Georgia Medicare-Medicaid Coordination of Benefits: A Complete Guide to Dual Eligibles, QMB SLMB QI QDWI, D-SNP, and Extra Help

Audience: Georgia residents who have both Medicare and Medicaid, or who may qualify for both; family caregivers helping a parent navigate Medicare premiums, drug coverage, and long-term care; people approaching age 65 with limited income; people with disabilities transitioning from SSI or SSDI to Medicare; community workers and SHIP counselors helping clients understand dual benefits.

What this guide covers: How dual eligibility works in Georgia. Who qualifies as a "dual" and what the four Medicare Savings Program categories mean. How the Qualified Medicare Beneficiary (QMB) program pays Medicare premiums, deductibles, and coinsurance, and why providers are federally prohibited from balance billing QMBs. How Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled and Working Individual (QDWI) categories work. How the Low-Income Subsidy (Extra Help) for Part D covers prescription drug costs, including the Inflation Reduction Act 2022 expansion to 150 percent of the federal poverty level. How Dual Special Needs Plans (D-SNPs) integrate Medicare and Medicaid, and the difference between coordination-only D-SNPs, Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs). How the Bipartisan Budget Act 2018 Section 50311 made D-SNP authority permanent and required integration, and how CMS Final Rule CMS-4201-F (April 2023) and CMS-4205-F (April 2024) restructured the integration framework. How Section 1924 spousal impoverishment protects a community spouse when the other spouse needs nursing facility care. How PACE (Program of All-Inclusive Care for the Elderly) under Section 1934 offers a comprehensive coordinated alternative. How Georgia administers the buy-in agreement under Section 1843. Six worked examples covering newly Medicare-eligible adults, full-benefit duals choosing between D-SNPs, balance billing disputes, the SSDI-to-Medicare transition, the working disabled, and the rural HCBS waiver option. A 14-question FAQ. And a contact list with phone numbers for Medicare, Social Security, Georgia DCH, GeorgiaCares SHIP counseling, and all seven major Georgia D-SNP plans.

Last verified: May 12, 2026

By Brevy Care Team · Last verified May 12, 2026

"Dual eligible" is the term for a person enrolled in both Medicare and Medicaid. The Georgia Medicare Savings Program is the principal mechanism by which Georgia Medicaid assists Medicare beneficiaries with limited income. Dual eligibles are not a homogeneous group: they include older adults who have aged into Medicare at 65 and qualify for Medicaid because of low income; people under 65 who became Medicare-eligible after 24 months of Social Security Disability Insurance and who qualify for Medicaid because of disability and low income; people with end-stage renal disease who qualify for Medicare regardless of age; and people with amyotrophic lateral sclerosis who qualify for Medicare immediately upon SSDI entitlement. What unites them is that two public insurance programs cover their care, and the way those programs interact determines what they pay and what services they can access.

Dual eligibles drive a disproportionate share of program spending and tend to be older, sicker, more functionally impaired, more likely to need long-term services and supports, and more likely to have multiple chronic conditions than either Medicare-only or Medicaid-only beneficiaries. Coordinating their benefits well is therefore central to managing both programs. A substantial share of Georgia's Medicare population is dually eligible; consult the CMS Medicare-Medicaid Coordination Office and Kaiser Family Foundation state dual-eligible data for current Georgia counts.

The legal architecture of dual eligibility sits at the intersection of two enormous federal statutes. Title XVIII of the Social Security Act establishes Medicare, with Sections 1818 through 1860D-42 covering hospital insurance, medical insurance, Medicare Advantage, and prescription drug coverage. Title XIX establishes Medicaid, with Section 1902 setting state plan requirements and Section 1905 defining covered services and special categories. The bridge between the two statutes is Section 1902(a)(10)(E), which mandates that state Medicaid programs cover Medicare Savings Program categories, and Section 1843, which authorizes the state-federal buy-in agreement under which Georgia Medicaid pays Medicare premiums for qualifying enrollees.

This guide translates that framework for Georgia families. It explains who qualifies for each dual eligibility category, what each category covers, how the Dual Special Needs Plan landscape works in Georgia, how the Inflation Reduction Act 2022 changed Extra Help, how spousal impoverishment protects married duals, and how to navigate enrollment and disputes. It is informational and does not constitute legal, medical, tax, or insurance advice. Eligibility, plan availability, premium amounts, and integration rules can change; always confirm specifics with the Georgia Department of Community Health (DCH), the Social Security Administration, GeorgiaCares SHIP, or qualified counsel before acting.

The four Medicare Savings Program categories

Medicare Savings Programs (MSPs) are state-administered programs that use Medicaid funds to pay Medicare premiums and, for some categories, cost-sharing. Section 1902(a)(10)(E) of the Social Security Act makes MSP coverage mandatory for state Medicaid programs; each state must offer all four categories. Georgia administers MSPs through the DCH ABD Medicaid Unit and DHS DFCS eligibility offices.

Qualified Medicare Beneficiary (QMB). Section 1905(p) defines QMB. Eligibility requires enrollment in Medicare Part A (or eligibility for premium-conditional Part A), countable income at or below 100 percent of the federal poverty level, and countable resources within set limits ($9,950 for an individual and $14,910 for a couple in 2026 per the CMS CY2026 LIS Resource Limits Memo, with the same limits applied to QMB/SLMB/QI by federal alignment). For a QMB enrollee, Georgia Medicaid pays: the Part A premium if the person owes one; the Part B premium of $202.90 per month for 2026; the Part A deductible of $1,736 per benefit period for 2026; the Part B deductible of $283 annual for 2026; and all Medicare coinsurance, including hospital coinsurance, skilled nursing facility coinsurance, and the 20 percent Part B coinsurance on most outpatient services. QMB is the most comprehensive of the four MSP categories.

"QMB only" refers to a person who qualifies for QMB but not full Medicaid (perhaps because resources are between the QMB limit and the Georgia ABD Medicaid resource limit, or because the person does not meet aged, blind, or disabled criteria). "QMB plus" refers to a person who qualifies for both QMB and full Medicaid. In Georgia, the ABD Medicaid income threshold is more restrictive than QMB's 100 percent FPL ceiling; verify current ABD income and resource limits on the Georgia DCH Aged, Blind, and Disabled Medicaid page. A person whose income falls between the ABD limit and 100 percent FPL with the right resource posture typically gets QMB only. A person under the ABD income and resource limits typically qualifies for QMB plus full Medicaid.

Specified Low-Income Medicare Beneficiary (SLMB). Section 1905(s) defines SLMB. Eligibility requires Medicare Part A enrollment, countable income between 100 and 120 percent FPL, and resources within the same limits as QMB. For an SLMB enrollee, Georgia Medicaid pays only the Part B premium ($202.90 per month for 2026). SLMB does not cover deductibles or coinsurance unless the person also qualifies for full Medicaid.

Qualifying Individual (QI). Section 1933 defines QI. Eligibility requires Medicare Part A enrollment, countable income between 120 and 135 percent FPL, and resources within the same limits as QMB. For a QI enrollee, Georgia Medicaid pays only the Part B premium. QI is funded through a federal block grant rather than the regular Medicaid match, and the block grant is allocated on a first-come, first-served basis. Crucially, QI is mutually exclusive with full Medicaid: a person cannot have both QI and full Medicaid in the same month.

Qualified Disabled and Working Individual (QDWI). Section 1905(p)(3)(B) defines QDWI. Eligibility requires loss of premium-free Part A because of return to work after a disability, countable income at or below 200 percent FPL, and resources within a tighter limit of $4,000 for an individual and $6,000 for a couple. For a QDWI enrollee, Georgia Medicaid pays only the Part A premium ($565 per month for a person with fewer than 30 quarters of Medicare-covered employment, or $311 per month for 30 to 39 quarters, in 2026). QDWI is the narrowest of the four categories and serves a small population.

A few features cut across all four categories. The resource test excludes the home, one car, household goods, burial space, and a $1,500 burial fund per person. Retirement accounts are generally counted unless in pay status. Income test counts gross Social Security (not net), pensions, wages (with disregards), and most other income; it excludes Supplemental Security Income, food stamps, and most needs-based assistance. Effective dates can be retroactive up to three months prior to the application month under 42 CFR 435.914, which can matter for Part B premium reimbursement.

The Part D Low-Income Subsidy (Extra Help) and the Inflation Reduction Act

The Part D Low-Income Subsidy, commonly called Extra Help, pays for Part D prescription drug coverage for low-income Medicare beneficiaries. Section 1860D-14 of the Social Security Act establishes the subsidy. For most of Extra Help's history, there were two tiers: full Extra Help for people at or below 135 percent FPL with limited resources, and partial Extra Help for people between 135 and 150 percent FPL. The partial tier required a small premium contribution and slightly higher copays, creating a cliff at the 135 percent FPL boundary.

The Inflation Reduction Act 2022 Section 11404 eliminated this cliff. Effective January 1, 2024, full Extra Help is available to all eligible Medicare beneficiaries at or below 150 percent FPL; consult the SSA Extra Help page for the current annual income threshold. Resource limits for full Extra Help in 2026 are $16,590 for an individual and $33,100 if married, per the SSA Extra Help benefit and the CMS CY2026 LIS Resource Limits Memo. Full Extra Help benefits include: no Part D premium (in plans at or below the regional benchmark); no Part D deductible; no coverage gap (donut hole) cost-sharing; and a maximum copay per drug of $12.65 for 2026 (lower for institutionalized or HCBS-waiver enrollees, who pay $0).

Dual eligibles receive Extra Help automatically. Anyone identified as QMB, SLMB, QI, full-benefit Medicaid, or SSI is "deemed" eligible for full Extra Help without a separate application. CMS sends a confirmation letter and assigns the enrollee to a benchmark Part D plan. For people not automatically deemed, a separate Extra Help application is filed with the Social Security Administration (Form SSA-1020) or through the state Medicaid agency.

The Inflation Reduction Act also introduced an annual out-of-pocket cap on Part D spending, effective January 1, 2025; the cap is $2,100 for 2026 (indexed for inflation from $2,000 in 2025). This cap applies to all Part D enrollees, not just LIS recipients. For LIS-eligible duals, the cap rarely binds because copays are already so low.

Original Medicare versus Medicare Advantage versus D-SNP

A dual eligible has three main coverage architecture options.

Option 1: Original Medicare plus standalone Part D plus Medicaid wraparound. The enrollee receives Part A and Part B through Original Medicare ("fee-for-service" or FFS), buys a standalone Part D prescription drug plan (with premium fully covered by Extra Help if eligible), and has full Medicaid for wraparound services (LTSS, dental, transportation, vision in Georgia's limited adult scope). For QMB enrollees, Medicaid pays the Medicare premiums and cost-sharing. Provider choice is broad: any Medicare-participating provider, any pharmacy that accepts the Part D plan. Medicaid is secondary payer for cost-sharing and primary for Medicaid-only services.

Option 2: Medicare Advantage (not a D-SNP) plus Medicaid wraparound. The enrollee receives Parts A, B, and usually D through a private MA plan (HMO, PPO, or other model). Network restrictions apply. Medicaid still covers wraparound services and pays MA premiums and cost-sharing for QMB enrollees. This option is less common for duals; CMS-4201-F and CMS-4205-F have aggressively restricted "look-alike" plans (MA plans that are not D-SNPs but enroll heavily from the dual population), pushing duals toward designated D-SNP products.

Option 3: Dual Special Needs Plan (D-SNP). A D-SNP is a Medicare Advantage plan specifically designed for dually eligible individuals, authorized under Section 1859(f) of the Social Security Act. D-SNPs vary in their level of integration with Medicaid, from coordination-only at one end to Fully Integrated Dual Eligible Special Needs Plans at the other. D-SNPs typically offer enhanced benefits not available in Original Medicare or standard MA: over-the-counter (OTC) allowances, transportation benefits beyond Medicaid NEMT, dental and vision allowances, and dedicated dual care coordinators. D-SNPs have network restrictions; the enrollee must use D-SNP network providers for non-emergency Medicare-covered services.

Choosing among these options depends on provider preferences, prescription needs, geography, integration desires, and whether the enrollee values the D-SNP supplemental benefits. GeorgiaCares SHIP counselors at 1-866-552-4464 provide free, unbiased counseling for this decision.

Dual Special Needs Plans (D-SNPs) and the integration framework

D-SNPs sit at the center of dual eligible policy because they are the vehicle through which Medicare and Medicaid increasingly coordinate. Section 1859(f) of the Social Security Act authorizes D-SNPs as a subset of Medicare Advantage Special Needs Plans. 42 CFR 422.2 provides the categorical definition, and 42 CFR 422.107 requires that every D-SNP execute a State Medicaid Agency Contract (SMAC) with the state Medicaid agency for the area it serves.

Bipartisan Budget Act 2018 Section 50311. This provision made D-SNP authority permanent. Before 2018, D-SNP authority was sunsetting and was reauthorized periodically. BBA 2018 also required all D-SNPs to integrate with Medicaid by 2021 (extended by subsequent rules), and defined two integration tiers above coordination-only:

• Highly Integrated Dual Eligible Special Needs Plan (HIDE-SNP): the D-SNP organization, or an affiliated entity under the same parent, also operates the Medicaid managed care plan that covers the enrollee. LTSS or behavioral health may be carved out. Care coordination across Medicare and Medicaid is required.
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): the D-SNP organization, or affiliated entity, operates both the Medicare D-SNP and a comprehensive Medicaid managed care plan that includes LTSS and behavioral health. The enrollee experiences single ID cards, integrated grievances and appeals, exclusively-aligned enrollment, and a single care management apparatus.

CMS Final Rule CMS-4201-F (April 2023). This rule restructured the D-SNP integration framework. Key elements: phased out look-alike plans; required exclusively-aligned enrollment for HIDE-SNP and FIDE-SNP enrollees (the enrollee cannot have a different Medicaid managed care plan than the D-SNP affiliate); required integrated member ID cards for FIDE-SNP enrollees; required integrated grievance and appeals processes; required that the D-SNP notify the enrollee when a Medicaid-covered service is involved.

CMS Final Rule CMS-4205-F (April 2024). This rule continued the integration push and tightened D-SNP marketing rules. Effective for contract year 2025: special enrollment periods for duals reduced from monthly to quarterly (one change per quarter in Q1, Q2, and Q3, plus the annual coordinated election period in Q4); enrollment broker requirements enhanced; further restrictions on D-SNP marketing materials and agent commissions.

Georgia D-SNP landscape. Several major carriers currently operate D-SNPs serving Georgia duals, with varying county coverage; the Medicare.gov Plan Finder shows the full list of plans available in your county for the current contract year. Most Georgia D-SNPs operate as coordination-only or HIDE-SNP; FIDE-SNP availability in Georgia is limited because Georgia Medicaid does not yet operate a fully integrated managed LTSS program. The CMS-4205-F integration timeline pushes Georgia toward more HIDE-SNP and FIDE-SNP availability over the coming contract years.

The QMB billing prohibition under the Medicare Savings Program

One of the most important and most violated dual eligible protections is the QMB billing prohibition. Three provisions of the Social Security Act work together: Section 1902(n)(3)(B) prohibits state Medicaid programs from reducing payment when a Medicare provider charges a QMB; Section 1905(p) defines QMB protections; and Section 1866(a)(1)(A) requires every provider that participates in Medicare to accept assignment for QMB beneficiaries and to look only to the state (not the patient) for Medicare cost-sharing.

In practice, this means that any provider who accepts Medicare cannot bill a QMB enrollee for any Medicare cost-sharing: not the Part A or Part B deductible, not the 20 percent coinsurance, not the hospital coinsurance, not the SNF coinsurance. The provider may bill Medicare and the state Medicaid agency, but never the QMB patient. This applies to all Medicare providers, whether or not they are also enrolled in Medicaid.

The prohibition does not apply to services Medicare does not cover (those follow Medicaid rules) or to services excluded by both programs (which the patient may owe). It also does not apply to non-QMB duals (SLMB, QI, QDWI, or full-Medicaid-only) for the cost-sharing portions; those duals are protected only to the extent their full Medicaid benefit covers cost-sharing, and Georgia historically pays "lesser-of" amounts (the lesser of the Medicare cost-sharing or the Medicaid rate minus the Medicare payment), which often means $0 in practice.

Common violations include: hospital ED bills sent to QMB patients for the Part A deductible; ambulance services billed for the 20 percent coinsurance; specialty office visits billing the 20 percent Part B coinsurance; collection agencies pursuing former patients for old Medicare cost-sharing balances. When a QMB enrollee receives such a bill, the response is: identify yourself as QMB in writing, cite Section 1902(n)(3)(B) and the federal prohibition, request the bill be rescinded, and report unresolved violations to CMS Region IV in Atlanta at 404-562-7500 or to HHS OCR Region IV at 1-800-368-1019. GeorgiaCares SHIP can help walk through this process.

Spousal impoverishment under Section 1924

When a married dual needs long-term institutional care (nursing facility) or HCBS waiver services that count for Section 1924 purposes, the spousal impoverishment provisions protect the spouse who remains in the community. Section 1924 of the Social Security Act, added by the Medicare Catastrophic Coverage Act 1988 and implemented at 42 CFR 435.722-435.726, allows the community spouse to retain a portion of the couple's resources and a monthly income allowance.

Resource allowance. The community spouse may keep up to the annually-indexed maximum in countable resources for 2026, or at least the indexed minimum, with the actual amount based on a "snapshot" of the couple's resources at the first day of continuous institutional stay of at least 30 days. Resources above the protected amount must be spent down to qualify the institutional spouse for Medicaid. Verify the current maximum and minimum on the CMS Spousal Impoverishment page.

Monthly income allowance. The community spouse keeps her or his own income entirely. If the community spouse's income is below the Minimum Monthly Maintenance Needs Allowance (MMMNA), the institutional spouse may "shift" income to the community spouse up to the MMMNA, with an excess shelter allowance bumping the cap up to an annually-indexed maximum. Pull the current CMS Spousal Impoverishment Standards for the 2026 MMMNA, excess-shelter ceiling, and maximum monthly maintenance needs allowance.

Application in Georgia. O.C.G.A. §49-4-145 incorporates federal Medicaid eligibility rules, and DCH applies Section 1924 not only to institutional Medicaid applicants but also to HCBS waiver applicants (CCSP, SOURCE, NOW, COMP, ICWP). This is more protective than the federal minimum, which requires §1924 only for institutional applicants. The Deficit Reduction Act 2005 gave states the option to extend §1924 to HCBS, and Georgia exercised that option.

Annuities, trusts, and look-back. Common spend-down planning techniques include Medicaid-compliant annuities (irrevocable, actuarially sound, naming the state as primary remainder beneficiary up to amounts paid), special needs trusts, and outright spend on exempt resources (home repairs, pre-paid burial). The Medicaid 60-month look-back period applies to transfers; uncompensated transfers within the look-back trigger a transfer penalty period of ineligibility. Elder law counsel is generally recommended for spousal-impoverishment planning.

PACE (Program of All-Inclusive Care for the Elderly)

PACE under Section 1934 of the Social Security Act is a fully coordinated model for dually eligible older adults who would otherwise need nursing facility care. PACE provides all Medicare and Medicaid covered services, plus additional services the PACE interdisciplinary team (IDT) deems necessary, in exchange for a single capitated payment from Medicare and Medicaid combined.

Eligibility. Age 55 or older; living in a PACE service area; certified by the state as needing nursing facility level of care; and able to live safely in the community at the time of enrollment with PACE services. Most PACE enrollees are dual eligibles, though Medicaid-only and private-pay enrollment is possible.

Benefit. PACE covers everything: primary care, specialty care, hospital, nursing facility (when needed), home care, adult day care at the PACE center, transportation, social work, mental health, prescription drugs, dental, vision, hearing, and any other service the IDT prescribes. There is no Medicare premium, deductible, or coinsurance to the enrollee for any covered service. Medicaid-eligible PACE participants pay no premium. PACE participants who are not Medicaid-eligible pay a monthly premium for the Medicaid portion of the capitated rate.

The PACE center. Enrollment usually involves attending the PACE center one or more days per week for primary care, therapy, social engagement, and meals. The center is the hub of the model; the IDT meets there, services are coordinated there, and transportation is provided to and from.

Georgia PACE programs. Georgia has two operating PACE programs:

• A.G. Rhodes in metro Atlanta serving counties in the Atlanta region.
• Senior Connections in the Savannah area serving coastal-Georgia counties.

Verify current service-area county boundaries on each PACE provider's website or via the Medicaid.gov PACE locator before assuming coverage. Most Georgia counties have no PACE option, which is a significant gap, particularly for rural duals who might benefit from comprehensive coordination but live outside a service area.

Medicare Part D coverage and coordination with Medicaid pharmacy

Part D is the Medicare prescription drug benefit, enacted in the Medicare Modernization Act 2003 and implemented in 2006. For duals, Part D is the primary drug coverage; Medicaid pays for only the small category of "Part D-excluded" drugs.

Part D coverage architecture. Part D plans are private plans, either standalone Prescription Drug Plans (PDPs) or built into Medicare Advantage plans (MAPDs). Each plan has a formulary (list of covered drugs), tiered cost-sharing, and a pharmacy network. CMS regulates Part D under 42 CFR 423; formulary requirements at 42 CFR 423.265 ensure each plan covers a meaningful range of drugs in each USP therapeutic category.

Auto-enrollment for full-benefit duals. CMS auto-enrolls full-benefit duals who do not select a Part D plan into a benchmark plan (a plan with premium at or below the regional LIS benchmark). The enrollee may switch plans at any time using the special enrollment period for LIS-eligible duals, though that SEP is now quarterly under CMS-4205-F. Auto-enrollment is intentionally random to spread duals across plans; the assigned plan may not be the best fit, and GeorgiaCares can help compare alternatives.

Part D-excluded drugs that Medicaid still covers. Federal Part D law (Section 1860D-2) excludes certain drug categories from Part D coverage:

• Barbiturates (limited circumstances)
• Benzodiazepines (now generally Part D-covered after 2013 expansion, with some narrow exclusions)
• Over-the-counter drugs (Part D doesn't cover; Medicaid may at state option)
• Vitamins and minerals (similar)
• Weight loss/gain, anorexia, fertility, cosmetic, hair growth drugs
• Symptomatic cough/cold medication
• Erectile dysfunction drugs (Medicare Part D excludes; some narrow Medicaid coverage)

Georgia Medicaid covers some of these excluded categories for full-benefit duals. Medicaid pharmacy claims for duals must include the Medicare denial or Part D non-coverage notice as documentation.

Coordination at the pharmacy counter. A dual eligible should present both insurance cards at the pharmacy: the Medicare or D-SNP card for Part D drugs, and the Medicaid card for Medicaid-covered or Part D-excluded drugs. Pharmacy systems route claims appropriately. When the pharmacy charges full price, this usually means the dual eligible's LIS status is not on file or the claim was rejected; GeorgiaCares or the Medicare 1-800 line can help.

Inflation Reduction Act Part D out-of-pocket cap. Effective January 1, 2025, total out-of-pocket Part D spending is capped annually for all Part D enrollees; the 2026 cap is $2,100 (indexed up from $2,000 in 2025). For LIS-eligible duals, this cap rarely binds because LIS copays are already so low that hitting the cap in a year is unusual. But for non-LIS Medicare beneficiaries with high-cost drugs, the cap is significant; for low-income non-dual Medicare beneficiaries with high drug costs, the cap creates a strong incentive to apply for Extra Help if income is at or below 150 percent FPL.

Long-term services and supports (LTSS) for duals

Medicare covers LTSS only narrowly: SNF coverage is limited to up to 100 days after a qualifying hospital stay (with cost-sharing after day 20); home health is for skilled care, not custodial; hospice is covered. Medicaid is the primary public payer of LTSS in the United States.

For Georgia duals who need LTSS, the pathway runs through Medicaid:

Institutional care. Nursing facility coverage under Section 1905(a)(4) for individuals meeting nursing facility level of care, with income usually under 300 percent of the SSI Federal Benefit Rate under the special income standard for institutional applicants; verify the current monthly cap on the SSA SSI Federal Benefit Rate page. Section 1924 spousal impoverishment protections apply.

HCBS waivers. Georgia operates five major waivers covering different populations (note: first-mention links above in the spousal-impoverishment section):

• CCSP (Community Care Services Program): frail older adults and adults with physical disabilities; nursing-home-level-of-care criterion
• SOURCE (Service Options Using Resources in a Community Environment): primary care case management overlay for ABDs needing care coordination
• NOW (New Options Waiver): adults with developmental disabilities
• COMP (Comprehensive Supports Waiver Program): adults with more intensive DD needs
• ICWP (Independent Care Waiver Program): adults 21-64 with physical disabilities

All five waivers are options for duals who meet eligibility criteria. The waiver covers the LTSS components (personal support, adult day, supported employment, respite, home modifications, etc.); Medicare continues to cover medical care.

Olmstead community integration. Olmstead v. L.C., 527 U.S. 581 (1999), the Supreme Court interpretation of ADA Title II, requires that individuals with disabilities receive services in the most integrated setting appropriate. This is the legal anchor for the HCBS-over-institutional preference and for Georgia's Olmstead Plan (Settlement Agreement with USDOJ 2010). For duals at risk of institutionalization, Olmstead requires the state to seriously consider community alternatives before placing in a nursing facility.

The Section 1843 buy-in agreement

The mechanism by which Georgia Medicaid pays Medicare premiums for QMB, SLMB, and QI enrollees is the buy-in agreement under Section 1843 of the Social Security Act. The buy-in agreement is a state-federal contract: Georgia agrees to pay Medicare premiums for specified categories of beneficiaries; CMS receives the payments and credits them against the Social Security premium deduction that would otherwise apply.

In practice, a QMB enrollee does not see the Part B premium deducted from her Social Security benefit. CMS receives the buy-in payment from Georgia and instructs SSA not to deduct. If the enrollee was paying the premium before QMB approval, CMS issues a refund for premium amounts paid retroactively (up to three months before the QMB effective date, per 42 CFR 435.914).

Buy-in administration is handled by the Georgia State Buy-In Unit within DCH. The unit reconciles a monthly file with CMS, identifies new QMB/SLMB/QI determinations, terminates buy-in for individuals who lose eligibility, and processes retroactive adjustments. Delays in buy-in processing are common in the first month or two after QMB approval; the enrollee may see one or two premium deductions before buy-in catches up, which are refunded later.

Worked example: Tasha, age 67, Atlanta, newly Medicare-eligible

Tasha is 67 and turned 65 two years ago, but stayed enrolled in her employer's health plan because she continued working. Two months ago she retired. She is now in her Medicare initial enrollment period for Part B (which extends 3 months after retirement under the Special Enrollment Period rules for employer-sponsored coverage). Her income places her around 111 percent of the federal poverty level. She has modest savings (under the MSP resource limit) and a paid-off car. She lives in Fulton County and has no spouse.

When she enrolled in Part B, SSA quoted her the standard Part B premium of $202.90 per month for 2026. She also applied for a standalone Part D drug plan and was quoted a modest premium for a benchmark-priced plan. Combined, she was looking at the standard Medicare cost-share architecture, plus deductibles and 20 percent coinsurance on the Part B side.

A neighbor suggested Tasha apply for Medicaid help. Tasha called DHS DFCS Fulton County, was directed to Form 297 (the Georgia ABD/MSP application), and filed it. She also called the Social Security Administration to apply for Extra Help (Form SSA-1020).

Outcomes:

• Tasha's income at 111 percent FPL is too high for QMB (100 percent FPL ceiling) but within the SLMB range (100-120 percent FPL). Georgia Medicaid approves her for SLMB. Medicaid will pay her $202.90 Part B premium starting next month, with retroactive coverage available for up to three months prior. She is NOT eligible for QMB cost-sharing protection, meaning she will still owe the $283 Part B deductible and 20 percent coinsurance on Part B services.
• Her income at 111 percent FPL is well under the 150 percent FPL Extra Help threshold. She is approved for full Extra Help, effective immediately. Her Part D premium drops to $0 (in a benchmark plan), her deductible is $0, and her copays are capped at the 2026 maximum LIS copay of $12.65 per drug.
• The Section 1843 buy-in processes the next month; the $202.90 Part B premium is no longer deducted from her Social Security check. Net monthly cash improvement: $202.90 (Part B premium) plus the standalone Part D premium plus drug copay savings.

What Tasha did right: applied for both MSP and Extra Help promptly; brought income verification (Social Security award letter) and resource documentation (bank statement, vehicle title); kept careful records of dates and case numbers.

Worked example: Eleanor, age 78, Macon, full-benefit dual choosing between D-SNP and Original Medicare

Eleanor is 78 and has been on Medicare since age 65. She lost her husband three years ago and her income dropped to a modest Social Security survivor benefit that places her well below 100 percent FPL. Her countable resources sit under the Georgia ABD Medicaid resource limit. She qualifies for full ABD Medicaid in Georgia and for QMB (income under 100 percent FPL). Her status is "QMB plus full Medicaid."

Eleanor has been on Original Medicare with a standalone Part D plan and Medicaid wraparound for the past three years. Her primary care physician is in Macon; she sees a cardiologist for atrial fibrillation; she takes seven prescription drugs. During the Medicare Open Enrollment Period (October 15 through December 7), she received a call from a marketing agent suggesting she switch to a D-SNP, specifically CareSource Dual Advantage, which would give her an OTC card worth $50 per month, transportation benefits, dental allowance, and the same Medicaid benefits she already has.

Eleanor called GeorgiaCares at 1-866-552-4464 to compare options. The SHIP counselor walked through:

• Her current PCP and cardiologist are in Original Medicare (any Medicare-participating provider). If she switches to CareSource Dual Advantage (a D-SNP), she would need to verify both providers are in CareSource's MA network. The counselor checked the plan finder: her PCP is NOT in the CareSource MA network, but her cardiologist is.
• Her current Part D plan covers all seven of her drugs at $0 or low copays under Extra Help. CareSource Dual Advantage's MAPD formulary covers six of seven; one drug (a brand-name heart medication) is on a higher tier requiring prior authorization.
• The OTC card, transportation, and dental allowance would add an estimated $700-$900 per year in value, BUT she would have to switch PCPs.

After consideration, Eleanor decided to stay in Original Medicare to keep her PCP. The supplemental benefits were tempting, but the PCP relationship was more important. She also confirmed with GeorgiaCares that she does NOT need a Medigap policy, because Medicaid wraps Medicare cost-sharing the same way Medigap would for a non-dual.

Worked example: Marcus, age 72, Albany, QMB plus, balance billing dispute

Marcus is 72 and a QMB-plus full Medicaid enrollee. He lives in Albany and recently went to the emergency department for chest pain at Phoebe Putney Memorial Hospital. The visit was Medicare-covered; Medicare paid the hospital $1,800. A few weeks later, Marcus received a bill for $400, described as "patient responsibility for Medicare cost-sharing."

Marcus's daughter, who lives in Atlanta and helps with paperwork, recognized this as likely a QMB billing violation. She called GeorgiaCares at 1-866-552-4464. The SHIP counselor confirmed the violation:

• Marcus is a QMB. Section 1902(n)(3)(B) and Section 1866(a)(1)(A) prohibit any Medicare provider from billing him for Medicare cost-sharing.
• The hospital, as a Medicare-participating provider, must accept Medicare's payment plus any Medicaid payment (or denial) as payment in full.

The counselor helped draft a letter to the hospital billing office citing the federal QMB billing prohibition and requesting the bill be rescinded. The letter included a copy of Marcus's QMB award letter and the Medicaid card.

Outcomes:

• Within two weeks, the hospital billing office rescinded the bill and apologized for the error.
• The counselor noted that this was the hospital's third reported violation in the past year and offered to file a complaint with CMS Region IV in Atlanta at 404-562-7500. Marcus's daughter agreed; the complaint went out the following day.
• Marcus owed nothing. If he had paid the $400 before disputing, the hospital would have been required to refund.

What Marcus and his daughter did right: caught the bill quickly, contacted SHIP for free expert help, documented in writing with the federal citation, escalated to CMS when the pattern of violations became clear.

Worked example: Aisha, age 58, Savannah, SSDI-to-Medicare transition

Aisha is 58 and lives in Savannah. She was approved for Social Security Disability Insurance (SSDI) in March 2024 after a multiple sclerosis diagnosis left her unable to continue working. SSDI income places her around 119 percent FPL. Medicare entitlement begins after a 24-month waiting period from SSDI start, which means Aisha becomes Medicare-eligible in March 2026.

In the pre-Medicare period (March 2024 through February 2026), Aisha's options were:

• Marketplace coverage with subsidies (her income fits the subsidized range)
• Georgia Pathways to Coverage (she did not qualify; Pathways is for incomes up to 100 percent FPL with work/community engagement)
• Georgia ABD Medicaid (her income exceeds the Georgia ABD ceiling)

She enrolled in a subsidized marketplace plan. In February 2026, anticipating her Medicare effective date of March 1, 2026, she filed Form 297 with DHS DFCS Chatham County for SLMB (her income fits the 100-120 percent SLMB range). She also applied for Extra Help with the Social Security Administration.

Outcomes:

• SLMB approved effective March 2026. Medicaid pays her $202.90 Part B premium each month for 2026. She does NOT have full Medicaid (income too high for ABD).
• Extra Help approved (income under 150 percent FPL). Full Extra Help benefits: $0 Part D premium in benchmark plan, copays capped at the 2026 maximum LIS copay of $12.65 per drug.
• She enrolled in Original Medicare plus a benchmark Part D plan. The marketplace coverage automatically terminated when her Medicare became effective.

Key insight: Aisha had to actively apply for SLMB. The buy-in does not happen automatically. SHIP counselors emphasize that newly Medicare-eligible individuals should apply for MSP and Extra Help in the month before or immediately upon Medicare entitlement to avoid premium deductions from Social Security.

Worked example: Jamil, age 65, Columbus, Qualified Disabled and Working Individual

Jamil is 65 and lives in Columbus. He was on SSDI from 2016 to 2024 with Medicare entitlement starting in 2018 (after 24-month wait). In 2024, his health improved and he returned to part-time work, earning approximately $35,000 per year. Under SSDI rules, after a trial work period and extended period of eligibility, his SSDI cash benefit terminated. His Medicare entitlement continues for a longer period (up to 93 months after the trial work period under the Ticket to Work and Work Incentives Improvement Act), but eventually he must pay the Part A premium if he keeps Medicare past the extended Medicare coverage period.

In 2026, Jamil's Medicare Part A premium kicked in: $311 per month for someone with 30-39 quarters of Medicare-covered employment. He also continues to pay the standard Part B premium of $202.90 per month for 2026.

Jamil's income at $35,000 per year is well over the SLMB cap. But the QDWI program has a higher income limit: 200 percent FPL, with disregards and a different counting methodology that effectively raises the practical limit; verify the current QDWI counting rules with DCH. His countable resources sit under the $4,000 QDWI resource limit.

He filed Form 297 with DFCS Muscogee County. QDWI approved. Medicaid pays his $311 Part A premium each month. He continues to pay the $202.90 Part B premium himself (QDWI does NOT cover Part B). He is not eligible for Extra Help at his income (over the 150 percent FPL Extra Help limit), so he pays standard Part D premium and copays.

Net benefit: $311 per month in saved Part A premium. Over a year, roughly $3,700 in savings. He keeps working and his Medicare stays intact.

Worked example: Diana, age 82, rural Georgia (Dougherty County), FIDE-SNP and PACE options

Diana is 82 and lives alone in Albany, Dougherty County. She has full-benefit dual coverage: Medicare since 65, full ABD Medicaid through Georgia (modest Social Security income well below 100 percent FPL; countable resources under the Georgia ABD limit). She has moderate dementia, hypertension, and mobility limitations. Her daughter lives in Atlanta and helps with paperwork but cannot provide daily care.

Recently, the CCSP assessment determined that Diana meets nursing-home-level-of-care criteria. The Area Agency on Aging service coordinator presented her with options:

• CCSP HCBS waiver: Diana stays home with a personal support worker, adult day care, home-delivered meals, and emergency response system. Medicare continues to cover medical care (PCP, hospital, specialists). Medicaid covers the CCSP waiver services.
• SOURCE: Primary care case management overlay providing care coordination across Medicare and Medicaid. Diana would have a SOURCE service coordinator who arranges and tracks all services.
• Nursing facility: Institutional Medicaid coverage; Section 1924 spousal impoverishment does not apply (Diana is unmarried).
• PACE: Not available in Dougherty County. A.G. Rhodes (Atlanta metro) and Senior Connections (coastal Georgia) are the only Georgia PACE programs.
• FIDE-SNP: Not available in Dougherty County for the current contract year; Georgia FIDE-SNP availability is limited.

After family discussion, Diana chose CCSP plus SOURCE coordination. The SOURCE coordinator manages communication between her Medicare-participating PCP, her Medicare Advantage plan she had elected the prior year (which she decides to drop, returning to Original Medicare for broader provider choice), and her CCSP-funded in-home aide and adult day program.

If Diana's needs progress and CCSP services become insufficient, the SOURCE coordinator can re-assess and transition her to nursing facility care. At that point, Section 1924 would not apply (no community spouse), and her income above the SSI Federal Benefit Rate would go toward her nursing facility cost-sharing as "patient liability," with Medicaid covering the remainder of the nursing facility rate.

Key insight: many rural Georgia duals do not have access to the most integrated coverage options (FIDE-SNP, PACE). Their pathway to coordination runs through SOURCE or through diligent self-coordination across Original Medicare and the relevant HCBS waiver.

Practical guidance for Georgia duals and their families

Apply for MSP and Extra Help promptly. Don't wait. The buy-in does not happen automatically; you must file Form 297 (or the equivalent online via Gateway) with DHS DFCS. Extra Help is a separate application with SSA, though deemed-eligible individuals receive Extra Help without applying. Retroactive coverage is available for up to three months prior, but only if you apply.

Don't accept a balance bill if you are QMB. Federal law prohibits it. Identify yourself as QMB in writing. Cite Section 1902(n)(3)(B). Request rescission. Escalate to CMS Region IV at 404-562-7500 if needed.

Compare D-SNPs carefully. Each plan has different networks, formularies, and supplemental benefits. GeorgiaCares at 1-866-552-4464 provides free, unbiased counseling. Don't enroll over the phone with a marketing agent without comparing alternatives.

Original Medicare is a legitimate choice. Duals are not required to enroll in a D-SNP. Original Medicare plus a standalone Part D plan plus Medicaid wraparound gives the broadest provider choice and is preferred by many full-benefit duals.

Update your address with both Medicare and Medicaid. Mail bounce-backs cause Medicare and Medicaid to terminate coverage. Use SSA's MySSA portal for Medicare contact info; use Gateway (gateway.ga.gov) for Medicaid.

Keep your Medicare and Medicaid cards together. Present both at every medical visit. The provider needs to bill correctly; if only one card is presented, the claim may not coordinate.

Use the dual SEP wisely. Post-CMS-4205-F, duals have one D-SNP/MAPD change per quarter in Q1, Q2, and Q3, plus the annual coordinated election period in Q4 (October 15 through December 7). Use these windows; once exhausted, you may be locked in until the next quarter.

Plan for LTSS. If your loved one is approaching the need for nursing facility care, talk to a CCSP/SOURCE counselor (ADRC 1-866-552-4464) and consider elder law counsel for spousal impoverishment planning. The five-year look-back means planning starts well before need.

Get personalized eldercare guidance. Brevy helps families navigate Medicare, Medicaid, and dual coverage decisions for older adults across Georgia and the United States.

CMS-4205-F implementation timeline and what changes for Georgia duals

The April 2024 Final Rule (CMS-4205-F) phases in over CY2025 through CY2027. For Georgia duals, key dates and what to watch:

CY2025 (in effect now):

• Quarterly SEP for D-SNP/MAPD changes (replacing monthly SEP)
• Tighter D-SNP marketing rules; reduced agent commission structures
• Look-alike plan restrictions enforced

CY2026:

• Further FIDE-SNP integration mandates
• Enhanced enrollment broker requirements
• Continued contraction of look-alike plans

CY2027:

• HIDE-SNP minimum standards strengthened
• Goal: every dual either in FIDE-SNP, HIDE-SNP with EAE, or Original Medicare plus traditional Medicaid (no coordination-only D-SNP except in limited circumstances)

For Georgia specifically, DCH is in active dialogue with CMS and the seven major D-SNP plans about increasing integration. Watch for new SMACs published on the DCH website that show expanded Medicaid responsibilities being shifted to D-SNPs.

FAQ

A few more common questions:

Am I a dual eligible if I have Medicare and Medicaid? Yes. "Dual eligible" is the term for any person enrolled in both programs. The category matters: full-benefit duals have both full Medicaid and Medicare; QMB-only and SLMB/QI duals have Medicare plus an MSP that pays premiums (and for QMB, cost-sharing) but not full Medicaid wraparound. To know your category, check your Medicaid award letter or call DCH Member Services at 1-866-211-0950.

What is the difference between QMB, SLMB, and QI? All three are Medicare Savings Programs. QMB (income up to 100 percent FPL) covers Medicare premiums, deductibles, and coinsurance. SLMB (100-120 percent FPL) covers only the Part B premium. QI (120-135 percent FPL) covers only the Part B premium and cannot be combined with full Medicaid. Resource limits are aligned across QMB/SLMB/QI: $9,950 individual and $14,910 couple for 2026 per the CMS CY2026 LIS Resource Limits Memo.

What is the difference between a coordination-only D-SNP, a HIDE-SNP, and a FIDE-SNP? A coordination-only D-SNP covers Medicare benefits and provides some Medicaid care coordination, but the Medicaid managed care plan may be entirely separate. A Highly Integrated Dual Eligible Special Needs Plan (HIDE-SNP) is operated by the same parent company as the enrollee's Medicaid managed care plan, with required integration of care management. A Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) operates both Medicare and comprehensive Medicaid managed care (including LTSS) under one entity, with single ID cards, integrated appeals, and exclusively-aligned enrollment. FIDE-SNP availability in Georgia is limited.

My Medicare premium was deducted from my Social Security check even after I got QMB approval. Why? There is typically a one- or two-month lag between QMB approval and the Section 1843 buy-in becoming active. During the lag, Social Security continues to deduct the Part B premium. Once buy-in is active, CMS refunds the deductions, retroactive to the QMB effective date. Contact the Georgia State Buy-In Unit at DCH or call DCH Member Services at 1-866-211-0950 if the refund does not arrive within three months of QMB approval.

Can I change my D-SNP whenever I want? No, not anymore. Under CMS Final Rule CMS-4205-F effective January 1, 2025, the dual special enrollment period was reduced from monthly to quarterly. You can change your D-SNP or MAPD once per quarter in Q1, Q2, and Q3, plus during the annual coordinated election period of October 15 through December 7 each year. Move, plan termination, and other specific events still trigger non-quarterly SEPs.

My husband needs nursing home care, but I want to keep our house and savings. What protections exist? Section 1924 of the Social Security Act, the spousal impoverishment provisions, protects the community spouse. You may keep up to an annually-indexed maximum in countable resources and a monthly income allowance up to the annually-indexed cap; pull the current CMS Spousal Impoverishment Standards for 2026 amounts. Your home is exempt from the resource count if you live there. Your one car is exempt. Georgia applies §1924 to both nursing facility applicants and HCBS waiver applicants. Elder law counsel is generally recommended for spousal-impoverishment planning, particularly around annuities, trusts, and the five-year look-back for transfers.

What is PACE and is it available in Georgia? PACE (Program of All-Inclusive Care for the Elderly) under Section 1934 of the Social Security Act is a fully coordinated benefit for older adults aged 55+ who meet nursing-home-level-of-care criteria but can live safely in the community. PACE provides all Medicare and Medicaid services plus additional services through an interdisciplinary team, in exchange for a single capitated payment. Georgia has two PACE programs: A.G. Rhodes (Atlanta metro) and Senior Connections (coastal Georgia). Most Georgia counties have no PACE option; verify current service-area boundaries on the providers' websites.

My drug copay at the pharmacy is high. I thought Extra Help made copays low. What's wrong? The most common reason is that your Extra Help status is not on file with the Part D plan or the pharmacy. Show your Medicare card and Medicaid card to the pharmacist and ask them to re-run the claim with LIS coding. If still high, call your Part D plan and Medicare 1-800-MEDICARE. GeorgiaCares SHIP can troubleshoot. The 2026 LIS maximum copay per drug is $12.65 for full LIS beneficiaries; institutionalized or HCBS-waiver duals pay $0.

What is the QDWI program and who is it for? Qualified Disabled and Working Individual. It is for people under 65 with disabilities who lost premium-free Medicare Part A because they returned to work. The program pays the Part A premium only (not Part B), and has tighter resource limits ($4,000 individual / $6,000 couple) than QMB/SLMB/QI but a higher income limit (approximately 200 percent FPL). It is the narrowest of the four MSPs and serves a small population in Georgia.

Contact list

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