Application Requirements

An application for any Family Medical Assistance COA may be made with any of the following forms:

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). 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:

An application requesting coverage for Medical Assistance for a BG member who had not requested coverage for him or herself on the last application filed.

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

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

An applicant applied for him or herself and children, but the case trickled to a lower COA. A change then occurs that would make him or her eligible.

An application was previously correctly denied for failure to submit PeachCare for Kids ® initial premium payment by the required due date.

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 applicant is already a Medical Assistance recipient and is changing to another COA, or a Continuing Medicaid Determination (CMD) is being completed.

Adding a Newborn Medicaid case

If a BG member is being added.

When removing the Reasonable Opportunity Period (ROP) penalty, or adding a child back, to the active AU effective the first day of the month that citizenship/immigration/identity verification was provided.

MAGI COA cases (except for P4HB) that close for failing to return verification will be reinstated if all the verification is returned within 90 days of closure; an application will not be required. Refer to Section 2706 - Medicaid Renewals .

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.