Georgia Pathways to Coverage 2026: 80-Hour Rule and Reporting

Georgia is the only state in the country that makes adults prove 80 hours of work, school, or volunteering before Medicaid will pay for their health care. That requirement runs through Georgia Pathways to Coverage, a Section 1115 demonstration launched July 1, 2023 that covers adults age 19 to 64 with household income at or below 100 percent of the federal poverty level (about $1,330 per month for one person in 2026) who complete at least 80 hours of qualifying activity each month and report it through Georgia Gateway.1,2 It is the only Medicaid coverage pathway for non-elderly, non-pregnant, non-disabled adults in Georgia who do not have minor children, because Georgia did not adopt the full Affordable Care Act (ACA) Medicaid expansion that would otherwise cover this group at 138 percent of FPL.

CMS approved an extension on September 25, 2025 that continues the demonstration through December 31, 2026, and effective October 1, 2025 Georgia eased several rules: members now report their qualifying activity only at application and at annual renewal rather than every month, a new qualifying activity was added (being a parent or legal guardian of a child under age 6 who is enrolled in Medicaid), and retroactive coverage now begins on the first day of the month the application is received. The same change set requires Pathways members to pay a copayment for certain services, except that copayments are not charged for members under age 21.1

Where Georgia Pathways to Coverage Comes From

Georgia Pathways to Coverage operates under a Section 1115 demonstration, the federal authority that lets the U.S. Department of Health and Human Services (HHS) approve time-limited Medicaid experiments. Through that waiver, Georgia is allowed to cover a group standard Medicaid would not (low-income adults without minor children) while attaching a qualifying-activity requirement that ordinary Medicaid does not permit.1 The program is run day to day by the Georgia Department of Community Health (DCH) through the Georgia Gateway eligibility system.

The waiver was first approved in 2020, withdrawn during a later federal review, restored after Georgia won a federal lawsuit, and launched on July 1, 2023. Pathways is currently the only work-requirement-based Medicaid coverage program operating in the country, after federal officials rescinded similar demonstrations in other states.

Who Qualifies for Georgia Pathways to Coverage

Pathways is built for working-age adults, not seniors. If you are checking coverage for a parent or relative who is 65 or older, or who has a disability determination, Pathways does not apply to them, and they would instead use Georgia's aged, blind, and disabled (ABD) Medicaid or a Medicare pathway. Eligibility has four parts: demographic, income, categorical, and procedural.

Demographic Eligibility

• Age 19 to 64 at the time of application1
• Georgia resident
• U.S. citizen or qualified non-citizen (lawful permanent resident, refugee, asylee, and certain other categories)

Income Eligibility

• At or below 100 percent of the federal poverty level. For 2026 the federal poverty guideline is $15,960 a year (about $1,330 a month) for one person and $27,320 a year for a household of three; the figure updates each January when HHS publishes new guidelines.2
• Income is counted using the Modified Adjusted Gross Income (MAGI) method, with the adjustments specified in the Pathways demonstration approval.

Categorical Eligibility

The applicant must NOT be eligible for any other Medicaid category:

• Not a parent or caretaker of a minor child
• Not pregnant
• Not 65 or older
• Not eligible for ABD (aged, blind, disabled) Medicaid based on a Social Security Administration (SSA) disability determination
• Not eligible for Long-Term Care (LTC) Medicaid
• Not eligible for any Medicare Savings Program (MSP) standalone

Applicants who are eligible for ABD, LTC, or who become parents during enrollment transition to the appropriate Medicaid category rather than remaining in Pathways.

Procedural Eligibility

Pathways adds procedural requirements not found in standard Medicaid:

1. 80 hours of qualifying activity each month
2. Reporting of that activity through Georgia Gateway at application and at annual renewal (the monthly-reporting requirement was removed effective October 1, 2025)

The 80-Hour Qualifying Activity Requirement

The applicant or enrollee must complete at least 80 hours of qualifying activity each month. As of October 1, 2025, that activity is documented at application and at annual renewal rather than reported every month.1

What Counts as Qualifying Activity

• Employment (W-2 wages, 1099 self-employment, or salary)
• On-the-job training through a recognized employer training program
• Job training programs through an approved vocational organization
• Enrollment in higher education at an accredited college or university (typically full-time or half-time student status converts to qualifying hours)
• Vocational rehabilitation through the Georgia Vocational Rehabilitation Agency or Roosevelt Warm Springs
• Community service at an approved nonprofit, religious organization, or government agency
• Being a parent or legal guardian of a child under age 6 who is enrolled in Medicaid (added effective October 1, 2025)

Documentation Requirements

For employment:

• W-2 pay stubs showing hours worked
• Employer letter on letterhead confirming hours
• 1099 records plus time logs (for self-employment)

For training or education:

• Enrollment verification from the institution
• Class schedule showing contact hours
• Tuition receipts

For vocational rehab:

• VR case manager attestation
• Program enrollment documentation

For community service:

• Letter from the approved organization on letterhead documenting hours
• Volunteer time log signed by the organization representative

Combined Activities

Hours from different qualifying activities can be combined to reach the 80-hour monthly total.

Exemptions From the Hour Requirement

• Documented temporary medical incapacity (with physician documentation)
• Caregiver of someone in their household with significant medical needs
• Documented enrollment in a substance use disorder (SUD) treatment program
• Pregnancy (but pregnant applicants typically qualify for pregnancy Medicaid instead and exit Pathways)
• Other case-by-case exemptions documented under DCH policy

What Pathways Costs: Copayments

Pathways does not charge a monthly premium. Effective October 1, 2025, however, Pathways members are required to pay a copayment for certain services. Copayments are not charged for Pathways members under age 21.1

A copayment is an out-of-pocket amount you pay at the point of care (for example, a set dollar amount for a doctor visit or a prescription), not a monthly bill you must pay to keep coverage. Because the specific copayment amounts and the services they apply to can change, confirm what you owe with your Georgia Families care management organization (CMO) or with DCH Member Services at 1-866-211-0950 before assuming a charge. If you are billed for something you do not believe you owe, ask the CMO to itemize the charge in writing.3

Reporting Qualifying Activity Through Georgia Gateway

Effective October 1, 2025, Pathways enrollees report their qualifying activity through Georgia Gateway at gateway.ga.gov at application and at annual renewal, not every month. Members are no longer required to submit a monthly report.1

Reporting Process

Reporting Schedule

As of October 1, 2025, reporting is required at application and at annual renewal rather than every month. Specific deadlines are set in the enrollee's Pathways notices; report by the date shown to avoid a compliance action.

Failure to Report or Failure to Meet the Qualifying Activity Requirement

If the enrollee fails to report on time or fails to meet the qualifying activity requirement:

1. DCH issues a notice of non-compliance
2. The enrollee has a set period to cure (submit late documentation or explain the shortfall)
3. If cure is successful, enrollment continues
4. If cure is not successful, the enrollee is disenrolled effective the end of the cure period

Reasons for Non-Compliance

The most common reasons enrollees fail to comply:

• Forgot the reporting deadline
• Did not understand the requirement
• Employer would not provide hour documentation on letterhead
• Lost job mid-month and could not document substitute qualifying activity
• Technical difficulties with Georgia Gateway
• Address changes resulted in mailed notices not being received

What Pathways Covers

Pathways covers the same services as standard Georgia Medicaid, delivered through one of the three Georgia Families care management organizations (CMOs).

Services Included

• Primary care
• Specialty care
• Hospital inpatient and outpatient care
• Prescription drugs (Georgia Families CMO members get their pharmacy benefit through their CMO and its pharmacy benefit manager; the fee-for-service population uses OptumRx, the PBM for Georgia Medicaid's FFS outpatient pharmacy program, per DCH. Gainwell Technologies is Georgia's GAMMIS (Georgia Medicaid Management Information System) fiscal agent and member contact center, not the statewide pharmacy benefit manager.)4
• Behavioral health and substance use disorder treatment
• Family planning
• Maternity care (if pregnancy occurs during enrollment, the enrollee typically transitions to pregnancy Medicaid)
• Dental and vision (limited; varies by CMO)
• Transportation to medical appointments (non-emergency medical transportation)
• Preventive care and screenings

NOT Covered

• Long-Term Care (Pathways enrollees who develop LTC needs transition to a different Medicaid category)
• Services Medicare covers (Pathways enrollees who become Medicare-eligible transition to dual-eligibility under a different framework)

CMO Choice

Pathways enrollees select from the three Georgia Families CMOs within the enrollment window after approval:5

• Amerigroup Community Care (Elevance): 1-800-600-4441
• CareSource Georgia (nonprofit): 1-855-202-0729
• Peach State Health Plan (Centene): 1-800-704-1484

The Georgia Families roster can change as the state's managed care contracts are reprocured, so confirm your plan options with DCH before you choose. Auto-assignment by default algorithm if no choice is made.

Does Coverage Reach Back Before You Applied?

Standard Medicaid can provide retroactive coverage for up to 3 months before the application date. Pathways does not provide that full 3-month look-back. Effective October 1, 2025, however, Pathways coverage begins on the first day of the month in which the application is received, so qualifying medical expenses from earlier in the application month can be covered.1

This is still a practical limitation. An applicant who incurs medical expenses in the months before the application month cannot have those earlier expenses paid by Pathways.

Why Pathways Enrollment Runs Low

The Georgia legislature projected enrollment significantly higher than actual first-year results.

Enrollment Numbers Through 2024

Quarterly enrollment data is published by DCH and tracked by KFF's Pathways monitoring. By the end of 2024, total enrollment remained in the low thousands.

• 2025 (rolling enrollment): Modest continued growth

Why Enrollment Is Low

Researchers, advocacy organizations, and policy analysts have identified several factors:

• Administrative burden of the qualifying-activity rules discourages eligible adults from completing the application or from maintaining enrollment (the monthly-reporting requirement that drove much of this burden was removed effective October 1, 2025)
• Employer education gaps: many small employers do not understand the documentation requirements or are reluctant to provide letters on letterhead
• Limited outreach budget compared to states that adopted full ACA expansion
• Confusion between Pathways and traditional Medicaid at the application level
• Technology challenges with Georgia Gateway, particularly for applicants without reliable internet
• Stigma and political concerns that discourage some eligible adults from applying

What This Means

Pathways was designed to cover a population similar to what would be covered under ACA Medicaid expansion in Georgia. It has covered a small fraction of that population in its first 18 months. The remaining majority of the would-be expansion population remains uninsured or seeks coverage through subsidized Affordable Care Act marketplace plans (which require income at least at 100 percent of FPL to qualify for premium tax credits in non-expansion states).

How Georgia Pathways to Coverage Compares to ACA Medicaid Expansion

The table below lines up the two coverage routes side by side, so you can see exactly where Pathways is narrower than full expansion.1

How the Hour Math Works

These two scenarios are illustrative only; they are not real people, and the numbers describe how the rules apply, not promised outcomes.

Combining activities to reach 80 hours

Someone who works part-time but not quite 80 hours a month can add an approved activity to make up the difference. For example, 30 hours of paid work plus 50 hours of volunteering at an approved nonprofit equals exactly 80 hours, which meets the requirement. As long as household income stays at or below 100 percent of the federal poverty level and the applicant has no other Medicaid route, this person qualifies.2 At each checkpoint they document both the work hours (pay stubs) and the volunteer hours (a letter on the organization's letterhead) through Georgia Gateway.

Losing a job mid-year

Someone who met the 80-hour requirement, then lost their job, faces a non-compliance action if their activity drops below 80 hours when a checkpoint comes due. DCH issues a notice and opens a cure period. During the cure period the member can document substitute qualifying activity (community service or job training) to reach the hours, submit a medical or hardship exemption if one applies, or explain the gap. If they cure, coverage continues; if they do not, coverage ends at the close of the cure period, and they can reapply once they can document qualifying activity again.

How to Appeal a Denial or Termination

If denied initial eligibility or terminated for non-compliance, here is the path to challenge it.

The Future of Pathways

The current Section 1115 demonstration is approved only through December 31, 2026, so the program's future turns on whether it is renewed.1 The political and policy debate about Pathways continues in 2026.

Arguments For Pathways

• Provides Medicaid coverage to a population that would otherwise be uninsured (since Georgia has not adopted ACA expansion)
• Work requirements may encourage workforce engagement
• Lower fiscal cost to Georgia than full ACA expansion

Arguments Against Pathways

• Enrollment has run far below the state's original projections
• Administrative cost per enrollee is high relative to the coverage delivered
• The qualifying-activity rules create administrative burden that suppresses enrollment among otherwise-eligible adults
• Full ACA expansion would cover a much larger share of the low-income adult population at lower administrative cost per enrollee
• The Section 1115 waiver must be renewed to continue past December 31, 2026, and a future federal administration could decline to renew it

What Could Change

• Georgia could adopt full ACA expansion (would require legislative action)
• DCH could further modify Pathways operational rules
• A future federal administration could rescind the Section 1115 waiver under the precedent that work requirements do not further Medicaid program objectives
• Pathways could be expanded to 138 percent of FPL

How to Verify the Numbers

• Section 1115 demonstration documents: medicaid.gov
• Pathways Policy Manual: dch.georgia.gov
• Federal poverty level guidelines: aspe.hhs.gov
• Enrollment numbers: DCH quarterly reports and KFF Pathways tracking
• Application: gateway.ga.gov

Learn More

Find personalized help navigating Georgia Pathways to Coverage 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.