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Georgia Pathways HIPP
What is Pathways HIPP?
The Georgia Pathways to Coverage™ Health Insurance Premium Payment (HIPP) program launched in January 2024. Pathways HIPP can help members who enroll in private health insurance through their employer, or employer-sponsored insurance (ESI), pay their healthcare premiums, deductibles, and co-payments.
When applying for Pathways, Medicaid will automatically verify if Pathways members with ESI may be eligible for Pathways HIPP. If approved for Pathways HIPP, the member will enroll in the health insurance plan available through their employer or their family member’s employer and Medicaid will make payments directly to the member to cover the premium amount. Pathways HIPP members will be insured through their employer or their family member’s employer and will receive financial support from Medicaid.
Pathways HIPP aims to encourage participation in employer-sponsored health insurance coverage and support members on their journey to financial independence.
Pathways HIPP is a separate program from the voluntary HIPP program for Medicaid members. As of January 2024, new Pathways members will be automatically enrolled in Pathways HIPP if they have eligible insurance available through their employer or their family member’s employer.
Who Participates in Pathways HIPP?
New Pathways applicants will be automatically evaluated for the Pathways HIPP program if they meet Pathways eligibility requirements and have health insurance available through their employer or their family member’s employer. If approved, individuals evaluated for Pathways HIPP will be required to participate in the program. Pathways members who applied for Pathways before January 2024 will be evaluated for Pathways HIPP at their annual redetermination date or after indicating that their employer or their family member’s employer offers ESI on the Report My Changes page in the Gateway customer portal.
If you are found eligible for Pathways and automatically enrolled in Pathways HIPP, you will receive a Pathways HIPP Welcome Packet in the mail with more information about the program.
Pathways HIPP Coverage Details
Medical Coverage: For any medical service visit, you must present your ESI and Medicaid cards to prevent paying out of pocket. While enrolled in Pathways HIPP, you are encouraged to seek a Medicaid provider within your ESI network; however, Pathways HIPP will also cover payments to non-Medicaid providers whose services are covered by your ESI plan. If you visit a non-Medicaid provider whose services are covered by your ESI plan, Medicaid will cover the full cost you incurred from the visit. Services will be paid for through Option 1, Advanced Payment or Option 2, Post-Visit Payment.
- Option 1: Advanced Payment (Prior to Provider Visit). You may request an advance of the cost-share for services covered by your ESI if you know the cost and make the request at least 30 days before the payment is due. You must include the payment amount, the date of the visit, provider documentation, which should include the expected cost of the upcoming visit, and your direct deposit information. If there is no direct deposit information given, you will be issued a check.
- Option 2: Post-Visit Payment. You may file for reimbursement of the cost-sharing amount if you are unable to use Option 1 in advance of the provider visit. You may also use this option for any bill received for services covered by your ESI for outstanding cost-sharing obligations following a visit. You must provide the payment amount, the date of the visit, the payment invoice and proof of payment, and your direct deposit information. If there is no direct deposit information given, you will be issued a check.
You may be required to verify your visit to a provider for which you requested cost-sharing assistance.
Prescription Coverage: For any pharmacy visit, you must present your ESI and Medicaid cards to prevent paying out of pocket. Pathways HIPP coverage is only accepted for prescriptions filled in pharmacies that participate in Medicaid. Most pharmacies are participating Medicaid providers. If you are charged out of pocket expenses at a Medicaid pharmacy, you may submit a reimbursement request using the same method as Option 2, Post-Visit Payment above.
For more information on how to submit a request for an advancement or reimbursement, please refer to your Pathways HIPP Welcome Packet or contact Gainwell Technologies/Georgia Pathways HIPP Unit at (678) 564-1162, Option 4.
How to Establish Coverage Once You’re Enrolled in Pathways HIPP
Once you have been approved for Pathways HIPP, you will receive your Pathways HIPP Welcome Packet, which outlines several actions you need to take to establish coverage. You will not be officially enrolled in Pathways HIPP until you are enrolled in the health insurance plan available through your employer or your family member’s employer. For example, if you are approved for Pathways HIPP in February and enroll in your ESI or your family member’s ESI in February, you could be enrolled in Pathways HIPP as soon as March 1.
If you are enrolling in ESI outside of the employer’s open enrollment period, Gainwell Technologies/Georgia Pathways HIPP Unit may mail you a Qualifying Event Letter to give to the employer to complete. For additional guidance, please reference the Qualifying Event Letter or contact Gainwell Technologies/Georgia Pathways HIPP Unit at (678) 564-1162, Option 4.
If you are the ESI policy holder, you must submit your paystubs by email, fax, or mail by the 15th of each month to receive your monthly premium payment from Pathways HIPP.
Submit your paystubs to the Gainwell Technologies/Georgia Pathways HIPP Unit:
- E-mail: [email protected]
- Fax: (833) 309-1979
- Mail: Gainwell Technologies/ Pathways HIPP Unit, 100 Crescent Centre Parkway, Suite 1000, Tucker, GA 30084
The final deadline for submitting paystubs to receive an advanced premium payment is the 23rd of each month. If you submit your paystub after the 23rd of the month, you will receive a reimbursement instead. The best way to ensure you receive your premium payment ahead of the monthly ESI premium deduction from your paycheck is to set up direct deposit. You will not need to provide a paystub to receive a premium payment the first month you are enrolled in Pathways HIPP because Gainwell Technologies/Georgia Pathways HIPP Unit will have confirmed this when evaluating you for Pathways HIPP.
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You can find detailed instructions for setting up direct deposit and submitting your paystubs in your Pathways HIPP Welcome Packet. For additional guidance, please contact Gainwell Technologies/Georgia Pathways HIPP Unit at (678) 564-1162, Option 4.
Maintaining Pathways HIPP Coverage
To remain eligible for Pathways HIPP, all members of your family enrolled in Pathways HIPP must continue to meet the Pathways eligibility requirements. If you are the ESI policy holder, your qualifying activity hours will be verified when you submit your paystubs monthly. If you are enrolled in Pathways HIPP through your family member’s ESI, you must report one or more qualifying activities for a total of 80 hours each month. For detailed instructions on how to report qualifying activities, visit https://pathways.georgia.gov/qualifying-activities.
If you choose to disenroll from ESI, you will no longer be eligible for Medicaid through Pathways and you will be terminated from Pathways coverage and the Pathways HIPP program.
If you are the policy holder and you do not provide a paystub for two consecutive months and Gainwell Technologies/Georgia Pathways HIPP Unit is not able to confirm that you remain enrolled in ESI, you will be terminated from Pathways HIPP. If Gainwell Technologies/Georgia Pathways HIPP Unit can confirm that you are still enrolled in ESI, then you will remain in the Pathways HIPP program. However, you will not receive premium payments until you submit your paystubs.
If you remain eligible for Pathways but you experience an involuntary loss of ESI coverage, you will transition to enrollment in a Care Management Organization (CMO) for Pathways. To learn more about Pathways, visit pathways.georgia.gov.
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