Ashley

Ashley is a former social worker and graduate student who gets her health insurance through the Pathways to Coverage program. During her yearly renewal, bureaucratic hurdles and unnecessary red tape almost resulted in her losing healthcare coverage.  

Ashley is a 31-year-old former social worker who is enrolled in graduate school and is living with a chronic health condition that requires consistent access to care. While on school breaks during graduate school, she also works as a residential advisor at a group home for young adults in foster care. Her income level and enrollment in a higher education program make her eligible for health insurance under the Pathways to Coverage program, which is Georgia’s Medicaid program for adults with lower incomes who work, go to school or volunteer at least 80 hours per month. Despite her high digital literacy and her past professional experience navigating Georgia’s Medicaid system, the unnecessary obstacles that she faced at her yearly renewal nearly kicked her off her coverage.

Applying for the Pathways to Coverage program

“I qualified for Pathways because I was a student, and I was only working a few hours a week, so I was in this weird place where I didn't qualify for Marketplace insurance because I didn't make enough. Pathways is for people that are below that threshold.

The initial application process was pretty easy. I think it took me about an hour and a half—two hours maybe—and it just wanted basic documents uploaded to the platform. After I submitted everything, it took about two weeks to hear back.

It was definitely a lot easier for me because I used to be a social worker, so I was very familiar with the platform and the system. I’ve helped a lot of clients apply for food stamps and Medicaid, and I also knew where to find all of my documents. I had all my passwords handy to get the documents that were needed. I don't think it would be as easy for someone that was not in my position because even tracking down the documents is a challenge, especially if it's someone who doesn't have easy access to technology.”

Navigating the Yearly Renewal Process

“Most people have to report qualifying activities every month, but if you're a student, you don't. I got a letter in the mail saying I didn't need to report qualifying hours due to my student status. With the renewal process, that was a little bit different.

The first time I got a renewal notification was in October 2024. I kept getting calls from Amerigroup [one of the care management organizations that deliver Medicaid programs like Pathways] saying that my Pathways is going to expire. But then I would log online to my Pathways account on Gateway and there'd be no option to renew, so I was really confused.

I called Amerigroup, and they said there were problems with my documents. Then, I called the state’s Pathways number and they were like, ‘No, there's no problem. There's nothing saying it's expired.’ I was really confused because I was told by the state that there was no problem, but the other organization was saying that there was a problem. This was in October. I just waited until November 1st to see if the claim would go through. Luckily, nothing happened. I don't know what happened with Amerigroup and Georgia Gateway. They were not on the same page. I still don't know exactly what the disconnect was at that time.

In December 2024, I started getting notifications that it's time to renew. This time, it was for real, and I could apply on the website. I reapplied the day I got the renewal notification, and I didn't think anything of it. When I checked my account in January, the renewal was denied.

I called to figure out what was going on. They said there was a problem with my documentation for the student status, and I provided a letter confirmation that I was enrolled and was supposed to graduate in May 2025. They said that they needed something more updated.

I kept calling. Every time I called, they would tell me something different about why I was denied. One of them said it was because I didn't upload my qualifying hours for January 2025, but it was before the monthly deadline for submitting those hours, so that didn't make any sense. Then another woman said that it was because my documentation hadn’t been reviewed yet. Another person said that they didn't know why, but I could start a fair hearing.

I submitted a request for a fair hearing and submitted all my documentation. This was mid-January, and I kept calling because I hadn't heard any updates. One person said that it was because I didn't have my pay stubs in for my job, so I asked her, ‘What we can do?’ because it was a few days before my coverage was supposed to expire. She said, ‘Just upload them and call back.’ Well, you can't call back the same day. You can only call once a day and get through. So I was like, ‘Can you just hold on for 5 minutes? I can upload them right now,’ and I convinced her to do that and got that uploaded. Finally, I called the day it was supposed to expire, and they had expedited everything. I did get approved, and it wasn't going to expire.

From January 3rd—when I found out it got denied—until January 31st, I was unsure. That was with all of the stress of trying to get all the documents and figure out what was going on. With all of the calling, I lost sleep, so I was not as alert at work at night. I still don't really know what the problem was.”

Trying to Access the Call Center and DFCS Case Workers

“I figured out that if you call right at 8:00am in the morning, you get a call back pretty quickly from a person. But, if you call back any other time, you can have to wait hours to get a call back. Throughout this whole process in January, I was calling my case managers that were on the notices. I didn't get a call back from them until February.

I heard back about the fair hearing in February, and it was just kind of a mess. I got asked by someone on the phone why family planning services wouldn't meet my needs. She had no idea the difference between Georgia Pathways and the family planning program, so that was kind of frustrating. The workers weren't trained. I think that the people on the phone were as helpful as they could be. They were polite. They seemed like they genuinely wanted to help, but it seemed more of a problem with the infrastructure and the training.

I found out I could only call once per day. I was like, ‘I'm having a really hard time getting through any time other than 8:00 AM,’ and she goes, ‘Oh, it's because you can only call once from the same number every day.’ This was January 30th, maybe, when I figured this out, so that was a really frustrating process. Then, to get through to a person, you have to learn which numbers to hit, and it took a lot of trial and error. I ended up writing down like, ‘First, you hit one, and then you hit two, then you hit two the next time, then one again, and there's an eight somewhere.’

I get texts whenever there's a notification uploaded to my portal and I also get letters, but the challenge with the letters is by the time they actually get there, it's way past the time that would be relevant. And there's some parts of the letters that are confusing because it doesn't directly say ‘eligible’ or ‘denied’.

I did go in-person one time to the DFCS office and was waiting outside. I got there when I thought it opened, and they gave me a ticket and they said it'd probably be two hours before I could meet with someone. I had to go to work, so I couldn't wait outside for two hours, and I was also getting harassed in the line and did not feel safe.”

Ashley’s Vision for the Future of Pathways

“Getting health insurance through Pathways made it a lot easier for me to focus on school. If I hadn't been able to get the treatment and diagnosis that I did, I would be struggling a lot more. My grades would be worse. Things definitely just got so much easier once I was able to get the healthcare that I needed. There have been some challenges finding providers that take Medicaid, so sometimes I've had to wait longer for appointments or had to drive a little bit farther. But, for the most part, I've been able to find care with all of the specialists that I needed.

I think making the phone service more accessible and outlining clear reasons why people were denied would improve the program. It'd be helpful to have a phone line that was easier to get connected with. When it takes 5 minutes to get through all the automated things, that's challenging, and then you get transferred to a virtual waiting area. You get a call back from them whenever there's someone available, which is really nice, but sometimes it can take hours if you're not calling right at 8:00am in the morning. And, if on that original notification, it just said, ‘Your student documentation is not current. We need something dated after January,’ then that would have been a whole lot easier than having to call multiple times to figure out why.

One of the big challenges with the qualifying activities and hours requirement is having to remember to upload those documents every month. For a lot of people that are in these low-income jobs, they don't have access to technology to get the documents in, they don't have access to transportation to get to the DFCS office, or their employers pay them in cash. Or what if someone gets sick and can't work and has worked less than 80 hours? What happens then? Are they going to be able to get all the paperwork to get the good cause exception? There's all kinds of barriers, and most people don't have access to the resources needed to support them in navigating this process and this paperwork.

I do think encouraging people to be enrolled in something to better themselves is helpful, but the strict requirements are make it very difficult for people that maybe would be eligible to get the right documentation. The idea of it might make sense, but I don't think it's practical for the majority of the population that would qualify for it. With my work at clinics, I have seen very few people that would qualify to be eligible that are able to go through this whole process to keep the insurance. I think students are kind of a separate demographic and are more easily able to handle all of the online stuff—getting the documents together, uploading the qualifying hours—but for the majority of population, that's not something that's practical.”

Ashley is a pseudonym for our storyteller who has requested to remain anonymous. She was interviewed in February 2025.