Georgia Access

PO Box 12264
Birmingham, AL 35202
www.georgiaaccess.gov

testone mobile
138 peachtree rd
atlanta, GA 30345

Account number: 100-001-672

Date: 02/24/2025
Re: Your Eligibility Results from Georgia Access

ApplicationID: 197412025
Application Date: 02/24/2025

Dear testone mobile,

We received your Georgia Access health insurance coverage application on 02/24/2025.

This letter has the results of your application and lists any follow-up steps that you may need
to take.

The Summary of your Application Results shown below indicates which health insurance
coverage programs each household member is eligible for based on the information
provided on your application. Please review the following information to understand the next
steps you need to take to enroll, including any documents you may need to submit to confirm
your eligibility.

Summary of your Application Results:

Household
Results
member(s)

Eligible to enroll in a health plan through Georgia Access but must

verify some information to stay eligible. See the "What documents
testone
should I submit?" section below for more details on what
mobile
documents you need to submit to keep your eligibility.
Applicant is eligible to buy a Catastrophic Plan

©2025 Georgia Access page 1 of 12

If you requested financial assistance on your Georgia Access application and were not
assessed as potentially eligible for Georgia Medicaid or PeachCare for Kids® then you can
ask for a full Medicaid determination at any time. To ask for a full determination, please click
"Request Full Medicaid Determination" within your application.

Household members eligible to enroll in health and/or dental insurance coverage

through Georgia Access

Based on the information provided on your application, the following household members are
eligible to enroll in health and/or dental insurance coverage through Georgia Access. Please
review the following table to understand any next steps you need to take to enroll, along with
any documents you may need to submit to confirm your eligibility. If you are already enrolled
and do not need to submit any documents, no further action is required.

Household
Results Next steps
member(s)

Choose a plan and pay

your first month's bill or
premium by 04/25/2025.
By 05/25/2025, send one
Eligible to enroll in health
of the documents listed in
insurance coverage through
the section below to
Georgia Access, but you need
confirm:
testone to provide more information to
mobile confirm your eligibility. You are lawfully
present
This result is based on the
household income you See the "What
provided on your application. documents should I
submit?" section for a list
of documents you can
submit to confirm your
eligibility.

If any household members are eligible for financial subsidies or become eligible at any time
in the future, it is important to note the importance of reconciling APTC received on your tax
years for all years members of the household will or have received APTC. Failure to
reconcile APTC received on your tax return for the applicable year could result in the denial
of financial assistance in the future. Please visit IRS.gov and search for "Form 8962" if you
would like more information about reconciling current or prior APTCs. You may also call the
Georgia Access Contact Center at 888-687-1503.

©2025 Georgia Access page 2 of 12

What should I do next?

Now that you are eligible for coverage through Georgia Access, it is time to enroll in a health
insurance plan within 60 days of your qualifying life event.

Follow the steps below to enroll in a plan. Again, if you are already enrolled, you do not need
to take any action at this time.

As of 02/24/2025, our records indicate that you do not currently have an account with a
certified Georgia Access enrollment partner. You can visit GeorgiaAccess.gov and select a
certified Georgia Access enrollment partner or the state-run Georgia Access portal to set up
an account.

Once you select a certified Georgia Access enrollment partner and create an account, you
can update your personal information and enroll in a plan.

If you need assistance, you can call the Georgia Access Contact Center at 888-687-1503.

You may need to submit documentation confirming your eligibility for coverage using a
Special Enrollment Period.
Select the right health insurance coverage for your health needs and budget.
Pay the first month's premium to start your coverage.
Complete any outstanding tasks listed under "Next Steps" in the table above for each
household member, which could include requests for documentation.
See the "What documents should I submit?" section of this notice for a list of
documents you can submit and how to submit them.

Factors impacting your eligibility

Eligibility Factors

Household
Eligibility Factors
Member (s)

APTC

Applicant's Tax filing status and Tax relationship has not been
identified.
testone mobile
CSR

Applicant's tax household income is above the income threshold

for eligibility for Cost-Sharing Reductions program

©2025 Georgia Access page 3 of 12

What documents should I submit?

See below for a list of documents that you can submit to confirm your eligibility for health
insurance coverage. You may need to send more than one document to resolve an issue, so
be sure to read the lists carefully.

Income Information

To confirm the income information provided on your application, and your eligibility for
financial help for coverage through Georgia Access you need to submit one of the following
documents. Make sure you are providing documentation for income for all persons on your
application who file a tax return.

1040 federal or state tax return. Note: It must contain first and last name, income
amount, and tax year. Starting with 2018 tax returns, if you file Schedule 1, you must
submit it with your 1040. Schedule 1 shows additional income and adjustments, like
capital gains, unemployment compensation, student loan interest, or self-employment
tax.
Wages and tax statement (W-2 and/ or 1099, including 1099 MISC, 1099G, 1099R,
1099SSA, 1099DIV, 1099SS, 1099INT). Note: It must contain your first and last name,
income amount, year, and employer name (if applicable).
Pay stub. Note: It must contain your first and last name, income amount, pay period or
frequency of pay with the date of payment. If a pay stub includes overtime, please
indicate average overtime amount per paycheck.
Self-employment ledger documentation (can be a Schedule C, the most recent
quarterly or year-to-date profit and loss statement, or a self-employment ledger). Note:
It must contain your first and last name, company name, and income amount. If you
are submitting a self-employment ledger, include the dates covered by the ledger, and
the net income from profit/loss.
Social Security Administration Statements (Social Security Benefits Letter). Note: It
must contain first and last name, benefit amount, and frequency of pay.
Unemployment Benefits Letter. Note: It must contain your first and last name, source
/agency, benefits amount, and duration (start and end date, if applicable).

Immigration status, including Lawfully Present status

To confirm your immigration status, submit one of the following valid documents:

Permanent Resident card (I-551, also known as Green Card)

Temporary I-551 Stamp (on passport or I-94, I-94A)
Immigrant Visa (with temporary I-551 language)

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 Employment Authorization card (EAD or I-766)
Arrival/Departure Record (I-94 or I-94A)
Arrival/Departure Record in foreign passport (I-94)
Foreign passport
Country of issuance Reentry Permit (I-327)
Refugee travel document (I-571)
Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)
Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019)
Notice of Action (I-797)
Alien registration number or an I-94 number
You can also provide these documents or statuses (please include a description of the
type or name of the document in the notes):
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
Document indicating withholding of removal
Administrative order staying removal issued by the Department of Homeland
Security (DHS)
Certification from U.S. Department of Health and Human Services (HHS) Office
of Refugee Resettlement (ORR)
Documentation of status as a Cuban/Haitian entrant
Documentation of status as a Resident of American Samoa

How do I submit documents?

As of 02/24/2025, our records indicate that you do not currently have an account with a
certified Georgia Access enrollment partner. You can visit GeorgiaAccess.gov and select a
certified Georgia Access enrollment partner or the state-run Georgia Access portal to set up
an account for Open Enrollment 2025.

You can use your account to upload a copy of the document(s) by the specified due date.
Uploading is the fastest way to get the documents processed.

If you need any assistance, you can call the Georgia Access Contact Center at 888-687-
1503.

OR

Mail a copy of the documents to the address below.

Make sure to write your name and Application ID, which would be included in your
eligibility notice, on all your documents. You should keep the original documents for
your records.
The documents must be postmarked by 05/25/2025.
Send a copy of the documents to:

©2025 Georgia Access page 5 of 12

 Georgia Access Contact Center
PO Box 12264
Birmingham, AL 35203

What happens if you miss your deadline?

If you do not meet your deadline, we will provide new eligibility results of the health
insurance coverage and financial assistance you are eligible for. These results will be
based on information from our data sources, not what you put on your application.

The new results may change your current health insurance coverage and financial
assistance eligibility.

If you were found eligible for Advance Premium Tax Credits (APTCs): the amount
could change, or you may lose it entirely
If you were found eligible for savings on out-of-pocket costs (known as "Cost Sharing
Reductions (CSRs)"): the amount could change, or you may lose these savings entirely
If you told us someone on your application is a U.S. citizen or U.S. national, or has
eligible immigration status, but do not submit the required documents in time: their
health insurance coverage could be terminated

How do I update my application or change plans?

If you have life changes and the information you gave us when you applied is no longer
correct, you need to let us know within 60 of the change. Changes may affect your eligibility
for:

Advance Premium Tax Credits (APTCs)

Cost Sharing Reductions (CSRs) that lower your copayments, coinsurance, and
deductibles
Coverage through Georgia Medicaid or PeachCare for Kids®.

Here are some examples of changes you should report:

Change in income
Birth, adoption, or court-ordered dependent
Change in lawful presence, incarceration, or American Indian/Alaskan Native status
Loss of minimum essential coverage
Marriage
Moved into the state
Death of a household member

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You can update your application and change your plan by setting up an account with a
certified Georgia Access enrollment partner. You can visit GeorgiaAccess.gov and select a
certified Georgia Access enrollment partner or the state-run Georgia Access portal to set up
an account.

If you enroll in a health insurance plan through Georgia Access and later become eligible for
other qualifying coverage, like Georgia Medicaid, PeachCare for Kids®, Medicare, or
coverage through a job, you will not be eligible for Advance Premium Tax Credits (APTCs),
although you can keep your plan and pay the full premium. If you become eligible for other
qualifying coverage, you must report this change to end your APTCs and let us know if you
also want to end your health insurance plan. If you do not stop the APTCs to your health
insurance company, we will update your application to remove the APTCs from your health
insurance plan. You will receive a notice of this decision.

What should I do if I think my eligibility results are wrong?

If you think there is an error with your results, the first step is to confirm that all the
information on your application is correct and up to date.

You can view and make edits to your application through your certified Georgia Access
enrollment partner or the Georgia Access portal.

If do not have a certified Georgia Access enrollment partner and you would like to choose
one to work with, you can view the full list at GeorgiaAccess.gov.

How do I request an appeal?

If your application information is correct and you believe the State made an error in your
eligibility results you may file an appeal. You have 90 days from the date of this eligibility
notice to file an appeal. Appeals may be filed by mail or electronically through your certified
Georgia Access enrollment partner or the Georgia Access portal.

As of 02/24/2025, you do not have an account with a certified Georgia Access enrollment
partner. You can visit GeorgiaAccess.gov and select a certified Georgia Access enrollment
partner or the state-run Georgia Access portal to set up an account with them to file an
appeal. You can submit the Georgia Access consumer appeal request form through your
certified Georgia Access enrollment partner account. The Georgia Access consumer appeal
request form is also available at GeorgiaAccess.gov .

OR

Mail a copy of the Georgia Access consumer appeal request form to the address below.

Make sure to write your name and Application ID, which would be included in this
notice, on your form.
Send a copy of the Georgia Access consumer appeal request form to:

©2025 Georgia Access page 7 of 12

 ATTN: Appeals
Georgia Access Contact Center
PO Box 12264
Birmingham, AL 35202

Appealing your eligibility for Georgia Medicaid or PeachCare for Kids®

If this notice says that you may be eligible for Georgia Medicaid or PeachCare for Kids®, the
Georgia Division of Family and Children Services (DFCS) will send a notice to let you know if
you qualify for these free or low-cost programs. If DFCS determines that you are not eligible
for Georgia Medicaid or PeachCare for Kids®, that notice will tell you how to ask for a
Georgia Medicaid or PeachCare for Kids® fair hearing through the Georgia fair hearing
process.

More about getting Georgia Medicaid or PeachCare for Kids®

If your eligibility results tell you that you are eligible to buy a health insurance plan, we do not
think you qualify for Georgia Medicaid or PeachCare for Kids®. Some people may still qualify
for Georgia Medicaid or PeachCare for Kids®, but only DFCS can make the final decision.

You may want to ask DFCS to continue your application if you:

Need a lot of medical services or have unpaid medical bills

Have a family income close to Georgia Medicaid or PeachCare for Kids® income limit,
or you do not agree with the income amount that was used to determine your eligibility
Have a disability
Had a pregnancy that ended within the last 12 months, and you were not covered by
Georgia Medicaid or PeachCare for Kids®

You can keep your coverage described in this notice while DFCS reviews your application.

For more information about your Georgia Medicaid or PeachCare for Kids® eligibility,
including your right to appeal if DFCS determines you are not eligible for Georgia Medicaid
or PeachCare for Kids®, visit https://medicaid.georgia.gov/

For more help:

What are my options to enroll in coverage?

There are various ways to enroll in coverage on Georgia Access. You can work with a
certified Georgia Access enrollment partner or use the Georgia Access portal. Certified
Georgia Access enrollment partners include web brokers, agents, and insurance companies.

What help do certified Georgia Access enrollment partners provide?

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Certified Georgia Access enrollment partners can help you shop for and compare available
health insurance plans, understand your eligibility results for financial assistance, enroll in
coverage, and answer your questions.

Once you set up an account with a certified Georgia Access enrollment partner, you will be
able to update and manage your information, view your Georgia Access notices, receive
your eligibility results, and enroll in a plan.

Certified Georgia Access enrollment partners and the Georgia Access Contact Center
provide the following services for consumers who request assistance:

Spanish-speaking representatives
Notice language translation in Spanish
Language line for 250 languages and dialects
Teletypewriter (TTY) line at 711
Large print notices
Braille services

If you need any of the above services, contact a certified Georgia Access enrollment partner
or call the Georgia Access Contact Center at 888-687-1503. These accommodations are
provided at no cost to you.

If you need in-person help, you can find a local agent in your area on GeorgiaAccess.gov.

Thank you,
Georgia Access

©2025 Georgia Access page 9 of 12

The determinations or assessments in this notice were made by the State of Georgia based upon 45 CFR 155.305,
155.410, 155.420-430 and 42 CFR 435.603, 435.403, 435.406 and 435.911.

Privacy Disclosure: The State of Georgia protects the privacy and security of the personally identifiable information (PII).
This notice was generated by the State of Georgia. The PII used to create this notice was collected from information you
provided on your application for health insurance coverage through Georgia Access. The State may have used data from
federal, state, and consumer reporting agencies to determine eligibility for the individuals on your application. The State of
Georgia only shares information about your application and eligibility, including this notice, with certified Georgia Access
enrollment partners with whom you have granted explicit authority to provide health insurance coverage through the
Georgia Access shopping and enrollment experience. You may revoke this authority at any time. This collection of and
authorized sharing of information does not constitute a breach of security under O.C.G.A. §§ 10-1-910 - 10-1-912. The State
of Georgia will provide notice if a breach of security of PII occurs in accordance with Federal law.

Nondiscrimination: Georgia Access does not exclude people or treat them differently because of race, color, national
origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and gender identity). If you think you have
been discriminated against or treated unfairly for any of these reasons, you can file a consumer complaint with the Office of
Commissioner of Insurance and Safety Fire by visiting https://oci.georgia.gov/file-consumer-insurance-complaint .

©2025 Georgia Access page 10 of 12

©2025 Georgia Access page 11 of 12
Reference number: 5875

©2025 Georgia Access page 12 of 12