If you enroll in Georgia's Pathways to Coverage, your benefits are shaped by a federal rule most people never hear named: the Alternative Benefit Plan. A Georgia Medicaid Alternative Benefit Plan (ABP) is a benefit package built to a commercial-insurance benchmark instead of the traditional Medicaid state plan, and federal law requires every ABP to cover ten Essential Health Benefits, meet mental health parity, and protect children's coverage. This guide explains what an ABP is, who must enroll and who is exempt, and how Georgia uses the framework today.

In This Guide

What a Georgia Medicaid Alternative Benefit Plan Is

A Medicaid Alternative Benefit Plan (ABP) is a benefit package a state delivers to a defined eligibility group through a coverage standard borrowed from commercial insurance, rather than through the traditional Medicaid state plan benefit package. The authority comes from Section 1937 of the Social Security Act, and the package must cover the ten Essential Health Benefits, satisfy mental health parity, and preserve EPSDT for children.

For a Georgia family, the practical question is usually narrower: does an ABP apply to me, and does it change what is covered? In Georgia today the answer is that ABPs are not the benefit package for most enrollees. Children, pregnant women, and people who are aged, blind, or disabled receive the standard state plan benefit package, not an ABP. The framework matters mainly in two places: the Pathways to Coverage program, which uses an ABP-like benefit structure, and the policy debate over whether Georgia should adopt full Medicaid expansion, which would cover a new adult group through an ABP.

Where ABPs Come From: Section 1937

Section 1937 of the Social Security Act, codified at 42 U.S.C. 1396u-7 and titled "State flexibility in benefit packages," lets a state cover specified populations through "benchmark coverage" or "benchmark-equivalent coverage" instead of the traditional state plan benefit package. The framework was substantially expanded by the Affordable Care Act (ACA) of 2010, which tied ABPs to the ten Essential Health Benefits, applied mental health parity, and made them the standard vehicle for the ACA's new adult group.

The structural difference from the traditional state plan is real but often modest. The traditional package is defined by a list of mandatory and optional service categories (inpatient hospital, physician services, laboratory and X-ray, and so on). An ABP instead requires coverage of the ten Essential Health Benefits at the level of a chosen benchmark plan. When a state uses the Secretary-approved option to set its own Medicaid state plan as the benchmark, the two approaches can produce nearly identical coverage.

Who Must Enroll, and Who Is Exempt

Section 1937 authorizes ABP coverage for groups specified in a state plan amendment, most importantly the ACA new adult group in states that expand. But the statute also lists individuals who cannot be required to enroll in an ABP without their consent. These exempt groups must be offered the standard state plan benefit package. Under 42 U.S.C. 1396u-7(a)(2)(B), the exempt list includes:

  • Pregnant women who are required to be covered
  • Individuals eligible on the basis of being blind or disabled
  • Dual eligibles (people entitled to Medicare)
  • Terminally ill individuals receiving hospice care
  • The medically frail and others with special medical needs, such as people with disabling mental disorders, chronic substance use disorders, or serious and complex medical conditions
  • Individuals who qualify for long-term-care services based on a medical condition, and people in institutional care
  • Several other categories, including certain women in the breast and cervical cancer treatment group and people receiving only emergency services

An exemption is a right, not a prohibition. A person in an exempt group may still choose to enroll in an ABP if it meets their needs, but they cannot be forced into one.

The Ten Essential Health Benefits

Every ABP must cover the ten Essential Health Benefits (EHB) defined by Section 1302(b) of the Affordable Care Act, codified at 42 U.S.C. 18022(b)(1). Section 1937 requires any benchmark or benchmark-equivalent package to "provide at least essential health benefits as described in section 18022(b).", The ten categories are:

  1. Ambulatory patient services (outpatient care)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

The benchmark plan a state chooses sets the baseline for each category. Where the benchmark falls short of an EHB category, the state must supplement it so the ABP still meets the full EHB standard, because Section 1937 requires any benchmark or benchmark-equivalent package to provide at least the essential health benefits described in Section 1302(b). If your plan's own benefit list appears to leave out a category, especially pediatric oral and vision care or habilitative services, ask your plan or Georgia Medicaid Member Services how that category is covered rather than assuming it is not.,

The Four Benchmark Options

An ABP must be at least actuarially equivalent to one of four federal benchmark plans. A state can also offer "benchmark-equivalent" coverage, which an actuary certifies to be at least actuarially equivalent in aggregate value to one of the four benchmarks.

Benchmark option Statutory basis What it is Key consideration
Federal Employees Health Benefits plan 42 U.S.C. 1396u-7(b)(1) The standard Blue Cross/Blue Shield preferred provider option offered to federal employees A broad, comprehensive commercial-style plan used as a reference point
State employee plan 42 U.S.C. 1396u-7(b)(1) A health plan generally available to the state's own employees Generosity and networks vary widely from state to state
Largest commercial HMO 42 U.S.C. 1396u-7(b)(1) The HMO with the largest insured commercial, non-Medicaid enrollment in the state Reflects managed-care benefit design in that state's market
Secretary-approved coverage 42 U.S.C. 1396u-7(b)(1) Any coverage the U.S. Department of Health and Human Services approves as appropriate Since the ACA, this can be the state's own Medicaid state plan package

The Secretary-approved option matters most in practice. It lets a state run an eligibility group through the ABP framework while keeping essentially the same benefit package providers and enrollees already know.

Mental Health Parity Under MHPAEA

ABPs must comply with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Section 1937 requires that the financial requirements and treatment limitations applied to mental health and substance use disorder (MH/SUD) benefits be no more restrictive than those applied to medical and surgical benefits.,

In plain terms, parity means an ABP cannot single out behavioral health for tighter limits. The comparison is made classification by classification: a financial requirement or treatment limitation on mental health and substance use disorder benefits cannot be more restrictive than the predominant one applied to substantially all medical and surgical benefits in the same classification. MHPAEA also reaches non-quantitative treatment limitations, including prior authorization and other medical management techniques, standards for network composition, and the methodologies used to set out-of-network reimbursement rates. Georgia's own parity protections are covered in our guide to Georgia Medicaid mental health parity.

How EPSDT Protects Children

Children under age 21 are not on the Section 1937 exempt list, but a separate protection makes that irrelevant to their coverage. Every ABP must provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services as a wrap-around for enrollees under 21. EPSDT, defined at Section 1905(r) of the Social Security Act, requires coverage of "such other necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan."

The effect is decisive: if a child needs a medically necessary service to correct or ameliorate a condition found through screening, EPSDT requires coverage even when that service is not in the ABP benefit package. The same wrap-around applies to a child in traditional Medicaid, so moving a child into an ABP does not narrow the correct-or-ameliorate standard that governs what must be covered. Georgia's children's coverage rules are detailed in our guide to Georgia Medicaid children and EPSDT.

What You Pay: Cost-Sharing

Cost-sharing in an ABP follows the same general Medicaid limits as the rest of the program: charges must be nominal, certain groups and services are protected from any cost-sharing, and there is a federal cap on total out-of-pocket cost as a share of family income. In Georgia, the concrete rule that applies to ABP-like coverage is the Pathways to Coverage copayment: Pathways members are subject to the same copayments as state plan Medicaid beneficiaries, meaning copayments for certain services, with none required for members under age 21 and none for beneficiaries enrolled in the Health Insurance Premium Payment (HIPP) program. Georgia's broader copay rules are covered in our guide to Georgia Medicaid cost-sharing and copays.

How Georgia Medicaid Uses Alternative Benefit Plans: Pathways to Coverage

Georgia has not adopted full ACA Medicaid expansion, so it does not cover the new adult group. Instead, Georgia runs Pathways to Coverage, a Section 1115 demonstration that provides limited expansion coverage. Pathways covers adults ages 19 through 64 with household income up to 100% of the federal poverty level who complete at least 80 hours per month of qualifying activities such as work, education, vocational training, or volunteering. As of 2026, 100% of the federal poverty level is about $15,960 a year for a household of one.,

Because Pathways operates under Section 1115 authority rather than Section 1937 directly, it is not a strict ABP. But its benefit package is built around the same Essential Health Benefits structure. Effective October 1, 2025, Georgia eased several Pathways rules: members report qualifying activities and hours only at application and at annual renewal instead of monthly; two qualifying activities were added, compliance with the SNAP Able-Bodied Adults Without Dependents requirement and caregiving for a child under six who is enrolled in or applying for Medicaid with the parent or legal guardian; and coverage now takes effect on the first day of the month in which the application was filed. That effective date is not automatic on filing: payment for covered services back to that date becomes available only once Georgia has determined the applicant eligible, which includes meeting the qualifying hours and activities requirement. CMS approved a temporary extension that continues Pathways through December 31, 2026; Medicaid.gov still lists the demonstration's status as pending, so coverage past that date is not settled. The full program is covered in our guides to Pathways to Coverage and Georgia Medicaid Section 1115 demonstrations.

What Full Expansion Would Change

If Georgia adopted full ACA Medicaid expansion, the change would run through the ABP framework. The ACA created the new adult group at Section 1902(a)(10)(A)(i)(VIII) for people under 65 who are not pregnant and not entitled to Medicare, with income up to 133% of the federal poverty level; a 5-percentage-point income disregard lifts the effective ceiling to 138% of the federal poverty level. In an expansion state, that group is covered through an ABP that includes all ten Essential Health Benefits.

Income and category alone no longer settle eligibility for that group. The 2025 budget-reconciliation law (Public Law 119-21) made subclause (VIII) subject to a new Section 1902(xx), under which a state must require an applicable individual to demonstrate community engagement as a condition of eligibility, beginning no later than the first day of the first quarter after December 31, 2026, or an earlier date the state specifies. So expansion would widen who qualifies and raise the federal share, but it would not trade Georgia's activity requirement for coverage with no conditions attached.

Expansion is financially favorable because of the enhanced federal match. Under Section 1905(y), the federal government pays an enhanced federal medical assistance percentage for the new adult group: 100% from 2014 through 2016, stepping down to 90% for 2020 and every year after. Georgia's non-expansion choice leaves a coverage gap: the state covers adults only through limited eligibility categories rather than the new adult group. Expansion would close that gap, and existing enrollees in traditional categories would keep their state plan benefits, protected by the Section 1937 exemptions.

How a State Sets Up an ABP

A state establishes an ABP by submitting a state plan amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS). The SPA identifies the population to be covered, specifies the benchmark or benchmark-equivalent coverage, describes the benefit package, documents EPSDT wrap-around for children and MHPAEA parity compliance, and sets the cost-sharing structure. CMS reviews the amendment for compliance with Section 1937 and its implementing regulations, and once approved the ABP becomes part of the state Medicaid plan. For Georgia, CMS Region IV in Atlanta provides regional oversight of state plan amendments and Section 1115 demonstrations such as Pathways. Georgia's state plan amendment process is covered in our Georgia Medicaid covered services guide.

Worked Examples

These examples are hypothetical and illustrative. They show how the rules apply to common situations; they are not predictions about any specific person's eligibility.

Example 1: Marcus, a Pathways enrollee in Atlanta

Marcus is a single adult in Atlanta who works part-time and earns well under the 100% of the federal poverty level ceiling for Pathways to Coverage. He applies through Georgia Gateway, documents his work hours, and enrolls. His benefit package is built around the Essential Health Benefits: hospital and physician care, emergency services, behavioral health, prescription drugs, preventive services, and laboratory and imaging., He must keep reporting his qualifying activities at renewal to keep coverage.

Example 2: Sarah, who may be medically frail, in Macon

Sarah has severe depression, anxiety, and PTSD and has been hospitalized twice in the past year. Federal law treats the medically frail (including people with disabling mental disorders) as exempt from being required to enroll in an ABP. In Georgia today, her most direct route to comprehensive coverage is aged, blind, and disabled (ABD) Medicaid based on a disability determination, which provides the full state plan benefit package and is well-suited to ongoing severe behavioral health needs. ABD Medicaid is also means-tested, and the financial test is tighter than Pathways': Georgia's ABD limits track the federal SSI standards, which for 2026 are $994 a month in income for an individual ($1,491 for a couple) and $2,000 in countable resources ($3,000 for a couple). Sarah should run both her income and her assets against those limits before assuming ABD is open to her.

Example 3: Janet, an 8-year-old in Augusta

Janet is newly diagnosed with type 1 diabetes after a screening at her well-child visit. Under EPSDT, she has access to any medically necessary service to correct or ameliorate a condition found through screening, whether or not it is otherwise in the benefit package: endocrinology visits, a continuous glucose monitor, insulin and supplies, diabetes education, and hospital care for complications. EPSDT applies the same way in or out of an ABP, so the benefit package itself is not the limit on what Janet can get for a condition her screening turned up.

Example 4: Tasha, who becomes pregnant while on Pathways, in Columbus

Tasha has been enrolled in Pathways and discovers she is pregnant. Pregnant women cannot be required to stay in an ABP. She can move to Georgia's Right from the Start pregnancy Medicaid, which covers pregnant women with income up to 220% of the federal poverty level and provides 12 months of postpartum coverage after the pregnancy ends, with no work or reporting requirement.

Common Misconceptions

"An ABP always covers less than traditional Medicaid"

Partly true at most. An ABP must cover the ten Essential Health Benefits and meet mental health parity, so it has a substantial floor. For some services, especially habilitative care and behavioral health under parity, an ABP can cover more than a traditional state plan.,

"Children in an ABP get less"

False. EPSDT applies to children in an ABP as a wrap-around, covering any medically necessary service to correct or ameliorate a condition found through screening.

"Georgia uses ABPs broadly"

False. Georgia has not adopted full expansion. ABP-like coverage in Georgia is limited to Pathways to Coverage, which runs under Section 1115 authority.

"If Georgia expanded, current enrollees would lose benefits"

False. Existing enrollees in traditional categories keep the standard state plan benefit package. The ABP would apply to the new adult group created by expansion, and the Section 1937 exemptions protect vulnerable groups.

Practical Guidance for Georgia Families

Find out which package applies to you. Most Georgia enrollees in traditional categories (children, pregnant women, and aged, blind, or disabled adults) receive the standard state plan benefit package, not an ABP. Pathways participants receive an ABP-like package.

If you are on Pathways, keep up your activity reporting at renewal through Georgia Gateway, and ask about good-cause exemptions if illness or caregiving keeps you from meeting the requirement.

If a service is denied or limited, you can appeal. Ask the Georgia Department of Community Health (DCH) Office of Appeals for a state fair hearing, and for a prescription drug use the formulary exceptions process to request a non-preferred medication based on medical necessity. If you think a behavioral health limit is stricter than the comparable medical or surgical limit, say so in that appeal and ask your care management organization for the parity analysis behind the limit, since plans that impose non-quantitative treatment limitations on mental health and substance use disorder benefits must perform and document a comparative analysis of each one.

If you have a child in an ABP, you can request any medically necessary service under EPSDT's correct-or-ameliorate standard, and appeal a denial through a state fair hearing.

If you may be medically frail or disabled, ask the Georgia Division of Family and Children Services (DFCS) about an ABD Medicaid application, or contact the Social Security Administration at 1-800-772-1213 about a disability determination.,

Where to Get Help

Georgia Medicaid Member Services (DCH) Verify your benefit package and check what your coverage includes. 1-866-211-0950https://www.gabar.org/about-the-bar/contact-us dch.georgia.gov
Georgia DFCS Customer Service Apply for Medicaid, including aged, blind, or disabled (ABD) coverage. 1-877-423-4746https://dhs.georgia.gov/contact
Social Security Administration Request a disability determination for ABD Medicaid. 1-800-772-1213https://www.medicare.gov/basics/get-started-with-medicare/sign-up/how-do-i-sign-up-for-medicare
Georgia Legal Services Program Free legal help appealing a denial or coverage limit. 404-377-0701 glsp.org
HealthCare.gov Screening and enrollment help if you fall outside Medicaid. 1-800-318-2596

Frequently Asked Questions

What is a Georgia Medicaid Alternative Benefit Plan?

A Georgia Medicaid Alternative Benefit Plan (ABP) is a benefit package authorized by Section 1937 of the Social Security Act that a state delivers using a commercial-insurance benchmark instead of the traditional Medicaid state plan. Every ABP must cover the ten Essential Health Benefits, meet mental health parity, and preserve EPSDT for children.

What are the ten Essential Health Benefits?

They are ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

Who is exempt from mandatory ABP enrollment?

Federal law exempts pregnant women required to be covered, people eligible on the basis of blindness or disability, dual eligibles, the terminally ill in hospice, the medically frail, people needing long-term care, and several other groups. They must be offered the standard state plan benefit package.

Does Georgia use Alternative Benefit Plans?

Not broadly. Georgia has not adopted full ACA Medicaid expansion. Its Pathways to Coverage program uses an ABP-like benefit structure under Section 1115 demonstration authority for adults up to 100% of the federal poverty level who complete 80 hours a month of qualifying activities.

Do children in an ABP get full coverage?

Yes. Children under 21 receive EPSDT as a wrap-around, so any medically necessary service to correct or ameliorate a condition found through screening is covered, even if it is not otherwise in the ABP benefit package.

Learn More

MedicaidGeorgia Pathways to CoverageGeorgia Pathways to Coverage in 2026: who qualifies at 100 percent of FPL, the 80-hour monthly activity rule, and reporting at application and annual renewal. MedicaidGeorgia Medicaid Eligibility and Income LimitsGeorgia Medicaid income limits in 2026: the $994 ABD limit, $2,982 long-term-care cap, $2,000 asset limit, Miller Trust, CSRA, and Pathways to Coverage. MedicaidGeorgia Medicaid Covered ServicesWhat Georgia Medicaid covers in 2026: hospital and doctor visits, prescriptions, dental, behavioral health, long-term care, and EPSDT for children. MedicaidGeorgia Medicaid Mental Health ParityGeorgia MHPAEA explained: how the 2016 Medicaid parity rule protects mental health and SUD coverage, the most common violations, and how to file a complaint. MedicaidGeorgia Medicaid Children and EPSDTHow Georgia Medicaid covers children under 21 through EPSDT in 2026: who qualifies, the care kids get that adults cannot, PeachCare limits, and how to appeal. MedicaidGeorgia Medicaid Section 1115 DemonstrationsGeorgia runs two Medicaid Section 1115 demonstrations: Pathways to Coverage (100% FPL, 80-hour work rule) and Planning for Healthy Babies (211% FPL).

Find personalized help understanding your Georgia Medicaid benefit package at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

BC

Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.