H.R. 1 Changes to Pathways

Beginning on January 1, 2027, the Georgia Pathways to Coverage eligibility requirements will change due to federal law (Working Families Tax Cut/H.R. 1 legislation). Current Pathways members will not be affected until renewal in 2027. 

Applicable Individual 

Individuals applying for Medical Assistance must meet the following requirements to be eligible for this program. The requirements for an applicable individual are not changing for Pathways.

  • Age 19-64
  • Income at or below 100% of the Federal Poverty Level 
  • Eligible for or enrolled in the State plan adult group or otherwise eligible for or enrolled in Pathways
  • Not pregnant
  • Not enrolled in Medicare Part A or B
  • Not otherwise eligible for or enrolled in a mandatory or optional coverage group under the state’s Medicaid State Plan

Community Engagement

Like the current program, individuals are required to demonstrate at least 80 hours per month of certain activities. For Pathways, the name of these activities is changing from “qualifying activities” to “community engagement.”

Individuals can demonstrate community engagement requirements if they meet one or more of allowable conditions that month.

These current community engagement activities will remain for the Pathways program:

  • Work at least 80 hours (full time or part time, including self employment)
  • Participate in 80 hours of community service
  • Participate in a work program for 80 hours
  • Enrolled in an educational program at least half-time

These will be new community engagement activities:

  • Earn a monthly income of at least $580 (income must be under 100% FPL.  
  • For seasonal workers, earn an average monthly income over the previous 6 months of at least $580 (income must be under 100% FPL)

These conditions will no longer be accepted as community engagement activities:  

  • Participate in job readiness activities (will now be included as an educational program activity) 
  • Have an inpatient hospital stay or short-term skilled nursing facility stay (see the “Short-Term Hardship Exception” section below)  
  • Participate in habilitation or rehabilitation activities, including substance use disorder treatment (see the “Specified Excluded Individual” section below)  
  • Be the Parent or Legal Guardian of a child under six years of age (see the “Specified Excluded Individual” section below) 

Like the current program, individuals may combine the community engagement activities to meet the 80-hours-per-month requirement. 

Exemptions

For certain applicable individuals, there are new exemptions from completing the community engagement requirements. Individuals are considered to have an exception for part of or all of a month if they are:

  • Under the age of 19
  • Qualify for or are enrolled in Medicare Part A or Medicare Part B
  • Described in any of the mandatory eligibility groups
  • An inmate of a public institution at any point during the 3-month period ending on the first day of the application month in which the individual is otherwise subject to the community engagement requirement 
  • A specified excluded individual which includes those who:
    • Are an American Indian or Alaska Native
    • Are a former foster care youth
    • Are an inmate of a public institution
    • Are a medically frail individual or individual who otherwise has special medical needs that significantly impair their ability to comply with the community engagement requirement (See Medically Frail attachments below)
    • Meet the Temporary Assistance for Needy Families (TANF) work requirements or is subject to the Supplemental Nutrition Assistance Program (SNAP) work requirements under the Food and Nutrition Act of 2008
    • Are a participant in a drug or alcohol rehabilitation or treatment program
    • Are a pregnant woman or woman in the postpartum period (0-12 months after birth)
    • Are a parent, guardian, caretaker relative or family caregiver of a dependent child 13 years of age and under or of a disabled individual
    • Are a veteran with a total disability rating

Short-Term Hardship Exception

Individuals may be eligible for a short-term hardship exception for part or all of a month to the community engagement requirements. The short-term hardship exceptions are:

  • An applicable individual receiving inpatient hospital services, nursing facility services, services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), inpatient psychiatric hospital services, or other services with a similar level of acute care. (Note: The individual must request approval from the state)
  • An individual residing in a county (or equivalent unit of local government) in which an emergency or disaster has been declared by the President under the National Emergencies Act or the Stafford Act. (Note: The State must obtain CMS approval before this specific exception can be utilized in Georgia.) 
  • An applicable individual residing in a county (or equivalent unit of local government) that has an unemployment rate that is at or above the lesser of 8 percent or 1.5 times the national employment rate. (Note: The State must obtain CMS approval before this specific exception can be utilized in Georgia.)
  • An applicable individual, or the dependent of the applicable individual, is required to travel outside of their community for an extended period of time to receive medical services necessary to treat a serious or complex medical condition that are not available within their community of residence. (Note: The individual must request approval from the state)

Prior Month Eligibility

Beginning on January 1, 2027, this new legislation will allow for a Pathways applicant to request one month of eligibility prior to the month that they are applying for benefits. Individuals will need to demonstrate compliance with community engagement requirements for the month prior to the one that they are requesting, as well as the application month. For example, if you apply for Pathways in February 2027, you will be given the option to request coverage for the month of January 2027. This means that you will need to demonstrate 80 hours of community engagement activities in December 2026 and January 2027.

Renewals and Compliance Checks

To meet the eligibility requirements, individuals must complete community engagement for at least one month immediately before the month of application, continuing monthly during Pathways enrollment, and at annual renewal. 

Change in Status

If members have a change in circumstance, like enrolling in private health insurance or no longer completing at least 80 hours a month of community engagement, they must report it to the Division of Family and Children Services (DFCS) as soon as the change occurs. Reporting can be done in person, online, or a phone call. 

Noncompliance

Noncompliance with community engagement requirements may result in losing health care benefits. Members will have the opportunity to provide additional information through a process before benefits are terminated. Members can also appeal the state’s decision through the fair hearing process. 

Next Steps

While these changes begin on January 1, 2027, current Pathways members should:

  • Continue to keep proof of your activities. If you do not qualify for an exception or exclusion, DFCS may ask for proof that you have completed your 80 hours or made at least $580 each month (without earning more than 100% FPL). Keep proof, such as pay stubs, school records and volunteer logs.
  • Update your contact information. Make sure DFCS has your correct address and phone number. If they need something from you, they will mail you a letter. 

New potential applicants should:

  • Keep proof of community engagement activities beginning December 2026. If you do not qualify for an exception or exclusion, DFCS may ask for proof that you have completed your 80 hours or made at least $580 each month (without earning more than 100% FPL). Keep proof, such as pay stubs, school records and volunteer logs.

More information will be provided at pathways.georgia.gov as it becomes available. You can also contact DFCS for more details. Locate your local office at dfcs.georgia.gov/locations or call the DFCS Customer Contact Center at 877-423-4746.

Reporting Changes

Members must report changes in the following situations: During your Medical Assistance eligibility period, you must report if anyone moves in or out of your home, any changes in your household income, and any changes in your household’s resources if you are receiving Medicaid for an adult. You must report these changes within 10 calendar days of the date on which the change occurs.

If you fail to report the required changes, you may have to repay any benefits you receive for which you were not eligible and you may also be prosecuted for fraud.

Members may report changes, check the status of benefits, and renew benefits online at gateway.ga.gov. Members may also report changes to their situation or receive information about their benefits by phone at 877-423-4746.

 

Medically Frail 

In accordance with federal regulations, DCH has developed a list of health conditions and diagnoses to assist in identifying the individuals who meet the criteria for medical frailty. Attachment A contains the list of health conditions and diagnoses that satisfy the criteria for medical frailty. Attachment B contains a listing of conditions that may meet the criteria for medical frailty if combined with certain diagnoses or documentation. DCH will develop a policy and process to determine if an individual is deemed medically frail based upon the health conditions listed in Attachment B. 

Attachment A  (PDF, 615.02 KB)  

Attachment B  (PDF, 2.78 MB)  

ADA accessible versions of Attachment A and B are forthcoming.