For a Georgia senior who has both Medicare and Medicaid, the two programs pay in a fixed order: Medicare pays first, and Medicaid pays last, after Medicare and any other insurance.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid Through Georgia's Medicare Savings Programs, Medicaid pays Medicare premiums and, for the lowest-income group (QMB), the deductibles and coinsurance as well.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 This guide explains how Georgia Medicare Medicaid dual eligibility works in practice and who qualifies for each program.
Who this is for: Georgians who have both Medicare and Medicaid or may qualify for both, the family caregivers helping them, people approaching 65 on a limited income, people moving from SSDI to Medicare, and the SHIP counselors and community workers who advise them.
What it covers: who counts as a "dual" in Georgia and what each of the four Medicare Savings Programs pays; why a QMB can never be balance billed; how Part D Extra Help works after the Inflation Reduction Act; how D-SNPs integrate the two programs and what CMS-4205-F and the 2027 integration rules change; spousal impoverishment under Section 1924; where PACE stands in Georgia; and the Section 1843 buy-in. Six worked examples and a contact list follow.
What dual eligibility means in Georgia
"Dual eligible" is the term for a person enrolled in both Medicare and Medicaid. The Georgia Medicare Savings Program is how Georgia Medicaid helps Medicare beneficiaries with limited income and resources pay their Medicare costs.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 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 can get Medicare at any age if they also meet its work-record or family conditions; and people with amyotrophic lateral sclerosis, whose Medicare starts the first month of SSDI entitlement with no 24-month wait.Centers for Medicare & Medicaid Services. (n.d.). I’m getting Social Security benefits before 65. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/get-started-with-medicare/before-65 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.
For a dual, Medicare pays first for Medicare-covered services and Medicaid pays last, after Medicare and any other health insurance the person has. Depending on the level of Medicaid a person qualifies for, Georgia may pay their share of Medicare costs, and Medicaid may pay for drugs and services Medicare doesn't cover.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid The legal bridge for the premiums is Section 1843 of the Social Security Act, which authorizes the buy-in agreement under which Georgia Medicaid pays Medicare premiums.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf
Eligibility rules, plan availability, premium amounts, and integration deadlines all change, so confirm the specifics with the Georgia Department of Community Health, the Social Security Administration, or GeorgiaCares SHIP before you act on them.
The four Georgia Medicare Savings Program categories
Medicare Savings Programs (MSPs) are state-run programs, administered through Medicaid, that help people with limited income and resources pay Medicare premiums and, for some categories, cost-sharing. There are four, defined by income relative to the federal poverty level.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 In Georgia, the Division of Family and Children Services (DFCS) handles MSP applications: apply online at Georgia Gateway, or call or visit your local DFCS office for a paper application (form 700).U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
Qualified Medicare Beneficiary (QMB). Section 1905(p)(1) of the Social Security Act defines QMB.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915 Eligibility requires Medicare 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, the federal limit shared by QMB, SLMB, and QI; a burial fund of up to $1,500 per person, or $3,000 for a couple, sits on top of that limit rather than inside it). 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. Those income and resource figures are the federal standards, not an absolute cutoff: states can effectively raise both by disregarding certain income and resources, so an applicant somewhat over either one should apply rather than rule themselves out.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023,Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
"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, ABD Medicaid uses the SSI standards: for 2026, $994 a month in income and $2,000 in countable resources for an individual, both well under QMB's $1,350 and $9,950.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html,U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 The Georgia DCH can confirm how those limits apply to you. 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). SLMB is the group in Section 1902(a)(10)(E)(iii) of the Social Security Act.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915 Eligibility requires both Medicare Part A and Part B, 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.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023,Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles SLMB enrollment does, however, automatically qualify the enrollee for Part D Extra Help: federal rules deem QMB, SLMB, and QI enrollees full-subsidy eligible.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
Qualifying Individual (QI). QI is the group in Section 1902(a)(10)(E)(iv), which the Act makes subject to Section 1933.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915 Eligibility requires both Medicare Part A and Part B, 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 comes out of a capped annual federal allocation to each state and is granted first-come, first-served, with preference given to people who received QI in the last month of the previous year. It also has to be applied for again every year: selection in one year does not entitle the enrollee to assistance in any later year. Like QMB and SLMB, QI enrollment automatically qualifies the enrollee for Part D Extra Help. QI is also only for people who don't qualify for any other Medicaid coverage, so a person with full Medicaid cannot have QI as well (they may still qualify for another Medicare Savings Program).U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
Qualified Disabled and Working Individual (QDWI). Federal eligibility rules for QDWI are at 42 CFR 435.126. 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: in 2026, $311 a month for someone who has, or whose spouse has, at least 30 quarters of Medicare-covered work, and $565 a month for people with disabilities who have exhausted other entitlement. Check a spouse's work record before assuming the higher figure. QDWI pays nothing beyond that Part A premium, and unlike QMB, SLMB, and QI it does not confer Part D Extra Help.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023,U.S. Government Publishing Office. (n.d.). 42 CFR §435.126 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-435.126,Centers for Medicare & Medicaid Services. (n.d.). Costs. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/costs/medicare-costs
A few features cut across all four categories. The published monthly income limits already include the $20 general income disregard, and the QDWI limits also build in earned-income disregards. Not everything you own counts toward the resource limit, either: a burial fund of up to $1,500 per person sits on top of it.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 Ask DFCS how it will treat a retirement account or any other asset you are unsure about. Effective dates are not all alike, and this is where families can end up expecting money back that never comes. Medicaid generally must be made effective no later than the third month before the month of application under 42 CFR 435.915, but only where the person actually received covered Medicaid services in that period and would have been eligible at the time, and the state plan fixes the exact date inside that window. QMB is different: Social Security Act Section 1902(e)(8) makes a QMB determination apply to services furnished after the end of the month in which the determination is first made, so QMB runs forward, not backward. For SLMB and QI, no federal source held here states any retroactivity rule at all, so ask DFCS or DCH how far back your category can reach rather than assuming three months.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915
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. Before 2024, Extra Help had two tiers, a full subsidy and a partial one.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
The Inflation Reduction Act eliminated the partial tier. Effective January 1, 2024, everyone who qualifies receives the full subsidy, and the income limit is below 150 percent FPL. For 2026 in the contiguous 48 states and DC that is about $23,940 a year for an individual and about $32,460 for a married couple (SSA Extra Help); Alaska and Hawaii work from higher poverty guidelines, so their limits are higher. Those are the limits for a one- and two-person household. If you support relatives who live with you, you are measured against a larger household's limit, and SSA leaves some payments out of income entirely, so apply rather than screening yourself out on the headline number. The limits move with the poverty guidelines and can go up each year, so if you are holding an older printed figure, measure yourself against these 2026 numbers instead.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
The 2026 resource limit for full Extra Help is $18,090 for an individual and $36,100 for a married couple living together. That pair already includes a burial allowance SSA adds automatically; the lower limit of $16,590 ($33,100 if married) applies only if you tell SSA that none of your resources will go toward funeral or burial expenses. Full Extra Help means no Part D premium in a plan priced at or below the regional benchmark (pick a costlier plan and you pay the difference) and no Part D deductible.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
Copays are a three-tier ladder, and the widely quoted $5.10 generic and $12.65 brand-name figures are the ceiling, not what every enrollee pays. For 2026: full-benefit duals who are institutionalized or receiving home and community-based services pay $0; full-benefit duals with income at or below 100 percent FPL pay $1.60 per generic and $4.90 per brand-name drug; and the $5.10 / $12.65 tier applies to full-benefit duals between 100 and 150 percent FPL and to QMB-only, SLMB-only, QI, and SSI-without-Medicaid enrollees.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
Dual eligibles receive Extra Help automatically. Anyone with Medicare who is also on full-benefit Medicaid, QMB, SLMB, QI, or SSI is "deemed" eligible for full Extra Help, and CMS tells them they do not need to apply; QDWI enrollees are not deemed.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025 Everyone else applies to the Social Security Administration (Form SSA-1020), and that Extra Help application also starts a Medicare Savings Program application with the state unless you object.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
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). It applies to all Part D enrollees, not just LIS recipients, and what counts toward it includes payments made on your behalf, Extra Help among them. So a dual on expensive drugs can reach the threshold even though their own copays are small, and once they do, covered Part D drugs cost nothing for the rest of the calendar year.Centers for Medicare & Medicaid Services. (2026). Final CY 2026 Part D Redesign Program Instructions - CMS. cms.gov. Retrieved Aug 22, 2026, from https://www.cms.gov/files/document/final-cy-2026-part-d-redesign-program-instruction.pdf
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 the premium covered by Extra Help, if eligible, up to the regional benchmark),U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025 and has full Medicaid for drugs and services Medicare doesn't cover.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid For QMB enrollees, Medicaid pays the Medicare premiums and cost-sharing.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 There is no plan network: any Medicare-participating provider will do. Medicaid pays last, after Medicare, and may pay for services Medicare doesn't cover.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid
Option 2: Medicare Advantage (not a D-SNP) plus Medicaid wraparound. The enrollee receives Parts A and B, and Part D if the plan includes drug coverage, through a private MA plan (HMO, PPO, or other model). Check that your doctors are in the plan's network before you join. Medicaid still covers wraparound services, and for QMB enrollees it still pays the Medicare premiums and cost-sharing.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
Option 3: Dual Special Needs Plan (D-SNP). A D-SNP is a Medicare Advantage plan built for dually eligible individuals; 42 CFR 422.2 defines it as a specialized plan for people entitled to Medicaid under a state plan. 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.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2 Ask any D-SNP exactly which extra benefits it includes before you join, and treat any $0 premium it advertises as a plan-design choice that varies by plan and state, not a legal guarantee.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2 Before joining a D-SNP, check that your doctors and pharmacy are in its network.
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.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
Dual Special Needs Plans (D-SNPs) and the integration framework
D-SNPs are the Medicare Advantage plans built to coordinate Medicare and Medicaid for people enrolled in both.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2 Under 42 CFR 422.107, every D-SNP must have a contract with the state Medicaid agency, the State Medicaid Agency Contract (SMAC), which at a minimum documents the plan's responsibility to coordinate Medicaid benefits, which categories of duals it may enroll, and the service area it covers. So which Georgia duals a given D-SNP may enroll, and where, is set in that plan's contract with the state.U.S. Government Publishing Office. (n.d.). 42 CFR 422.107 — Special needs plans and dual-eligible individuals: contracts with States (eCFR). ecfr.gov. Retrieved Oct 9, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-B/section-422.107
Integration tiers. Above coordination-only, federal rules recognize more tightly integrated plans:
- Highly Integrated Dual Eligible Special Needs Plan (HIDE-SNP): a more integrated D-SNP short of full integration. A HIDE-SNP with exclusively aligned enrollment counts as an "applicable integrated plan," which combines Medicare and Medicaid grievances and appeals into a single process.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2
- Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): a D-SNP run by a single entity holding both the Medicare Advantage contract and the state Medicaid managed care contract, whose Medicaid contract covers, to the extent the state's Medicaid program covers them, primary and acute care (including Medicare cost-sharing), long-term services and supports (including at least 180 days of nursing facility coverage a year), behavioral health, home health, and medical equipment and supplies, with exclusively aligned enrollment and one combined grievance and appeals process.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2
CMS Final Rule CMS-4205-F (April 2024). For contract year 2025, this rule restructured the dual/LIS special enrollment period: it sunset the prior quarterly SEP and replaced it with a once-per-month SEP that lets a dual or LIS enrollee change their standalone Part D drug plan in any month (42 CFR 423.38(c)(4)), plus a separate once-per-month integrated-care SEP (42 CFR 423.38(c)(35)) that lets a full-benefit dual move into an aligned, integrated D-SNP. The monthly Part D SEP is closed to someone who has been notified they are an at-risk or potential at-risk beneficiary under Part D's drug management program, until that identification ends.U.S. Government Publishing Office. (n.d.). 42 CFR §423.38 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-423.38 The same rule finalized the aligned-enrollment limits that begin in 2027, covered in the timeline below.U.S. Government Publishing Office. (n.d.). 42 CFR 422.2267 - Required materials and content (member ID card). ecfr.gov. Retrieved Aug 22, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.2267
Integration requirements for 2027. Beginning no later than contract year 2027, a D-SNP that is an "applicable integrated plan" must give its enrollees one integrated member ID card for both the Medicare and the Medicaid plan, and one integrated health risk assessment instead of two.U.S. Government Publishing Office. (n.d.). 42 CFR 422.2267 - Required materials and content (member ID card). ecfr.gov. Retrieved Aug 22, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.2267
Georgia D-SNP plans. Which D-SNPs serve Georgia duals, and in which counties, changes by contract year; the Medicare.gov Plan Finder shows the plans available in your county for the current year.
The Georgia Medicare Savings Program QMB billing prohibition
If you are a QMB, the billing prohibition is the protection to know before you pay any medical bill. Several provisions of the Social Security Act work together. Where a state pays less than the full Medicare cost-sharing, Section 1902(n)(3)(A) treats the Medicare payment plus any Medicaid payment as payment in full, and Section 1902(n)(3)(B) says the QMB has no legal liability to pay the provider for the service. CMS also names Sections 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) as authority for the protection.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm
In practice, this means that no Medicare provider or supplier, pharmacies included, may bill a QMB enrollee for any Medicare Part A or Part B cost-sharing: not the deductibles, not the 20 percent coinsurance, not the hospital coinsurance, not the SNF coinsurance, even when Georgia Medicaid pays nothing toward it. The provider may bill the state Medicaid program for that cost-sharing, but never the QMB patient. This applies to all Medicare providers, whether or not they are also enrolled in Medicaid, and a QMB cannot agree to pay it anyway.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm
The prohibition covers Medicare Part A and Part B cost-sharing on items and services Medicare covers, so it does not reach a service Medicare does not cover. It protects people in the QMB group on every date of service they are a QMB; SLMB, QI, and QDWI enrollment does not carry it.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm Two charges sit outside it: a QMB can still get a bill for a small Medicaid copayment, if one applies, and Part D drug copays are separate, though Extra Help holds a QMB to no more than $12.65 per covered drug in 2026.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
Bills that break the rule can look like these: 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: show the provider your Medicare and Medicaid cards (or a Medicare Summary Notice showing you are in the QMB Program), put it in writing citing Section 1902(n)(3)(B), and ask for the bill to be withdrawn and anything you paid refunded. If the billing continues, call 1-800-MEDICARE (1-800-633-4227), which can confirm your QMB status and ask the provider to stop billing you and refund what you paid. If a debt collector keeps calling, file a complaint with the Consumer Financial Protection Bureau at 1-855-411-2372.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm GeorgiaCares SHIP can help walk through this process.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
Spousal impoverishment under Section 1924
When a married dual needs nursing facility care or HCBS waiver services, the spousal impoverishment provisions of Section 1924 of the Social Security Act (42 U.S.C. 1396r-5) protect the spouse who remains in the community, letting that spouse keep a share of the couple's resources and, where their own income is low, a monthly income allowance.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm
Resource allowance. For 2026 the federal spousal-impoverishment resource standards are a minimum of $32,532 and a maximum of $162,660, and each state elects its standard within that range.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm Georgia's own resource chart gives a nursing-home applicant with a spouse at home a limit of $162,660 plus the applicant's own $2,000, or $164,660.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html The $162,660 maximum is not an absolute ceiling: a fair hearing, where the at-home spouse needs more to reach the minimum monthly income allowance, or a court order can protect a larger amount, though the state must first count all of the nursing-home spouse's available income toward that need. For the federal rules behind these figures, see CMS's Medicaid Spousal Impoverishment page.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm
Monthly income allowance. Georgia does not count the at-home spouse's income when it tests the applicant against the $2,982 monthly income cap.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html If the at-home spouse's own income is low, part of the nursing-home spouse's income can be diverted to them. Federally, the Minimum Monthly Maintenance Needs Allowance is $2,705 a month from July 1, 2026 through June 30, 2027, the excess-shelter standard used in the housing calculation is $811.50 a month, and the maximum allowance is $4,066.50 a month for 2026; a fair hearing can raise the allowance where exceptional circumstances cause significant financial duress.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm Georgia's own standard for this diversion, the Community Spouse Maintenance Need Standard, is $4,066.50 a month from January 2026.Centers for Medicare & Medicaid Services. (2026). CMS CMCS Informational Bulletin — Updated 2026 SSI and Spousal Impoverishment Standards (April 27, 2026). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/federal-policy-guidance/downloads/cib04272026.pdf The amount actually diverted is that standard minus the at-home spouse's own income after mandatory deductions such as income taxes, so a spouse with some income of their own receives less than $4,066.50.U.S. Government Publishing Office. (n.d.). 42 CFR § 435.725 — post-eligibility treatment of income of institutionalized individuals in SSI States (eCFR, current). ecfr.gov. Retrieved Oct 13, 2026, from https://www.ecfr.gov/current/title-42/section-435.725 If a court has ordered support for the at-home spouse, the allowance cannot be less than the ordered amount.U.S. Government Publishing Office. (n.d.). 42 CFR § 435.725 — post-eligibility treatment of income of institutionalized individuals in SSI States (eCFR, current). ecfr.gov. Retrieved Oct 13, 2026, from https://www.ecfr.gov/current/title-42/section-435.725
Application in Georgia. Georgia carries the income protection into its HCBS waivers, not only nursing homes: income can be diverted to a spouse at home for someone in a nursing home, institutionalized hospice, EDWP (delivered through the CCSP and SOURCE service models), NOW, COMP, or ICWP.U.S. Government Publishing Office. (n.d.). 42 CFR § 435.725 — post-eligibility treatment of income of institutionalized individuals in SSI States (eCFR, current). ecfr.gov. Retrieved Oct 13, 2026, from https://www.ecfr.gov/current/title-42/section-435.725 For a married EDWP applicant whose spouse is neither in EDWP nor in an institution, DCH counts both spouses' assets together against a spousal limit, and the applicant must move assets above $2,000 in their own name to the at-home spouse within one year of the month Medicaid eligibility begins.Centers for Medicare & Medicaid Services. (2026). CMS CMCS Informational Bulletin — Updated 2026 SSI and Spousal Impoverishment Standards (April 27, 2026). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/federal-policy-guidance/downloads/cib04272026.pdf
Annuities, trusts, and look-back. A Medicaid-compliant annuity must name the state as remainder beneficiary (first, or second after a spouse or a minor or disabled child, moving to first if that person gives the remainder away for less than fair market value), and, unless it is a retirement-type annuity such as one bought with IRA money, it must also be irrevocable and nonassignable, actuarially sound, and pay out in equal amounts with no deferral or balloon payment. Georgia's manual adds that payments must be monthly.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396p(c)(1)(F),(G), 1396p(c)(2) and 1396p(e)(1) - United States Code, 2024 Edition (govinfo.gov, GPO). govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396p.htm Medicaid looks back 60 months from the application for assets given away for less than fair market value; such a transfer triggers a penalty period during which Medicaid will not pay for nursing facility or waiver care, though the rest of the person's Medicaid coverage continues. Transfers to a spouse, or to a trust solely for a blind or disabled child, are exempt.U.S. Social Security Administration. (n.d.). Social Security Act sec. 1917(c) [42 U.S.C. 1396p(c)] - Taking into account certain transfers of assets: look-back date, penalty period, start date, divisor, and the (c)(2) exceptions (SSA Compilation of the Social Security Laws). ssa.gov. Retrieved Oct 8, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1917.htm An elder law attorney can help you plan around these rules before any money moves.
PACE (Program of All-Inclusive Care for the Elderly)
PACE is authorized for Medicaid by Section 1934 of the Social Security Act and for Medicare by Section 1894, with its federal rules at 42 CFR Part 460. It serves people who need a nursing facility level of care but can still live safely in the community.U.S. Government Publishing Office. (2019). 42 CFR 460.150 — Eligibility to enroll in a PACE program (eCFR, current/rolling text; last amended 84 FR 25676, June 3, 2019). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/section-460.150
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. You do not have to have Medicare or Medicaid to enroll, and you must meet annual recertification requirements to stay in.U.S. Government Publishing Office. (2019). 42 CFR 460.150 — Eligibility to enroll in a PACE program (eCFR, current/rolling text; last amended 84 FR 25676, June 3, 2019). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/section-460.150
Benefit. Georgia's DCH describes PACE as comprehensive medical and social services for people living in the community who meet a nursing facility level of care.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Sep 4, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates A participant who is eligible for Medicaid pays no monthly premium, and the PACE organization may not bill them for anything beyond any Medicaid spenddown or post-eligibility income amount they owe. A participant who is not eligible for Medicaid pays a monthly premium equal to the Medicaid capitation amount, plus a Medicare capitation amount if they are enrolled in only one of Part A and Part B.U.S. Government Publishing Office. (2019). 42 CFR 460.150 — Eligibility to enroll in a PACE program (eCFR, current/rolling text; last amended 84 FR 25676, June 3, 2019). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/section-460.150
The PACE center. Georgia's PACE solicitation describes care delivered mainly in an adult day health center, with in-home and referral services around it and services available 24 hours a day, 7 days a week, all year.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Sep 4, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates
PACE in Georgia. Georgia has moved past procurement. After a November 15, 2024 stakeholder town hall, DCH ran a competitive PACE solicitation through the Department of Administrative Services (Georgia Procurement Registry event 41900-DCH0000139). The two state pages disagree on the closing date, and the procurement system of record governs: DCH advertises May 16, 2025, while the DOAS registry gives June 4, 2025, which is the operative close. Awards have since been posted. As of a September 4, 2026 check, the DOAS event carries Notices of Intent to Award for the Athens, Savannah, and Gainesville PACE regions, Notices of Award for Gainesville and Savannah, and a PACE Service Regions Award Announcement. What no state source yet says is whether any awarded center has actually opened its doors, so do not assume either that PACE is running in Georgia or that it is unavailable. DCH's own PACE Updates page lags the procurement record (its newest item is still the April 2025 RFP link), so check CMS's PACE page and ask DCH about the awarded region before counting on a seat. Unless you confirm a center is open near you, the other routes to coordinated care are a D-SNP, EDWP's SOURCE model, or coordinating Original Medicare and an HCBS waiver yourself.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Sep 4, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates
Medicare Part D coverage and coordination with Medicaid pharmacy
Part D is the Medicare prescription drug benefit. For duals, Medicare covers prescription drugs instead of Medicaid, and if Medicare doesn't cover a prescription, Medicaid may still cover it in certain situations.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid
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.
Automatic enrollment for duals. A dual is automatically enrolled in a Medicare drug plan that covers their drug costs.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid The enrollee may switch standalone Part D plans once a month using the dual/LIS special enrollment period, which CMS-4205-F changed to a monthly opportunity effective 2025.U.S. Government Publishing Office. (n.d.). 42 CFR §423.38 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-423.38 The plan you are placed in may not be the best fit for your drugs, and GeorgiaCares can help compare alternatives for free.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
Drugs Part D won't cover. When a Part D plan won't cover a drug, Medicaid may still cover it in certain situations, so ask Georgia Medicaid Member Services at 1-866-211-0950 before paying out of pocket.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid,Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
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 drugs Medicare doesn't cover that Medicaid may.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid If the pharmacy charges full price, GeorgiaCares or 1-800-MEDICARE can help you sort it out.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship,Centers for Medicare & Medicaid Services. (n.d.). Contact Medicare — Medicare.gov. medicare.gov. Retrieved Jul 23, 2026, from https://www.medicare.gov/talk-to-someone
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). The cap reaches LIS-eligible duals more often than it looks, because Extra Help payments made on your behalf count toward the $2,100, not just what you hand over at the counter. For non-LIS beneficiaries with high-cost drugs it is significant, and a strong reason to apply for Extra Help if income is below 150 percent FPL. Two related 2026 rules are worth knowing: no Part D plan may set a deductible above $615, and every plan must offer the Medicare Prescription Payment Plan, which spreads your out-of-pocket drug costs into capped monthly payments across the year. It does not lower what you owe in total, only when you pay it, so it helps most when costs land early in the year.Centers for Medicare & Medicaid Services. (2026). Final CY 2026 Part D Redesign Program Instructions - CMS. cms.gov. Retrieved Aug 22, 2026, from https://www.cms.gov/files/document/final-cy-2026-part-d-redesign-program-instruction.pdf
Long-term services and supports (LTSS) for duals
Medicare covers LTSS only narrowly: skilled nursing facility coverage generally requires a prior inpatient hospital stay and ends after day 100, with coinsurance of $217 a day for days 21 through 100 in 2026.Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles Medicaid may pay for services Medicare doesn't cover.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid
For Georgia duals who need LTSS, the pathway runs through Medicaid:
Institutional care. Nursing facility coverage for individuals meeting nursing facility level of care. Georgia is an income-cap state: it tests the applicant's gross countable income against $2,982 a month in 2026, which is 300 percent of the $994 SSI Federal Benefit Rate, and an applicant at or above the cap can qualify by setting up a Qualified Income Trust.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html,U.S. Social Security Administration. (2026). SSI Federal Payment Amounts for 2026. ssa.gov. Retrieved Aug 8, 2026, from https://www.ssa.gov/oact/cola/SSI.html Section 1924 spousal impoverishment protections apply.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm
HCBS waivers. Four 1915(c) waivers are established by the sources behind this guide, and they cover different populations. Treat them as the four this guide covers, not as a complete census: no source read here enumerates every 1915(c) waiver Georgia operates, and Georgia's own waiver-programs page also lists the Georgia Pediatric Program (GAPP) for medically fragile children.
- EDWP (Elderly and Disabled Waiver Program): administered by DCH for frail older adults and adults with disabilities who are otherwise eligible under a nursing facility level of care, covering case management, adult day care, alternative living services, personal care, home-delivered meals, and respite for family caregivers. EDWP is delivered through two service models, not two separate waivers: CCSP (Community Care Services Program) and SOURCE (Service Options Using Resources in a Community Environment), the model that adds enhanced case management coordinated through a primary care physician. Applications for either model go through Georgia's 12 Aging and Disability Resource Connection (ADRC) offices
- ICWP (Independent Care Waiver Program): a limited number of adults who apply between the ages of 21 and 64 with severe physical disabilities or traumatic brain injury, qualifying at either a nursing facility or a hospital level of care; services include personal support, home health, specialized equipment, counseling, emergency response systems, and home modifications
- NOW (New Options Waiver) and COMP (Comprehensive Supports Waiver Program): both serve people with intellectual or developmental disabilities. DCH delegates day-to-day operation to the Department of Behavioral Health and Developmental Disabilities through six regional field offices. Eligibility requires an intellectual disability, or a closely related developmental disability such as autism, cerebral palsy, or epilepsy that substantially impairs intellectual or adaptive functioning, originating at birth or during the developmental years (by age 18 for an intellectual disability, by age 22 for a developmental disability)
Each of these is an option for a dual who meets its eligibility criteria. The waiver covers the LTSS components, such as personal support, adult day care, respite, or home modifications, depending on the waiver.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 Medicare still pays first for Medicare-covered medical care.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid
Olmstead community integration. Olmstead v. L.C., 527 U.S. 581 (1999), began with two women kept at Georgia Regional Hospital at Atlanta after their clinicians said they were ready for a community program. The Supreme Court held that unjustified segregation of people with disabilities is discrimination under Title II of the Americans with Disabilities Act, and that public entities must provide community-based services when those services are appropriate, the person does not oppose them, and they can be reasonably accommodated given the state's resources and the needs of others it serves.archive.ada.gov. (n.d.). About Olmstead. Retrieved Oct 9, 2026, from https://archive.ada.gov/olmstead/olmstead_about.htm
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. Once buy-in takes effect, the federal government bills Georgia for the premium and stops collecting it from the enrollee. QDWI works differently: Georgia pays that Part A premium through a separate group-payer process, not the buy-in.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf
In practice, a QMB enrollee stops seeing the Part B premium deducted from her Social Security benefit, because a state paying under a buy-in agreement is the one exception to that mandatory deduction. If premiums were deducted for any month she is enrolled in the state buy-in, she gets a refund from SSA, and that refund does not count as income for SSI.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf The QMB effective date sets the limit: QMB coverage applies to services furnished after the month the determination is made.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915 The SSA refund covers only months you were enrolled in the buy-in, so ask DFCS which month your buy-in starts.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf
Buy-in does not switch on the moment you are approved. It runs through a data exchange between Georgia and CMS, which federal rules require daily, and CMS tells states to follow the federal start and stop dates even when processing is delayed, so you may keep seeing the premium withheld for one or more months after approval. No published rule fixes how long that lag, or the refund that follows it, takes.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf
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. Because she had job-based coverage, she can sign up for Part B without a late penalty in a Special Enrollment Period that ends 8 months after her job or that coverage ends, whichever comes first.Centers for Medicare & Medicaid Services. (n.d.). Open Enrollment. medicare.gov. Retrieved Sep 2, 2026, from https://www.medicare.gov/health-drug-plans/open-enrollment 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.Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
A neighbor suggested Tasha apply for Medicaid help. Tasha applied for the Medicare Savings Program with DFCS through Georgia Gateway.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 She also called the Social Security Administration to apply for Extra Help (Form SSA-1020).U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
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, and once the buy-in takes effect, Medicaid pays her $202.90 Part B premium. She asks DFCS whether SLMB can be backdated in her case rather than assuming it can: no federal rule held here sets a retroactivity window for SLMB. 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.Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
- Her income at 111 percent FPL is well under the 150 percent FPL Extra Help threshold. She is approved for full Extra Help. Her Part D premium drops to zero (in a benchmark plan), her deductible is zero, and her copays are capped at the 2026 maximum LIS copay of $12.65 per brand-name drug.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
- Once the Section 1843 buy-in takes effect, which can lag her approval by a month or more, the $202.90 Part B premium is no longer deducted from her Social Security check.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf Net monthly cash improvement: $202.90 (Part B premium) plus the standalone Part D premium plus drug copay savings.Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
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."U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
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 a dual-eligible D-SNP, which would give her an over-the-counter (OTC) card worth about fifty dollars a month, transportation benefits, a dental allowance, and the same Medicaid benefits she already has.Centers for Medicare & Medicaid Services. (n.d.). Open Enrollment. medicare.gov. Retrieved Sep 2, 2026, from https://www.medicare.gov/health-drug-plans/open-enrollment
Eleanor called GeorgiaCares at 1-866-552-4464 to compare options. The SHIP counselor walked through:Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
- Her current PCP and cardiologist are in Original Medicare (any Medicare-participating provider). If she switches to the D-SNP, she would need to verify both providers are in that plan's MA network. The counselor checked the plan finder: her PCP is NOT in the D-SNP's network, but her cardiologist is.
- Her current Part D plan covers all seven of her drugs at no cost or low copays under Extra Help. The D-SNP'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 several hundred dollars a 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: as a QMB, she has Medicaid paying her Medicare deductibles and coinsurance, and providers cannot bill her for them.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
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 a local hospital emergency department for chest pain. The visit was Medicare-covered; Medicare paid the hospital about eighteen hundred dollars. A few weeks later, Marcus received a bill for four hundred dollars, 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:Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
- 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 explained that if the hospital billed him again, the next step would be a call to 1-800-MEDICARE (1-800-633-4227), which can confirm his QMB status and ask the provider to stop billing him.
- Marcus owed nothing. If he had paid the four hundred dollars before disputing, he would have had the right to a refund.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm
What Marcus and his daughter did right: caught the bill quickly, contacted SHIP for free expert help, documented in writing with the federal citation, and knew where to call if the billing started again.
Worked example: Aisha, age 58, Savannah, SSDI-to-Medicare transition
Aisha is 58 and lives in Savannah. Her Social Security Disability Insurance (SSDI) benefits began in March 2024 after a multiple sclerosis diagnosis left her unable to keep working. SSDI income places her around 119 percent FPL. Medicare entitlement begins with the 25th month of SSDI benefits, so her Medicare starts in March 2026.Centers for Medicare & Medicaid Services. (n.d.). I’m getting Social Security benefits before 65. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/get-started-with-medicare/before-65
Until then her income was too high for Georgia ABD Medicaid and she did not fit Pathways to Coverage, which reaches only up to 100 percent FPL, so she took a subsidized marketplace plan.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html In February 2026, anticipating her Medicare effective date of March 1, 2026, she applied for SLMB with DFCS through Georgia Gateway (her income fits the 100-120 percent SLMB range).U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 She also applied for Extra Help with the Social Security Administration.
Outcomes:
- SLMB approved. Once the buy-in takes effect, Medicaid pays her $202.90 Part B premium each month for 2026. She does NOT have full Medicaid (income too high for ABD).Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
- Extra Help approved (income under 150 percent FPL). Full Extra Help benefits: no Part D premium in a benchmark plan, copays capped at the 2026 maximum LIS copay of $12.65 per brand-name drug.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
- She enrolled in Original Medicare plus a benchmark Part D plan, and she ended her marketplace plan herself before Medicare started: marketplace coverage does not stop on its own when Medicare begins, and her premium subsidy ended once she could get premium-free Part A.Centers for Medicare & Medicaid Services. (n.d.). Medicare & the Marketplace. medicare.gov. Retrieved Sep 28, 2026, from https://www.medicare.gov/basics/get-started-with-medicare/other-paths/medicare-marketplace
Key insight: SLMB does not start on its own; Aisha had to apply. (An Extra Help application with SSA also starts an MSP application unless you object.)U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 Applying for MSP and Extra Help around the time Medicare starts shortens the stretch of premium deductions from Social Security.
Worked example: Jamil, age 60, Columbus, Qualified Disabled and Working Individual
Jamil is 60 and lives in Columbus. He went on SSDI in 2010, with Medicare starting in 2012. In 2017 his health improved and he returned to part-time work that now pays roughly thirty-five thousand dollars a year, which eventually ended his SSDI cash benefit. Because his disabling impairment continued, he kept premium-free Part A for at least 93 months after his trial work period; once that ran out, he could keep Part A only by paying a premium.Centers for Medicare & Medicaid Services. (n.d.). I’m getting Social Security benefits before 65. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/get-started-with-medicare/before-65
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.Centers for Medicare & Medicaid Services. (n.d.). Costs. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/costs/medicare-costs,Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
Jamil's income of about thirty-five thousand dollars a year is well over the SLMB cap. But QDWI's income limit is 200 percent FPL, and because its published figures build in earned-income disregards, the 2026 limit is $5,405 a month for an individual; his roughly $2,900 a month is under it. His countable resources sit under the $4,000 QDWI resource limit.U.S. Government Publishing Office. (n.d.). 42 CFR §435.126 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-435.126
He applied with DFCS through Georgia Gateway. 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).Centers for Medicare & Medicaid Services. (n.d.). Costs. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/costs/medicare-costs,Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles QDWI does not bring Extra Help with it, and his income is well above the headline Extra Help limit of about $23,940 a year, but SSA notes that people with work earnings can sometimes still qualify, so it is still worth his applying.U.S. Government Publishing Office. (n.d.). 42 CFR §435.126 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-435.126,U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
Net benefit: $311 per month in saved Part A premium, or roughly thirty-seven hundred dollars over a year. He keeps working and his Medicare stays intact.Centers for Medicare & Medicaid Services. (n.d.). Costs. medicare.gov. Retrieved Oct 15, 2026, from https://www.medicare.gov/basics/costs/medicare-costs
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, the EDWP service model: 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 waiver services delivered under CCSP.
- SOURCE: the other EDWP service model, which adds enhanced case management coordinated through a primary care physician.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
- Nursing facility: Institutional Medicaid coverage; Section 1924 spousal impoverishment does not apply (Diana is unmarried).
- PACE: Not something she can count on today. Georgia has posted Notices of Award for the Gainesville and Savannah PACE regions and Notices of Intent to Award for Athens, Savannah, and Gainesville, but no state source says whether any awarded center has opened to participants, so the coordinator suggests asking DCH whether any will reach Dougherty County.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Sep 4, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates
- FIDE-SNP: Only if one serves Dougherty County in the current contract year, which the Medicare.gov Plan Finder shows.
After family discussion, Diana chose EDWP through the SOURCE model, which adds enhanced case management coordinated through a primary care physician.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 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 waiver-funded in-home aide and adult day program.
If Diana's needs progress and waiver 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). Georgia would let her keep a $70 monthly personal needs allowance, and the rest of her income, after deductions such as her health-insurance premiums, would go toward the cost of her care as "patient liability."U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Sep 3, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-435/subpart-H/section-435.725
Key insight: the most integrated options, PACE and a FIDE-SNP, may not reach a given Georgia county, so a rural dual may need to coordinate care through SOURCE or 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 apply with DFCS, online through Georgia Gateway or at your county office, or start the MSP application through an Extra Help application with SSA.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023,Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip Extra Help is a separate application with SSA, though deemed-eligible individuals receive Extra Help without applying.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025 Do not count on backdating to rescue a late application. QMB runs forward from the month after the determination, and no federal rule held here gives SLMB or QI a retroactive window at all.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915 Medicaid itself does have one, at 42 CFR 435.915: coverage reaches back as far as the third month before the application month, but only for covered services actually received in that period by someone who would have been eligible then, and the state plan sets the exact date inside the window. A Section 1115 demonstration can shorten it, and a statute is about to: Section 71112 of Public Law 119-21 cuts the window for applications filed on or after January 1, 2027 to two months for most enrollees and one month for the ACA adult expansion group. If a past medical bill is what you are trying to cover, file before that date rather than after.U.S. Government Publishing Office. (2024). 42 U.S.C. 1396a(a)(34) — U.S. Code, 2024 Edition (govinfo.gov), the text in force for applications made before January 1, 2027. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396a.htm
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. If the billing continues, call 1-800-MEDICARE (1-800-633-4227).U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm
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.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
Original Medicare is a legitimate choice. Duals are not required to enroll in a D-SNP: a dual can still pick Original Medicare or a Medicare Advantage plan.Centers for Medicare & Medicaid Services. (n.d.). Medicare.gov — Medicaid. medicare.gov. Retrieved Sep 27, 2026, from https://www.medicare.gov/basics/costs/help/medicaid Original Medicare plus a standalone Part D plan plus Medicaid wraparound lets you see any Medicare-participating provider, with no plan network to stay inside.
Update your address with both Medicare and Medicaid. Mail that cannot reach you can mean a missed notice. Update your Medicaid address through Georgia Gateway (gateway.ga.gov) or the Gateway Customer Service Center at 1-877-423-4746, and make sure Medicare has your new address too.Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
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, full-benefit duals get a once-a-month special enrollment period to change their standalone Part D plan, plus a separate once-a-month integrated-care SEP to move into an aligned, integrated D-SNP, alongside the fall Medicare Open Enrollment Period (October 15 through December 7).U.S. Government Publishing Office. (n.d.). 42 CFR §423.38 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-423.38,Centers for Medicare & Medicaid Services. (n.d.). Open Enrollment. medicare.gov. Retrieved Sep 2, 2026, from https://www.medicare.gov/health-drug-plans/open-enrollment A monthly window is not a reason to switch often, so compare formularies and pharmacy networks before you move.
Plan for LTSS. If your loved one is approaching the need for nursing facility care, call Georgia's Aging and Disability Resource Connection at 1-866-552-4464, where applications for EDWP's CCSP and SOURCE models start, and consider elder law counsel for spousal impoverishment planning.Administration for Community Living. (n.d.). National Family Caregiver Support Program. acl.gov. Retrieved Sep 3, 2026, from https://acl.gov/programs/support-caregivers/national-family-caregiver-support-program,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 Medicaid's 60-month look-back on transfers means planning starts well before need.U.S. Social Security Administration. (n.d.). Social Security Act sec. 1917(c) [42 U.S.C. 1396p(c)] - Taking into account certain transfers of assets: look-back date, penalty period, start date, divisor, and the (c)(2) exceptions (SSA Compilation of the Social Security Laws). ssa.gov. Retrieved Oct 8, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
Get personalized eldercare guidance. Brevy helps families work through Medicare, Medicaid, and dual coverage decisions for older adults across Georgia and the United States.
The D-SNP integration timeline and what changes for Georgia duals
Federal D-SNP rules phase in over several contract years. For Georgia duals, the dates to watch:
CY2025 (in effect now):
- Monthly dual/LIS SEP for standalone Part D changes, plus a monthly integrated-care SEP for aligned D-SNP enrollment (replacing the prior quarterly SEP)U.S. Government Publishing Office. (n.d.). 42 CFR §423.38 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-423.38
CY2027:
- A D-SNP that is an "applicable integrated plan" must issue a single integrated member ID card serving as the card for both the Medicare and the Medicaid plan (42 CFR 422.2267(e)(30)(viii))
- The same plans must run one integrated health risk assessment meeting both the Medicare and the Medicaid requirements, so the enrollee completes a single assessment rather than two (42 CFR 422.101(f)(1)(v))
- Aligned-enrollment limits begin where the D-SNP's organization or its parent also holds the state Medicaid MCO contract in the same service area: that organization may generally offer only one D-SNP for full-benefit duals there, and must limit new enrollment to people in its Medicaid plan (CMS-4205-F)U.S. Government Publishing Office. (n.d.). 42 CFR 422.2267 - Required materials and content (member ID card). ecfr.gov. Retrieved Aug 22, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.2267
CY2030:
- Those D-SNPs may only enroll or keep people who are in (or enrolling in) the affiliated Medicaid plan, apart from a period of deemed continued eligibilityU.S. Government Publishing Office. (n.d.). 42 CFR 422.2267 - Required materials and content (member ID card). ecfr.gov. Retrieved Aug 22, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.2267
Which of these plans serve your Georgia county is a Plan Finder question each fall.
FAQ
What does QMB stand for and what does it pay?
Qualified Medicare Beneficiary. It is the most generous of the four Medicare Savings Programs. For a QMB enrollee with income at or below 100 percent of the federal poverty level and limited resources, Georgia Medicaid pays the Part A premium (if owed), the Part B premium of $202.90 per month for 2026, the Part A deductible, the Part B deductible, and all Medicare coinsurance. QMB enrollees cannot be balance billed by any Medicare provider under federal law.Centers for Medicare & Medicaid Services. (2026). 2026 Medicare Parts A & B Premiums and Deductibles. cms.gov. Retrieved Sep 4, 2026, from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
My provider sent me a bill for Medicare coinsurance. I'm QMB. What do I do?
The bill violates federal law. Sections 1902(n)(3)(B), 1905(p)(3), and 1866(a)(1)(A) of the Social Security Act prohibit any Medicare provider from billing a QMB enrollee for Medicare cost-sharing. Write to the provider citing your QMB status (attach the award letter) and request rescission; if you already paid, you have the right to a refund. If the billing continues, call 1-800-MEDICARE (1-800-633-4227), and if a debt collector keeps calling, you can file a complaint with the Consumer Financial Protection Bureau at 1-855-411-2372.U.S. Social Security Administration. (n.d.). Social Security Act Sec. 1902 [42 U.S.C. 1396a] - State Plans for Medical Assistance (subsection (n)(3)). ssa.gov. Retrieved Jul 10, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1902.htm GeorgiaCares SHIP at 1-866-552-4464 can help you with the letter.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
What is Extra Help and how do I get it?
Extra Help, also called the Part D Low-Income Subsidy or LIS, pays for Medicare prescription drug coverage. Since January 1, 2024, under the Inflation Reduction Act, everyone who qualifies, with income below 150 percent of the federal poverty level, gets the full subsidy. People with Medicare who are on full Medicaid, QMB, SLMB, QI, or SSI automatically get Extra Help; QDWI enrollees do not. Others apply through the Social Security Administration (1-800-772-1213, Form SSA-1020).U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 Full Extra Help means no Part D premium (in benchmark plans), no deductible, and copays on a three-tier ladder for 2026: $0 for full-benefit duals who are institutionalized or on an HCBS waiver, $1.60 generic and $4.90 brand for full-benefit duals at or below 100 percent FPL, and $5.10 generic and $12.65 brand for everyone else who qualifies.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
Should I enroll in a Dual Special Needs Plan (D-SNP)?
It depends on your priorities. A D-SNP is a Medicare Advantage plan built to coordinate your Medicare and Medicaid, and any extra benefits or $0 premium it advertises vary by plan rather than being guaranteed.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2 Check that your doctors and pharmacy are in its network before you join; if they are not, you would need to switch. If you value provider choice over supplemental benefits, Original Medicare plus a standalone Part D plan plus Medicaid wraparound may serve you better. GeorgiaCares SHIP at 1-866-552-4464 provides free, unbiased comparison counseling. Don't enroll over the phone with a marketing agent without comparing alternatives.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
How do I apply for Medicare Savings Programs in Georgia?
Apply online through Georgia Gateway at gateway.ga.gov, in person at your local DFCS county office, or call 1-877-423-4746 to request a paper application.Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip Provide proof of income (Social Security award letter, pension statements), proof of resources (bank statements), proof of Medicare entitlement (red, white, and blue Medicare card), and identification. Federal rules give the state up to 45 days to decide, or 90 days if you apply on the basis of disability.U.S. Government Publishing Office. (2026). 42 CFR 435.912(c)(3) — Timely determination of eligibility (eCFR current text, as revised eff. July 31, 2026). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/section-435.912 Do not plan around backdating: QMB takes effect after the month the determination is made, and no federal rule held here sets a retroactivity window for SLMB or QI. Medicaid's own three-month reach under 42 CFR 435.915 is conditional and narrows for applications filed on or after January 1, 2027.U.S. Government Publishing Office. (n.d.). 42 CFR 435.915 — Effective date (Medicaid eligibility). ecfr.gov. Retrieved Jul 10, 2026, from https://www.ecfr.gov/current/title-42/section-435.915,U.S. Government Publishing Office. (2024). 42 U.S.C. 1396a(a)(34) — U.S. Code, 2024 Edition (govinfo.gov), the text in force for applications made before January 1, 2027. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396a.htm For help with the application itself, call DFCS at 1-877-423-4746; for free counseling, call GeorgiaCares SHIP at 1-866-552-4464.dhs.georgia.gov. (n.d.). Georgia Department of Human Services - Contact (Customer Contact Center / Office of Family Independence). Retrieved Sep 4, 2026, from https://dhs.georgia.gov/contact,Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship
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 the Gateway Customer Service Center at 1-877-423-4746, which handles Medicaid eligibility questions.Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
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, with a burial fund of up to $1,500 per person on top.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Sep 4, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023 All three also automatically qualify the enrollee for Part D Extra Help, so the premium each pays is not the whole benefit. Those are federal standards rather than absolute cutoffs, so someone somewhat over should apply rather than rule themselves out, and QI must be applied for again each year.U.S. Social Security Administration. (2026). SSA - POMS: HI 00815.023 - Medicare Savings Programs Income and Resource Limits - 02/26/2026. secure.ssa.gov. Retrieved Aug 7, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0600815023
What is the difference between a coordination-only D-SNP, a HIDE-SNP, and a FIDE-SNP? Every D-SNP, including a coordination-only one, must have a contract with the state Medicaid agency that makes it responsible for coordinating the delivery of Medicaid benefits for its enrollees.U.S. Government Publishing Office. (n.d.). 42 CFR 422.107 — Special needs plans and dual-eligible individuals: contracts with States (eCFR). ecfr.gov. Retrieved Oct 9, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-B/section-422.107 A Highly Integrated Dual Eligible Special Needs Plan (HIDE-SNP) is more integrated than that, and one with exclusively aligned enrollment combines Medicare and Medicaid grievances and appeals into one process. A Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) is run by a single entity holding both the Medicare Advantage contract and the state Medicaid managed care contract, covers long-term services and supports among its Medicaid benefits, and has exclusively aligned enrollment and a single appeals process.U.S. Government Publishing Office. (n.d.). ecfr.gov. Retrieved Aug 7, 2026, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-A/section-422.2 Check the Medicare.gov Plan Finder for which types serve your county.
My Medicare premium was deducted from my Social Security check even after I got QMB approval. Why? The Section 1843 buy-in runs through a data exchange between Georgia and CMS rather than starting the moment you are approved, so the Part B premium can keep coming out of your check for one or more months. Once buy-in is effective, SSA refunds the premiums deducted for any month you are enrolled in the buy-in. No published rule fixes how long the lag or the refund takes.Centers for Medicare & Medicaid Services. (n.d.). CMS Manual for State Payment of Medicare Premiums, Chapter 1: Program Overview and Policy — the billing switch (Pub. 100-24). cms.gov. Retrieved Aug 7, 2026, from https://www.cms.gov/files/document/chapter-1-program-overview-and-policy.pdf If it is dragging on, call Social Security at 1-800-772-1213 about the deductions,U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025 and the Gateway Customer Service Center at 1-877-423-4746 to confirm your Medicaid approval.Centers for Medicare & Medicaid Services. (n.d.). CMS Medicaid.gov - Where Can People Get Help With Medicaid & CHIP? (Georgia row). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
Can I change my D-SNP whenever I want? Under CMS Final Rule CMS-4205-F, effective January 1, 2025, full-benefit duals get a once-a-month special enrollment period to change their standalone Part D drug plan, plus a separate once-a-month integrated-care SEP to enroll in an aligned, integrated D-SNP. This replaced the prior quarterly SEP, so the window is now monthly rather than quarterly. The fall Medicare Open Enrollment Period (October 15 through December 7) and event-based SEPs, such as after a move, also still apply.U.S. Government Publishing Office. (n.d.). 42 CFR §423.38 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-423.38,Centers for Medicare & Medicaid Services. (n.d.). Open Enrollment. medicare.gov. Retrieved Sep 2, 2026, from https://www.medicare.gov/health-drug-plans/open-enrollment
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. For 2026 the federal resource standard runs from $32,532 to $162,660,U.S. Government Publishing Office. (2024). 42 U.S.C. 1396r-5 (Social Security Act sec. 1924, spousal impoverishment), United States Code, 2024 Edition, U.S. Government Publishing Office (govinfo) — the CSRA is the GREATEST of four alternatives; the dollar cap binds only clauses (i) and (ii)(II); (e)(2) fair-hearing and (f)(3) court-order routes carry no dollar amount. govinfo.gov. Retrieved Oct 13, 2026, from https://www.govinfo.gov/content/pkg/USCODE-2024-title42/html/USCODE-2024-title42-chap7-subchapXIX-sec1396r-5.htm and Georgia's chart lets a nursing-home applicant with a spouse at home keep $162,660 plus their own $2,000. Your own income is not counted against your husband's $2,982 monthly income cap.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html If your income is low, part of his can be diverted to you: Georgia's 2026 standard is $4,066.50 a month,Centers for Medicare & Medicaid Services. (2026). CMS CMCS Informational Bulletin — Updated 2026 SSI and Spousal Impoverishment Standards (April 27, 2026). medicaid.gov. Retrieved Sep 4, 2026, from https://www.medicaid.gov/federal-policy-guidance/downloads/cib04272026.pdf and the diversion is that standard minus your own income after mandatory deductions.U.S. Government Publishing Office. (n.d.). 42 CFR § 435.725 — post-eligibility treatment of income of institutionalized individuals in SSI States (eCFR, current). ecfr.gov. Retrieved Oct 13, 2026, from https://www.ecfr.gov/current/title-42/section-435.725 Georgia allows that diversion for EDWP, NOW, COMP, and ICWP waiver recipients as well as nursing-home residents.U.S. Government Publishing Office. (n.d.). 42 CFR § 435.725 — post-eligibility treatment of income of institutionalized individuals in SSI States (eCFR, current). ecfr.gov. Retrieved Oct 13, 2026, from https://www.ecfr.gov/current/title-42/section-435.725 Georgia excludes some property from the resource count, so ask DFCS how your house and car are treated.U.S. Social Security Administration. (1975). Social Security Administration (ssa.gov) - SSI Federal Payment Amounts, 1975 and later (annual table; 2026 row). ssa.gov. Retrieved Nov 3, 2026, from https://www.ssa.gov/oact/cola/SSIamts.html An elder law attorney can help with spousal-impoverishment planning, particularly around annuities, trusts, and Medicaid's 60-month look-back for transfers.U.S. Social Security Administration. (n.d.). Social Security Act sec. 1917(c) [42 U.S.C. 1396p(c)] - Taking into account certain transfers of assets: look-back date, penalty period, start date, divisor, and the (c)(2) exceptions (SSA Compilation of the Social Security Laws). ssa.gov. Retrieved Oct 8, 2026, from https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
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 program for adults aged 55+ who meet nursing-home-level-of-care criteria but can live safely in the community.U.S. Government Publishing Office. (2019). 42 CFR 460.150 — Eligibility to enroll in a PACE program (eCFR, current/rolling text; last amended 84 FR 25676, June 3, 2019). ecfr.gov. Retrieved Aug 3, 2026, from https://www.ecfr.gov/current/title-42/section-460.150 Georgia's DCH describes it as comprehensive medical and social services, and the state's solicitation describes care delivered mainly through an adult day health center. Georgia has procured PACE and posted awards: as of a September 4, 2026 check, the state procurement registry carries Notices of Award for the Gainesville and Savannah PACE regions and Notices of Intent to Award for Athens, Savannah, and Gainesville. No state source says whether any awarded center has opened to participants yet, so ask the awarded region directly rather than assuming PACE is either running or unavailable. DCH's own PACE Updates page still shows only the April 2025 RFP and lags the procurement record.Georgia Department of Community Health. (n.d.). Program of All-Inclusive Care for the Elderly (PACE) Updates. dch.georgia.gov. Retrieved Sep 4, 2026, from https://dch.georgia.gov/programs/program-all-inclusive-care-elderly-pace-updates
My drug copay at the pharmacy is high. I thought Extra Help made copays low. What's wrong? Start by showing the pharmacist both your Medicare card and your Medicaid card. If the copay is still high, call your Part D plan first, then 1-800-MEDICARE if the plan cannot fix it.Centers for Medicare & Medicaid Services. (n.d.). Contact Medicare — Medicare.gov. medicare.gov. Retrieved Jul 23, 2026, from https://www.medicare.gov/talk-to-someone GeorgiaCares SHIP can help troubleshoot.Administration for Community Living. (n.d.). Administration for Community Living — State Health Insurance Assistance Program (SHIP). acl.gov. Retrieved Jul 30, 2026, from https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship In 2026, no full-LIS beneficiary pays more than $5.10 per generic or $12.65 per brand-name covered drug, and many pay less: full-benefit duals at or below 100 percent FPL pay $1.60 and $4.90, and institutionalized or HCBS-waiver duals pay nothing. If you have full Medicaid, your income is at or below 100 percent FPL, and you are charged the top tier, that is worth querying; a QMB-only, SLMB-only, or QI enrollee without full Medicaid is correctly on the top tier.U.S. Social Security Administration. (n.d.). SSA POMS HI 03030.025 - Resource Limits for Subsidy Eligibility. secure.ssa.gov. Retrieved Jun 22, 2026, from https://secure.ssa.gov/poms.nsf/lnx/0603030025
What is the QDWI program and who is it for? Qualified Disabled and Working Individual. It is for people with disabilities who are working and lost their Social Security disability benefits and 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: 200 percent FPL, which with earned-income disregards built in comes to $5,405 a month for an individual in 2026. Unlike the other three, it does not bring Extra Help with it.U.S. Government Publishing Office. (n.d.). 42 CFR §435.126 — Electronic Code of Federal Regulations (eCFR). ecfr.gov. Retrieved Jun 25, 2026, from https://www.ecfr.gov/current/title-42/section-435.126
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