Georgia Medicaid Section 1115 Demonstrations (2026): Pathways and P4HB

Section 1115 of the Social Security Act is one of the most consequential and least-understood Medicaid mechanisms. Section 1115 gives the Secretary of Health and Human Services broad authority to approve state demonstration projects that waive or modify Medicaid program requirements to test innovative service delivery, eligibility, or financing arrangements. Almost every distinctive state Medicaid feature in the country exists because of Section 1115 demonstration authority. California's CalAIM, New York's Medicaid Redesign Team, Tennessee's TennCare, Massachusetts's MassHealth, Indiana's HIP, Oklahoma's SoonerCare, and many others all rely on Section 1115. Georgia operates two active Section 1115 demonstrations: Pathways to Coverage, a partial Medicaid expansion that covers low-income adults who satisfy a qualifying-activity requirement, and Planning for Healthy Babies (P4HB), which provides family planning services and interpregnancy care to low-income women of reproductive age.

Each demonstration has its own statutory authority, eligibility rules, benefit package, cost sharing structure, operational mechanics, evaluation requirements, and history. Each interacts with the broader Georgia Families managed care framework. Each has been shaped by federal litigation, CMS approval cycles, state legislative decisions, and operational experience over years of implementation.

This guide translates the Section 1115 framework for Georgia families and stakeholders. It covers how Section 1115 authority works, the federal regulatory framework, budget neutrality and Special Terms and Conditions, the Pathways to Coverage demonstration in operational detail (population, qualifying activities, member reporting, redetermination, benefits), the Planning for Healthy Babies demonstration in operational detail (Family Planning Only and Interpregnancy Care groups, benefits), the work-requirement litigation history and its implications for Pathways, examples from other states to provide context, and worked scenarios for Georgia families. A frequently asked questions section addresses the most common questions families ask. A contact directory provides the phone numbers needed to apply, report hours, request a redetermination, or appeal a denial.

How Georgia Medicaid Section 1115 authority works

Statutory authority

Section 1115 of the Social Security Act has two distinct authorities that the Secretary of HHS exercises in approving state demonstrations:

Section 1115 waiver authority allows the Secretary to waive compliance with provisions of the standard Medicaid state plan. The state plan requirements include statewideness (the program must operate uniformly throughout the state), comparability of benefits (eligible individuals in similar circumstances must receive comparable benefits), freedom of choice of provider, and many other foundational rules. A state can waive any of these requirements through Section 1115 waiver authority if the waiver is necessary to enable the state to carry out a demonstration project that is likely to assist in promoting the objectives of federal Medicaid law.

Section 1115 expenditure authority allows the Secretary to authorize federal financial participation for expenditures that would not otherwise qualify as expenditures under the state plan. This authority is used to cover populations or services not authorized under state plan rules. P4HB, for example, relies heavily on expenditure authority because it covers a benefit package and a population that would not be authorized under the state plan.

The Secretary's authority is conditional. The Secretary may grant a demonstration only when the demonstration is "likely to assist in promoting the objectives" of federal Medicaid law. Federal courts have interpreted this requirement to mean that the Secretary must consider the demonstration's impact on coverage and on the Medicaid program's core objective of furnishing medical assistance to low-income individuals. The Secretary cannot approve a demonstration that would substantially reduce coverage without adequately analyzing and justifying that reduction.

Regulatory framework

CMS implements Section 1115 through implementing regulations. The framework establishes the procedures and requirements that govern every demonstration's lifecycle.

State public notice rules require the state to publish a public notice on its Medicaid website with a defined period for public comment before submitting a demonstration application to CMS. The state must hold multiple public hearings in different parts of the state. The state must consult with federally recognized Indian tribes located in the state through tribal consultation processes. The public notice must describe the proposed demonstration including eligibility, benefits, cost sharing, delivery system, and budget neutrality.

Application requirements specify the content of the demonstration application. Required components include a comprehensive description of the demonstration, eligibility and enrollment, benefits and cost sharing, delivery system, demonstration financing including budget neutrality calculations and projections, evaluation design, and other operational details.

CMS review establishes the CMS process for reviewing and approving demonstration applications including review timelines, opportunities for state-CMS negotiation, and federal interagency coordination.

Monitoring requires the state to submit quarterly and annual reports to CMS on demonstration operations. Monitoring metrics are specified in the Special Terms and Conditions.

Evaluation requires each demonstration to have an independent evaluation conducted by a contracted external evaluator. The evaluation must include a research design with specific hypotheses, data collection, analysis, and reporting. Mid-point evaluation reports are due partway through the demonstration period. Final summative evaluation reports are due at the end.

Annual reports require the state to submit detailed annual reports describing operations, progress on goals, challenges, and proposed improvements.

Post-approval changes require public notice for substantive amendments to an approved demonstration and for extension requests.

Budget neutrality

Budget neutrality is the binding operational constraint on Section 1115 demonstrations. CMS will not approve a demonstration that costs the federal government more over the demonstration period than the program would have cost without the demonstration. The budget neutrality framework requires:

• Estimates of expenditures with and without the demonstration
• Projection of caseload and per capita costs under both scenarios
• Identification of savings that offset new expenditures
• A specific budget neutrality cap that limits total federal expenditures over the demonstration period

Budget neutrality calculations are technically complex and involve both prospective projections at approval and retrospective reconciliation during and after the demonstration period. The federal Office of the Actuary at CMS reviews state budget neutrality projections.

Special Terms and Conditions (STCs)

When CMS approves a demonstration, it issues a Special Terms and Conditions document that becomes the operating contract between CMS and the state. STCs cover:

• Eligibility groups including specific income limits, asset rules, and qualifying conditions
• Benefits and cost sharing including covered and excluded services, premium and copayment amounts and structures, and beneficiary protections
• Delivery system including managed care arrangements, provider network requirements, and quality standards
• Evaluation design including specific hypotheses, data sources, methodology, and reporting
• Reporting obligations including quarterly and annual reports, evaluation reports, and specific monitoring metrics
• Budget neutrality including projected expenditure caps and reconciliation processes
• Other operational rules unique to the specific demonstration

STCs are updated through amendments over the demonstration period.

Demonstration terms and extensions

Section 1115 demonstrations are typically approved for an initial multi-year term. Extensions can run several additional years depending on the demonstration type and CMS approach. Extensions require updated public notice, tribal consultation, updated budget neutrality projections, and CMS review. Many large state demonstrations have been continuously operated and extended for decades, with substantive changes through amendments.

Independent evaluation

Independent evaluation is a foundational requirement. The state contracts with an external evaluator (typically an academic research institution, evaluation firm, or research organization) who conducts the evaluation according to a CMS-approved evaluation design. Mid-point and final evaluations are public documents posted on the CMS and state Medicaid agency websites. Evaluation results inform CMS decisions on extension, amendment, and broader policy direction.

CMS modification and termination authority

CMS retains authority to modify or terminate a demonstration if the state fails to comply with STCs, if the demonstration is not promoting federal Medicaid objectives, or if budget neutrality is breached. Termination typically follows extended noncompliance and corrective action plan failure.

Work-requirement litigation that shaped Georgia Medicaid Section 1115 demonstrations

Understanding Georgia's Pathways to Coverage demonstration requires understanding the broader work-requirement litigation history.

Background

During the Trump administration, CMS issued a State Medicaid Director Letter inviting states to apply for Section 1115 demonstrations that conditioned Medicaid eligibility on participation in work or community-engagement activities. This represented a significant policy shift. CMS subsequently approved work-requirement demonstrations from Arkansas (Arkansas Works), Kentucky (Kentucky HEALTH), Indiana (HIP), Michigan, New Hampshire, and others.

The Arkansas demonstration began implementation. Within several months, tens of thousands of Arkansas Medicaid enrollees lost coverage due to failure to satisfy or report on the work requirement.

Stewart v. Azar (Kentucky HEALTH)

The Stewart v. Azar litigation challenged the CMS approval of Kentucky's work-requirement demonstration. The plaintiffs, individuals who would lose coverage under the demonstration, argued that the Secretary's approval was arbitrary and capricious under the Administrative Procedure Act because the Secretary failed to adequately consider the demonstration's impact on the core Medicaid objective of providing health coverage to low-income individuals.

The U.S. District Court for the District of Columbia vacated the Kentucky approval. The court held that the Secretary failed to adequately consider how the demonstration would affect Medicaid's core objective of furnishing medical assistance. The court rejected the government's argument that promoting "health" through work requirements was a sufficient Medicaid objective without consideration of coverage loss. The court held that the Medicaid statute's core objective is furnishing medical assistance, not promoting work, and the Secretary's approval analysis was inadequate.

Gresham v. Azar (Arkansas Works)

In Gresham v. Azar, the same district court vacated the Arkansas approval on similar grounds. By the time of the Arkansas ruling, tens of thousands of Arkansas Medicaid enrollees had lost coverage due to the work requirement. The court's analysis emphasized that the Secretary's approval did not adequately address:

• Coverage loss and the impact on individuals who lost coverage
• Costs to the state of administering the requirement
• Operational complexities and beneficiary burden
• The mismatch between the policy and the population (most Medicaid enrollees who could work were already working)

D.C. Circuit affirmation

The U.S. Court of Appeals for the D.C. Circuit affirmed both district court decisions in a unanimous opinion. The D.C. Circuit emphasized that the Medicaid statute's core objective is furnishing medical assistance, that the Secretary must consider the coverage impact of any demonstration approval, and that approval of work requirements without adequate coverage-impact analysis is arbitrary and capricious.

Aftermath

Following Stewart and Gresham, several pending work-requirement applications were withdrawn or modified. Other approvals were paused or implementation suspended. The Biden administration's CMS withdrew approval letters for work requirements in multiple states and signaled disapproval of new work-requirement applications.

How Pathways is different

Georgia's Pathways to Coverage demonstration was approved by the Trump administration's CMS in late 2020 and is distinct from the vacated Arkansas and Kentucky demonstrations in several ways:

• Pathways is not a full Medicaid expansion. It is a partial expansion that does not adopt the full income ceiling available under the ACA's full expansion option.
• The work requirement is structured as a condition of eligibility for a new coverage category, not as a requirement imposed on an already-eligible population.
• Georgia argued, and the federal district court accepted, that Pathways provides coverage to an otherwise uncovered population (the coverage gap) and therefore promotes federal Medicaid objectives even with the work requirement.

The Biden administration's CMS attempted to rescind portions of the Pathways approval (specifically the work requirement and the originally approved premiums). Georgia challenged the rescission in federal court. The U.S. District Court for the Southern District of Georgia ruled in favor of Georgia, holding that CMS's rescission was arbitrary and capricious. The court reinstated the original Pathways approval, including the work requirement.

Pathways launched on July 1, 2023 following the favorable district court ruling. CMS approved an extension of the demonstration on September 25, 2025, continuing the program through December 31, 2026.

Pathways to Coverage in operational detail

Population

Pathways to Coverage covers adults in a defined working-age range with household income up to the program's income ceiling (approximately the federal poverty level for a single individual; consult Georgia Gateway for current figures) who satisfy qualifying activity requirements. The population excludes adults who already qualify for Medicaid under another category. Excluded populations include:

• Parents and caretaker relatives qualifying under the parent/caretaker eligibility group up to the relevant income limit
• Pregnant women qualifying under Pregnancy Medicaid
• Individuals with disabilities qualifying under SSI-related Medicaid
• Individuals receiving SSI
• Adults qualifying under any other Medicaid eligibility group

Qualifying activities

To enroll in Pathways and to maintain coverage, the individual must complete at least 80 hours per month of qualifying activity. The 80-hour monthly threshold has not changed. Qualifying activities include:

• Employment (paid or unpaid; full-time, part-time, or self-employment)
• Job training, including on-the-job training and registered apprenticeships, plus job readiness activities such as job search, resume preparation, interview preparation, and structured workforce development programs
• Education including post-secondary education (degree-seeking or credential-seeking at an accredited institution, with credit hours converted to qualifying activity hours under STC rules)
• Volunteering or community service with qualifying nonprofit organizations
• Being the parent or legal guardian of a child under age 6 who is enrolled in Medicaid. Georgia added this qualifying activity effective October 1, 2025.
• Vocational rehabilitation through Georgia Vocational Rehabilitation or other authorized programs

Activities must be verifiable through documentation. Employment is verified through employer payroll records, pay stubs, or tax records. Education is verified through school enrollment documentation. Volunteering is verified through the organization's documentation. Status as the parent or legal guardian of a Medicaid-enrolled child under age 6 is verified through documentation of the relationship and the child's Medicaid enrollment. The state may accept additional forms of verification under STC procedures.

Premiums

Pathways does not charge premiums. The original Pathways approval included monthly premiums on a sliding scale for enrollees above a lower income tier, paired with Member Reward Accounts, but Georgia never implemented those premiums and the Member Reward Accounts, and the state formally dropped them. There is no Pathways premium to pay and no premium-related disenrollment.

Cost sharing

Pathways enrollees are subject to cost sharing for certain services. Cost sharing amounts are subject to federal Medicaid cost-sharing limits as adjusted by the demonstration STCs. Common services subject to copayment include outpatient hospital visits, non-emergency emergency department visits, certain prescription drugs (typically brand-name drugs when generic alternatives are available), and certain non-preventive services.

Preventive services, family planning services, pregnancy-related care (in the event of pregnancy occurring during enrollment), and emergency services are not subject to cost sharing.

Member reporting of qualifying activities

Effective October 1, 2025, enrollees report their qualifying activities only at application and at annual renewal, through Georgia Gateway or by other DCH-approved means. Members no longer report every month. Originally, and until October 2025, Pathways required members to report qualifying activity hours each month, which was a core operational burden. Reporting now works like this:

• At application, the enrollee logs into Georgia Gateway and enters qualifying activity by category and uploads supporting documentation (pay stubs, enrollment verification, volunteer logs, proof of a parent/guardian relationship to a Medicaid-enrolled child under age 6)
• At annual renewal, the enrollee again confirms qualifying activity and uploads current documentation
• Failure to confirm qualifying activity at renewal can affect continued eligibility

Under the original monthly-reporting design, high rates of non-reporting produced high rates of coverage churn. Enrollees who were working, studying, or volunteering and could meet the qualifying-activity standard often lost coverage because they did not understand or complete the monthly reporting steps. Moving to reporting only at application and annual renewal was one of the changes Georgia made to reduce that churn.

Redetermination

Pathways enrollees complete a full redetermination at annual renewal, when they also confirm their qualifying activity.

At each annual redetermination, the enrollee must verify continued eligibility including income, household composition, and qualifying activity. Failure to complete redetermination by the deadline can trigger disenrollment.

Suspension and re-enrollment

Failure to meet qualifying activity requirements or failure to complete redetermination can trigger suspension of coverage. Suspended enrollees can re-enroll by completing the required actions:

• Documenting and confirming qualifying activity
• Completing redetermination
• Submitting a re-enrollment request

Coverage is reinstated effective the first day of the month following completion of required actions.

Benefit package

Pathways enrollees receive a comprehensive Medicaid benefit package similar to Alternative Benefit Plans under federal Medicaid law. Covered services include:

• Physician services
• Outpatient hospital services
• Inpatient hospital services
• Prescription drugs (formulary applies)
• Behavioral health including mental health and substance use disorder treatment
• Preventive services
• Family planning services
• Maternity care if pregnancy occurs during enrollment
• Emergency services
• Durable medical equipment
• Laboratory and radiology
• Other standard Medicaid benefits

Delivery system

The Pathways benefit package is delivered through the Georgia Families managed care organizations under standard Georgia Families managed care contracts. Pathways enrollees choose a CMO at enrollment or are auto-assigned. The CMO administers the benefit, manages utilization, contracts with the provider network, processes claims, and handles grievances and appeals. The Georgia Department of Community Health oversees CMO performance through the standard managed care quality framework including HEDIS measures, CAHPS surveys, quality withholds, and the EQRO Annual Technical Report.

Enrollment

Pathways enrollment has been substantially lower than initial state projections. Actual enrollment in the first year of implementation was a small fraction of the original state projections. Enrollment growth has been constrained by:

• The qualifying-activity reporting burden (originally monthly, eased to application and annual renewal effective October 1, 2025)
• Limited public awareness of the program
• Administrative complexity of the application and reporting process
• Comparison with full-expansion alternative (which Georgia has not adopted)
• Difficulty for many otherwise eligible adults in producing acceptable documentation of qualifying activity

Georgia state oversight and CMS monitoring have flagged the enrollment gap as a concern requiring corrective action. Effective October 1, 2025, Georgia eased the rules to simplify reporting and reduce administrative friction: members now report qualifying activities only at application and annual renewal rather than monthly, the previously approved-but-never-implemented premiums and Member Reward Accounts were dropped, and parents or legal guardians of a child under age 6 enrolled in Medicaid can now satisfy the qualifying-activity requirement.

Application

Applications for Pathways are submitted through Georgia Gateway, by phone at 1-877-423-4746, by mail, or in person at a county DFCS office. Applicants must submit:

• Identity and citizenship documentation
• Income documentation
• Qualifying activity documentation (employment records, school enrollment, etc.)
• Household composition information
• Other application materials standard for any Medicaid application

The Pathways application portal in Georgia Gateway includes specific Pathways-related modules for entering qualifying activity details and uploading documentation.

Effective October 1, 2025, retroactive Pathways coverage begins on the first day of the month in which the application is received, so approved applicants are covered back to the start of their application month.

Pathways customer service

The Pathways to Coverage member services line is 1-844-241-1900. The line handles enrollment questions, qualifying activity reporting support, and general Pathways inquiries.

Planning for Healthy Babies (P4HB) in operational detail

Who P4HB covers

P4HB covers women of reproductive age with household income at or below the program's income ceiling (a moderate share above the federal poverty level; consult Georgia Gateway for the current threshold). The population excludes:

• Women eligible for full Medicaid under another category (pregnant women, parents/caretakers under the parent/caretaker limit, individuals with disabilities, etc.)
• Women with other creditable coverage including employer-sponsored insurance, ACA marketplace plans, or other public coverage providing comparable family planning benefits

P4HB has two distinct enrollment groups based on the woman's prior delivery history:

• Family Planning Only: women who have not had a Medicaid-paid delivery. They receive family planning services and limited reproductive health services.
• Interpregnancy Care (IPC): women who have had a Medicaid-paid delivery and are now in the interpregnancy period. They receive expanded benefits including limited primary care for conditions that affect future pregnancies, resource case management, and treatment for select chronic conditions.

Benefits: Family Planning Only

The Family Planning Only group receives a focused family planning benefit including:

• Annual physical exam
• Contraceptive services and supplies including all FDA-approved contraceptive methods (oral contraceptives, contraceptive patches, vaginal rings, injectable contraceptives, intrauterine devices, contraceptive implants, emergency contraception, barrier methods, fertility awareness methods, and other methods)
• Sterilization including tubal ligation and other permanent contraception (with informed consent and waiting period requirements per federal Medicaid sterilization rules)
• Pregnancy testing
• Sexually transmitted infection screening and treatment
• Cervical cancer screening including Pap smear and HPV testing
• Breast cancer screening including clinical breast exam and screening mammogram referral
• Family planning education and counseling
• Preconception counseling for women planning future pregnancies

Benefits: Interpregnancy Care

The Interpregnancy Care group receives the Family Planning Only benefits plus enhanced services:

• All Family Planning Only benefits
• Limited primary care focused on chronic disease management for conditions that affect future pregnancies (hypertension, diabetes, depression, substance use disorder, obesity, asthma)
• Resource case management to address social determinants of health and connect women with community resources including WIC, housing assistance, food assistance, transportation assistance, and other services
• Treatment for hypertension, diabetes, depression, and substance use disorder
• Limited dental care
• Behavioral health services
• Smoking cessation support

P4HB Interpregnancy Care does not cover acute care services unrelated to family planning or interpregnancy care, hospital admissions other than family planning-related, or long-term services and supports.

P4HB cost sharing

P4HB has no member premiums and limited cost sharing. Most P4HB services are provided with no copayment.

How to apply for P4HB

P4HB application is submitted through Georgia Gateway alongside Medicaid and PeachCare applications. Eligibility staff determine whether the applicant qualifies for full Medicaid (under any standard category), P4HB Interpregnancy Care (if she had a Medicaid-paid delivery), P4HB Family Planning Only (if she has not had a Medicaid-paid delivery and is otherwise eligible), or no coverage. If eligible for full Medicaid, the applicant is enrolled in full Medicaid rather than P4HB.

CMO administration

P4HB enrollees are assigned to one of the Georgia Families CMOs. The CMO administers the P4HB benefit package under the DCH-CMO contract including authorization of services, claims processing, provider network management, and beneficiary services. Many P4HB services are provided through Georgia FQHCs, Title X family planning clinics, Department of Public Health county health departments, and obstetric providers.

Annual redetermination

P4HB enrollees complete a standard annual redetermination. Continuous eligibility provisions apply to certain populations.

Demonstration history

P4HB has been a Georgia Section 1115 demonstration for over a decade. It has been renewed and amended multiple times. The current Special Terms and Conditions govern operations and benefit details. P4HB is structurally similar to family planning demonstrations operated by other states including Texas Healthy Texas Women, California Family PACT (now operated under the Medi-Cal Family PACT Program), Oklahoma family planning waiver, and others.

Comparison: Pathways vs. P4HB

The two Georgia demonstrations serve very different purposes and operate on different rules.

Both demonstrations are administered through the Georgia Families managed care organizations under standard managed care contracts. Both interact with the Georgia Families quality framework including HEDIS measures, CAHPS surveys, and quality withholds. Both are evaluated under independent evaluation contracts.

Other Georgia Medicaid Section 1115 peers nationally

To understand Georgia's demonstrations in the broader context of how states use Section 1115, several other state examples are illustrative:

California CalAIM

California's California Advancing and Innovating Medi-Cal (CalAIM) is a sweeping demonstration that consolidated multiple Medi-Cal waivers, introduced Enhanced Care Management (ECM) and Community Supports (formerly Whole Person Care services), pre-release services for incarcerated individuals (under the Section 1115 reentry initiative), justice-involved population reforms, and broad delivery system transformation. CalAIM is one of the largest and most complex 1115 demonstrations in the country.

New York Medicaid Redesign Team and DSRIP

New York's Medicaid Redesign Team and the Delivery System Reform Incentive Payment (DSRIP) program funded substantial hospital and provider transformation through New York's Section 1115 authority. Subsequent New York waivers have addressed health equity, social determinants, and continued delivery system reform.

Tennessee TennCare III

Tennessee's TennCare III demonstration is a comprehensive managed care demonstration with directed payment mechanisms for hospitals and shared savings arrangements with the state.

Massachusetts MassHealth

MassHealth has been operated as a Section 1115 demonstration for decades. It covers eligibility expansions, delivery system reforms, and the Massachusetts approach to integrating Medicaid and Children's Health Insurance Program coverage.

Indiana HIP (Healthy Indiana Plan)

Indiana's Healthy Indiana Plan implements ACA expansion with premium contributions through Personal Wellness and Responsibility (POWER) Accounts, which function as health savings accounts tied to monthly contributions and cost sharing.

Arkansas Works (private option)

Arkansas's Section 1115 premium assistance demonstration uses Medicaid funds to purchase ACA marketplace plans for the expansion population, an arrangement distinct from the later vacated work-requirement demonstration.

These examples illustrate the wide range of policy choices available through Section 1115 and the substantial role the demonstration authority plays in shaping state Medicaid programs.

Worked examples: how Georgia families experience the demonstrations

Marcus, 32, Atlanta, employed full-time, Pathways through employment

Marcus is 32, lives in southwest Atlanta, and works full-time at a warehouse earning income that, on its face, sits above the program's ceiling. After Marcus's household composition is correctly counted for Medicaid purposes (his household includes only himself), his counted income is reduced by standard MAGI disregards to a level that falls just under the program's income ceiling.

Marcus enrolls in Pathways through Georgia Gateway. He provides his employer information, pay stubs, and tax records to document that he exceeds the 80-hour monthly qualifying-activity threshold through employment. His enrollment is approved.

Marcus reports his qualifying activity at application and then again at his annual renewal, uploading current pay stubs each time. Because reporting is no longer monthly, he does not have to log in every month, which removes the recurring step that used to cause many enrollees to lose coverage.

Marcus pays no Pathways premium. The program charges no premiums, so there is nothing to set up or auto-debit.

Marcus receives the standard Pathways benefit package through his assigned CMO. He uses the benefit primarily for preventive care, treatment of his chronic back pain, and prescription medications.

Marcus completes his annual redetermination by submitting updated income and employment documentation. His coverage continues.

Aisha, 24, Macon, college student, Pathways via post-secondary education

Aisha is 24, a full-time student at Mercer University in Macon enrolled in a typical full-time course load, and works part-time tutoring earning modest income. She qualifies for Pathways.

Aisha enrolls through Georgia Gateway and reports her qualifying activity as education. CMS guidance permits credit hours to count toward the 80-hour monthly requirement at a conversion rate that includes both classroom time and structured study time. With her full-time course load plus a study-time multiplier, Aisha qualifies based on education alone, and her tutoring hours provide additional cushion.

Aisha pays no premium because Pathways charges no premiums. She receives the Pathways benefit package through her CMO. She uses the benefit for student health visits at the university clinic (which is an in-network provider), mental health counseling, and a prescription for her anxiety medication.

Aisha confirms her qualifying activity at application and again at her annual renewal, providing updated enrollment verification. She no longer has to report her education hours every month.

Tonya, 38, southwest Georgia, P4HB to Pregnancy Medicaid to 12-month postpartum

Tonya is 38, lives in a southwest Georgia rural county, and is between pregnancies. She had a Medicaid-paid delivery 2 years ago for her younger child, who is now 2 years old. Tonya's income is above the standard parent/caretaker Medicaid limit but below the P4HB IPC limit.

Tonya is currently enrolled in P4HB Interpregnancy Care because she previously delivered with Medicaid. P4HB IPC provides her with annual physicals, contraception (a hormonal IUD inserted at the postpartum visit, with the IUD still in place), treatment for her gestational diabetes that has progressed to type 2 diabetes, depression screening and treatment, resource case management, and limited dental care.

When Tonya becomes pregnant again (with planned timing aligned with her IUD removal), she transitions from P4HB IPC to full Pregnancy Medicaid. Pregnancy Medicaid covers prenatal care, labor and delivery, and the postpartum period. After delivery, Tonya remains in full Medicaid for the federal 12-month postpartum period. During the 12-month postpartum period, she receives comprehensive Medicaid benefits including continued diabetes management, postpartum mental health care, and her newborn's well-child care.

After the 12-month postpartum period ends, Tonya returns to P4HB IPC because her income remains in the P4HB range and she has had a Medicaid-paid delivery.

Diana, 55, rural Albany, Pathways via community service

Diana is 55, lives in Albany, and is a full-time unpaid caregiver for her 82-year-old mother. Diana has no earned income of her own.

Diana qualifies for Pathways but must meet the 80-hour monthly qualifying-activity threshold. Volunteer caregiving for a family member does not typically count under Pathways qualifying-activity rules, and her mother is an adult, so the parent or legal guardian of a child under age 6 activity does not apply to her either. Diana enrolls in a community service program with a local nonprofit that provides services to other low-income seniors. She volunteers each week helping with meals on wheels deliveries, transportation for medical appointments, and senior center activities. The nonprofit provides Diana with a volunteer log documenting her hours.

Diana enrolls in Pathways through Georgia Gateway. No premium applies because Pathways charges no premiums. She receives the Pathways benefit package and uses it for treatment of her hypertension, arthritis, and annual screening services.

Diana documents her volunteering at application and again at her annual renewal, uploading her volunteer log as documentation. She does not have to report her hours every month.

Tyrell, 22, Atlanta, job loss, qualifying through job search, annual reporting

Tyrell is 22, lives in Atlanta, and has been enrolled in Pathways while working part-time at a fast food restaurant. He qualified easily on his employment hours at application.

His employer then closes the location and he loses his job. Tyrell spends his time looking for work. Job-search activities count as job readiness activity, which is part of the job training qualifying-activity category, so as long as he is putting in at least 80 hours per month across job search, interviews, and structured workforce development, he continues to satisfy the qualifying-activity standard.

Because reporting changed effective October 1, 2025, Tyrell does not have to file a monthly report on those job-search hours. He simply keeps documentation (records of applications submitted, interviews attended, and time spent) and confirms his qualifying activity at his annual renewal. He keeps his coverage and does not miss doctor appointments or pharmacy refills for his ADHD medication during his job search.

Under the original design, until October 2025, this same situation often ended badly: an enrollee who was in fact satisfying the qualifying-activity standard by searching for work could still lose coverage because they did not file the monthly report or did not realize job search counted. If Tyrell ever has a question about what counts or how to document it, he can call the Pathways customer service line at 1-844-241-1900. Moving from monthly reporting to confirmation only at application and annual renewal is exactly the change Georgia made to prevent this kind of avoidable coverage loss.

Sarah, 29, Augusta, P4HB IPC after Medicaid delivery

Sarah is 29, lives in Augusta, and recently delivered her first child through Medicaid Pregnancy Coverage. Sarah's 12-month postpartum coverage extends her full Medicaid for 12 months after delivery. During the 12 months, she completes her postpartum recovery, treats her postpartum depression, and begins long-acting contraception (an etonogestrel implant inserted at week 6 postpartum).

After the 12 months end, Sarah's income (from her part-time work plus her partner's income) is too high for parent/caretaker Medicaid but qualifies her for P4HB Interpregnancy Care. Sarah enrolls in P4HB IPC seamlessly with no gap in coverage.

P4HB IPC provides Sarah with continued contraception (her implant remains in place), continued treatment for her postpartum depression (now transitioning to ongoing depression management), resource case management connecting her with breastfeeding support and child care resources, and limited primary care for her postpartum thyroid condition (subclinical hypothyroidism being monitored without medication).

Sarah's child remains enrolled in full Medicaid under standard children's eligibility.

Practical guidance

How to apply for Pathways to Coverage

Visit Georgia Gateway or call 1-877-423-4746 to apply for any Georgia Medicaid program including Pathways. The application asks about your household, income, assets, and qualifying activity. You can save and return to your application. You can also apply in person at a county DFCS office or by mail.

You will need:

• Identity documentation (driver's license, state ID, passport, or other)
• Citizenship or qualified non-citizen documentation
• Income documentation (pay stubs, tax returns, employer information)
• Qualifying activity documentation (employment records, school enrollment, volunteer logs, etc.)
• Social Security number or proof of application
• Household member information

After applying, you will be assigned to one of the Georgia Families CMOs. You can choose your CMO at enrollment.

For Pathways-specific questions including qualifying activity reporting and operational issues, call the Pathways member services line at 1-844-241-1900.

How to apply for Planning for Healthy Babies (P4HB)

P4HB applications are submitted through the same Georgia Gateway portal alongside Medicaid and PeachCare applications. Eligibility staff will determine which program you qualify for based on your income, household, and circumstances. If you qualify for full Medicaid, you will be enrolled in full Medicaid rather than P4HB.

If you qualify for P4HB Interpregnancy Care, you must have had a Medicaid-paid delivery to be eligible for the IPC group. If you have not had a Medicaid-paid delivery but otherwise qualify, you will be enrolled in the Family Planning Only group.

After applying, you will be assigned to one of the Georgia Families CMOs.

How to maintain Pathways coverage

To maintain Pathways coverage, you must:

• Confirm your qualifying activity at application and at your annual renewal through Georgia Gateway (you no longer report every month)
• Complete your redetermination on time
• Report changes in your situation including income changes, household changes, or address changes

If you experience any change that could affect your eligibility, report it promptly through Georgia Gateway or by calling 1-877-423-4746. Reporting changes immediately is better than risking discovery during redetermination.

How to maintain P4HB coverage

P4HB coverage is renewed annually through the standard redetermination. Report any changes in your situation including income, household, or address through Georgia Gateway. If you become pregnant, contact DCH immediately to transition to full Pregnancy Medicaid.

How to appeal a Pathways or P4HB denial

If your Pathways or P4HB application is denied or your coverage is terminated, you have the right to appeal. Within 30 calendar days of the notice of denial or termination, file an appeal request with DCH through Georgia Gateway, by calling 1-866-211-0950, by mail, or in person at a DFCS office. Request a fair hearing if your appeal is not resolved to your satisfaction. The fair hearing is conducted by the Georgia Office of State Administrative Hearings (OSAH) at 404-651-7500. You can request continuation of benefits during the appeal if you were previously enrolled. Consider engaging free legal help from Georgia Legal Services Program at 1-833-457-7529 or, in metropolitan Atlanta, Atlanta Legal Aid Society at 404-524-5811.

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The brevy.com Georgia Medicaid section provides additional guides covering the full Georgia Medicaid program, the Georgia Families CMOs, the managed care quality framework, the application process, eligibility income limits, pregnancy coverage, family planning, behavioral health coverage, EPSDT, telehealth, and many other related topics. The guides are written for Georgia families navigating these complex systems and reference the federal authorities, state regulations, contract provisions, and operational details that determine how the system actually works.

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• Georgia Medicaid State Plan Amendments Process
• Georgia Medicaid hub covers the full Georgia Medicaid program including eligibility, enrollment, benefits, and CMO structure.
• Georgia Medicaid: how to apply covers the application process for any Georgia Medicaid program including Pathways and P4HB.
• Georgia Medicaid Pathways to Coverage provides a focused deep dive on the Pathways program.
• Georgia Medicaid family planning provides a focused deep dive on P4HB and family planning coverage.
• Georgia Medicaid managed care plans covers the Georgia Families CMOs that administer both demonstrations.
• Georgia Medicaid appeals and fair hearings provides the procedural detail for appealing denials.

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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.