2256 Pathways Qualifying Activities Reporting | Medicaid

To be eligible for Georgia Pathways 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.

Qualifying Activities include:

For definitions and acceptable verification of each QA type, please see Chart 2256.3 - Qualifying Activities.

A/Rs must report at least 80 hours of engagement in a qualifying activity or activities at application and provide documentation for verification that they meet the hours and activities threshold for the most recent four weeks available. The submitted four weeks must be within the eight weeks prior to the application date.

Once enrolled in Pathways, A/Rs are required to report and verify their hours and activities monthly by the 3^rd of the month to maintain eligibility. The final deadline for late reporting is the 17^th of the month. Exceptions to this monthly reporting are the following:

If the A/R fails to report and verify their prior month qualifying activities and hours or reports insufficient hours by the 17^th of the month without submitting a Good Cause Exception request, they will enter a suspension period for up to three consecutive months starting the calendar month immediately following the month in which reporting was required.

If the A/R reports and verifies their hours from the prior month up until the 17^th of the third month of suspension, the member is no longer in suspension starting the first day of the calendar month following reporting.

A/Rs must attest to the hours and activities completed and submit supporting documentation validating hours and activities. If A/Rs fail to meet the threshold of at least 80 hours in a given month, they can submit a Good Cause Exception request for consideration to continue/reinstate eligibility. Good Cause Exceptions are temporary circumstances that prevent or diminish an A/R’s ability to fulfill the hours and activities threshold during the reporting period.

If the Good Cause Exception is submitted timely and approved, the A/R will not enter a suspension period in the month following non-compliance with hours and activities requirements. The A/R may only request a Good Cause Exception for the prior month of activities and hours. The timeline for reporting Good Cause Exceptions is the same as for reporting qualifying hours and activities stated in previous section Qualifying Activities Hours Reporting.

The A/R will be allowed up to 120 hours of Good Cause Exception hours per certification year even if no longer required to report monthly. Refer to Exceptions to Six Consecutive Months of Qualifying Activity Reporting for more information on exceptions to monthly report. The Good Cause Exception hours will reset upon the certification of a new Period of Eligibility (POE).

Acceptable Good Cause Exception reasons are as follows:

A/Rs must select one of the acceptable reasons for the Good Cause Exceptions, provide written explanations of the circumstances, indicate number of hours requested, and submit supporting documentation. A/Rs may request a maximum of 120 hours per certification period.

To make a Good Cause Exception request, the member must complete four requirements:

At the time of submitting the request, the member must attest that s/he was unable to fulfill their qualifying hours and activities due to the Good Cause reason that is selected.

The A/R may make a Good Cause Exception request at the same time as reporting their qualifying hours and activities.

If by the 3^rd day of the month a member does not report their hours or reports insufficient hours (i.e., any amount less than 80), and does not submit a Good Cause Exception request by this date, then they will receive instructions on the Good Cause Exception request process in their Monthly Qualifying Activity Incomplete Notice.

The A/R may request a Good Cause Exception through the same channels used to report their qualifying hours and activities, as follows:

The A/Rs who submit a Good Cause Exception Request will be subject to audit and are informed of this requirement at initial application approval of Pathways.

If the A/R chooses the “Other” category as the reason for the Good Cause Exception request, a task will be created and routed to an eligibility worker to review and approve/deny the request.

Good Cause Exception requests received during the renewal month will be determined using the hours remaining in that certification period.

Acceptable documentation for Good Cause Exception requests is defined as follows:

If the A/R is compliant with reporting qualifying hours and activities timely (by the 23^rd of each month) for six consecutive months of enrollment in Pathways, s/he will no longer be required to report monthly for the remainder of s/he time in Pathways.

A/R must complete the hours and qualifying activities reporting requirements (self-attestation and documentation for verification) for the month prior to submitting the renewal to be determined eligible for Pathways.

A/Rs who were exempt from monthly reporting due to successfully completing six months of consecutive reporting are required to report at renewal. They must report and provide documentation for verification of their hours and activities for the month prior to submitting their renewal to be determined eligible for Pathways at redetermination.

For members who are reporting monthly at the time of redetermination, the month reported within their renewal will count towards their six consecutive months of reporting required to be exempt from ongoing monthly reporting in the future.

The member must continue to report their hours and activities and provide documentation for verification each month until six consecutive months of reporting and verification are met. The six months of consecutive reporting may span across certification periods.

There are circumstances in which the A/R is not subject to the six consecutive months of qualifying activity reporting requirement. They are not subject to this requirement; they will receive a Change Notice for Reporting Requirements. This notice will be customized according to the below table.

If the applicant is determined eligible for Pathways and provides verification of completing a minimum of 80 hours total (not on average) of employment during the most recent six consecutive months prior to application for which verification is available, then the A/R will be exempt from reporting.

Applicants will have the opportunity to report and provide verification for the most recent six consecutive months of employment prior to application for which verification is available.

If the A/R successfully submits six months of documentation at application or after notified via a VCL, they will be notified in their Approval Notice that they are not required to participate in six consecutive months of qualifying hours and activity reporting upon enrollment.

If the A/R fails to submit the six months of documentation within a reasonable timeframe, they are no longer considered for a reporting exception. Failure to submit six months of documentation upfront is optional and not required, so it does not impact their eligibility for Pathways ongoing. They will be notified in their Approval Notice that they are required to participate in six consecutive months of qualifying hours and activity reporting upon enrollment.

Fluctuations in the A/R’s community engagement, either in number of hours or types of activities, is not considered a change in circumstances. This does not need to be reported if the A/R still meets the requirements of the program of at least 80 hours/month of engagement in qualifying activities.

Normal fluctuations include the following:

In the event the A/R incurs a change in their qualifying activities that results in not meeting the minimum hours threshold of 80 hours/month, the A/R has a responsibility to report this as a change in circumstance. The A/R may submit a Good Cause Exception request (if applicable).

To qualify for Pathways, A/Rs must report at least 80 hours per month of engagement in a qualifying activity or activities before eligibility can be approved. All applicants must verify they meet the qualifying activities and 80 hours threshold for the most recent four weeks available within the eight weeks prior to an application.

If any Pathways Medical Assistance applicant or member with a disability who is no longer able to perform any work, education, or Qualifying Activity needs assistance to meet the 80-hour Pathways Qualifying Activities requirement in a month, the applicant or member with a disability can make the following Reasonable Modification requests that are specific to Pathways Qualifying Activity:

Please see Chart 2256.4 - Reasonable Modifications vs. Reasonable Accommodations as a quick reference to understanding Reasonable Modification requests.

Eligibility Workers will process, review, and make decisions on Pathways applicant and member requests for Reasonable Modifications specific to Pathways qualifying hours and activities requirement. See the following examples:

In addition to the Reasonable Modification types listed above, Pathways applicants and members are afforded the same access to Reasonable Modifications that are available for all categories of Medicaid. (For examples, please refer to Medicaid Manual Policy Section 2020 Americans with Disabilities Act (ADA) and Section 504). If an applicant or member needs a Reasonable Modification or Communication Assistance, the applicant or member should contact his or her caseworker or call DFCS at 404-657-3433 or DCH at 678-248-7449. The applicant or member may also make the request online at dfcs.georgia.gov/adasection-504-and-civil-rights. If the applicant or member is deaf, hard-of-hearing, deaf-blind or have difficulty speaking, s/he can call DFCS at the numbers above by dialing 711 (Georgia Relay).

The definition of disability used in Pathways follows the Americans with Disabilities Act (ADA) definition which states that an A/R meet any of the following three criteria:

The eligibility worker will contact the potential Pathways eligible A/R to determine next steps for the applicant’s/member’s Reasonable Modification request for Pathways qualifying hours and activities. The eligibility worker will:

The eligibility worker will attempt to reach the A/R following the current practice of conducting two unscheduled telephone attempts prior to scheduling an interview with the A/R who is requesting a Reasonable Modification for Pathways qualifying hours and activities due to a disability. If the A/R is not reached after two telephone attempts, the eligibility worker will schedule an interview. The A/R will receive a notice with their scheduled interview time and contact information for the assigned eligibility worker. The notice will indicate that failure to complete the interview will result in a denial for Pathways Medicaid.

If the A/R is not reached after the scheduled interview, the eligibility worker may deny their application.

If the A/R reports that they are able to meet the qualifying hours and activities for Pathways eligibility, the eligibility worker will offer information on potential resources available to help the A/R get engaged with employment, education, training, or volunteer activities, if needed.

The A/R’s Medical Assistance application will pend for up to 90 days to allow the A/R to demonstrate compliance of four weeks of engagement with the qualifying hours and activities threshold. If the A/R submits verification of compliance with the Pathways hours and activities requirement within the 90 days, the eligibility worker will approve the application for Pathways. If the A/R fails to submit verification of compliance with the Pathways hours and activities requirement within 90 days, the application will be auto denied.

If the A/R reports that they are unable to meet the qualifying hours and activities requirement due to their disability, the eligibility worker will offer a referral to the GVRA Vocational Rehabilitation Program to assist the A/R with coming into compliance. If the A/R accepts the referral, the eligibility worker will make a referral to GVRA. The worker will obtain verbal consent prior to the referral that the individual consents to a referral to GVRA.

The Standard of Promptness (SOP) for processing of Pathways A/Rs who have been referred to GVRA is 90 days from the date of authorization of a referral to GVRA. A Pathways application will remain in “Eligible – Pending GVRA Enrollment Status” until the member’s referral to GVRA is dispositioned as enrolled or denied.

If an A/R is determined eligible and enrolled in services for GVRA, Gateway automatically updates the Medical Assistance application to indicate enrollment in GVRA, which is a qualifying activity for Pathways. If GVRA enrollment status is received manually, a worker will be able to update the case with GVRA enrollment information. The A/R will be enrolled in Pathways effective the first of the month following receipt of the eligibility determination and enrollment from GVRA, or the month following receipt of initial premium payment, if applicable.

If an A/R is determined ineligible and therefore not enrolled for GVRA, upon receipt of this information Gateway will authorize a denial for Pathways and a denial notice will be sent. The denial notice will specify that an A/R is not eligible for Pathways for failure to meet the hours and activities threshold and that the agency has been informed of their denial from GVRA. The denial notice will include information regarding other workforce development resources, which is provided to all applicants who are denied for failure to meet the qualifying activities requirement.

If an A/R has been pending for Pathways due to a referral to GVRA, the A/R will continue to pend for Pathways until an enrollment status is received from GVRA.

A/Rs who are eligible for Pathways due to being enrolled in GVRA will be considered to be meeting the monthly hours and activities requirements for Pathways if they remain in compliance with the terms of the GVRA program. Enrollment in GVRA is considered a qualifying activity for Pathways. Enrolled A/Rs will not be required to report on monthly activities if they remain in compliance with the terms of the GVRA program. GVRA will notify Gateway through an interface (if consent was granted by A/R) when a Pathways program participant is no longer an active client with GVRA, either due to graduation from the program or due to disenrollment.

GVRA will send information to Gateway (if consent was granted by A/R) when a client is disenrolled from the GVRA Vocational Rehabilitation Program, if the A/R has not completed the six consecutive months of reporting requirement, Gateway will issue a notice informing the member that they are no longer an active client of GVRA and will need to come into compliance with the Pathways requirements through engagement in other qualifying activities in order to maintain eligibility.

If the A/R was enrolled in GVRA for at least six months prior to transitioning to Pathways, this fulfills the six consecutive months of reporting requirement. They will be exempt from the requirement to report qualifying hours and activities ongoing. They will not report qualifying activities until Pathways redetermination.

If an A/R is already enrolled in Pathways and develops a condition which is temporary and prohibits their monthly compliance with the qualifying hours and activities, they may request a Good Cause Exception from the qualifying hours and activities. For more information about Good Cause Exception please refer to section located within this chapter labeled Good Cause Exception. However, if the A/R develops a physical or mental impairment that substantially limits one or more major life activity, the A/R may report a Reasonable Accommodation from their employer, educational institution, organization, or supervisor to maintain their current activity.

Reasonable Accommodations for Pathways only refers to changes made by an employer/supervisor/institution for an A/R with a disability to allow the person to work or engage in an activity. The A/R must request a Reasonable Accommodations directly from the employer/supervisor/institution or through GVRA. DFCS staff do not collect verification of disabilities for a Reasonable Accommodation nor make determinations on the types of Reasonable Accommodations that area necessary for the Pathways applicant/recipient to be able to engage in a qualifying activity.

The only circumstance in which DFCS needs to be informed about a Reasonable Accommodation made between the employer/supervisor/institution and the Pathways A/R is if the member has reduced work/engagement hours and will be unable to meet the minimum of 80 hours/month required for Pathways eligibility. In this circumstance, the A/R will report and provide verification of the Reasonable Accommodation granted by his or her employer/supervisor/institution and the eligibility worker will reduce the A/R’s monthly minimum qualifying activities and hours requirement to maintain ongoing Pathways eligibility accordingly.

To maintain eligibility, Pathways members must report a change in circumstance and request a Reasonable Modification or report that they were granted a Reasonable Accommodation that allows them to work fewer than 80 hours per month, using the same channels available for submitting Good Cause Exception requests (i.e., phone, mail, in-office, online portal).

Please see Chart 2256.4 - Reasonable Modifications vs. Reasonable Accommodations for an overview of how these terms are used for the Pathways program and as a quick reference to understanding Reasonable Modification requests and Reasonable Accommodations granted by employers/supervisors/institutions.