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 every month before Medicaid will pay for their health care. That requirement runs through a Section 1115 demonstration launched in 2023, covering adults age 19 to 64 with incomes 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. 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 Medicaid expansion that would otherwise cover this group at 138 percent of FPL.

Pathways was approved by CMS under the first Trump administration, briefly blocked under the Biden administration, restored after litigation, and finally launched after a redesigned implementation plan. It is operationally unique in the national Medicaid landscape. As of 2026, Georgia is the only state operating a work-requirement-based Medicaid coverage program for adults below 100 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), retroactive coverage now begins on the first day of the month the application is received, and the previously approved premiums and Member Reward Accounts were dropped before they were ever charged. This guide explains the legal authority, the eligibility framework, the qualifying activity and reporting rules, the covered services, what happens when a participant fails to comply, how to appeal a denial or termination, and the broader policy debate about whether Pathways is achieving its stated goals.

Federal and Georgia Authority

Pathways exists under Section 1115 demonstration authority and is operationalized through Georgia DCH policy and Georgia Gateway technical infrastructure.

Federal Authority

• Section 1115 of the Social Security Act, codified at 42 USC 1315 (the primary demonstration authority)
• 42 USC 1396a(a)(10) (statutory eligibility groups, which Pathways modifies via waiver)
• 42 USC 1396a(a)(17) (comparability of services, waived)
• 42 USC 1396a(a)(1) (statewideness, waived to limit Pathways to specific geographic implementation if needed)
• 42 USC 1396a(a)(23) (freedom of choice of provider, waived to require managed care)
• 42 USC 1396a(a)(34) (3-month retroactive coverage, waived)
• 42 CFR 431.400-431.428 (Section 1115 demonstration approval and evaluation procedures)
• 42 CFR 435 Subpart J (eligibility determination procedures, modified by Pathways)

Georgia Authority

• O.C.G.A. Title 49 Chapter 4 (Public Assistance, including Medicaid administration)
• Georgia Pathways Section 1115 Demonstration Application (CMS approval document; original approval October 2020; modified approval after litigation; current operations effective 7/1/2023)
• DCH Pathways Policy Manual (operational procedures)
• Georgia Gateway Operating Procedures (electronic reporting and verification infrastructure)
• Georgia Families Provider Manual (CMO-level operations for Pathways enrollees)

Litigation History

• October 2020: CMS approval under the first Trump administration
• December 2021: CMS rescission under the Biden administration based on the Becerra v. Cochran framework, which questioned whether work requirements furthered Medicaid program objectives
• August 2022: Federal District Court for the Northern District of Georgia ruled in favor of Georgia, allowing Pathways to proceed
• April 2023: CMS issued a modified approval allowing Georgia to proceed with the work-requirement structure
• July 1, 2023: Pathways launches
• September 25, 2025: CMS approves an extension continuing the demonstration through December 31, 2026, with eased rules effective October 1, 2025 (reporting only at application/renewal, a new qualifying activity, retroactive coverage to the first of the application month, and premiums/Member Reward Accounts dropped)

Pathways is the only work-requirement Medicaid demonstration currently operating after the Biden administration rescinded similar demonstrations in Arkansas, Kentucky, New Hampshire, and other states.

Eligibility

Pathways eligibility has four parts: demographic, income, categorical, and procedural.

Demographic Eligibility

• Age 19 to 64 at time of application
• Georgia resident
• U.S. citizen or qualified non-citizen (LPR, refugee, asylee, certain other categories)

Income Eligibility

• At or below 100 percent of the federal poverty level (about $1,330 per month for an individual in 2026; the exact figure updates each year when the federal poverty guidelines are published)
• Income is calculated using MAGI methodology under 42 USC 1396a(e)(14), with 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 SSA disability determination
• Not eligible for 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)

There is no premium. The premiums originally approved for Pathways were dropped effective October 1, 2025 before any were charged.

The 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.

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. For example, part-time work hours and community service hours can be combined.

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 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

Premiums (Dropped)

Pathways has no premium. The Section 1115 approval originally authorized income-based monthly premiums and Member Reward Accounts, but Georgia never charged them, and CMS approval of the extension on September 25, 2025 dropped both effective October 1, 2025.

Earlier guidance described a premium scaled to income across tiers near 100 percent of FPL. That structure is no longer in effect. If you see a premium notice or are asked to pay a Pathways premium, contact DCH Member Services at 1-866-211-0950 to confirm, because no premium is currently charged.

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.

Reporting Process

1. Log in to Georgia Gateway
2. Navigate to Pathways qualifying-activity reporting
3. Enter qualifying activity hours by category (employment, training, education, vocational rehab, community service, parent/guardian of a Medicaid-enrolled child under 6)
4. Upload supporting documentation (pay stubs, letters, schedules)
5. Affirm under penalty of perjury

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

Covered Services

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 fiscal agent and member contact center, not the statewide pharmacy benefit manager.)
• 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:

• 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.

Retroactive Coverage

Standard Medicaid provides retroactive coverage up to 3 months prior to the application date under 42 USC 1396a(a)(34). 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.

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. By contrast, an applicant under standard Medicaid (e.g., a parent or pregnant woman) could receive retroactive coverage reaching up to 3 months back.

Enrollment Reality

The Georgia legislature projected enrollment significantly higher than actual first-year results. Actual enrollment has been substantially lower than projected.

Enrollment Numbers Through 2024

Enrollment grew slowly after launch but remained well below original projections 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).

Comparison: Pathways vs. ACA Medicaid Expansion

Worked Examples

Example 1: Mr. Foster, 32, Part-Time Work

Facts: Mr. Foster, 32, single, no children. Works 30 hours/week at a coffee shop ($1,200/month). Lives with parents in DeKalb County. No other Medicaid eligibility (not parent, pregnant, disabled, elderly).

Eligibility:

• Income: $1,200/month; approximately 90 percent of FPL, below the 100 percent limit (about $1,330/month for one person in 2026)
• Activity: 30 hours/week x 4.3 weeks is roughly 130 hours/month, well above the 80-hour requirement
• No premium (premiums were dropped effective October 1, 2025)
• Approved

Ongoing process:

• Documents qualifying activity hours through Georgia Gateway at application and at annual renewal
• No premium due
• Coverage continues

Example 2: Ms. Jackson, 45, Mixed Activity

Facts: Ms. Jackson, 45, single, no children. Works part-time at a retail store (30 hours/month, $400/month earnings). Volunteers at a food bank 50 hours/month. Total income $400/month (about 32 percent of FPL).

Eligibility:

• Income: 32 percent of FPL, well below 100 percent
• Activity: 30 hours work plus 50 hours community service equals 80 hours, which meets the monthly requirement exactly
• No premium applies (premiums were dropped effective October 1, 2025)
• Approved

Ongoing process:

• Documents work hours plus community service hours at application and at annual renewal
• Documentation: pay stubs + food bank letter on letterhead
• No premium due
• Coverage continues

Example 3: Mr. Patel, 28, Lost Job Mid-Month

Facts: Mr. Patel, 28, single, no children. Met the 80-hour qualifying activity requirement for the first 4 months on Pathways. Laid off on the 15th of month 5. Could not find new work that month.

Eligibility:

• Month 5 activity: well below the 80-hour requirement
• DCH issues non-compliance notice
• Cure period begins

Cure options:

• Document substitute qualifying activity (community service or job training) during the cure period to reach 80 hours for month 5
• Submit medical or hardship exemption documentation if applicable
• Explain the gap with documentation of job search efforts (DCH discretion; not a guaranteed exemption)

Outcome:

• If cured: enrollment continues
• If not cured: disenrolled end of month 6; can reapply with documentation of qualifying activity

How to Appeal a Denial or Termination

If denied initial eligibility or terminated for non-compliance:

1. File a State Hearing request with the Office of State Administrative Hearings (OSAH) at 1-404-651-7500 by the deadline on the notice
2. Request aid pending promptly if the action is a termination or reduction of existing coverage
3. Gather documentation: notice, application records, activity documentation
4. Free legal help available through Georgia Legal Services Program at 1-833-457-7529, Atlanta Legal Aid at 1-404-524-5811, or community legal organizations

The OSAH ALJ reviews the case and issues a decision. Federal review under 42 CFR 431.220 is rare but possible.

The Future of Pathways

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

• Far below enrollment projections
• Administrative cost per enrollee is high relative to coverage delivered
• Work requirements create administrative burden that suppresses eligible-population enrollment
• ACA expansion would cover 50 to 100 times more adults at lower per-enrollee administrative cost
• The Section 1115 waiver requires renewal; future federal administrations may rescind

What Could Change

• Georgia could adopt full ACA expansion (would require legislative action)
• DCH could further modify Pathways operational rules (the October 1, 2025 changes already eased reporting, added a qualifying activity, and dropped premiums)
• The current Section 1115 extension runs through December 31, 2026 and would require another renewal to continue beyond that date
• 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

For free legal help with a Pathways case, contact Georgia Legal Services Program at 1-833-457-7529 or Atlanta Legal Aid at 1-404-524-5811. For more on the broader Georgia Medicaid framework see brevy.com's guides at /medicaid/georgia/eligibility-income-limits and /medicaid/georgia.

Learn More

• Georgia Medicaid Eligibility and Income Limits
• How to Apply for Georgia Medicaid
• Georgia Medicaid Managed Care Plans
• Georgia Section 1115 Demonstrations
• Georgia Medicaid Pregnancy Coverage
• Georgia Medicaid Overview

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.