Benefits and Services
As a CareSource member, you can get the same necessary medical services that are covered by other Georgia Families® health plans, like doctor visits, prescription drugs and hospital services. And, as a CareSource member, you get more. Learn more about these extra benefits.
CareSource covers all medically necessary Medicaid-covered services. Some of these services have a small member cost, called a copay or copayment. You’ll pay this at the health care provider’s office or facility.
Health partners may not refuse to provide services if you cannot make the copayment. However, a health partner may, upon accepting you as a Medicaid or PeachCare for Kids® patient, charge you for non-covered services.
Some copayments are a set amount, but other copayments are cost-based. This means the amount you pay depends on the cost of the service. For more information, refer to your member handbook.
Set Amount Copayments
Members who have copays have a set copay amount for some care settings, like:
- $2 for most services received at a Federally Qualified Health Center or Rural Health Center
- $3 for services received at an outpatient facility or surgery center
- $3 for emergency room visits (This fee is waived for emergency medical conditions.)
- $12.50 for inpatient care per admission
Some PeachCare for Kids® copays are cost-based, like provider office visits. This means the amount owed depends on the cost of the service. For example, if a covered service costs $25, a PeachCare for Kids® member would pay a $1 copay for that service. All PeachCare for Kids® copays are limited to no more than 5% of the family’s income. You may owe between $0.50 to $3 per service, based on the range below. Georgia Medicaid members’ copayments are not cost-based.
|Category of Service||Copayment (Amount Member Pays)|
|Ambulatory surgical centers/birthing||$3.00|
|Durable medical equipment||$2.00|
|Federally Qualified Health Centers||$2.00|
|Free-Standing Rural Health Clinic||$2.00|
|Home health services||$3.00|
|Hospital-Based Rural Health Center||$2.00|
|Inpatient hospital services||$12.50|
|Oral maxillofacial surgery||Cost-Based|
|Orthotics and prosthetics||$3.00|
|Outpatient hospital services||$3.00|
|Pharmacy – preferred drugs||$0.50|
|Pharmacy – non-preferred drugs||Cost-Based|
|Physician assistant services||Cost-Based|
Cost-Based Copayment Schedule
|Cost of Service||Copayment (Amount Member Pays)|
|$10.00 or less||$0.50|
|$10.01 to $25.00||$1.00|
|$25.01 to $50.00||$2.00|
|$50.01 or more||$3.00|
Please call Member Services to ask about services not listed or to get more information about copays.
The following Georgia Medicaid members do not have to pay copayments:
- Medicaid members under age 21
- Pregnant women
- Members with breast and/or cervical cancer
- Members in nursing homes
- Members in hospice care
- American Indians
- Alaskan natives
Also, these PeachCare for Kids® members do not have to pay copayments:
- PeachCare for Kids® members age six and under
- Nursing facility residents
- Members in hospice care
For a complete list of these services, refer to your member handbook. If you have further questions, contact Member Services.
Services Not Covered
CareSource will not pay for the following services that are not covered by Medicaid:
- Abortions except in the case of a reported rape, incest or when medically necessary to save the
life of the mother
- All services or supplies that are not medically necessary
- Experimental services and procedures
- Infertility treatment for males or females, including reversal of voluntary sterilizations
- Services/care you receive in another country
- Alternative medicine
- Plastic or cosmetic surgery that is not medically necessary
- Voluntary sterilization if under 21 years of age or legally incapable of consenting to the procedure
This is not a complete list of the services that are not covered by Medicaid or CareSource.
If you have a question about whether a service is covered, please refer to your member handbook or call Member Services.
Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.