Georgia Pathways to Coverage is a new program that helps low-income adults who may not qualify for regular Medicaid in Georgia get the healthcare they need. Georgia Pathways has specific rules for who can join, including a requirement to work or be involved in the community. Ahead, we explore the program's services, deadlines, and how to navigate challenges like coverage denials and work requirement modifications.
In July 2023, Governor Brian Kemp launched Georgia Pathways to Coverage, a limited Medicaid expansion plan to provide health coverage to low-income adults in Georgia in the coverage gap—meaning, people who earn too much to qualify for traditional Medicaid but not enough to afford private insurance or qualify for subsidies under the Affordable Care Act (ACA).
Those in the coverage gap typically fall between 100% and 138% of the federal poverty level (FPL). While traditional Medicaid expansion would cover individuals up to 138% of the FPL, Georgia Pathways only extends coverage to those earning up to 100% of the FPL and who meet additional work or community engagement requirements.
Not every Georgian family fits the eligibility rules. To be eligible for Georgia Pathways to Coverage, your care recipient must meet the following standards:
The Georgia Pathways to Coverage requires participation in qualifying activities for at least 80 hours monthly. Here are some examples of approved qualifying activities:
These activities promote work skills development, financial independence, and community engagement.
You can still apply for a Medicaid waiver if you are enrolled in Georgia Pathways to Coverage, but approval depends on meeting the specific eligibility requirements of the waiver program. Georgia Pathways and Medicaid waivers are separate programs, so being on Georgia Pathways does not exclude you from applying for or receiving a waiver.
To qualify for a Medicaid services waiver, such as the Georgia Elderly and Disabled Waiver, you must meet the waiver's specific criteria, which typically include age, disability status, income, and level of care needs.
While Georgia Pathways provides basic health coverage, waivers offer additional support, like structured family caregiving, adult day health services, and respite care, that standard Medicaid or Georgia Pathways do not always cover. If you meet the waiver requirements, you can benefit from both programs simultaneously.
Georgia Pathways to Coverage provides recipients access to supports and services similar to those traditionally covered by Medicaid services, including:
Under the Georgia Pathways to Coverage program, certain services are not covered, including:
If you think your loved one is eligible based on income and other rules, they should fill out the initial application. Just like a regular Medicaid application, you'll need to provide medical history, identification documents, and work history paperwork. There are several ways to apply for Georgia Pathways to Coverage:
Once enrolled, low-income adults get access to health care through Georgia Pathways, bridging the coverage gap for uninsured people. To maintain coverage, program requirements include monthly reporting of hours of qualifying activities.
The reporting deadline is the 17th of the month following the reported period. For instance, if coverage starts in September, you should report qualifying activities and required verification for August by September 17th to ensure coverage continues in October. Make sure to report a combination of activities with qualifying hours and submit any relevant paperwork, such as medical bills, to verify your activities.
Coverage may be temporarily suspended if you fail to report activities by the deadline. After three consecutive months of non-reporting, your loved one may lose access to Medicaid services under Georgia Pathways.
If your loved one has a disability or other qualifying condition that prevents them from meeting the 80 hours of qualifying activities, they may be eligible for a Reasonable Modification. This adjustment allows flexibility in meeting the activity requirement to accommodate their specific situation.
If your care recipient is denied coverage for failing to meet the 80 hours of qualifying activities, and you believe they qualify for a reasonable modification, you have the right to appeal. The denial letter will outline the appeal process and provide the necessary contact information. When appealing, include relevant documentation, such as medical records, to support your case.
The Georgia Pathways to Coverage program does not fully help everyone in the coverage gap. People who earn just a little more than the program's 100% Federal Poverty Level (FPL) limit and those who cannot meet the program's work or community engagement requirements often still struggle to find affordable healthcare options.
We want to help families get the support they need to care for their loved ones. Even if you have Georgia Pathways to Coverage, you might also qualify for extra help through Medicaid waiver services like Structured Family Caregiving. Givers is here to help you understand these options and make sure you get the resources and support that are available to you.
