Other Considerations

Pathways and Care Management Organizations – A/Rs enrolled in Pathways will be automatically assigned into a Care Management Organization (CMO), except A/Rs who are enrolled in ESI and determined to be cost-effective. A/Rs will have 90 days after auto-assignments to change CMOs.

Pathways Manual Audit Process - As part of ongoing operations for Pathways, auditing of enrolled members will be conducted to verify compliance with the qualifying hours and activities requirements. All Pathways members assigned to a CMO or enrolled in ESI claimed through a spouse or family member will be subject to program audits. Upon approval in Pathways, the eligibility approval notice is generated which contains language to inform the A/R of the requirement to comply with random and periodic audits to maintain coverage under Pathways.

Enrolled Pathways members within the following two categories are subject to audit:

Members who have reported hours and activities.

Members who have submitted Good Cause Exception request.

Pathways members who are enrolled in the Pathways Health Insurance Premium Payment (HIPP) program are not required to report qualifying hours and activities monthly unless the Pathways member Employer-Sponsored Insurance (ESI) is claimed through a spouse or family member. As such, they are not subject to the qualifying hours and activities compliance audit.

The Pathways Program eligibility audit process will consist of third party, collateral or both types of verification of the qualifying hours and activity documents submitted by the member for the most recent month available within the case. Third party verification may be obtained via work number or computer matches. Collateral contact may be made verbally by telephone or in writing. Additionally, members who are exempt from monthly reporting are expected to have certain forms of documentation available to show their continued engagement in qualifying activity or activities. If audited, the member will need to provide documents to verify compliance with qualifying hours and activities.

Applying for Pathways – A/Rs can apply for Pathways through the following methods:

Online through the Customer Portal at gateway.ga.gov

By calling 1-877-423-4746

In-person at any Division of Family and Children Services (DFCS) office

By paper application