behavioral support needs
• Protection and advocacy support needs

Based on SIS scores, DBHDD assigns the individual to one of four tiers:

• Tier 1: Lowest support needs
• Tier 2: Moderate support needs
• Tier 3: Higher support needs
• Tier 4: Highest support needs

There are also exceptional rate provisions for individuals whose needs exceed Tier 4. Tier assignment drives the per-person budget under NOW or COMP. Higher tiers receive higher budgets to fund more intensive services.

The tier assignment is reviewed periodically (typically every two to three years, or when significant changes occur). Reassessment can result in tier change up or down. Tier change appeals follow the standard Medicaid fair hearing process under 42 CFR 431 Subpart E.

Intake and Evaluation (I&E)

People seeking NOW or COMP services in Georgia apply through the Individual IDD Connects portal (or on paper to a Regional Field Office), and DBHDD Regional Field Office Intake and Evaluation staff review what they submit. The I&E process runs in this order:

For ICF/IID specifically, families can also approach private ICF/IID providers directly for admission consideration. The ICF/IID provider works with DBHDD and DCH on the LOC determination and Medicaid enrollment.

Georgia Crisis Response Service (GCRS) for IDD

GCRS is DBHDD's IDD crisis response system. It was established and expanded as part of the 2010 DOJ Olmstead settlement to ensure that Georgians with IDD have access to crisis services that can prevent unnecessary institutional placement.

GCRS services include:

• Mobile crisis response: in-person, statewide, available 24/7. Trained staff respond to behavioral crises in the home or community.
• Crisis stabilization: short-term residential stabilization for situations that cannot be managed in the home or community.
• Behavioral consultation: ongoing consultation with families and providers on behavior support strategies.
• Family education: training for families on behavior, communication, and crisis management.

GCRS is funded by DBHDD and operated by community providers under contract. Access is through the Georgia Crisis and Access Line (GCAL) at 1-800-715-4225, the 24/7 line DBHDD directs Georgians to call for the state's behavioral-health crisis system; you can also call or text 988.5

GCRS exists to divert behavioral crises from psychiatric hospitalization, emergency-department visits, and institutional placement, and it is a key piece of Georgia's community-based IDD infrastructure.

Money Follows the Person (MFP)

Money Follows the Person (MFP) is a federal Medicaid grant program, originally authorized by Section 6071 of the Deficit Reduction Act of 2005 and extended by Section 2403 of the Affordable Care Act, that gives states enhanced federal matching funds to move people from institutional settings (ICF/IIDs, nursing facilities) into home and community-based settings. Section 5114 of the Consolidated Appropriations Act, 2023 extended it with $450 million a year for federal fiscal years 2024 through 2027, so the current authorization runs through September 30, 2027.13 The Georgia Department of Community Health implemented Georgia's MFP on September 1, 2008, and runs it jointly with DBHDD and the Department of Human Services Division of Aging Services.14

For ICF/IID-to-community transitions in Georgia, the destination is typically NOW or COMP. MFP provides:

• An enhanced federal match after the transition. MFP pays Georgia a higher federal match than the regular FMAP for a defined post-transition period, reducing the cost to the state.13
• One-time transition costs. Apartment deposit, first month's rent, furniture, household setup, moving expenses.
• Wraparound supports during transition. Pre-transition planning, peer mentoring, family support.

MFP has been a key tool for moving Georgians out of ICF/IIDs and into community settings supported by NOW or COMP.

Worked example 1: Tyrell, 24, Atlanta, IDD post-school transition

Tyrell has a moderate intellectual disability with onset before age 22. He graduated from public school at age 22, using IDEA Part B extended eligibility for special education up to age 22. The family is considering options for ongoing supports.

The family knows two main paths:

• ICF/IID placement. Full residential active treatment with around-the-clock supports and a comprehensive program. Best for individuals with very high support needs or behavioral complexity that cannot be safely supported in less restrictive settings.
• NOW or COMP waiver. Community living with family or in a host home, supported employment, day programs. Tyrell can live in the community and receive supports tailored to his needs.

The family applies through an Individual IDD Connects account with the Georgia Collaborative ASO, and DBHDD Regional Field Office Intake and Evaluation staff review the application.4 Tyrell's IDD eligibility is confirmed (his school records and prior assessments document the diagnosis and adaptive deficits). The Supports Intensity Scale (SIS) is administered. Tyrell scores in Tier 3, indicating moderate-to-higher support needs.12

The family chooses NOW with community living supports. After several years on the Planning List (statewide, people on the list have been waiting nearly five years on average), a NOW slot becomes available.2 Tyrell moves to a host home setting with a provider in his Region 3 (Atlanta) network. He works part-time at a local grocery store with job coaching support. He attends a community day program two days a week. His care coordinator (effectively serving the QIDP role in the community waiver context) ensures the Individual Service Plan addresses his goals: increasing independence in money management, developing peer relationships, and exploring vocational training options.

Three years later, Tyrell has saved enough to consider supported living in his own apartment. His SIS is re-administered; he is still Tier 3 but with reduced support intensity. The family and provider develop a transition plan to supported living, and Tyrell moves into his own apartment with daily supports.

Worked example 2: Elena, 35, Macon, dual MI/IDD complex behavioral

Elena has both moderate intellectual disability (IQ 55, significant adaptive behavior deficits) and a serious mental illness (schizoaffective disorder with treatment-resistant features). She has significant behavioral challenges including periodic episodes of self-injury and aggression. She has been in and out of state-operated facilities for the past decade.

Under the 2010 DOJ Olmstead settlement, Georgia is required to transition her to a community setting. Her current placement at a state-operated facility is no longer appropriate under the settlement framework.12

The DBHDD Region 2 (Macon/Dublin) transition team convenes:

• DBHDD regional coordinator
• The current state facility's QIDP and clinical team
• GCRS clinical staff (for crisis planning)
• The family
• A prospective COMP provider with expertise in dual MI/IDD
• A Board Certified Behavior Analyst (BCBA)
• A psychiatrist familiar with treatment-resistant SMI

The transition plan includes:

• COMP waiver enrollment with intensive residential supports
• 24/7 staffing with behavioral expertise (provider has staff trained in trauma-informed care, de-escalation, and IDD-specific behavioral intervention)
• Coordination with mental health services through a community mental health center
• Crisis plan with GCRS backup for behavioral escalation
• Money Follows the Person funding for transition costs (apartment setup, behavior support training, family wraparound)
• Behavior plan overseen by the BCBA and reviewed by the human rights committee at the COMP provider (analogous protections to 42 CFR 483.450 even though Elena is now in a community setting)

After a 90-day transition planning period, Elena moves to a specialized community residential setting operated by the COMP provider. She has two staff with her around the clock initially, tapering to one staff plus on-call as her stability improves. Her psychiatrist sees her weekly initially, then bi-weekly. GCRS has responded to two crisis episodes in her first six months but no hospitalization has been required.

Two years later, Elena is stable in her community placement. She participates in a structured day program, has a small social network at the COMP provider, and visits family weekly. Her behavioral episodes have decreased substantially.

Worked example 3: Diana, 8, Savannah, medically complex IDD

Diana has profound intellectual disability and complex medical needs: tracheostomy with ventilator dependence at night, G-tube feeding, intractable epilepsy with daily seizures, and orthopedic complications requiring frequent therapy. Her family has been managing her care at home with private duty nursing (PDN) coverage but family income exceeds Medicaid eligibility limits.

Options the family is considering:

• ICF/IID with skilled nursing. Some private ICF/IIDs serve medically complex children, but most prefer adult populations. The family is not enthusiastic about Diana leaving home.
• Katie Beckett TEFRA. Institutional LOC determination (hospital or NF level), parent income disregarded under Section 1902(e)(3), Medicaid eligibility based on Diana's own income (zero). Services delivered in the home.
• NOW or COMP. Available, but the service array may not match medical complexity (NOW/COMP focus on developmental supports; medical complexity may exceed available service intensity).

The family chooses Katie Beckett TEFRA (Diana is 8, well inside Georgia's rule that the child's age not extend past the month they turn 19). Diana is assessed as meeting hospital or NF LOC because her medical complexity requires that level of care without supports. The family gets the application from the Centralized Katie Beckett Medicaid Team, and the level-of-care packet (the Form DMA 6A physician's recommendation for pediatric care, the Form DMA 706 medical necessity/level-of-care statement, and the Form DMA 704 cost-effectiveness form) goes to Alliant Health Solutions, which makes the LOC determination. A separate cost-effectiveness step, worked on the Form DMA 704 and the Form DMA 708 worksheet, compares the physician's estimated monthly cost of home care against the institution's monthly Medicaid billing rate; because in-home care costs less, the application proceeds. The determination is approved, and level-of-care determinations meeting the Katie Beckett standard are authorized for no less than two years.9

With Katie Beckett TEFRA, parent income is disregarded under Section 1902(e)(3). Diana qualifies for full Medicaid based on her own income (zero) and resources. Medicaid pays for:

• Private duty nursing (16 hours/day during waking hours and night ventilation supervision)
• Durable medical equipment (ventilator, suction machine, G-tube supplies)
• Therapies (PT, OT, speech)
• Specialty physician services
• Prescription medications
• Hospitalizations and other acute care

Diana stays with her family. She receives skilled care at home, attends school with a nurse, and participates in family life. Her level-of-care approval runs for at least two years before it has to be re-established.9

Worked example 4: Aisha, 19, Albany, PASRR Level II from nursing facility

Aisha has intellectual disability (diagnosed in childhood; IQ 60; significant adaptive deficits) and was admitted to a nursing facility in Albany following a car accident that left her with significant orthopedic injuries (femur, pelvis), traumatic brain injury, and rehabilitation needs.

The nursing facility's admission process required PASRR Level I. The Level I screen flagged her IDD diagnosis (documented from prior records). A Level II evaluation was required before admission.

DBHDD Region 4 (Albany) administered the PASRR Level II:

• Confirmed ID with adaptive deficits and onset before 22 (documented from childhood records)
• Determined she does need short-term skilled rehabilitation that the NF can provide (PT, OT, speech, wound care)
• Determined that after rehabilitation, she should NOT remain in the NF, and should transition to a community setting with appropriate IDD supports
• Required the NF to provide PASRR-specified specialized services while she is there (focus on IDD-appropriate communication, behavioral supports, and care planning)
• Set a transition planning timeline

After 90 days of skilled rehabilitation, Aisha is medically stable and ready to transition. DBHDD enrolls her in COMP (the family advocates for COMP given her support needs and the complexity of her TBI-related needs). MFP funds her transition. She moves to a supported living apartment with COMP-funded services (8 hours/day community living supports, behavior consultation, transportation, and day program). She accesses ongoing physical therapy through Medicaid State Plan benefits.

One year post-transition, Aisha has substantially recovered from her injuries, participates in a community day program three days a week, and is exploring vocational training. Her IDD-related supports continue under COMP.

Practical guidance for Georgia families

Starting the process

If your family member has intellectual or developmental disability and you are seeking services in Georgia, the starting point is a NOW/COMP application:

• Create an Individual IDD Connects account with the Georgia Collaborative ASO and upload the required documents, or fax or mail a paper application to your DBHDD Regional Field Office. Call that office if you need help with either route.4
• Gather diagnostic and educational records ahead of time (IEP records, neuropsychological evaluations, medical records)
• Be prepared to discuss daily functioning, support needs, and family situation
• Ask about Planning List placement, ICF/IID options, and the Supports Intensity Scale

Applying for Medicaid

ICF/IID services and NOW/COMP services require Medicaid eligibility. Apply for Medicaid through Georgia Gateway (the state's eligibility portal) or through your Division of Family and Children Services (DFCS) office:

• For institutional Medicaid (ICF/IID), use the 300 percent SSI special-income rule or another applicable pathway3
• For Katie Beckett TEFRA (a child whose age does not extend past the month they turn 19, with institutional LOC needs), get the application from the Centralized Katie Beckett Medicaid Team at 678-248-7449, from any local DFCS office by mail, telephone, or fax, or online at Georgia Gateway9
• For SSI recipients, Medicaid is automatic

Considering placement options

The key questions for choosing among ICF/IID, NOW, COMP, and Katie Beckett:

• What is the level of support needed? SIS scores, behavioral complexity, medical complexity, and adaptive functioning all matter.
• What is the family situation? Is the family able to provide primary care with supports? Is respite needed? Are there safety concerns?
• What is the person's preference? Where appropriate, the individual's own preferences must be central to the decision.
• What is available? Planning List wait times for NOW/COMP run to years, with the statewide average near five. ICF/IID may be more immediately available. Katie Beckett TEFRA requires institutional LOC for a child whose age does not extend past the month they turn 19.2,9
• What does the Olmstead integration mandate require? The most integrated setting appropriate to the person's needs is the policy preference, but ICF/IID is not categorically inappropriate if the person's needs cannot be safely met in less restrictive settings.

Active treatment in an ICF/IID

If your family member is in an ICF/IID, you should expect:

• A QIDP designated for your family member, who is reachable and responsive
• An Individual Program Plan within 30 days of admission, with specific objectives
• Annual review of the IPP with interdisciplinary team input including family
• Active programming throughout the day, not just supervision
• Regular progress documentation
• Behavioral interventions that are positive, skill-building, and time-limited
• Restraints used only when necessary, only as part of a written program, and only with required approvals

If active treatment is not occurring, you can file a complaint with DPH Healthcare Facility Regulation (404-657-5550), file a complaint with DBHDD, or contact the Georgia Long-Term Care Ombudsman, the Division of Aging Services program that investigates complaints from facility residents.15

Transition from ICF/IID to community

If your family member is in an ICF/IID and you want to explore transition to a community setting (NOW or COMP), the process runs in this order:

Under the 2010 DOJ Olmstead settlement and Georgia's policy framework, transition to less restrictive settings is generally supported and funded.

Appeals

If Medicaid denies, reduces, or terminates a benefit related to ICF/IID, NOW, or COMP services, you have appeal rights under 42 CFR 431 Subpart E. You must receive written notice that includes:

• The action being taken
• The reason for the action
• The effective date
• Citation to the regulation or policy
• Your right to request a fair hearing
• The time frame for requesting the hearing

Read the deadline off your own notice. Federal law at 42 CFR 431.221(d) caps how long a state's request window may run at 90 days from the date the notice is mailed. That 90 days is a ceiling on the state, not a floor you are guaranteed: Georgia DFCS policy directs that a hearing on an eligibility decision be requested within 30 days of the notice, so the operative deadline is the one printed on your notice of action, which may be well short of 90 days.16

Continued benefits are tied to the effective date, not to a flat 10 days. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date the action takes effect, it may not terminate or reduce the service until a decision is rendered after the hearing (unless the sole issue is one of federal or state law or policy). A request made after the effective date does not trigger that continuation; a separate rule, 42 CFR 431.231, lets the agency reinstate services if you request a hearing no more than 10 days after the date of action. And if the agency's action is later sustained, 42 CFR 431.230(b) permits it to recoup the cost of services furnished solely by reason of the continuation.17

Fair hearings in Georgia are conducted by the Office of State Administrative Hearings (OSAH) under O.C.G.A. §50-13. You have the right to representation, to present evidence, to cross-examine witnesses, and to receive a written decision.

Resources for appeals:

• Georgia Legal Services 1-833-457-752918
• Disability Rights Georgia (Georgia's Protection and Advocacy agency) 1-800-537-2329
• Georgia Advocacy Office 1-800-537-2329

Quality concerns and complaints

If you have concerns about the quality of care in an ICF/IID:

• File a complaint with DPH Healthcare Facility Regulation 404-657-5550
• Contact the Long-Term Care Ombudsman, run by the Division of Aging Services15
• File a complaint with DBHDD 404-657-2252
• Contact Disability Rights Georgia 1-800-537-2329 (Georgia's P&A agency)
• For abuse or neglect, call 911 if the person is in immediate danger. Otherwise report to Adult Protective Services, the state program that responds to reports of abuse, neglect, and exploitation of adults with disabilities and older adults; if you do not have Georgia's APS intake number, the Eldercare Locator at 1-800-677-1116 will connect you19,20

CMS oversight and minimum standards

ICF/IIDs are surveyed annually by DPH Healthcare Facility Regulation under contract with CMS. Surveys evaluate compliance with the federal Conditions of Participation at 42 CFR Part 483 Subpart I. Deficiencies are categorized by scope and severity. Significant deficiencies can result in:

• Plan of correction requirement
• Civil money penalties
• Denial of payment for new admissions
• Termination of Medicaid certification

The Long-Term Care Ombudsman program operates in ICF/IIDs as well as nursing facilities, providing complaint investigation and advocacy.

CMS minimum staffing standards in ICF/IIDs are set primarily at 42 CFR 483.430 (direct care staff sufficient to ensure active treatment, with specific staff-to-client ratios based on facility size and population needs). The CMS minimum staffing rule finalized in 2024 for nursing facilities (3.48 hours per resident day, 24/7 RN) applies to nursing facilities, not ICF/IIDs; ICF/IIDs have their own staffing framework focused on active treatment delivery rather than nursing care hours.

Where to get help

To start an application, ask about the Planning List, report a quality concern, or get help appealing a decision, these are the offices to call.

Learn More

Find personalized help navigating Georgia ICF/IID, NOW, and COMP services at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.