Bringing your baby home from the NICU with nursing care in Georgia

A Georgia baby who still needs skilled care can leave the NICU with nursing at home through GAPP, the Georgia Pediatric Program, when the baby has full Georgia Medicaid and the care is medically necessary. The hospital’s discharge planning team usually starts the request while your baby is still in the NICU, through a nursing agency you choose. The earlier it starts, the more likely nursing is in place on the day you go home.

Discharge from the NICU can arrive quickly after weeks or months of waiting, and families are often handed agency names in a hurry. This page explains how home nursing is arranged from the hospital, how long it takes, and what to have ready before your baby comes home.

Start before discharge day

Children in the hospital are reviewed by a discharge planning team: the referring physician, your baby’s primary physician, the discharge planner, staff from the nursing agency, you as the primary caregivers, and a social worker (GAPP manual §802). Hospitals apply for GAPP through their discharge planning or social services department (§703.1).

The referring physician or discharge planner will help you find a Medicaid-enrolled GAPP agency, and the Department of Community Health can help if needed. The choice is yours: families have freedom of choice of provider (§801.1). Our guide to choosing a GAPP provider has the questions to ask.

The manual asks for the paperwork at least 30 days before care should start (§703.3), so the conversation about home nursing belongs early in your baby’s stay, not on discharge day.

Medicaid for your baby

GAPP needs full Georgia Medicaid. PeachCare for Kids is not eligible (§925.11).

• If you had Medicaid when your baby was born, your baby is eligible for Newborn Medicaid from the month of birth through the month of the first birthday, whichever Medicaid program you were on (Georgia Medicaid). Ask DFCS before the first birthday which category comes next.
• If you did not, your baby is not covered automatically and needs a Medicaid application through DFCS. GAPP cannot be approved while a Medicaid application is pending (§701).
• If your income is too high for Medicaid, Katie Beckett, also called TEFRA, can give a child 18 and under Medicaid without counting the parents’ income, based on the level of care the child needs. See our Katie Beckett guide.

Many children on Georgia Medicaid belong to a care management organization (CMO). The manual says the agency’s submission of the GAPP request removes the child from the CMO, and that this can take up to 30 days to show on their eligibility (§801). Ask the discharge planner what that means for your baby’s other care.

What the review looks at

GAPP approves care that is medically necessary, judged on your baby’s overall condition, equipment and the level and frequency of care needed (§702.1.1). On the state’s nursing evaluation form, the DMA-6(A), the physician records needs such as prematurity or failure to thrive, slow feeding, tube feeding, oxygen, a cardiopulmonary monitor or pulse oximetry, suctioning, nebulizer treatments, and a trach or home ventilator. If your baby is going home with a trach, a ventilator or a feeding tube, our pages on each go further.

After a lengthy hospital stay, the agency can accept your baby’s latest progress notes or discharge summary as the physician’s orders, as long as they include everything required and the hours being requested (§805).

How long it takes

• Alliant Health Solutions, which reviews GAPP requests for the state, has 30 days to review a complete request (§703.2.5).
• Emergency admissions are reviewed within five days once the required information is in (§827). Ask the discharge team whether your baby’s request qualifies.
• Requests that are still incomplete after 30 days are normally withdrawn, but that rule does not apply to children who are in the hospital awaiting discharge (§801).
• Once approved, care must start within 60 days (§703.3).

Your part, and your training

GAPP is built around the family. The primary caregiver must help with care at home and stay in regular contact with the agency (§702.1.2), and you must name an emergency contact the agency can reach if it cannot reach you (§702.1.3). At the planning meeting before admission, the agency reviews and you sign a Letter of Understanding about how the program works (§807, §921).

One of GAPP’s stated goals is to teach parents to care for their child safely when a nurse is not there (§825.5). Your agency keeps a teaching plan and a caregiver skills checklist that records what you have learned (§918). Much of that learning starts in the NICU. Make sure the checklist reflects what you can and cannot yet do on your own.

A discharge checklist for GAPP

• Your baby’s Medicaid number, or the DFCS or Katie Beckett application in progress.
• A GAPP agency you chose, invited to the discharge planning meeting.
• The physician’s orders and statement of medical necessity, or the discharge summary the agency will use instead.
• The Letter of Understanding signed at the planning meeting, and the Freedom of Choice form.
• An emergency contact named, with phone numbers, who knows they are listed.
• Your training started and recorded on the caregiver skills checklist.
• A nursing start date that matches discharge day, and the agency’s plan if a shift cannot be staffed.

The whole path, with space for your own dates and contacts, is in our printable Georgia parent guide to home nursing.

If your baby goes back into the hospital

GAPP does not pay for care while your child is in the hospital (§703.2.3). The agency must let the state know about hospital stays (§818.11), and a stay longer than 30 days needs a discharge summary or hospital progress notes before care restarts (§818.12). If your baby comes home needing more or less care, that is a change in condition, submitted within five days (§827).

Babies Can’t Wait

Alongside GAPP, Babies Can’t Wait is Georgia’s early intervention program for infants and toddlers with special needs, from birth to the third birthday, regardless of income (Georgia Department of Public Health). It works through an Individualized Family Service Plan (IFSP). Ask the discharge team whether your baby should be referred.

What to ask an agency

• How many of your nurses in my county have cared for a baby coming home from the NICU, with needs like my baby’s?
• Will someone from your agency attend the discharge planning meeting?
• Can you staff the first nights at home, and what happens if a nurse calls out? Agencies must have provisions for back-up staffing (§609.4).
• Who trains me, and who signs off my caregiver skills checklist?

If your baby is in the NICU and may need nursing at home, tell us about your baby and we will tell you honestly whether we can staff the care in your county. The full program rules are in our GAPP guide.

Common questions

Can my baby come home from the NICU with a nurse in Georgia?

Yes, if your baby has full Georgia Medicaid and GAPP approves skilled nursing as medically necessary. The hospital's discharge planning or social services department usually starts the request, through a GAPP-approved agency that you choose.

Does my newborn have Medicaid?

If you were receiving Georgia Medicaid when your baby was born, your baby is eligible for Newborn Medicaid from the month of birth through the month of the first birthday. If you were not, your baby needs a Medicaid application through DFCS, and Katie Beckett (TEFRA) may help if your income is too high.

How long does GAPP approval take after the NICU?

Alliant Health Solutions has 30 days to review a complete request, and emergency admissions are reviewed within five days once the required information is in. The rule that withdraws requests still incomplete after 30 days does not apply to children in the hospital awaiting discharge. Starting before discharge day is what keeps the gap short.

Who chooses the home nursing agency?

You do. The referring physician or the hospital discharge planner helps you find a Medicaid-enrolled GAPP agency, and the Department of Community Health can help, but families have freedom of choice of provider.

Sources

1. Georgia Department of Community Health, Part II Policies and Procedures for Georgia Pediatric Program (GAPP) In-Home Nursing, July 1, 2025 edition, published on GAMMIS under Provider Manuals.
2. Georgia Department of Community Health, Georgia Pediatric Program (GAPP) provider presentation, June 2023, published on the Georgia Medicaid Management Information System portal.
3. Georgia Medicaid, Waiver Programs.
4. Georgia Department of Community Health, Community Based Services.
5. Georgia Medicaid, Eligibility FAQs (Newborn Medicaid).
6. Georgia Department of Public Health, Babies Can’t Wait.
7. Georgia Medicaid, TEFRA/Katie Beckett.

Please read. This article is general information about a public program, not medical, legal or financial advice, and it is not a decision about your child. Program rules change. Confirm anything that matters with the Georgia Department of Community Health or with a GAPP participating agency before you rely on it.