Georgia Medicaid Managed Care Plans (CMOs) 2026

Most Georgians on Medicaid do not get their care directly from the state. They get it through a contracted managed care company, called a Care Management Organization (CMO), under a program called Georgia Families. Three CMOs share the statewide contract: Amerigroup Community Care (owned by Elevance Health), CareSource (a nonprofit), and Peach State Health Plan (owned by Centene).1 A separate program called Georgia Families 360 coordinates care for children, youth, and young adults in foster care or receiving adoption assistance, and for select youth involved with the Department of Juvenile Justice.

Note (verified September 2026): DCH's own pages name three current Georgia Families CMOs and no fourth, so WellCare of Georgia is not a plan you can choose today. A 2024 reprocurement named a different proposed slate for the next contract period, but DCH's most recent posted update (April 23, 2026) says that procurement is still in the protest phase pending the Notice of Award. Pending that notice, DCH will extend the current three-CMO contracts through June 30, 2027, an extension conditioned on the award not issuing, so it can end sooner. No member transition has happened and no go-live date is published.1

The choice of CMO matters for provider networks, care coordination quality, specialty services, the member service experience, and your prescriptions: each CMO runs its own pharmacy benefit through its own pharmacy benefit manager, and DCH links a separate drug formulary for each plan.2 Picking the right CMO at enrollment can save months of frustration. And if your CMO is not serving you well, federal law gives you a 90-day right to change after initial enrollment, plus mid-year changes for cause and an annual open enrollment window.

In This Guide

• Key Takeaways
• How Georgia Medicaid Managed Care Plans Work: Georgia Families and Its Authority
• Who Must Enroll and Who Stays in Fee-for-Service
• The Care Management Organizations
• Georgia Families 360 for Foster and Adoption-Assistance Children
• What CMOs Cover (and What Is Carved Out)
• Pharmacy: Who Administers Your Drug Benefit
• Dental, Vision, and Non-Emergency Medical Transportation
• How Auto-Assignment Works
• The 90-Day Right to Change
• Annual Open Enrollment and For-Cause Changes
• How to Compare Georgia Medicaid Managed Care Plans
• Prior Authorization Rules
• Appeals: CMO Internal Appeal and OSAH Fair Hearing
• Three Worked Examples
• Common Mistakes Members Make

How Georgia Medicaid Managed Care Plans Work: Georgia Families and Its Authority

Georgia Families is the state's mainstream Medicaid and PeachCare for Kids managed care program, run through three contracted Care Management Organizations under the Georgia Department of Community Health. It enrolls the large majority of non-elderly, non-disabled, non-long-term-care Medicaid and PeachCare for Kids members in Georgia.1

The federal authority is Section 1915(b) of the Social Security Act, which allows states to require Medicaid beneficiaries to enroll in managed care plans by waiving the standard freedom-of-choice provision. The implementing federal managed care regulations govern the program structure. Georgia's 1915(b) waiver is renewed in five-year cycles and is approved by the Centers for Medicare and Medicaid Services.

Under the waiver, Georgia contracts with full-risk Care Management Organizations on a capitated basis. The state pays each CMO a per-member-per-month rate based on the member's eligibility category and risk profile, and the CMO is responsible for arranging covered services. The CMO bears actuarial risk: if its members use more services than the capitation rate covers, the CMO absorbs the loss; if they use less, the CMO retains the difference (subject to medical loss ratio requirements).

This structure transfers some of the management complexity from the state to the contracted plans, in exchange for predictable budget and consolidated accountability. The trade-off is that members must accept the network and care management approach of their assigned plan, with limited ability to use out-of-network providers except in emergencies.

Who Must Enroll and Who Stays in Fee-for-Service

Georgia Families is mandatory for most adult and pediatric Medicaid and CHIP populations, but several important categories remain in fee-for-service or are served by different programs.

Must enroll in Georgia Families CMO:

• Low Income Medicaid (LIM) parents and children under family Medicaid rules
• Right from the Start Medicaid (RSM) pregnant women and infants
• PeachCare for Kids (Georgia CHIP) children
• Adoption-assistance children (now generally through Georgia Families 360)
• Foster care children (through Georgia Families 360)
• Pathways to Coverage 1115 demonstration enrollees (adults 19-64 with household income up to 100% of the Federal Poverty Level who complete a monthly qualifying-activity requirement; covered in our Pathways to Coverage guide)4
• Family Planning Waiver participants
• Most other categorical Medicaid populations

Not in Georgia Families CMO (fee-for-service or different program):

• Aged, Blind, Disabled (ABD) categorical eligibles, including SSI Medicaid and Q-track ABD
• Nursing Facility Medicaid (long-term institutional care)
• HCBS waiver participants: ICWP, NOW, COMP run fee-for-service through DCH directly, as does the Elderly and Disabled Waiver Program (EDWP). CCSP and SOURCE are the two service-delivery models found within EDWP rather than separate 1915(c) waivers. SOURCE is the model that coordinates physician-led care management with home and community-based services, and like CCSP it sits outside the Georgia Families CMO structure (covered in our SOURCE guide).3
• Full-benefit dual eligibles in certain categories receive Medicaid services FFS while Medicare handles primary coverage
• Medicare Savings Program-only enrollees (QMB-only, SLMB-only, QI) have no full Medicaid benefit and therefore are not in any CMO

If you are not sure which category your family falls into, the Georgia Families enrollment broker can confirm at the time of application or redetermination, at 1-888-GA-Enroll (1-888-423-6765).5

The Care Management Organizations

All three CMOs operate statewide. Members in any Georgia county can choose any of the three.1

A few notes on the market structure:

Amerigroup has been in Georgia since the original Georgia Families launch and is owned by Elevance Health (the former Anthem). It has the deepest tenure with Georgia providers.

CareSource is the only nonprofit in the three-CMO mix. It is an Ohio-based nonprofit health plan focused on Medicaid and Marketplace coverage.

Peach State Health Plan is owned by Centene Corporation, the largest Medicaid managed care company in the United States. WellCare of Georgia is not on DCH's current Georgia Families roster, which names only these three plans.1

Georgia Families 360 for Foster and Adoption-Assistance Children

Georgia Families 360 is a separate program for children whose health and behavioral health needs are highly intertwined with the child welfare and juvenile justice systems.

Who is enrolled in Georgia Families 360:

• Children, youth, and young adults in foster care
• Children, youth, and young adults receiving adoption assistance
• Select youth involved with the Department of Juvenile Justice1

Why a separate program: These children typically need integrated physical health, behavioral health, and care coordination that bridges the medical and child welfare systems. Concentrating the population in one program lets the state hold a single plan responsible for the full continuum of services. DCH's current Georgia Families pages do not name the plan administering the 360 program, so confirm the plan with DFCS rather than relying on an older article that names one.1

Key features:

• Higher-intensity care coordination than mainstream Georgia Families
• Integrated behavioral health (mental health and SUD) with no carve-out
• Trauma-informed care training for the CMO care coordinators
• Wraparound services for children with multiple system involvement
• Specialty pediatric networks (especially for children with disabilities)
• Transition support for youth aging out of foster care

For families adopting children from foster care, the GF 360 enrollment continues for the duration of the adoption-assistance agreement.

What CMOs Cover (and What Is Carved Out)

The three Georgia Families CMOs cover a broad range of services, but several important categories are "carved out" of the CMO benefit and paid fee-for-service or through separate state contracts.

Covered by the CMO (capitated):

• Primary care
• Specialist care (with referral or direct access depending on CMO and specialty)
• Hospital inpatient and outpatient
• Behavioral health (mental health and substance use disorder treatment)
• Maternity and newborn care
• Family planning (federal law bars the CMO from restricting which qualified family planning provider a member uses, in or out of network, and bars cost sharing for those services)6
• Preventive care, well-child visits, immunizations
• Diagnostic services (lab, imaging)
• Therapy services (physical, occupational, speech)
• Durable medical equipment (with prior authorization)
• Emergency services (covered with no prior authorization, including from out-of-network providers in a true emergency, under federal Medicaid managed care law)7

Carved out of the CMO benefit:

• Long-term care services (NF Medicaid, most HCBS waivers)
• Specialty mental health services delivered by Community Service Boards (often coordinated alongside CMO services)
• Certain dental and vision services for adults (limited adult benefit)
• Non-emergency medical transportation, which DCH administers through a contracted statewide broker rather than through the CMOs8
• Hospice (FFS in some configurations)

When a member uses a carved-out service, the provider bills Medicaid directly through DCH rather than billing the CMO. The CMO is not responsible for authorizing or coordinating the carved-out service, although CMOs often help with referrals.

Pharmacy: Who Administers Your Drug Benefit

Georgia Medicaid's outpatient pharmacy benefit is not run by a single statewide manager. Who administers your pharmacy claims, and which drug list applies to you, depends on how you are enrolled.2

Who administers the benefit:

• Fee-for-service members. For the fee-for-service (FFS) population, OptumRx is the state's Pharmacy Benefits Manager (PBM) for the Georgia Medicaid outpatient pharmacy program. OptumRx processes FFS outpatient pharmacy claims and reimburses enrolled pharmacy providers.2
• Georgia Families CMO members. Members enrolled in Amerigroup, CareSource, or Peach State receive their pharmacy benefit through their CMO and the CMO's pharmacy benefit manager, not through OptumRx.2

A note on Gainwell Technologies. DCH describes Gainwell as the fiscal agent for Medicaid and PeachCare for Kids since 2010, and Gainwell staffs the GAMMIS customer service lines. No DCH page assigns Gainwell a pharmacy-benefit-manager role; DCH names OptumRx in that role for the fee-for-service program. If you have read that a single statewide manager handles every Georgia Medicaid pharmacy claim, that is not what DCH's own pages describe.2

Why the drug list can differ by CMO: Georgia's Office of Health Strategy and Coordination reported that Georgia Medicaid has three CMOs plus a fee-for-service program, "resulting in four different drug lists," and that CMOs or their subcontracted pharmacy benefit managers generally prefer to manage their own drug lists. DCH's managed care page carries a separate drug formulary link for each CMO.2 That description of the CMO side comes largely from a January 2023 state study, so confirm the current arrangement with DCH or with the plan itself before relying on it.

Practical implications for choosing a CMO: If your concern is whether a specific drug is covered, do not assume the answer is the same across all three CMOs. Pull the drug formulary for each plan you are considering, or call that plan's member services with the drug name and dose before you enroll. Prior authorization steps and pharmacy networks also vary by CMO.

Dental, Vision, and Non-Emergency Medical Transportation

Dental. Coverage depends on age:

• Children under 21: Comprehensive dental coverage including preventive, restorative, and orthodontic (for medically necessary cases) is a mandatory Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Delivered through CMO dental networks or a DCH-contracted dental benefit manager depending on configuration.6
• Adults 21 and older: Effective July 1, 2024, Georgia expanded adult Medicaid dental beyond the old emergency/extraction-only scope. Adults now have access to comprehensive dental services (diagnostic, preventive, restorative such as fillings and crowns, root canals, periodontal, dentures, emergency dental, and oral surgery), subject to frequency limits and prior authorization for some procedures, delivered through the CMOs and fee-for-service.9

Vision. Coverage varies by age:

• Children under 21: Comprehensive vision benefit under EPSDT, which federal law (Social Security Act §1905(r)(2)) requires to include diagnosis and treatment of vision defects, including eyeglasses.6
• Adults 21 and older: Limited adult vision benefit. Routine eye exams are typically covered periodically; replacement glasses are limited.

Non-emergency medical transportation (NEMT). Effective April 1, 2026, Verida (formerly Southeastrans) is the sole statewide NEMT broker for Georgia Medicaid, covering all five regions (North, Atlanta, Central, East, and Southwest); Modivcare no longer provides Georgia Medicaid NEMT. Eligible Medicaid members arrange covered, medically necessary rides through Verida rather than through their CMO, and DCH administers the benefit and contracts the broker. Eligibility requires that the member have no other available transportation and that the appointment be for a Medicaid-reimbursable service. Rides cost the member nothing, and NEMT is a ride-share program, so other members may be in the vehicle with you.8

Book three workdays out, or you may not get the ride. Call the broker between 7 a.m. and 6 p.m., Monday through Friday, and make the request at least three workdays before a non-urgent scheduled appointment, a window that counts the day you call but not the day of the appointment. The three-day rule is not absolute: DCH says requests for urgent care and other exceptions may be arranged more quickly, defines urgent care as an unscheduled episodic situation with no immediate threat to life or limb where the member must be seen that day and treatment cannot wait until tomorrow, and says valid urgent requests will be honored within three hours. The call center runs 24/7 for "Where's My Ride" and hospital discharges.8

How Auto-Assignment Works

When a Georgia resident is approved for a Medicaid category that requires CMO enrollment, the Georgia Families enrollment broker assigns the member to a CMO under one of two scenarios.

Scenario one: member selects a CMO. During the application process, members are asked to choose their preferred CMO. The choice can be made through Georgia Gateway, by phone, or in person at a DFCS office. The selected CMO becomes effective on the coverage start date (typically the first of the month following approval).

Scenario two: auto-assignment. If the member does not select a CMO within the enrollment window, the broker auto-assigns. The auto-assignment algorithm considers:

• Existing family member CMO assignment (to keep families together)
• Geographic load balancing across the three CMOs
• Provider continuity if the member has been receiving Medicaid services from providers in a specific CMO network
• Special needs categories (children with chronic conditions may be assigned with consideration of network depth in their condition)

Auto-assignment is intended to be reasonably matched, but it is algorithmic and does not reflect personal preferences.

The 90-Day Right to Change

Federal law gives every Medicaid managed care member the right to change plans without cause during the 90 days following initial enrollment (or the date the state sends the enrollment notice, whichever is later), and at least once every 12 months after that. This is a hard federal right, set at 42 CFR 438.56(c), that Georgia must honor.10

How to use the 90-day window:

Why the 90-day window matters: Auto-assignment is the most common reason families end up with a CMO that does not match their needs. The 90-day window gives families time to discover that their preferred providers are not in network, that prior authorization is harder than expected, or that the care coordination is not working, and to switch without having to demonstrate cause.

Annual Open Enrollment and For-Cause Changes

Georgia operates an annual open enrollment period for Georgia Families members, during which any member can switch CMOs without having to demonstrate cause. Georgia Families describes this as the point at which a member has been in their plan for a year, and mails the member information about changing plans at that time.5 After open enrollment closes, members are locked in until the next annual cycle.

Changing your doctor is not the same as changing your plan. A member can change primary care providers at any time, with no window and no cause required, as long as the new PCP is in that member's health plan. If your problem is the doctor rather than the plan, you do not have to wait for open enrollment or build a for-cause case. Call your CMO's member services and ask for a new PCP.5

For-cause changes outside open enrollment. Federal law lists permissible causes for mid-year change at 42 CFR 438.56(d)(2), including:10

• The member moves out of the CMO's service area
• The CMO does not, because of moral or religious objections, cover the service the member needs
• The member needs related services performed at the same time, not all of them are available within the network, and a provider determines that receiving them separately would subject the member to unnecessary risk
• For members using managed long-term services and supports, a residential, institutional, or employment-supports provider moves from in-network to out-of-network and the member would face a disruption in their residence or employment
• Other reasons including poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member's care needs

A state that limits disenrollment also has to give members written notice of these rights at least 60 days before each enrollment period starts, and has to give a member timely access to a State fair hearing if the state decides there is no good cause for the change.10

To request a for-cause change, the member contacts the Georgia Families enrollment broker or DFCS caseworker, explains the cause, and provides supporting documentation if available. The state evaluates the request and either grants the change or denies and explains why.

In practice, for-cause changes are granted when there is a clear network gap (the member's specialist is not in the CMO's network and no equivalent specialist is reasonably available), a quality-of-care issue (substantiated complaint about coordination or denial of services), or a continuity issue (the member needs to remain with established providers due to medical complexity).

How to Compare Georgia Medicaid Managed Care Plans

Because dental and vision are largely uniform within each age category and the core benefit structure is set by state contract, the practical differences between Amerigroup, CareSource, and Peach State come down to a few specific areas.

1. Provider network depth. This is the single biggest differentiator. Before selecting a CMO, check whether your family's existing primary care provider, specialists, and preferred hospital are in network. Each CMO publishes a provider directory online; verify by calling the CMO's member services to confirm participation.

2. Care coordination quality. Members with chronic conditions (diabetes, asthma, heart disease, depression), complex pregnancies, NICU graduates, or significant special needs will interact heavily with a care coordinator. Quality varies by CMO, by region within the CMO, and by individual coordinator. Asking other families with similar needs which CMO has worked well is often more useful than published metrics.

3. Member service experience. Hold times, knowledgeable representatives, mobile app usability, online portal functionality, and provider directory accuracy vary by CMO. Calling each CMO's member services line and asking a specific question (such as "I'm a new member with a child who has asthma. How would you help me find a pulmonologist?") gives a useful signal.

4. Behavioral health access. All three CMOs integrate behavioral health into the medical benefit. But the depth of the behavioral health network (especially for child therapy, psychiatric medication management, and SUD treatment) varies significantly. For families where behavioral health is a primary concern, this is a critical comparison point.

5. Specialty programs. Each CMO offers some value-added or extra-benefit programs beyond the contracted services, including diaper subsidies, school-based supplies, healthy-pregnancy rewards, GED preparation, and similar offerings. These vary annually based on each CMO's discretion and are worth checking at the time of enrollment.

6. Geographic strength. Some CMOs have stronger networks in metro Atlanta; others have stronger networks in rural counties. If you live in a rural area, check the network depth carefully before assuming all three are equivalent.

7. Drug formulary. If anyone in the household takes a specific or high-cost drug, check that drug against each plan's formulary before choosing.2

Prior Authorization Rules

Prior authorization (PA) is the process by which a CMO requires advance approval before paying for certain services. Each CMO has its own PA list, but federal law and DCH contract impose timing standards.

Timing standards: Federal law sets maximum decision timelines for standard prior-authorization requests. Under 42 CFR 438.210(d), a managed care plan must make a standard service-authorization decision within a state-set timeframe that may not exceed 7 calendar days after receiving the request for rating periods that start on or after January 1, 2026 (the prior 14-calendar-day cap applies to earlier rating periods), with a possible extension of up to 14 additional days when the member or provider asks for it or the plan justifies a need for more information that is in the member's interest. An expedited decision applies when the standard timeframe could seriously jeopardize the member's life, health, or ability to attain, maintain, or regain maximum function; the plan must then decide as expeditiously as the member's condition requires and no later than 72 hours after it receives the request, again with a possible extension of up to 14 calendar days. For an expedited decision, note that the regulation names the member, not the provider, as the one who can ask for that extension.11

Two exceptions to those clocks. Prior authorization for a covered outpatient drug is not governed by these timeframes at all; 42 CFR 438.210(d)(3) sends drug decisions to the notice rule in section 1927(d)(5)(A) of the Social Security Act instead. And if you are a dual eligible enrolled in an applicable integrated plan (the aligned Medicare-Medicaid arrangements defined at 42 CFR 422.561), your plan follows the Part C timelines at 42 CFR 422.629 through 422.634 rather than the 7-day and 72-hour figures above.11

Services that commonly require PA:

• Non-emergency inpatient hospitalization
• High-cost imaging (MRI, CT, PET in some cases)
• Specialty drugs (handled through the pharmacy benefit)2
• Specialty durable medical equipment
• Outpatient surgery (non-emergent)
• Behavioral health intensive services (residential treatment, inpatient psychiatric)
• Therapy beyond initial threshold visits

Services that do NOT require PA:

• Emergency services
• Most preventive care
• Routine primary care visits
• Basic lab and imaging
• Family planning services

If PA is denied, the member receives a notice of action explaining the denial and the right to appeal. The denial notice triggers the appeal timeline.

Appeals: CMO Internal Appeal and OSAH Fair Hearing

Level one: CMO internal appeal. Under 42 CFR 438.402(c)(2)(ii), you have 60 calendar days from the date on the adverse benefit determination notice to file your appeal with the CMO; federal rules allow the plan only one level of internal appeal, and it can be requested orally or in writing.12

• CMO must resolve a standard appeal within 30 calendar days, and an expedited appeal within 72 hours, under 42 CFR 438.408(b) (either timeframe may be extended by up to 14 calendar days)13
• The CMO appeal can be filed by phone, by mail, by fax, or online through the member portal
• Members may have a representative (family member, attorney, advocate)
• Members may submit additional medical records or expert opinions

Level two: State Fair Hearing at OSAH. You may request a State fair hearing after the CMO tells you it is upholding its adverse benefit determination. Under 42 CFR 438.408(f)(2), the state must give you no less than 90 and no more than 120 calendar days from the CMO's notice of resolution to request the hearing; the exact deadline inside that band is set by the state, so check Georgia's. There is one escape from waiting: if the CMO fails to follow the notice and timing rules in 42 CFR 438.408, you are deemed to have exhausted its appeal process and may go straight to a State fair hearing.13

• Hearing scheduled by OSAH (typically by phone or video)
• Administrative Law Judge issues a written decision
• Decision can be appealed to Superior Court within the applicable deadline

The filing deadline and the coverage deadline are not the same deadline, and the coverage one is far shorter. Benefits do not keep running on their own while the fair hearing is pending. Under 42 CFR 438.420(c)(2), continued benefits end if you fail to request both the State fair hearing and continuation of benefits within 10 calendar days after the CMO sends its notice of adverse resolution. A member who uses the full 90-to-120-day window to file keeps the appeal and loses the coverage in the meantime. If the service matters to you now, file within 10 days and say in writing that you are requesting continuation of benefits.13

Aid pending appeal. If the CMO has reduced, suspended, or terminated a service that was previously authorized, the member can request continuation of services during the appeal by filing the appeal promptly, within the deadline stated on the notice of action. Under the federal continuation rule, the request has to reach the agency before the action takes effect; a request made after that date does not trigger continuation, though a separate rule lets the agency reinstate services when the hearing is requested no more than 10 days after the date of action. The services continue at the previous level until the appeal is decided. If the appeal is ultimately decided against the member, recovery is limited: the agency may recoup only the cost of services that were furnished solely by reason of the continuation, not the cost of everything received while the appeal was pending.14

If you were cut off with no advance notice, reinstatement is a right, not a favor. Under 42 CFR 431.231(c) the agency must reinstate and continue services until a hearing decision when all three of these are true: the action was taken without the advance notice the rules require; you request a hearing within 10 days of receiving the notice of action (receipt is treated as 5 days after the date on the notice unless you show it arrived later); and the agency determines the action came from something other than the application of federal or state law or policy.14

Ask for continuation; do not wait for it. Georgia's DFCS Medicaid manual continues eligibility and patient liability during an appeal upon the member's request, and only when that request arrives within 10 days of the date of the notice. The same manual says DCH reserves the right to require repayment of continued benefits if the member loses the hearing. Put the request in writing, keep a copy, and note the date.14

Legal help. Georgia Legal Services Program (statewide outside metro Atlanta) and Atlanta Legal Aid (metro counties) provide free representation in Medicaid appeals for qualifying clients.

Three Worked Examples

Example 1: New enrollee with a chronic condition selects a CMO

The Reynolds family applied for Medicaid for their two children after a job loss. Both children have asthma; one has eczema. Through Georgia Gateway, they selected Peach State Health Plan at enrollment after checking that their existing pediatrician was in network. After the first month, they realized Peach State's prior authorization process for nebulizer supplies was slower than they had expected and the asthma care coordinator they were assigned was not responsive.

Using the 90-day right to change. Within the 90-day window, they called the Georgia Families enrollment broker and requested a change to CareSource, where the same pediatrician was also in network. They submitted no documentation, no justification, and no waiting period applied, because the federal 90-day window is a without-cause right.10 The change took effect on the first of the following month. They received new ID cards and continued seeing the same pediatrician with a different CMO as the payer.

Lesson. The 90-day window is a no-questions-asked window. Families who are not certain about their initial assignment should use this period actively.

Example 2: Mid-year switch for cause during pregnancy

Martinez is in her second trimester. She is enrolled with Amerigroup, but her preferred OB is not in the Amerigroup network. The OB is in network with Peach State Health Plan. She is more than 90 days past initial enrollment and outside the annual open enrollment period.

For-cause change request. Martinez calls the enrollment broker and requests a for-cause change to Peach State, citing the need for continuity with her established prenatal care provider and the gap in Amerigroup's OB network for her geographic area. She provides the OB's letter confirming she is an established patient. Lack of access to providers experienced in dealing with a member's health care needs is one of the federally listed causes.10 DCH grants the change after review. The new CMO assignment takes effect the first of the following month, and Peach State's care coordinator contacts her to set up high-risk pregnancy management.

Lesson. Continuity with established prenatal providers is a recognized for-cause basis. Documentation from the provider supports the request.

Example 3: Adoption-assistance child auto-enrolled in Georgia Families 360

The Johnson family finalized the adoption of their foster daughter Naya. Naya has been in foster care for three years with significant trauma history and is currently receiving therapy and psychiatric medication management. At adoption finalization, DFCS confirmed that Naya is eligible for Title IV-E adoption assistance, which automatically maintains her Medicaid eligibility.

Auto-enrollment in Georgia Families 360. Because Naya is an adoption-assistance child, she is enrolled in Georgia Families 360 rather than a standard Georgia Families CMO.1 The 360 plan assigns a care coordinator who specializes in trauma-informed pediatric care, contacts the Johnsons, and coordinates the transition from Naya's foster care behavioral health providers to a network arrangement that continues the same therapy and medication providers.

Lesson. The integrated care coordination is one of the key benefits the program provides for this population.

Common Mistakes Members Make

1. Letting auto-assignment happen by default. Auto-assignment does not consider personal preferences. Make an affirmative choice during the application process.
2. Not checking provider networks before selecting. The most common cause of CMO frustration is discovering that your preferred PCP, specialist, or hospital is not in network.
3. Missing the 90-day right to change. This window is short. Set a reminder in your calendar at enrollment so you reassess before it expires.
4. Assuming every CMO covers your drugs the same way. Each CMO runs its own pharmacy benefit through its own pharmacy benefit manager and has its own drug formulary, so check your prescriptions against the formulary of the plan you are considering. (Fee-for-service members are served by the state's manager, OptumRx, instead.)2
5. Confusing Medicaid CMOs with Medicare D-SNPs. The grocery cards, OTC cards, gym memberships, and similar perks heavily advertised by health plans are typically Medicare D-SNP features for dual-eligibles 65+, not Medicaid CMO features.
6. Filing only the CMO appeal and missing the OSAH window. If the CMO denial stands, you have only a limited time to file at OSAH. Do not let this window close.
7. Not requesting aid-pending appeal in time. The window from the notice of action is strict. Filing in time continues services; filing after the deadline does not.
8. Not knowing about the family planning provider freedom. Enrollment in a CMO cannot restrict which qualified family planning provider a member uses, in or out of the plan's network, and no cost sharing may be charged for those services.6
9. Forgetting about Georgia Families 360 for adopted children. Adoption-assistance children stay in GF 360, not a standard CMO. Trying to switch them to a standard CMO is the wrong move.
10. Not engaging the care coordinator for chronic conditions. CMOs assign care coordinators to high-needs members. Using the coordinator actively (rather than letting them be a one-time check-in) is the difference between good and poor managed care.

Bottom Line for Georgia Families

Georgia Medicaid managed care is built around three contracted Care Management Organizations that share the statewide Georgia Families mainstream Medicaid and CHIP market, plus the separate Georgia Families 360 program for children, youth, and young adults in foster care or receiving adoption assistance and for select youth involved with the Department of Juvenile Justice.1 Pharmacy is administered by OptumRx for fee-for-service members and by each CMO's own pharmacy benefit manager for CMO members, with a separate drug formulary published for each plan, so check your prescriptions plan by plan.2

The right CMO for your family depends primarily on provider network depth, specialty access, care coordination quality, and member service experience. The 90-day right to change after initial enrollment is the most valuable consumer protection in the system; use it actively.

Get Help With Georgia Medicaid Managed Care

If you need help selecting a CMO, switching plans, appealing a denial, or finding in-network providers, the following resources are available. For member services, use the number on your member ID card.

Learn More

Find personalized help navigating Georgia Medicaid managed care 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.