Application Requirements

An application for any ABD Medicaid COA may be processed from any of the following application documents:

Form 297 Application for TANF, SNAP, or Medical Assistance

Form 508 SNAP, TANF, Medical Assistance Renewal Form

Form 632 Presumptive Eligibility (PE) for Pregnancy

Form 632H Qualified Hospital Presumptive Eligibility Application

Form 632W Presumptive Eligibility (PE) Women’s Health Medicaid Application

Form 700 Application for Medicaid & Medicare Savings for Qualified Beneficiaries

Form 94 Medicaid Application

Form 94A Medicaid Streamlined Application

Federally Facilitated Marketplace (FFM) application (Obsolete as of 12/2024)

GA Access Application

Gateway Medical Assistance Online Application

Gateway Medical Assistance Renewal

Low Income Subsidy Application – SSA 1020B (LISA- application for Medicare Part D)

PeachCare for Kids® Application (Obsolete as of 09/2017)

Provider Portal Online Application

SSA Model Medicare Savings Plan (MSP) application

SUCCESS Application for Assistance (AFA) (Obsolete as of 09/2017)

Women’s Health Medicaid Review Form (Obsolete as of 12/2022)

A completed application consists of a signed (either written, not typed, or electronic such as via Gateway) application with information sufficient to contact the A/R or authorized representative (AREP). Refer to 2050-Application Processing Overview . The signature does not necessarily have to be that of the A/R. Any information that is missing, incomplete or otherwise unclear may be obtained from the A/R or AREP after the signed application is received and registered in the system by the agency.

A new signed application is required in the following situations:

When adding a program for an A/R who has been an ineligible spouse in an active AU and who is now requesting Medical Assistance for him or herself under a different COA from a recipient spouse.

An application was previously correctly denied due to failure to provide required verification. A/R wants to reapply in a subsequent month for ongoing benefits. Although the application date is protected, the A/R should sign another application unless there is good cause for not initially providing the verification.

An application was previously correctly denied due to not meeting a basic or financial eligibility criteria. A/R now meets these criteria and wants to reapply for ongoing benefits. Have the A/R complete and sign another application.

A new application is NOT required in the following situations:

If the system denies the application because the worker has not acted timely on the case

If the A/R is already a Medical Assistance recipient and is changing to another COA, a Continuing Medicaid Determination (CMD) is being completed or if an SSI recipient is entering a NH

If a current recipient is being added as a recipient to an existing AU, such as SSI added to Q-Track or Q-Track added to AMN

A non-applicant is added to an existing AU, even if the AU cascades to a lower COA or the spenddown amount is increased.

Homeless AUs are NOT required to provide a physical address but must provide sufficient information to establish Georgia residency. The applicant’s statement is acceptable unless conflicting information is known to the agency.