FAQs
What is Georgia Pathways?
Georgia Pathways to Coverage™, or Pathways, helps low income Georgians who may not qualify for traditional Medicaid.
Pathways gives low-income Georgians who are not eligible for Medicaid today an opportunity to gain access to health care coverage through Medicaid.
How do I know if I am eligible for Georgia Pathways?
To be eligible for Pathways, you should:
- Be a Georgia resident
- Be a U.S. citizen or legal resident
- Be between 19 and 64 years of age
- Have a household income of up to 100% of the Federal Poverty Level
- Prove that you are doing at least 80 hours of qualifying activities (QAs) per month
- Not qualify for any other type of Medicaid
How do I know if my income is below 100% of 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.
What are acceptable QAs I can do to be eligible for Pathways?
To get health care coverage through Georgia Pathways, you must be do 80 hours of QAs. You can do more than one QA to get to 80 hours.
The qualifying activities include:
| Qualifying Activity | Description |
|---|---|
| Employment | Includes full- and part-time work |
| Self-employment | Some examples are 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 to prepare for employment. These can be
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 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 four hours towards their QA requirement. |
| Community Service | Projects that serve the community in fields such as
|
| Community Service-Relative Caregiving | 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 provide care with two or more providers, please enter a QA record for each provider. |
| Vocational Education Training | Organized educational programs that prepare people to work in current or future jobs. The Department of Community Health (DCH) decides how many course hours are needed. |
| 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 | Being eligible to receive Supplemental Nutrition Assistance Program (SNAP) benefits under the Work Program/Able-Bodied Adults Without Dependents (ABAWD) program. Being in this program may only meet the Pathways QA 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. The coverage effective date is the first of the month in which you apply. 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 must pay copayments when they get care. 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 of the QAs.
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 of one or more of the QAs. Self-employment is a QA.
Once I am enrolled, how do I report my hours each month?
To remain eligible for Medicaid coverage through Georgia Pathways you must complete at least 80 hours of QAs.
QAs will only be verified at initial application, annual renewal, and when an individual reports a change. You must report a change in circumstance to the State, even if that change may impact your eligibility. All Pathways members are required to report a change within 10 days.
- For any reported change, you will be reviewed for eligibility for all Medicaid categories of assistance, including Pathways.
- You may submit a change request through the current channels available, including:
- Gateway Customer Portal (CP)
- In-person
- Phone
What is a Good Cause Exception?
Good Cause Exceptions are temporary circumstances that keep a member from being able to fulfill their hours. You may request a Good Cause Exception in a month when you did not meet the 80-hour QA requirement. Your 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?
You may request a Good Cause Exception when reporting a change to your QAs. You may only request a Good Cause Exception for the prior month of activities and hours. You 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.
| Good Cause | Definition for Pathways | Verification |
|---|---|---|
| Family emergency or life event | You or a member of your immediate family was a victim of/involved in domestic violence, divorce, legal proceeding, legal matter, or temporary incarceration during the reporting period; or the you were confirmed to serve jury duty during the reporting period. Immediate family means your spouse, child, parent, brother, or sister. Immediate family also includes any other person who resides in your household and is recognized by law as your dependent. |
|
| Birth, adoption, foster placement, or death of an immediate family member | A member of your immediate family was born, was adopted, or died during the reporting period. You received a placement of a foster child in the home, including those in kinship during the reporting period. |
|
| Temporary illness/short term injury | You 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 | You or a member of your 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 | You were 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 | You were evicted from their home or became homeless during the reporting period. |
|
| COVID-19 | You are unable to fulfill the hours and activities requirements because you were 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 you were 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 do at least 80 hours of QAs. If you need help doing 80 hours, 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. You can also appeal a decision that impacts your continued coverage, such as termination. Your decision letter will have information on how to appeal a decision and who to contact if you have questions.
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 health care coverage from Georgia Pathways might impact you, contact the United States Citizenship and Immigration Services (USCIS) directly before you apply. 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