Requirements to join the Georgia Pathways to Coverage program differ from other Georgia Medicaid programs. To be eligible, you must:

• Be a Georgia resident.
• Be a U.S. citizen or legal resident.
• Not be eligible for any other category of Medicaid.
• Be between the ages of 19 and 64.
• Have a household income of up to 100% of the Federal Poverty Level (FPL).
• Not be incarcerated in a public institution.
• Prove that you are doing one or more qualifying activities per for at 80 hours per month.

Georgia Pathways members are eligible to receive the same State Plan benefits as other Medicaid groups. Coverage would start the first day of the following month after approval.

Pathways members will need to pay a copay when you get care, just like other Medicaid members. If you cannot pay your copay, you will still get the covered services. Copays are not required for Pathways members under age 21.

Georgia Pathways does not cover non-emergency medical transportation (NEMT) except for members ages 19-20 who are receiving Early Period Screening, Diagnosis, and Treatment (EPSDT) as required by Medicaid for children under 21.

In order to qualify for Pathways, an individual must:

1. Report at least 80 hours of qualifying activities when applying.
2. Provide proof showing they met the hours and activity requirements for the most recent 4 weeks within the 8 weeks before their application date.

If an applicant has a disability, they can request a Reasonable Modification for a referral to GVRA or the option for extra time to complete their 80 hours.

Applicants who think they qualify for Georgia Pathways but do not get approved, can appeal the decision. If a decision results in the suspension or termination of their Georgia Pathways coverage, members can appeal that too. The decision letter will include information on how to appeal a decision and who to contact if members have questions about appealing a decision.

Coverage in Pathways is retroactive. Your coverage starts onthe first day of the month you apply.

• New members are covered retroactively through Fee-for-Service (FFS).
• After your eligibility is approved, your coverage moves to a Care Management Organization (CMO) two days later. 
• Pathways does not help pay medical bills from months before you applied.

Members eligible for Georgia Pathways will be auto assigned into a CMO using the State’s existing assignment methodology. 

To remain eligible for Medicaid coverage, through the Georgia Pathways, it is expected that a member 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.

There is no requirement to report and upload proof of qualifying activity completion monthly. Qualifying activities will only be verified during the initial application, annual renewal and when a member 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 ten (10) days.

For any reported change, Pathways members will be reviewed for eligiblitiy for all Medicaid categories of assistance, including Pathways.

You can submit a change request through one of the following options below:

• Gateway Customer Portal (CP): You can access Gateway by visiting www.gateway.ga.gov.
• Paper/Mail: Mail your Change Request to your local Department of Family & Children’s Services (DFCS) office.
• In-Person: Visit your local DFCS office.
• Telephone: You may call by phone at 1-877-423-4746 or 711 for those who are deaf, hard of hearing, deaf-blind or have difficulty speaking, to attest to your hours and activities.

Qualifying Activities help you keep your Georgia Pathways to Coverage.  Each activity has a description and a way it can be verified.

The easiest way for a member to report their hours is online at The Georgia Gateway website through 'Report My Change.’ 

Members can also report their hours:

• By mailing a paper form to your local Division of Family & Children Services (DFCS) office: visit Department of Family & Children Services
• By phone at  1-877-423-4746 or 711 for those who are deaf, hard of hearing, deaf-blind or have difficulty speaking.
• In-person at your local Division of Family & Children Services (DFCS) office. To find the location and business hours for a DFCS office, visit: dfcs.ga.gov/locations.

Please note, members qualifying activities may need to be verified. Qualifying activity requirements will only apply to Pathways and not those who are enrolled under the traditional Medicaid program.

If you need assistance with meeting your qualifying hours, obtaining or sustaining employment please visit https://www.pshpgeorgia.com/members/medicaid/social-determinants-of-health.html.

Georgia Pathways members can visit the Georgia Medicaid Management Information System (GAMMIS) site, to login to the secure portal using their provider ID number and personal identification pin to verify eligibility as well as to access Medicaid information, resources, claims, and more.

Good Cause Exceptions help members when they cannot meet their Qualifying Activities.

You can request a Good Cause Exception for not meeting the 80 hours of Qualifying Activities during the reporting month. The Good Cause Exception must be a situation that temporarily prevents, or changes your ability to, complete Qualifying Activity and Hours. You can submit this request directly to the State using one of the following state-approved methods:

• Gateway: You can access Gateway by visiting www.gateway.ga.gov
• Paper/Mail: mail request to a local Department of Family & Children’s Services (DFCS) office
• In-person at your local DFCS office
• Telephone: You may call in your Good Cause Exception request at 1-877-423-4746 or 711 for hearing-impaired.

You must complete the following requirements to make a Good Cause Exception request.

• Select a reason for the Good Cause Exception from the options, or select “other”
• Provide a written explanation of the event
• Indicate the number of hours requested for the Good Cause Exception
• Submit documentation to support the request

You can only request a Good Cause Exception for the previous month’s Qualifying Activity and Hours. A maximum of 120 hours of Good Cause Exceptions per certification year.

The table shows the allowed Good Cause Exception reasons, a description, and how they are verified.

Our Member Engagement Team

Peach State Health Plan’s Member Engagement Team is here to help you stay covered and make the most of your Georgia Pathways benefits. We are committed to supporting you every step of the way so you can maintain your eligibility and renew your benefits on time.

Our team is available by phone, email, in-person and through monthly GA Pathways events. At these events, you can get hands-on help with:

• Meeting your Qualifying Activities requirements
• Understanding and using your current health plan benefits
• Preparing for your annual renewal so there are no gaps in your coverage

In addition, our team provides personalized support that includes:

• Conducting health and social needs assessments
• Screening and triaging Pathways Members
• Connecting you with resources like transportation, housing, and other supports that help you stay on track with your Qualifying Activities

We work closely with you and our trusted Community Partners to ensure you have the tools, resources, and guidance you need to keep your coverage and thrive.

For more information about upcoming events, please visit our Community Events page https://www.pshpgeorgia.com/events.html and navigated to our GA Pathways events.

If you have a disability, you may qualify for extra help called Reasonable Modifications or Reasonable Accommodations. These supports can make it easier to keep your Pathways coverage and meet program rules.

Reasonable Modifications

Reasonable Modifications are changes the State or eligibility staff can make to Pathways rules or processes to support you.

Examples include:

• Letting you keep Pathways coverage for up to 90 days if you cannot work or take part in qualifying activities because of a disability. During this time, you will be referred to and go through the intake process with the Georgia Vocational Rehabilitation Agency (GVRA).
• Adjusting the minimum required hours if you cannot meet the 80-hour rule due to a disability and have written proof from your employer or organization.

Important: Enrollment in GVRA itself is a qualifying activity. It is not considered a Reasonable  Modification.

Reasonable Accommodations

Reasonable Accommodations are different. These are changes made by your employer or school to help you work or take part in activities.

• You must ask your employer, school, or GVRA directly for these accommodations.
• DFCS (the Department of Family and Children Services) does not decide or verify these  accommodations.

The only time DFCS needs to know about an accommodation is if it lowers your hours below the 80-hour monthly requirement. In that case, the State can change your required hours so you can keep your Pathways coverage.

Definition of Disability

For Pathways, disability is defined by the Americans with Disabilities Act (ADA). You may qualify if you:

1. Have a physical, mental, or sensory condition that limits daily activities.
2. Have a history of such a condition.
3. Are seen as having such a condition.

This is different from the definition of disability used for Aged, Blind, and Disabled (ABD) Medicaid.

Every year, Pathways members must renew their coverage. This is called redetermination. During this process, the State reviews your information in Gateway to see if you still qualify for benefits.

For Pathways members, the rules and timelines are the same as other Family Medicaid programs:

• Auto-renewal: About 60 days before your renewal date, the State will try to renew your coverage automatically.
• If auto-renewal doesn’t work: You will get a Renewal Notice about 45 days before your renewal date.
• You must complete and return it on time.
• If you miss the deadline: Your coverage will end on the last day of your current coverage period.

It is very important to respond quickly to any letters or notices you get from the State so you don’t lose your health coverage by missing a deadline.

You still have time to act if your coverage ends:

• You have 90 days after your coverage ends to submit your renewal.
• If you are still eligible, your coverage will restart without a gap.
• If you do not renew within 90 days, you must apply again for Medicaid

For more information about renewing your coverage, please visit our How to Renew page https://www.pshpgeorgia.com/members/medicaid/how-to-enroll.html or The Stay Informed website.