2195 Pathways | Medicaid

Age – Must be an adult age 19 through 64. Refer to Section 2255 - Age (Family Medicaid).

Citizenship/Immigration/Identity – A/R must be a U.S. citizen or meet immigration eligibility requirements. Refer to Section 2215 - Citizenship/Immigration/Identity.

Enumeration – A/R must furnish, apply for, or agree to apply for a Social Security Number (SSN) for each member, unless Good Cause for SSN is established, is penalized. Refer to Section 2220 - Enumeration.

Tax Filer and Non-Tax Filer Status – A/Rs expected to be included on the next tax return filed are potentially eligible to receive MAGI Medicaid. A/Rs that meet non-tax filer criteria are potentially eligible to receive MAGI Medicaid. Refer to Section 2245 - Living With A Specified Relative/Tax Filer/Non-Filer Status.

Residency - AU members must be residents of Georgia and not incarcerated in a public institution. Refer to Section 2225 - Residency.

Third Party Liability Requirements – The A/R is required to provide information regarding any Third-Party Liability (TPL) available to any Potential Pathways member. The A/R must assign his/her TPL rights to DCH, unless Good Cause for TPL exists. Refer to Section 2230 - Third Party Liability.

Potential Pathways Member is not eligible for any other Medicaid class of assistance (Family or ABD).

Modified Adjusted Gross Income (MAGI) - The total taxable net income of the AU must be equal to or less than the MAGI income limit of the AU size. For Pathways the household income can be up to 100% of the FPL, which includes a 5% of the FPL income disregard. After the 5% disregard and all applicable 1040 and Pre-tax deductions the A/R income must be equal to or less than 95% of the FPL. Refer to Appendix A2 - Family Medicaid Financial Limits TOC.

Qualifying Activities - In order to be eligible for Pathways at application, an A/R must demonstrate that they are currently engaged in at least 80 hours per month of a qualifying activity or combination of activities.

Maintaining Eligibility – To remain eligible for Medicaid coverage through Pathways, an A/R must report their hours at annual renewal and within 10 days of a change in hours and/or Qualifying Activity type. Reporting of hours will include an A/R’s self- attestation of activity hours, accompanied by supporting documentation for verification. If an A/R fails to report and verify their hours at renewal or from a reported change in QA hours or activity, they will be terminated from the program unless they have a Good Cause Exception.

Cost-effectiveness is defined as a savings of $1.00 or more per year for the State. It takes into account the cost to the State paying the A/R’s cost-sharing obligations, including premiums, for the employer’s insurance compared to the cost of paying Medicaid capitation rates. Cost-effectiveness will be determined by the Third-Party Liability (TPL) vendor using their proprietary formulas and processes.

HIPP Referral Process - An A/R who reports having access to or reports being currently enrolled in ESI at application will be referred to the TPL vendor Health Management Systems (HMS) for an ESI cost-effectiveness determination if they are identified as potentially eligible for Pathways. The A/R will receive a notice informing them of this referral.

Participation in qualifying activities that would impact their eligibility for the program (e.g., reduction of hours engaged below 80-hour threshold, withdrawal from full-time enrollment in an institution of higher education, etc.)

Employer access to ESI (e.g., gain of access to ESI that was not indicated in the Medical Assistance application)

Failure to Report a Change - If the State is made aware that a member failed to report a change that makes them ineligible for Pathways or any other COA, the member will be terminated effective the first day following the month timely notice expires.

Transition from Another COA to Pathways at Change - Existing Medicaid A/Rs age 18 or older will have the opportunity to be evaluated for Pathways when reporting a change and signing the Pathways Contract. If eligible and approved for Pathways, coverage will begin prospectively on the first of the month following authorization of the approval.

Targeted Advance Notice - Gateway will identify A/Rs currently enrolled in other classes of assistance who are coming to a known termination date (due to age) and who are under 120% of the FPL and include a Targeted Advance Notice with their Change/Termination Notice. The Targeted Advance Notice will include information such as the Pathways program overview, and information on submitting a change or new application and reporting qualifying activities for consideration of coverage through Pathways.