FAQs
What is Georgia Pathways?
Georgia Pathways to Coverage™, or Pathways, is a Medicaid program for Georgians ages 19-64 who meet the eligibility requirements and otherwise would not qualify for traditional Medicaid.
Pathways is a program that will give low-income Georgians who are not eligible for Medicaid today an opportunity to gain access to healthcare coverage through Medicaid. Georgia residents have been able to apply for the program since July 1, 2023.
Pathways members are eligible to receive the same State Plan benefits as other Medicaid groups, with the exception of Non-Emergency Medical Transportation (NEMT). However, Pathways members ages 19 and 20 who are receiving Early Period Screening, Diagnosis, and Treatment (EPSDT) may access NEMT as part of their benefits.
How do I know if I am eligible for Georgia Pathways?
To be eligible for Georgia Pathways, an individual must:
- Be a Georgia resident
- Be a U.S. citizen or legal resident
- Be at least 19 years old and between the ages of 19 and 64
- Be low-income, with a household income up to 100% FPL
- Prove that they are doing one or more qualifying activities for at least 80 hours per month
- Not be eligible for any other category of Medicaid
- Not be incarcerated in a public institution
How do I know if my income is below the poverty line?
You can use the link below to see if your income falls below the Federal Poverty Level. This depends on your family size. Family size means how many people are in your family and live with you. Federal Poverty Level Guidelines are updated annually and available here: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines.
What are the qualifying activities?
To get healthcare coverage through Georgia Pathways, you must be doing 80 hours per month of the qualifying activities. You can do more than one qualifying activity to get to 80 hours in a month. The qualifying activities include:
| Qualifying Activity | Description |
|---|---|
| Employment | Includes full- and part-time work |
| Self-employment | Some examples include but are not limited to owning one’s own business, cutting grass, collecting cans for recycling, babysitting, selling food items, taxi/food delivery service, etc. |
| On-the-job Training | Training given to a paid employee while he/she is working in the job. |
| Job Readiness | Activities directly related to preparation for employment. Some examples include but are not limited to life-skills training, GED course enrollment, resume building, and habilitation or rehabilitation activities, including substance use disorder treatment. Rehabilitation activities must be determined to be necessary and documented by a qualified medical professional. |
| Job Readiness-Skilled Nursing Facility and Job Readiness-Hospital Stay | An inpatient hospital stay/short-term skilled nursing facility (SNF) stay is considered a habilitation or rehabilitation activity under job readiness only at initial application. For each day of an inpatient hospital stay/SNF stay, an applicant may claim 4 hours towards their monthly Qualifying Activities requirement. |
| Community Service | Approved community service programs are limited to projects that serve a useful community purpose in fields such as health, social service, environmental protection, education, urban and rural redevelopment, welfare, recreation, public facilities, public safety, and childcare. |
| Community Service-Relative Caregiving | This is when an individual is providing relative caregiving services also known as Structured Family Caregiving within Elderly Disabled Waiver Program (EDWP), Community Care Service Program (CCSP), or Service Options Using Resources in a Community Environment (SOURCE). If you are providing care with two or more providers, please enter a qualifying activity record for each provider. |
| Vocational Education Training | Organized educational programs that prepare individuals for employment in current or emerging occupations. Course hour requirements for vocational education training shall be determined by the Department of Community Health (DCH). |
| Enrollment and active engagement in the Georgia Vocational Rehabilitation Agency (GVRA) Vocational Rehabilitation program | Enrollment and active engagement in the GVRA Vocational Rehabilitation program. |
| SNAP Works Program | Compliance with the eligibility requirements to receive Supplemental Nutrition Assistance Program (SNAP) benefits under the Work Program/Able-Bodied Adults Without Dependents (ABAWD) program. An individual enrolled in this program may only meet the Pathways qualifying activity requirement if they are completing a work activity. |
| Parent and Legal Guardian of a Child Under Six Years of Age |
|
If I am eligible, when will my coverage start?
Coverage in Pathways is retroactive, with the coverage effective date being the first of the month in which the customer applies. For example, if you apply in July and get approved in August, your coverage begins on July 1.
What benefits does Georgia Pathways cover?
Georgia Pathways covers many of the same medical services as other Medicaid plans, including:
- Doctor visits
- Hospital stays
- Emergency services
- Prescriptions
- Labs and x-rays
- Family planning services
- Mental health services
- Preventive and wellness services
- Chronic disease management services
Pathways members are eligible to receive the same State Plan benefits as other Medicaid groups, with the exception of Non-Emergency Medical Transportation (NEMT). However, Pathways members ages 19 and 20 who are receiving Early Period Screening, Diagnosis, and Treatment (EPSDT) may access NEMT as part of their benefits.
*Please note that past medical bills will not be covered*
Copayment
All Pathways members enrolled in a CMO will be required to pay copayment amounts at point of service, in alignment with other classes of assistance as reflected in the State’s Medicaid Plan. Pathways members who are unable pay their copayment cannot not be denied care for a covered service. Copayments are not required for Pathways members under age 21.
| Service | Amount |
|---|---|
| Inpatient Hospitalization | $12.50 for entire stay |
| Outpatient Hospital Visit | $3.00 per visit |
| Non-Emergency Use of the ED | $3.00 |
| Primary Care | $0.00 |
| Specialist | $2.00 |
| Durable Medical Equipment | $3.00; $1.00 for rentals and supplies |
| Pharmacy | $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 |
If I only work part-time, could I be eligible for Georgia Pathways?
You may be eligible for Georgia Pathways if you are doing at least 80 hours per month of one or more of the qualifying activities. If you do not work 80 hours in a month, you could complete 80 hours by doing another qualifying activity. For example, if you work 40 hours each month and do community service for 40 hours each month, you may qualify.
If I am self-employed, could I be eligible for Georgia Pathways?
You may be eligible for Georgia Pathways if you are self-employed. You must be doing at least 80 hours per month of one or more of the qualifying activities. Self-employment is a qualifying activity.
Once I am enrolled, how do I report my hours each month?
To remain eligible for Medicaid coverage through Georgia Pathways, it is expected that an individual completes at least 80 hours of qualifying activities per month, though there is no requirement to report and upload proof of qualifying activity completion monthly. Qualifying activities will only be verified at initial application, annual renewal, and when an individual reports a change. Members are required to report a change in circumstance to the State, even if that change may impact their eligibility. All Pathways members are required to report a change within 10 days.
- For any reported change, Pathways members will be reviewed for eligibility for all Medicaid categories of assistance, including Pathways.
- A member may submit a change request through the current channels available, including:
- Gateway Customer Portal (CP)
- In-person
- Phone
What is a Good Cause Exception?
Pathways Members may request a Good Cause Exception in a month when they did not meet the 80 hour qualifying activities requirement. Their options for submitting a Good Cause request to the State are the same channels for reporting a change.
What counts as a Good Cause Exception?
Members may request a Good Cause Exception when reporting a change to their qualifying activities. Good Cause Exceptions are broadly defined as temporary circumstances that prevent or diminish a member’s ability to fulfill the hours and activities threshold during the reporting period. Members may only request a Good Cause Exception for the prior month of activities and hours. Members may use a Good Cause Exception in the event of a Pathways audit.
Acceptable Good Cause Exceptions reasons, definitions, and verifications are provided in the table below. xxx
| Good Cause | Definition for Pathways | Verification |
|---|---|---|
| Family emergency or life event | The individual or a member of their immediate family was a victim of/involved in domestic violence, divorce, legal proceeding, legal matter, or temporary incarceration during the reporting period; or the individual was confirmed to serve jury duty during the reporting period. Immediate family means the individual’s spouse, child, parent, brother and sister. Immediate family also includes any other person who resides in the individual’s household and is recognized by law as a dependent of the individual. |
|
| Birth, adoption, foster placement, or death of an immediate family member | A member of the individual’s immediate family was born, was adopted, or died during the reporting period. The individual received a placement of a foster child in the home, including those in kinship during the reporting period. |
|
| Temporary illness/short term injury | The individual experienced a temporary illness or short-term injury that resulted in an inability to work, attend school, or perform other regular daily activities for over three consecutive calendar days during the reporting period. |
|
| Serious illness or hospitalization of member, or immediate family member | The individual or a member of the individual’s immediate family was hospitalized or otherwise incapacitated during the reporting period due to illness, injury, impairment, or physical or mental condition that involves inpatient care in a hospital, hospice, or residential medical care facility; or continuing treatment by a health care provider. |
|
| Natural or human-caused disaster | The individual was a victim of a natural or human-caused disaster, such as a flood, storm, earthquake, serious fire, industrial accident, shooting, act of terrorism, incidents of mass violence, or other declared incident of mass trauma during the reporting period. |
|
| Temporary homelessness | The individual was evicted from their home or became homeless during the reporting period. |
|
| COVID-19 | $The individual is unable to fulfill the hours and activities requirements because the individual was quarantining in response to having COVID-19 symptoms, a COVID-19 diagnosis, or exposure to COVID-19, or because of a closure of the place(s) related to COVID-19 where the individual was meeting the hours requirement. |
|
| Other | The individual or a member of their immediate family was a victim of/involved in domestic violence, divorce, legal proceeding, legal matter, or temporary incarceration during the reporting period; or the individual was confirmed to serve jury duty during the reporting period. Immediate family means the individual’s spouse, child, parent, brother and sister. Immediate family also includes any other person who resides in the individual’s household and is recognized by law as a dependent of the individual. |
|
Good Cause Exception Submission Requirements
In order to make a Good Cause Exception request, the member must complete four steps:
- Select a reason for the Good Cause Exception from a list of pre-defined options, or select “other”
- Provide a written explanation of the circumstance
- Indicate the number of hours requested for Good Cause
- Submit documentation to support the request
At the time of submitting the request, the member attests that they were unable to fulfill their qualifying hours and activities due to the Good Cause reason that is selected.
- What if something happened in my life, like I got married or got a new job that paid me more, and I need to report a change? The easiest way to report a change is online though the Customer Portal at ga.gov
You could also report a change:
- By mailing in a paper form to your local Division of Family and Children Services (DCFS) office
- By calling 1-877-423-4746
- In-person at a Division of Family and Children Services (DFCS) office
What if I have a disability?
If you have a disability, you could still be eligible for Georgia Pathways. You must be doing at least 80 hours per month of one or more of the qualifying activities. If you need help doing 80 hours per month, you can ask for a reasonable modification.
Can I appeal a decision about my eligibility or any decision that affects my coverage?
Yes. If you think you should be covered under Georgia Pathways but were denied coverage, you can appeal this decision. A decision that impacts your continued coverage, such as termination, can be appealed as well. Your decision letter will have information on how to appeal a decision and who to contact if you have questions about appealing a decision.
If I enroll, could it affect my citizenship?
It is possible that enrollment in Medicaid may be considered a public charge. If you think that getting healthcare coverage from Georgia Pathways might impact you, contact the United States Citizenship and Immigration Services (USCIS) directly before applying. It is important to understand how this might affect you. For more information on what it means to be a public charge, visit USCIS’s website www.uscis.gov or call at 1-800-375-5283.
You also can find more information on DCH’s GA Pathways web page here: pathways.georgia.gov
Benefits and Services
As a CareSource member, you can get the same necessary medical services that are covered by other Georgia Pathways to Coverage health plans, like doctor visits, prescription drugs and hospital services.
CareSource covers all medically necessary Medicaid-covered services. Georgia Pathways to Coverage members have no copay.
A health partner may, upon accepting you as a Georgia Pathways to Coverage patient, charge you for non-covered services.
For more information, refer to your member handbook. <Link pathways handbook here>
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
- Acupuncture
- 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 or 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 Georgia Pathways to Coverage 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.
PLAN DOCUMENTS
The Member Handbook is a quick reference guide to your health care benefits. You can quickly look up information such as your covered benefits and services, where to get care and your rights and responsibilities as a CareSource member.
If you have a problem reading or understanding this information, call us at 1-855-202-0729 (TTY: 1-800-255-0056 or 711). We can explain this in English or in some other language. If you have problems seeing or hearing, alternative formats or special help can be provided. This is all at no cost to you. We will complete your request within 7 calendar days.
FORMS
We want you to easily find the forms you need for your CareSource plan. Listed below are all the forms you may need as a CareSource member.
Explanations of when and why you may need to use a form are also provided below. Look for instructions on each form. The instructions will tell you where you need to return each form, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.
For more information on Georgia Pathways to Coverage: pathways.georgia.gov
You can find CareSource forms here:
- gateway.ga.gov – Use this link for the DCH Enrollment Broker site.
- Tell Us – Use this form when you would like to send us a question or request online.
- Grievance/Appeal Form – Use this form when you have a complaint about service you have received or would like to dispute a decision that has been made.
- Medicaid Eligibility Redeterminations
- Pharmacy Preferred Drug List
- Pharmacy Conditions for Coverage and Utilization Limits
- Prescription Reimbursement Claim Form
- What’s New?
- Member Claim Form (Coming Soon)
- Fraud, Waste and Abuse Reporting Form – Use this form if you think a health partner or a CareSource member is committing fraud, waste or abuse. To find out more, visit the Fraud, Waste, & Abuse page.
- Member Consent/HIPAA Authorization Form– Use this form to give your consent to share your health information with your providers and/or release health information to someone you name. Or, download this hard-copy version and mail or fax the completed form to us. Please allow up to 30 days to process the hard-copy form.
- IRS 1095B Information
- IRS 1095B Form
- Letter from Georgia Department of Community Health
- More Information
- Frequently Asked Questions about the 1095B Tax Form
Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.