Understanding Medical Assistance
A Handbook About Medical Assistance Services in Georgia
Important Information
My name as printed on my Medical Assistance Card:
The telephone number for reporting changes or obtaining
information about my Medical Assistance coverage:
My county Social Security Administration ofce (if you
receive Supplemental Security Income {SSI}):
My Care Management Organization’s Name (CMO):
My CMO’s telephone number:
My Doctor’s name and telephone number:
My Pharmacy’s name and telephone number:
1
1-877-423-4746
Table of Contents
About this Handbook ................................................................................................ 3
What is Medical Assistance?
.................................................................................... 4
Who is Eligible for Medical Assistance in Georgia? .................................................. 8
Should You Apply for Medical Assistance?
............................................................. 10
How to Apply for Medical Assistance in Georgia?
.................................................. 12
What Documents are Needed to Apply for Medical Assistance?............................. 14
What Happens After You Apply for Medical Assistance?
......................................... 16
How Does Medical Assistance Work?
..................................................................... 18
About Co-Payments
................................................................................................ 21
About Your Medical Assistance Card ...................................................................... 25
What is Covered under Medical Assistance
............................................................ 30
Planning for Healthy Babies®
................................................................................. 34
Your Rights and Responsibilities
............................................................................. 36
Frequently Asked Questions ...................................................................................39
Georgia Families .....................................................................................................44
Abbreviations Used in this Booklet ..........................................................................47
For more information about Medical Assistance eligibility
and how to apply, you can speak with a representative at
your local DFCS office or call the DFCS call center at
877-423-4746. You may find DFCS county contact
information at www.dfcs.dhr.georgia.gov; click on your
county of residence name.
To locate a county health department, call 404-657-2700
or log on to the Georgia Department of Public Health
(DPH) Web site at: dph.georgia.gov, go to the ‘Programs’
tab, choose the ‘District and County Operations’ option and
click the ‘District Ofce Directory’ link.
For questions about Right from the Start Medical
Assistance Group (RSM), call 877-427-3224 or visit dch.
georgia.gov/right-start-medical-assistance-group.
For questions about your Medical Assistance card, call
866-211-0950 or visit www.mmis.ga.gov.
To learn more about Georgia Families, call 888-423-6765
or log on to www.georgia-families.com.
Helpful Telephone
Numbers and Web Sites
2
You may also go online to dch.georgia.gov or
www.gateway.ga.gov. Georgia Gateway is an online
tool which allows Georgians to get answers to
questions or apply for many health and human service
programs.
Sometimes, Medical Assistance programs and its rules may seem hard to understand. This handbook will help you
understand how Medical Assistance programs work, and whether the programs can help you and your family.
If you think you or your family members may be eligible for a type of Medical Assistance, this handbook will explain
how to apply for Medical Assistance and how to get medical care after you have been approved.
Although every state has Medical Assistance programs, each state’s programs are different. This handbook explains
how these programs work in Georgia.
This handbook will provide you with telephone numbers that will help you get more information about Medical
Assistance. Write down the names and numbers on the inside front cover of this handbook, so that you’ll have them
when you need them!
Remember to always update any changes to your Medical Assistance contacts.
About This Handbook
3
What is Medical
Assistance?
4
Medical Assistance is the term for a variety of programs that helps those who can’t afford medical insurance pay for some or
all their medical bills.
Good health is important to everyone. There are many factors that contribute to your health. Some activities contribute to
good health, such as eating a balanced diet, exercising, wearing your seat belt, getting immunizations and u shots. Others
hurt your health like smoking, excessive alcohol use and overeating.
If you can’t afford to pay for medical insurance right now, Medical Assistance may be able to help you get the care that you
need to get healthy and to stay healthy.
With many types of Medical Assistance covered in this booklet, your family will receive care through a plan often referred to
as a Care Management Organization (CMO) (Amerigroup, CareSource, PeachState or WellCare). You will choose a health
plan and a Primary Care Physician (PCP) who is best for you.
Your family will be able to receive a variety of medical care services from the PCP and other specialists. Your family will
have an identication card listing the health plan and the PCP’s name, address and phone number.
The types of Medical Assistance programs that you may qualify for in Georgia are: Medicaid and PeachCare for
Kids®. These programs will be explained later in this booklet.
5
What is Medicaid?
Medicaid is a health insurance program under Medical Assistance that covers many groups of people. Medicaid covers
eligible parents/caretakers with children under age 19, children under age 19, pregnant women, and people who are age 65
or older, blind or disabled. Medicaid is administered by the Georgia Department of Community Health (DCH).
6
What is PeachCare for Kids®?
PeachCare for Kids (PCK) is a health insurance program under Medical Assistance that covers eligible children from
birth to the month of their 19th birthday. It is administered by DCH. This program was designed specically for working
families who do not have access to affordable private health insurance.
For children ages 6 and older, you may be required to pay a low fee each month and co-pays. The monthly fee is
referred to as a premium payment. Co-pays may be required when services are rendered by the provider. Co-pays
could range from $0.50 to as much as $3.00.
7
Who Is Eligible for Medical
Assistance in Georgia ?
8
Medicaid
Many groups of people are covered by Medicaid.
Even within these groups, different requirements must
be met. These may include your age; whether you
are pregnant, age 65 or older, blind or disabled; your
income and assets; and whether you are a U.S. citizen
or a qualied immigrant. Non-qualied immigrants,
unlawfully admitted or undocumented immigrants may
be eligible for Emergency Medical Assistance only.
When you apply for Medicaid, the requirements listed
above will be considered before a decision is made.
Your child may be eligible for coverage if he or she is
a U.S. citizen or a lawfully admitted immigrant, even
if you are not. Eligibility for children is based on the
child’s citizenship status, not the parent’s citizenship
status; however, the parent’s income is counted toward
the income limit.
In general, you may be eligible for Medicaid if your
income is low and you match one of the descriptions
below:
• You think you are pregnant.
• You are a child or teenager, under age 19.
• You are age 65 or older.
• You are legally blind.
• You have a disability.
• You need nursing home care.
PeachCare for Kids
Children are eligible for PCK if they are under the age
of 19 and their family’s income is within a certain level.
Children cannot receive PCK, if they are eligible for
Medicaid or if they have other health insurance at the
time of application.
Medicaid/PeachCare for Kids
9
10
Should You Apply for
Medical Assistance?
When you apply for Medical
Assistance, your application will be
carefully reviewed by an Eligibility
Specialist and those requesting
assistance will be reviewed for the
most appropriate type of coverage. In
general, you should apply for Medical
Assistance if you match one of the
descriptions below:
Pregnant Woman:
Apply for Medical Assistance if you
think you are pregnant. If you are on
Medical Assistance when your child
is born, both you and your child will
be covered. You may be covered for
another 60 days after your child’s
birth. Your child may be covered for up
to one year.
Children and Teenagers:
Apply for Medical Assistance if you are
the parent/caretaker or guardian of a
child who is under age 19 and your
family needs help paying for medical
care.
If you were in foster care when you
turned age 18 or aged out of foster
care and you are under the age of 26,
you may be eligible for either Former
Foster Care Medicaid or Chafee
Medicaid.
Aged, Blind or Disabled People:
Apply if you are aged (65 or older),
blind or disabled, and have low
income and few resources (such as
bank accounts, real property or other
items that can be sold for cash).
Apply if you are terminally ill and want
to receive hospice services.
Apply if you are aged, blind or
disabled; live in a nursing home; and
have low income and limited assets.
Apply if you are aged, blind or
disabled and need nursing home care,
but can stay at home with special
community-care services.
Apply if you are eligible for Medicare
and have low income and limited
assets.
Some Other Situations:
Apply if you are eligible for or leaving
Temporary Assistance for Needy
Families (TANF) and need health care
coverage.
Apply if you are a parent or caretaker
with children under age 19 and have
very low or no income and few assets.
(You do not have to be receiving
TANF.)
Apply at your local Department of
Public Health Ofce if you have breast
or cervical cancer.
If you are pregnant, under 19, 65 or
older, blind or disabled, even if your
income is over the limits, if you owe
medical bills you should apply.
11
How to Apply for
Medical Assistance in
Georgia?
12
There are several different ways to apply for Medical
Assistance in Georgia. You may apply online at www.
gateway.ga.gov, (select “Medical Assistance” as a program)
by telephone at 877-423-4746, in person (by going to the
local DFCS ofce, Public Health Department or Social
Security ofce), or by requesting forms to be mailed to you
that you can ll out at home and mail and bring back.
You can contact DFCS in your county. The DFCS ofce will
take your application or assist you online with applying for
Medical Assistance. You can also visit the Web sites of the
Georgia Department of Community Health (DCH) at
www.dch.georgia.gov or the Georgia Department of
Human Services (DHS) Division of Family and Children
Services at www.dfcs.dhs.georgia.gov to obtain more
information or an application you can download, ll out, and
bring or send back.
Applications, including the online application, are also
available in Spanish.
You may also apply for most types of Medical Assistance for
families, children, or pregnant women at Right from the Start
Medical Assistance Group (RSM) ofce. RSM has workers
available to take your application early in the morning, in
the evening and on weekends. These workers are located
in non-traditional sites, such as hospitals, public health
departments, housing projects, etc.
If you think you are pregnant, contact your county Health
Department, Federally Qualied Health Center, Primary
Health Care Center or Hospital. (Call the Georgia
Department of Public Health at 404-657-2700 to nd out
where to apply in your county.) If you are pregnant and
eligible, you can get a Medical Assistance certication form
on the same day that you apply. You can get prenatal care
for yourself and your baby immediately.
If you are aged (65 years old or older), blind or have a
disability and have little or no income, apply for the
Supplemental Security Income (SSI) program by contacting
your local Social Security ofce. If you are approved for SSI,
you will automatically receive Medicaid. You may also apply
for Medical Assistance at the DFCS ofce, but you will not be
able to apply for SSI there. Call 800-772-1213 or go to www.
ssa.gov to nd the closest Social Security ofce. People
who are deaf or hard of hearing may call the Social Security
Administration toll-free TTY number at 800-325-0778, 7 a.m.
to 7 p.m., Monday through Friday.
13
14
What Documents Are
Needed to Apply for
Medical Assistance?
When you apply for Medical Assistance; the application process will move along more quickly if you have the
information about yourself and your children handy. You may not need all the items on the list, but these are the kinds
of documents that will help:
• A copy of your birth certicate or other proof of identity and citizenship or immigration status
• ID cards issued by federal, state or local government agencies or entities either containing a picture or
identifying information, such as name, date of birth, sex, height, eye color and address to conrm identity
• Social Security numbers, for each person requesting Medical Assistance
• Paycheck stubs, payroll records or recent W-2 forms covering at least the past four weeks
• Letters or forms that show your income from Social Security, SSI, Veterans Administration, retirement,
pensions, unemployment, worker’s compensation or all sources of income
• Current health insurance policies, health insurance cards, or other health insurance information
• Life insurance policies
• Recent bank statements or bank books, and/or most recent tax return
• Information about property you own (such as land, or stocks and bonds)
If you need help nding this information, call 877-423-4746 or 877-427-3224.
15
What Happens After
You Apply for Medical
Assistance?
16
Once you complete an application
for Medical Assistance, an eligibility
specialist will review your application.
The Eligibility Specialist will make sure
that all the necessary information has
been received.
Applicants ineligible for Medical
Assistance based on income, will
have their information transferred to
the Federally Facilitated Marketplace
(FFM) to determine if they qualify for
subsidies, cost-sharing reductions,
premium tax credits or private health
coverage.
If you have medical bills from the past
three months that you were not able
to pay, report them on your application
when you apply. If you are eligible for
Medicaid, it is possible that Medicaid
will pay for some of these bills, even
if you were not enrolled in Medicaid
at that time. PCK does not provide
coverage for months prior to your
application.
You will nd out whether you are
eligible for Medical Assistance within
45 days after you apply. A letter will be
mailed to you telling you whether you
are eligible or ineligible. (If you have a
disability and your disability has to be
veried, the process may take up to 60
days.)
You may report changes, access your
notice/letter, and renew your benets
online at www.gateway.ga.gov. You
will need to create an account. You
may also report changes about your
situation or get information about your
benets by phone at 877-423-4746 or
877-427-3224.
If you are eligible and approved for
Medical Assistance, you will receive a
plastic Medical Assistance card in the
mail. We will mail information to you
about your Medical Assistance. It is
very important that you let DFCS (or
the Social Security Administration if you
receive SSI) know your new address
when you move.
If you are enrolled in a Georgia
Families Care Management
Organization(CMO), you will also need
to carry your Georgia Families CMO
card with you. Your doctor, pharmacist
or other medical care provider will need
to see this card as well as your Medical
Assistance card.
If you have other health insurance that
may cover some or all your medical
services, tell your medical care provider
about the other insurance. You MUST
show your Medicare or other insurance
card to your medical care provider
when you go in for medical care.
Once approved for Medical Assistance,
your eligibility must be renewed once
every 12 months. You will receive a
notice the month before your renewal
month.
Your personal situation may change
-- for example, if you get a different
job, if your family size changes, or if
you move -- an administrative renewal
may be completed on your coverage if
the change reported affects eligibility.
Also, eligibility will be extended for an
additional 12 months. This will change
the month your Medical Assistance
renewal is due. You will receive a
notice that an administrative renewal
was processed on your case.
If your situation changes, you must
contact us by calling 877-423-4746 or
877-427-3224 or go online to www.
gateway.ga.gov. If you are receiving
SSI, you must call the Social Security
Administration ofce at 800-772-
1213 as soon as you know about any
changes.
17
How Does Medical
Assistance Work?
18
Once you are eligible for a Medical Assistance program,
there are different ways that you can receive medical
services. You may participate in Georgia Families or
receive services from any provider who accepts Medical
Assistance payments. These are described below:
Georgia Families
Georgia Families is a managed care program that
delivers health care services to members of PCK and
some Medicaid members. The program is a partnership
between DCH and Georgia Families CMO. By providing a
choice of health plans, Georgia Families allows members
to select a health care plan that ts their needs. The
health plans you can choose from are: Amerigroup,
CareSource, PeachState or WellCare. You will initially be
assigned to a CMO servicing in your area and will then
have 90-days to choose a different plan that is serviced in
your area. You are also able to select a PCP.
Children enrolled in PCK, children under age 19,
parent(s) or caretaker(s) with children under age 19,
pregnant women and women with breast or cervical
cancer, are eligible to participate in Georgia Families.
Members who maintain eligibility will continue enrollment
through Medicaid or PCK.
Not everyone may participate in Georgia Families.
Medicaid members that do not participate in Georgia
Families are those who are:
• Eligible for Medicare;
• Presumptively eligible pregnant women, children
under age 19, former foster care children, parent/
caretaker with children under age 19, women’s
health (Women with breast or cervical Cancer);
• Members of a federally recognized Indian Tribe;
• Members eligible for SSI;
• Children enrolled in:
•
Georgia Pediatric Program (GAPP)
• Multi-Agency Team for Children (MATCH)
• Nursing home and hospice patients;
• Home and Community based services;
• Members enrolled under group health plans for
whom DCH provides payment of premiums,
deductibles, coinsurance and other cost sharing.
19
Children’s Medical Services (CMS)
•
Who Accepts Medicaid?
Other Medical Care Providers Who Accept Medicaid
If you do not belong to Georgia Families, you will not be assigned to a doctor or organization for your medical care.
When you need a checkup or any medical services that are covered by the program, you can present your Medical
Assistance card and other insurance card to any doctor, dentist, pharmacist or clinic who accepts Medicaid. After you
receive your medical services and other health insurance policies have been billed, the Medicaid program will pay the
doctor or clinic directly for all remaining covered services.
Medical Care Providers Who Do Not Accept Medicaid or PeachCare for Kids
If you receive services from a medical care provider who does not accept Medicaid or PCK, then Medical Assistance will not
pay for the services. If you still want to receive services from a provider who does not accept Medicaid or PCK, you will be
responsible for the cost of that care.
20
About Co-Payments
21
Depending on your Medical Assistance category, you may
have to make a small co-payment when you receive medical
care, but Medical Assistance will pay most or all of the bill.
You cannot be denied service because you are not able to
pay the co-payment. However, your provider may bill you for
the co-payment amount.
Doctors, hospitals or other medical care providers enrolled
in the Medical Assistance program must accept Medicaid or
PCK as payment in full, except for co-payment amounts.
There is no cost for children under age six, children in Foster
Care or American Indians and Alaskan Natives (AI/AN).
For children ages six and older, PCK requires a monthly
premium. Premiums increase on a sliding scale based on
family size, age of children and household income. A co-
payment is required for some services. Your medical care
provider will let you know when a co-payment is required.
There are no deductibles for services covered by PCK.
You will receive a letter that will tell you how much your
monthly premium is and when it is due each month.
Premiums are due the rst day of the month, 30 days before
the month of coverage. For example, the payment you make
on January 1 will cover care during the month of February.
When you make a payment, please write your PCK account
number on the check or money order. You will receive
a coupon booklet if you would like to mail your monthly
payments. Mail the monthly coupon with the check or money
order to:
PeachCare for Kids®
P.O. Box 44031
Jacksonville, FL 32231
Always mail your monthly premium on time and to the
address above. If the payment is not received, your child’s
coverage will be canceled.
You can make premium payments or set up automatic debit
online at www.gateway.ga.gov or by using our Interactive
Voice Response System by calling 877-427-3224.
Your premium may change when your income changes,
so be sure to report any changes in your income within ten
days. You may report changes by logging into your account
at www.gateway.ga.gov or by calling 1-877-427-3224.
22
What if Coverage is Canceled Due to Late
Payments?
If your child’s coverage is canceled because the payment was short or not received on time, your child will be locked out
of PCK for a period of one month. You should call toll-free 877-427-3224 to have coverage reinstated. For example, if your
coverage is canceled for January and you would like to have it reinstated for February, your February payment is due by
January 1. You will be notied when the coverage will be reinstated. Until coverage is reinstated, you will be responsible for
any charges for medical care your child receives. If reinstatement is requested for the canceled month, the premium must
be received in that month.
23
Important Facts to Remember
• Before you visit the doctor, dentist or pharmacist, locate your Medical Assistance and CMO cards. Make sure
you are still covered, then write down your questions so that you won’t forget to ask them. Take a friend or
relative along to help.
• If your doctor or dentist writes you a prescription for medicine, ll the prescription and follow your doctor’s
instructions even if you start feeling better right away. Ask your doctor or pharmacist if you have any questions
about taking your medicine.
• Make sure your doctor is aware of all medications that you are currently taking.
• If you can’t make it to an appointment with your doctor or dentist, call to cancel and reschedule as soon as
possible. This way, you’ll have another scheduled appointment on the doctor’s calendar.
24
About Your Medical
Assistance Card
25
After you are approved for Medical Assistance, you will
receive an identication card in the mail. One card will be
mailed to each enrolled member in the family.
Your card will look like a credit card and will t in your wallet,
so carry it with you at all times. In case of an emergency,
you will need to show your Medical Assistance card before
receiving medical services.
The card will have your name and your member
identication number printed on the front. Please protect
your Medical Assistance card and member identication
number.
How Your Provider Will Use the Card
Your provider will use your card to get information from
the Medical Assistance system. This information is very
important in making sure that the Medical Assistance
program pays for the services you received.
Some of the things your provider can see by accessing the
Medical Assistance system are:
• If you are eligible for services;
• If you must pay a co-payment for services;
• If there are any limits on the services, you can
receive; and
• If you have other health insurance.
Questions
If you have questions about your card or how to use it, call
the Member Contact Center at 866-211-0950.
Front of Card
Back of Card
26
Things to Remember
• Always keep your card(s) with you;
• Your Medical Assistance and CMO cards are for your use only. It is against the law for anyone else to use your
cards;
• If your eligibility for Medical Assistance stops, do not throw your card away. You may become eligible again and
may be able to use the same card to receive services;
• Always show your card before receiving medical services. If you are a member of Georgia Families, you may be
required to show your Medical Assistance and Georgia Families cards before you receive medical services;
• Always get your card(s) back after your visit is completed or your prescription is lled.
27
Need a Ride?
Georgia Medicaid currently contracts with two Non-Emergency Medical Transportation (NEMT) Brokers to arrange
NEMT services for eligible Medicaid members to and from medical treatments, medical evaluations, obtaining
prescriptions from pharmacies and medical equipment. Each NEMT broker covers different regions of the state. Call
the broker assigned to the county you live in to schedule non-emergency medical transportation Monday through
Friday from 7 a.m. to 6 p.m. You must schedule your transportation at least three days before your appointment date.
Locate your county below and contact the assigned broker at the number provided. If you have a question, comment
or complaint about NEMT, please call the Member Contact Center toll-free at 1-866-211-0950 for assistance.
28
SOURCE Agencies
Contact Number
Atlanta Region --
Southeastrans
Toll free
866-388-9844
Local
404-209-4000
Assigned Counties: Dekalb, Fulton and Gwinnett
North Region --
Southeastrans
Toll free
866-388-9844
Local
678-510-4555
Assigned Counties: Banks, Barrow, Bartow,
Catoosa, Chattooga, Cherokee, Cobb, Dade,
Dawson, Douglas, Fannin, Floyd, Forsyth,
Franklin, Gilmer, Gordon, Greene, Habersham,
Hall, Haralson, Jackson, Lumpkin, Morgan, Murray,
Paulding, Pickens, Polk, Rabun, Stephens, Towns,
Union, Walker, Walton, White and Whiteld
Central Region --
Logisticare
Toll free
888-224-7981
Assigned Counties: Baldwin, Bibb, Bleckley, Butts,
Carroll, Clayton, Coweta, Dodge, Fayette, Heard,
Henry, Jasper, Jones, Lamar, Laurens, Meriwether,
Monroe, Newton, Pike, Putnam, Rockdale,
Spalding, Telfair, Troup, Twiggs and Wilkinson
East Region --
Logisticare
Toll free
888-224-7988
Assigned Counties: Appling, Bacon, Brantley,
Bryan, Bullock, Burke, Camden, Candler, Charlton,
Chatham, Clarke, Columbia, Efngham, Elbert,
Emanuel, Evans, Glascock, Glynn, Greene, Han-
cock, Hart, Jeff Davis, Jefferson, Jenkins, Johnson,
Liberty, Lincoln, Long, Madison, McDufe, McIn-
tosh, Montgomery, Oconee, Oglethorpe, Pierce,
Richmond, Screven, Taliaferro, Tattnall, Toombs,
Treutlen, Ware, Warren, Washington, Wayne,
Wheeler and Wilkes
Southwest Region --
Logisticare
Toll free
888-224-7985
Assigned Counties: Atkinson, Baker, Ben Hill,
Berrien, Brooks, Calhoun, Chattahoochee, Clay,
Clinch, Coffee, Colquitt, Cook, Crawford, Crisp,
Decatur, Dooly, Dougherty, Early, Echols, Grady,
Harris, Houston, Irwin, Lanier, Lee, Lowndes,
Macon, Marion, Miller, Mitchell, Muscogee, Peach,
Pulaski, Quitman, Randolph, Schley, Seminole,
Stewart, Sumter, Talbot, Taylor, Terrell, Thomas,
Tift, Turner, Upson, Webster, Wilcox and Worth
29
What does Medical
Assistance Cover?
30
It’s always a good idea to ask your
doctor or pharmacist whether the
specic service or item you need is
covered under Medical Assistance.
There are some limits to these
services and some may require you
or your doctor to get permission from
Medical Assistance rst; this is called
prior approval. Generally, Medical
Assistance covers the following
services:
• Doctor and nurse ofce
visits (when you visit a doctor
nurse for checkups, lab
tests, exams or treatment)
• Prescription drugs
• Inpatient hospital services
(room and board, drugs, lab
tests and other services when
you must stay in the hospital)
• Outpatient hospital services
you receive in a hospital even
though you do not stay in the hospital
overnight
• Nursing facilities (nursing homes)
• Emergency ambulance services
• Preventive dental care, llings and
oral surgery for children
• Certain emergency dental care for
adults
• Non-emergency transportation (to get
to and from medical appointments, for
Medicaid members only)
• Medical equipment and supplies
prescribed by a doctor for use in your
home (such as wheelchairs, crutches
or walkers)
• Exams, immunizations (shots) and
treatments for children (see box below)
• Family planning services (such
as exams, drugs, treatment and
counseling)
• Home health services ordered by
a doctor and received in your home
(such as part- time nursing, physical
therapy or home health aides)
• Hospice care services provided by a
Medicaid hospice provider
• Vision care for children (limited
services for adults)
• Hearing services for children
What is Covered Under Medical Assistance?
Check Out Health Check!
Medical Assistance pays for most
medical services that children need.
The Georgia program that provides
checkups and immunizations for
children under 21 is called Health
Check.
Ask your doctor about it!
31
Other Services and Items Covered Under Medical
Assistance May Include:
• Case management
• Diagnostic, screening and preventive services
• Laboratory services
• Medicare premiums, deductibles and coinsurance
• Mental health clinic services
• New Options Waiver (NOW)
• Comprehensive Supports Waiver Program (COMP)
• Community Care Services Program (CCSP)
• Independent Care Waiver Program (ICWP)
• Nurse midwife and nurse practitioner services
• Nurse visits in the home after delivery of your baby
• Orthotics and prosthetics (articial limbs and replacement devices)
• Podiatry services
• Psychological services (for people under the age of 21)
• Therapy services (physical, occupational and speech)
• Rural Health Clinic and Federally Qualied Health Center services
• Childbirth education classes
• Birthing center services
• Dialysis and services for end-stage renal (kidney) disease
• Durable medical equipment (DME)
32
What is Not Covered Under Medical Assistance?
There are services not covered under Medical Assistance. These include services that are not medically necessary, private-
duty nursing, medical services and care given by a responsible relative or member of your household, cosmetic surgery,
experimental items and chiropractic services, among others. If you’re not sure, ask your medical care provider!
If you are not sure whether a service is covered, call the Member Contact Center at 866-211-0950 or call your
Georgia Families CMO if you are enrolled in one.
33
Planning For Healthy
Babies®
34
Planning for Healthy Babies® (P4HB) is a waiver program under Medical Assistance. P4HB covers family planning
services to eligible women ages 18 through 44 who meet the monthly family income criteria, not otherwise covered by
insurance (including Medicare), and not receiving coverage under another Medicaid category. P4HB also covers Inter-
Pregnancy Care (IPC) services, including primary care case management, for eligible women who delivered a very
low birth weight baby (VLBW) as of, January 1, 2011.
The primary goals of the P4HB program are to reduce Georgia’s low birth weight (less than 2500 grams or 5 lbs. 8 oz.)
and very low birth weight (less than 1500 grams or 3 lbs. 5 oz.) rates; reduce the number of unintended and high risk
pregnancies in Georgia; and to reduce Medicaid costs by reducing the number of unintended pregnancies. There are
three levels of services under P4HB: Family Planning, Inter-Pregnancy Care and Resource Mother.
For more information about P4HB call 877-427-3224 or go online to
www.dch.georgia.gov/planning-healthy-babies. To apply, for P4HB, please go online to www.gateway.ga.gov.
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Your Rights and
Responsibilities
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Once you are eligible for Medical Assistance, you have
certain rights, but you also have some responsibilities
that go with those rights. Be aware of your rights and
responsibilities.
Your Rights:
You have the right to apply for any medical assistance
program of your choice.
You have the right to timely and adequate notice.
You must receive notice in writing before the Medical
Assistance program takes any action to end your eligibility.
You have the right to a fair hearing.
You can request a fair hearing if you disagree with a
decision regarding your Medical Assistance eligibility or if
you feel that the Medical Assistance program has not served
your medical needs properly. To request a hearing for
Medicaid, contact your county DFCS ofce or call 877-423-
4746 within 10 days of the date shown on the notice about
eligibility or services.
To request a hearing for PCK, call 877-427-3224 within 10
days of the date shown on the notice about eligibility or
services.
You have a right to fair treatment.
Under DCH’s policy, the Medical Assistance program cannot
deny you eligibility for benets based on your race, age,
sex, disability, national origin, political or religious beliefs. To
report Medical Assistance fraud/abuse, eligibility or provider
discrimination, call the DCH Ofce of Inspector General at
404-463-7590 or toll-free at 800-533-0686.
Your responsibilities:
You are responsible for providing true and complete
information about your circumstances.
The information you provide must be true and must include
your complete income, the size of your family, your current
address and other information that helps the Medical
Assistance program decide whether you continue to be
eligible for services.
You are responsible for reporting changes in your
circumstances.
If your income, resources, living arrangements, family size
or other circumstances change, they could affect your
eligibility. It is your responsibility to report your changes
to DFCS, RSM, PCK, or if you receive SSI, let the Social
Security Administration know about these changes within 10
days of the change.
If you have other health or dental insurance, you
must give the State of Georgia the rights to these
payments.
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Report all health insurance plans when you apply for Medical Assistance. These might include private health
insurance, Medicare, Tricare formerly, (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS),
car or home insurance. You also need to report whether you receive any money from an injury resulting from an
accident.
You also must report when any health insurance changes. When you apply for Medical Assistance, your right to any
payment made by a health plan is automatically given to Medicaid. Medical care providers usually get these payments
and then Medicaid pays them based on how much the health plan paid. However, if a health plan pays you for a
service, you cannot keep the money. You are responsible for giving the money to Medicaid. Contact your local DFCS
ofce to learn how you can give the money to Medicaid.
PCK members cannot have other health insurance.
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FAQ’s
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Frequently Asked Questions About Medical
Assistance
What is the IRS Form 1095-B?
Beginning January 2016, Medical Assistance members
will receive Form 1095-B from the Georgia Medicaid/PCK
program. Members who receive their medical assistance
through a CMO (Amerigroup, CareSource,PeachState or
WellCare) will also receive this form from Georgia Medicaid/
PCK. This form is required by the IRS, because of the
Affordable Care Act to verify that individuals have at least
minimal essential coverage. The January 2015 tax season
was the rst year these forms were mailed and this process
will continue annually.
The 1095-B is an information form. Just like a W-2 form,
it contains information that is required by individuals to
complete their taxes. Also, like a W-2 form, the 1095-B
form will be provided to the IRS to show the months each
individual had health insurance through Georgia Medicaid/
PeachCare for Kids.
What if I lose my card?
If you lose your Medical Assistance card, call the Member
Contact Center to get a new one. You can reach a
representative at 866-211-0950, Monday through Friday, 7
a.m. to 7 p.m. You may also contact your local county DFCS
ofce or log on to www.mmis.georgia.gov.
What if I need services while I’m away from Georgia?
If you need medical services while you’re in another state,
the doctor or hospital treating you must call the Provider
Services Contact Center (PSCC) at 800-766-4456 (toll
free) to get prior approval before providing services or the
Georgia Families CMO provider line, if you are enrolled.
(If you are in an emergency situation, and are taken to a
hospital emergency room, prior approval is not required.)
What if I want to change my PCP?
If you want to change your PCP, you need to call your CMO
health plan. The number is on your Georgia Families CMO
identication card.
What if I want to change health plans?
Open enrollment is only held once a year. If you want to
change your CMO health plan, you need to call Georgia
Families at 888-423-6765 to nd out about the open
enrollment period.
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A Guide to Medicaid Waiver Programs in Georgia
When should I call Medicaid/PeachCare for Kids® and
when should I call Georgia Families?
You and your family will only receive care through Georgia
Families if they are enrolled in Medicaid/PCK. You must
respond to letters from Medicaid/PCK about maintaining you
and your family’s enrollment and letters about renewing your
eligibility. You need to call Medicaid/PCK at 877-423-4746
or 877-427-3224 when you have questions about enrollment
in the program, premium payments, income verication,
citizenship, identity and when you move or have any change
in your household that affects your eligibility. It is very
important to keep your address updated.
Can I pay the PeachCare for Kids monthly premiums
ahead of time?
Yes, you can pay for one or more months ahead of time. If
you do choose to pay for more than one month at a time,
please be sure to include the coupons for those months
(from your coupon book) along with your payment, or write
your PCK account number on the top of your check or
money order. If your child becomes ineligible or coverage
is canceled, the balance in your account will be returned to
you.
What if I get a bill from a medical care provider?
If you get a bill from a doctor, hospital or other provider that
you think Medical Assistance should have paid, call 866-
211-0950 or write to the Member Inquiry Unit, GHP, P.O.
Box 105200, Tucker, GA 30085-5200 and ask for a “Fullard”
review.
You can also go to www.mmis.georgia.gov and click on
Member Information, and then select Member Notices. You
will see Fullard Review Submission Package. This link will
include all the forms and instructions needed to request
your Fullard Review. Once you have submitted all required
information, the Member Contact Center will investigate to
see whether Medicaid should have paid the bill. It will send
you a letter about the ndings.
FULLARD REVIEW PROCESS
Q: What is a Fullard Review and why might I want one?
A: You can request a Fullard Review if you believe you are
getting bills for services that Medicaid should have paid.
In a review, bills are submitted and considered. You and
the provider will be sent copies of the nal outcome of the
review.
Q: Who can request a Fullard Review?
A: You, your authorized representatives who are listed on
your record or the Payee/Other Spouse or Parent who are
on your record.
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Q: What steps should I take to request a Fullard
Review?
A: It’s very simple. See below:
1. Go to the Georgia Medicaid Management Information
System (GAMMIS) Web portal at www.mmis.georgia.
gov.
2. Click on the Member Information Tab.
3. Click on Member Notices
4. At the bottom of the page, select the document titled
Fullard Review Submission Package. This is the form with
instructions about how and where to send your request
for review.
NOTE: If you do not have internet access, you may
call the Member Contact Center at 866-211-0950 and
ask them to send you the Fullard Review Submission
Package. This process takes a bit longer. If you use the
internet to access GAMMIS, you will get the form on the
same day.
Q: Should I check anything before I send in my
request?
A. Yes, check to conrm that you were an active member
on the date you received service. If you were and gave
the provider the Medicaid details, you can request a
Fullard Review.
If you were not an active member on the date you
received service, contact DFCS to see if you qualify for
coverage.
If you were assigned to Amerigroup, CareSource, Peach
State or WellCare, then you need to ask the CMO you
were assigned to about any questions you have about
your bills.
If you received retro-coverage for the date of service and
you gave the provider the retro-coverage details, you can
request a Fullard Review.
Q: What if my Medical Assistance is cut off or if it is
not meeting my medical needs properly?
A. If you get a notice saying your Medical Assistance will
end or that a service will not be covered and you think it
is a mistake, ask for a fair hearing right away. You may
use the hearing request form at the end of the notice you
received. It is important to ask for the hearing within 10
days from the date shown on the notice if you want to
keep on getting services while you appeal. Call 1-877-
423-4746 to ask for the hearing. After calling, follow up in
writing within 15 days.
Q; When can I go to the Emergency Room?
A. If you believe the situation is an emergency and you
need care immediately, go to the emergency room right
away.
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• Any life threatening or disabling condition
• Sudden or unexplained loss of consciousness
• Possible broken bones
• Coughing up or vomiting blood
• High Fever with stiff neck, Mental confusion
• Difculty breathing or speaking
• Cut or wound that won’t stop bleeding
• Chest pain; numbness in face, arm or leg
• Severe shortness of breath
• Major Injuries
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Some examples of when you should go to the emergency room are:
Georgia Families
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What is Georgia Families?
Georgia Families is a program for most Medicaid and all
PCK members. Members enrolled in Georgia Families
are initially assigned a health plan and must choose a
primary care physician. If you do not choose, a primary care
physician one will be chosen for you.
What is a Health Plan?
A health plan is a group of doctors, nurses, hospitals and
other health care providers who provide the members of the
plan all the health services that they need. As a member of
a health plan, you will not have to look for doctors or other
providers yourself. Your health plan will have all the health
care professionals you need.
What is a Primary Care Physician?
A Primary Care Physician (PCP) is the person you will go to
for regular checkups and other basic health care services.
Over time, your PCK will get to know you and your health
care needs. Your PCK will also refer you to specialists and
other health care providers if you need more specialized
health care.
Who should enroll?
If you are a Georgia Families participant, you will be
assigned to a health plan upon approval for coverage. You
may select a different health plan during the rst 90 days of
enrollment. Georgia Families can assist you with a selection
if you request it at either www.georgia-families.com or by
calling 1-888-GA-Enroll (1-888-423-6765).
Who should not enroll?
These Medicaid members will not enroll in Georgia Families:
• Members who can get Medicare.
• People who are blind.
• People with disabilities.
• Children with special health care needs.
Please note: Georgia Families is only for members already
enrolled in Medicaid or PCK. If you want to apply for
Medicaid or PCK, call 877-423-4746 or visit the website at
www.gateway.ga.gov.
Will my benets change?
No. You will get the same Medicaid or PCK benets and
services that you get now. The only difference is that now
you will get these medical care services through a health
plan.
Will I still have to pay premiums to PeachCare for Kids?
Yes. If you have a child in PCK, you must continue to pay
your monthly premium directly to PCK.
Georgia Families Frequently Asked Questions
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Do I get to choose the health plan I want?
Upon approval for coverage you will be assigned to a health plan. You will get a notice from Georgia Families about which
health plan you’ve been assigned to. After that, you have 90 days to choose a different health plan by contacting Georgia
Families at either www.georgia-families.com or by calling 1-888-GA-Enroll (1-888-423-6765) Health plans that work with
Georgia Families are:
Amerigroup
Phone: 800-600-4441
TDD/TTY: 711
Web site: www.myamerigoup.com/GA
CareSource
Phone: 855-202-0729
TDD/TTY: 800-255-0056
Web site: www.caresource.com/ga
Peach State Health Plan
Phone: 800-704-1484
TDD/TTY: 800-255-0056
Web site: www.pshp.com
WellCare
Phone: 866-231-1821
TDD/TTY: 877-247-6272
Web site: www.wellcare.com/Georgia
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Abbreviations Used in this Booklet
CHAMPUS – Civilian Health and Medical Programs of the Uniformed Services/Tricare
CMO – Care Management Organization
CMS – Children’s Medical Services
DCH – Georgia Department of Community Health
DFCS – Division of Family and Children Services
DHS – Department of Human Services
GAPP – Georgia Pediatric Program
MATCH – Multi-Agency Team for Children
PCK - PeachCare for Kids
P4HB - Planning for Healthy Babies
PCP – Primary Care Physician
SSI – Supplemental Security Income
TANF – Temporary Assistance for Needy Families
TDD – Telecommunications Device for People who are Deaf
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A Publication of the Georgia Department of
Community Health
Dch.georgia.gov
Revised September 2017
