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).Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo A separate single-CMO contract called Georgia Families 360 serves foster youth, adoption-assistance children, and youth involved with juvenile justice.
Note (verified June 2026): WellCare of Georgia is no longer a separate Georgia Families Medicaid CMO; the current statewide roster is the three plans named above. (WellCare remains a Medicare brand in Georgia, which is a different program.) A 2024 reprocurement proposed a different future slate of CMOs, but as of mid-2026 that award is in the bid-protest phase with no announced go-live date, and the current three-CMO contracts have been extended (reported through June 30, 2027).Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo
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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx 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.Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo
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)Centers for Medicare & Medicaid Services. (n.d.). Medicaid.gov (CMS) - State Waivers List entry: Georgia Pathways to Coverage. medicaid.gov. Retrieved Jul 30, 2026, from https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81441
- 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).Centers for Medicare & Medicaid Services. (1915). CMS/Medicaid.gov — Georgia 1915(c) HCBS waivers (DCH corrective action plan). medicaid.gov. Retrieved Aug 3, 2026, from https://www.medicaid.gov/medicaid/home-community-based-services/downloads/ga-prop-cap.pdf
- 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).Georgia Department of Community Health. (n.d.). Georgia Families. medicaid.georgia.gov. Retrieved Aug 1, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families
The Care Management Organizations
All three CMOs operate statewide. Members in any Georgia county can choose any of the three.Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo
| CMO | Parent Company | Profit Status |
|---|---|---|
| Amerigroup Community Care | Elevance Health (formerly Anthem) | For-profit |
| CareSource | CareSource Group (Ohio-based) | Nonprofit |
| Peach State Health Plan | Centene Corporation | For-profit |
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 and operates the separate Georgia Families 360 single-statewide contract.
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, which Centene also owns, is no longer a separate Georgia Families Medicaid CMO.Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo
Georgia Families 360 for Foster and Adoption-Assistance Children
Georgia Families 360 is a separate single-statewide CMO contract 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 in foster care (DFCS custody)
- Children receiving adoption assistance under Title IV-E
- Youth involved with juvenile justice
- Former foster youth ages 18-20
Why a separate program: These children typically need integrated physical health, behavioral health, and care coordination that bridges the medical and child welfare systems. The single-CMO model concentrates accountability and lets the state hold one plan responsible for the full continuum of services. Amerigroup has historically held this contract through its Elevance subsidiary.
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)Office of the Law Revision Counsel, U.S. House of Representatives. (n.d.). 42 U.S.C. 1396d(a)(4)(C) — Office of the Law Revision Counsel, U.S. Code (mandatory family planning benefit). uscode.house.gov. Retrieved Jun 26, 2026, from https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d&num=0&edition=prelim
- 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)U.S. Government Publishing Office. (n.d.). 42 CFR 438.114(c)(1)(i) — Emergency and poststabilization services; emergency services covered regardless of provider contract (ecfr.gov, current). ecfr.gov. Retrieved Aug 1, 2026, from https://www.ecfr.gov/current/title-42/section-438.114
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 CMOsGeorgia Department of Community Health. (n.d.). Non-Emergency Medical Transportation. medicaid.georgia.gov. Retrieved Jul 17, 2026, from https://medicaid.georgia.gov/programs/all-programs/non-emergency-medical-transportation
- 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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
- 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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx 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.Office of the Law Revision Counsel, U.S. House of Representatives. (n.d.). 42 U.S.C. 1396d(r) — EPSDT definition (uscode.house.gov, OLRC prelim rolling edition). uscode.house.gov. Retrieved Aug 1, 2026, from https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d&num=0&edition=prelim
- 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.Centers for Medicare & Medicaid Services. (n.d.). CMS - Georgia State Plan Amendment GA-24-0005 approval package (approval letter, Form CMS-179, approved SPA page 10a Adult Dental Services). medicaid.gov. Retrieved Jul 30, 2026, from https://www.medicaid.gov/medicaid/spa/downloads/GA-24-0005.pdf
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.Office of the Law Revision Counsel, U.S. House of Representatives. (n.d.). 42 U.S.C. 1396d — Definitions (uscode.house.gov, prelim edition). uscode.house.gov. Retrieved Aug 3, 2026, from https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d&num=0&edition=prelim
- 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.Georgia Department of Community Health. (n.d.). Non-Emergency Medical Transportation. medicaid.georgia.gov. Retrieved Jul 17, 2026, from https://medicaid.georgia.gov/programs/all-programs/non-emergency-medical-transportation
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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.56 — Disenrollment: Requirements and limitations (eCFR, current). ecfr.gov. Retrieved Jul 31, 2026, from https://www.ecfr.gov/current/title-42/section-438.56
How to use the 90-day window:
Contact the enrollment broker
Call Georgia Families at 1-888-GA-Enroll (1-888-423-6765), TDD 1-877-889-4424, or go to www.georgia-families.com. You can also contact your DFCS caseworker or log in to Georgia Gateway.Georgia Department of Community Health. (n.d.). Georgia Families. medicaid.georgia.gov. Retrieved Aug 1, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families
Select the new CMO
Choose Amerigroup, CareSource, or Peach State. No cause or documentation is required within the 90-day window.
Note the effective date
The change typically takes effect on the first of the following month.
Watch for new ID cards
The new CMO mails you new member ID cards.
Schedule a new PCP appointment if needed
If your primary care provider is not in the new CMO's network, pick an in-network PCP and set up a first visit.
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. Open enrollment timing is set by DCH and communicated to members through annual notices. After open enrollment closes, members are locked in until the next annual cycle.
For-cause changes outside open enrollment. Federal law lists permissible causes for mid-year change at 42 CFR 438.56(d)(2), including:U.S. Government Publishing Office. (n.d.). 42 CFR 438.56 — Disenrollment: Requirements and limitations (eCFR, current). ecfr.gov. Retrieved Jul 31, 2026, from https://www.ecfr.gov/current/title-42/section-438.56
- 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 to be performed at the same time, and not all related services are available within the network
- 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 health care needs
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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.210(d)(1)(i)(B) — Timeframe for standard authorization decisions (current, eCFR). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210
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)Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
- 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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.402 — General requirements: Grievance and appeal system (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/section-438.402
- 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)U.S. Government Publishing Office. (n.d.). 42 CFR 438.408(b)(2), (b)(3) and (c)(1) — Resolution and notification: standard, expedited, and extension of timeframes (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408
- 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 only after the CMO's one internal appeal is exhausted. 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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.408(f) — Requirements for State fair hearings (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408
- 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
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.U.S. Government Publishing Office. (n.d.). 42 CFR 431.230 — Maintaining services (eCFR, current/rolling edition). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/section-431.230
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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.56 — Disenrollment: Requirements and limitations (eCFR, current). ecfr.gov. Retrieved Jul 31, 2026, from https://www.ecfr.gov/current/title-42/section-438.56 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.U.S. Government Publishing Office. (n.d.). 42 CFR 438.56 — Disenrollment: Requirements and limitations (eCFR, current). ecfr.gov. Retrieved Jul 31, 2026, from https://www.ecfr.gov/current/title-42/section-438.56 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. The single statewide CMO (Amerigroup under the 360 contract) 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
- Letting auto-assignment happen by default. Auto-assignment does not consider personal preferences. Make an affirmative choice during the application process.
- 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.
- 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.
- 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.)Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
- 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.
- 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.
- 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.
- 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.Office of the Law Revision Counsel, U.S. House of Representatives. (n.d.). 42 U.S.C. 1396d(a)(4)(C) — Office of the Law Revision Counsel, U.S. Code (mandatory family planning benefit). uscode.house.gov. Retrieved Jun 26, 2026, from https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d&num=0&edition=prelim
- 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.
- 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.
Frequently Asked Questions
Which CMO is best in Georgia?
There is no single "best" CMO. The answer depends on which providers you want to use, where you live in the state, what conditions you and your family have, and what your priorities are for care coordination, behavioral health, and member service. Provider network, specialty access, care coordination quality, behavioral health depth, and the plan's drug formulary are the main areas where the three CMOs differ.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx Check the provider directories and drug formularies online, and call member services for each CMO, before making your selection.
Can I keep my doctor when I switch to a different CMO?
Only if your doctor is in network with the new CMO. Each CMO has its own provider network, and most providers contract with multiple CMOs but not all three. Before switching, verify network participation by checking the new CMO's provider directory or calling member services. If your doctor is in network with both your current CMO and your target CMO, you can switch and keep the same doctor.
What is Georgia Families 360 and is my child enrolled in it?
Georgia Families 360 is a separate single-CMO contract that serves children in foster care, children receiving adoption assistance under Title IV-E, juvenile justice involved youth, and former foster youth ages 18-20. The contract has historically been operated by Amerigroup. Children in these categories are auto-enrolled in GF 360 and cannot switch to a standard Georgia Families CMO. To verify your child's enrollment, contact your DFCS caseworker or check Georgia Gateway.
Who runs the pharmacy benefit for my CMO?
Your CMO does, through its own pharmacy benefit manager, and DCH links a separate drug formulary for each CMO. Only the fee-for-service population is served by the state's Pharmacy Benefits Manager, OptumRx. Check your prescriptions against the formulary of the plan you are in or considering. Gainwell Technologies is Georgia's GAMMIS fiscal agent, and no DCH page assigns it a pharmacy-benefit-manager role.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
Does long-term care go through a CMO?
No. Nursing facility Medicaid, ICWP, NOW, COMP, and the Elderly and Disabled Waiver Program (EDWP) all run outside the Georgia Families CMO structure. CCSP and SOURCE are the two service-delivery models found within EDWP rather than separate waivers (SOURCE is covered in our SOURCE guide).Centers for Medicare & Medicaid Services. (1915). CMS/Medicaid.gov — Georgia 1915(c) HCBS waivers (DCH corrective action plan). medicaid.gov. Retrieved Aug 3, 2026, from https://www.medicaid.gov/medicaid/home-community-based-services/downloads/ga-prop-cap.pdf PACE, the Program of All-Inclusive Care for the Elderly, is a separate model again, but as of mid-2026 Georgia has no confirmed operating PACE site: the state issued a PACE request for proposals that closed in May 2025 and the program is still in procurement.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates Our Georgia PACE guide tracks the current status. See our long-term care guide for the full overview.
How do I switch CMOs?
Call Georgia Families at 1-888-GA-Enroll (1-888-423-6765), go to www.georgia-families.com, contact your DFCS caseworker, or log in to Georgia Gateway.Georgia Department of Community Health. (n.d.). Georgia Families. medicaid.georgia.gov. Retrieved Aug 1, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families Within 90 days of initial enrollment, you can switch without cause. Outside that window, you must wait for annual open enrollment or demonstrate cause (network gap, quality of care issue, continuity of care need with established providers). The change typically takes effect the first of the month following the request.
What happens if my CMO denies a service?
You have the right to file an internal CMO appeal within 60 calendar days of the date on your denial notice, and the CMO must resolve a standard appeal within 30 calendar days (72 hours if expedited) under federal Medicaid managed care rules.U.S. Government Publishing Office. (n.d.). 42 CFR 438.408(b)(2), (b)(3) and (c)(1) — Resolution and notification: standard, expedited, and extension of timeframes (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408 If the CMO denial stands, you can request a State Fair Hearing through the Office of State Administrative Hearings (OSAH); the state must give you 90 to 120 calendar days from the CMO's resolution notice to do so.U.S. Government Publishing Office. (n.d.). 42 CFR 438.408(f) — Requirements for State fair hearings (eCFR, current). ecfr.gov. Retrieved Aug 8, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408 If the service was previously authorized and is being terminated or reduced, you can request continuation of services during appeal by filing promptly within the deadline stated on the notice.
Is behavioral health carved out of the CMO?
No. The three Georgia Families CMOs integrate behavioral health (mental health and substance use disorder treatment) into the medical benefit. There is no separate behavioral health carve-out company that members deal with. However, public sector mental health services delivered through Community Service Boards (CSBs) and the Department of Behavioral Health and Developmental Disabilities (DBHDD) operate alongside the CMO benefit, especially for serious mental illness, IDD services, and crisis response.
Is WellCare still a Georgia Families Medicaid CMO?
No. As verified in June 2026, WellCare of Georgia is no longer a separate Georgia Families Medicaid CMO. The current statewide roster is three plans: Amerigroup Community Care, CareSource, and Peach State Health Plan. WellCare still operates in Georgia as a Medicare brand, which is a different program from Georgia Families Medicaid, so do not confuse a WellCare Medicare plan with a Georgia Families Medicaid CMO.Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo
Where can I get free help understanding my CMO benefits?
Georgia Legal Services Program (statewide outside metro Atlanta) and Atlanta Legal Aid (metro Atlanta counties) provide free legal representation for Medicaid appeals and benefits issues for qualifying clients. For general member support, call your CMO's member services line directly. For applications, redetermination, and category changes, contact DFCS or use Georgia Gateway at gateway.ga.gov.
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 a single-statewide Georgia Families 360 contract for foster and adoption-assistance children.Georgia Department of Community Health. (n.d.). Care Management Organizations (CMO). medicaid.georgia.gov. Retrieved Jul 13, 2026, from https://medicaid.georgia.gov/programs/all-programs/georgia-families/care-management-organizations-cmo 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.Georgia Department of Community Health. (n.d.). OptumRX. dch.georgia.gov. Retrieved Jul 30, 2026, from https://dch.georgia.gov/providers/provider-types/pharmacy/optumrx
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.