Eligibility FAQs

Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age; whether you are pregnant, have disabilities, are blind, or aged; your income and/or assets; and whether you are a U.S. citizen or a lawfully admitted immigrant.

When you apply for Medicaid, the requirements listed above will be taken into account 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 status, not the parent's.

In general, you should apply for Medicaid if your income is low and you match one of the descriptions below:

• You think you are pregnant
• You have been diagnosed with breast or cervical cancer
• You are a child or teenager age 18 or under
• You are over the age of 65
• You are blind
• You have disabilities
• You need nursing home care.

Other situations that may make you eligible:

• If you are leaving Temporary Assistance for Needy Families (TANF) and need health coverage.
• If you are a family with children under 19 and have very low or no income.
• If your income is higher than the limits and you have medical bills you owe (and you are pregnant, under 18 or over 65, blind, or disabled.)
• If a child is in foster care or adopted
• If you or someone in your family needs health care, you should apply for Medicaid even if you are not sure whether you qualify. Some income and resources do not count against you. For example, owning your home may not stop you from getting Medicaid. Every group has its own income limits, which increase on a regular basis.

Perhaps. Medicaid coverage is available to pregnant women, children, elderly persons age 65 or older, disabled persons who cannot work, and low income families with children under age 18. Disability is defined as the inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment(s) that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. If you meet one of the listed criteria, you should apply for

You will be responsible for any bills, if you do not communicate with your doctor about your application for Medicaid. It will be the doctor’s decision to accept you as a Medicaid patient and file your claim(s) retroactively, if you become eligible. Once you have been determined eligible for Medicaid by the DFCS, you will receive an approval notice in the mail. The medical provider can use information from the approval notice to confirm your eligibility while you are waiting to receive your Medicaid card.

You can find out if you qualify for Medicaid or other medical assistance and social service programs by speaking with a representative at your local DFCS office. You may also find DFCS county contact information at www.dfcs.dhr.georgia.gov, click on your county of residence name. Call 877-423-4746 for additional information about Medicaid.

You should receive your Medicaid card within one to two weeks of being determined eligible.

Income is money that you get from working, or money that someone gives you, or checks that you receive, such as a Social Security check, or unemployment benefits. Whether your income level qualifies you or your family for Medicaid depends on the size of your family and the Medicaid program for which you are applying.

Income limits are set each year by the federal government to define the Federal Poverty Level (FPL)for different family sizes. In general, if your household income is at or below the current 133 percent FPL for your household size, your family is likely to be eligible for Medicaid. Children from ages 1 to 5 can qualify for Medicaid benefits when household income is at or below  149 percent of the FPL. Children under age 19 who live in families with incomes at or below the 205 percent of FPL are eligible for low cost health insurance under the Right from the Start Medicaid (RSM) program. Pregnant women and infants under age one qualifies for Medicaid with family income at or below the 220 percent of FPL, and pregnant women count as two (or more) family members.

See our tables of income limits for applying for Georgia Medicaid programs to find out where your family income is, in relation to these income benchmarks.

Yes. If your income is low, and you have minor children, you and your children can have private health insurance and still be eligible for Medicaid. You should tell your Medicaid worker about your private insurance and provide a copy of your health insurance card for your Medicaid record. If you have both private health insurance and Medicaid, you should show both your Medicaid card and your private health insurance card to your medical provider each time you receive services.

No. If you currently pay for health insurance or Medicare coverage or have the option of getting that coverage, but cannot afford the payment, Medicaid can pay the premiums under certain circumstances. You may be eligible for the Medicare Buy-in Program if you receive Medicare. This program pays your Medicare premiums and deductibles.

No. Medicaid is different from state to state. Contact or visit your county DFCS office for more information.

Georgia Pathways to Coverage™ offers Medicaid coverage to eligible Georgians who are U.S. citizens or legally residing non-citizens, are ages 19-64 who have a household income of up to 100 percent of the Federal Poverty Level (FPL), are not otherwise eligible for traditional Medicaid, are not incarcerated, and can document that they meet the qualifying activities threshold.

Qualifying activities include full-time or part-time employment, on-the-job training, job readiness assistance programs, community service, vocational educational training, enrollment in the Vocational Rehabilitation program of the Georgia Vocational Rehabilitation Agency (GVRA), and higher education. Qualifying activity requirements only apply to Pathways members, and not those enrolled under traditional Georgia Medicaid. Furthermore, there are currently no member copays or premiums associated with Pathways.

For more information about Pathways, visit dch.geaorgia.gov/georgiapathways. To apply, visit gateway.ga.gov.

A child is eligible for Newborn Medicaid if born to a mother eligible for and receiving Medicaid under any Medicaid program including Supplemental Security Income related Medicaid or any Aged, Blind or Disabled Medicaid program, or to a mother receiving Emergency Medical Assistance.

A child is eligible for Newborn Medicaid for up to 13 months beginning with the month of birth and continuing through the month in which the child reaches age one. Eligibility begins with the birth month, regardless of when the agency is notified of the birth.

If the pregnant woman was not eligible for Medicaid when the child is born, that newborn is not automatically eligible for Newborn Medicaid.

In order to qualify for Medicaid for breast or cervical cancer, a woman must be:

• Diagnosed and in need of treatment for breast or cervical cancer

• Low-income (at or below 200 percent of the FPL Income Guidelines). (See table for more information: income limits for applying for Georgia Medicaid programs

• Uninsured

• Under age 65

• A Georgia resident and

• A U.S. citizen or qualified alien     

Any uninsured, low-income woman who has been diagnosed with breast or cervical cancer should go to the county health department in their county of residence. You may contact Public Health at 404-657-2700 for county health department locations.

If a woman applied for or was receiving Medicaid coverage on or before the date of the miscarriage, she is eligible for two months after the pregnancy ends. A woman may be eligible for up to three months of retroactive coverage before the date of application as long as she was financially eligible and pregnant in those retroactive months.

There are two types of coverage for RSM:

• RSM for pregnant women pays for medical care for pregnant women, including labor and delivery and for up to 60 days after pregnancy ends. Pregnant women who qualify are entitled to the full-range coverage of Medicaid services. Services covered include doctor visits, prescription drugs and inpatient and outpatient hospital services.
• RSM for children pays for medical care for children from birth through the last day of the month in which the child turns nineteen (19) years of age. These children may qualify at various income levels depending on age, family size and income. Children who qualify are entitled to the full-range of Medicaid covered services, including doctor visits, health checkups, immunizations, dental and vision care and prescription drugs.