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CMS approves Medicaid expansion in Georgia with work requirements

CMS estimates that more than 30,000 people will receive Medicaid coverage during the first year of the demonstration.

Jeff Lagasse, Associate Editor

Today, the Centers for Medicare and Medicaid Services said it has taken steps to advance a package of state-led reforms that could result in thousands of uninsured Georgians gaining access to coverage.

Specifically, CMS announced the approval of Georgia's new Medicaid section 1115 demonstration called "Pathways to Coverage." It requires working-age Georgia adults who are ineligible for Medicaid to opt into Medicaid coverage by participating in qualifying activities such as work and education, as well as meeting premium and income requirements.

This applies to those between the age of 19 to 64, with income up to and including 100% of the federal poverty level, and is effective today through September 30, 2025, with implementation beginning July 1, 2021.

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CMS began implementing work requirements for Medicaid coverage two years ago, a move opposed by those who said it would kick many receiving coverage off of Medicaid's rolls.

In Georgia, those who already qualify for Medicaid today will not be directly affected. 

CMS estimates that more than 30,000 people will receive Medicaid coverage during the first year of the demonstration, while nearly 65,000 Georgians will enroll in Medicaid or receive Medicaid premium assistance for coverage through Employer Sponsored Insurance over the five-year demonstration.

In order to qualify for the program, individuals must comply with specific requirements, including participating in 80 hours of work monthly, or other qualifying activities. Most people with income between 50% and 100% of the FPL will be required to make initial and ongoing monthly premium payments.

Applicants and beneficiaries with disabilities who require reasonable accommodation will have options available to complete and report their qualifying activities and hours. The state is providing support to those not already working in order to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities. 

"Pathways to Coverage" is intended to leverage the flexibilities outlined in the Healthy Adult Opportunity guidance that CMS released earlier this year. The HAO was designed to give states a broad suite of flexibilities in exchange for meeting certain performance and spending targets.  For example, while the demonstration program affords the state a great deal of flexibility, it also requires Georgia to report on a range of key quality measures, and CMS will monitor the state's performance.

The state will also be required to develop a rigorous evaluation design and submit evaluation reports to CMS to assess the effectiveness of testing these policies. And as with all section 1115 demonstrations, Georgia will be financially accountable to an agreed-upon budget-neutrality test.


Georgia is also pursuing complementary reforms of its individual health insurance market through a section 1332 State Relief and Empowerment Waiver, also referred to as a section 1332 waiver. CMS has completed its review of Georgia's 1332 waiver request and is working with the state and federal partners to finalize the terms and conditions for approval.

This waiver is designed to put Georgia on a path to change the systemic issues with the state's individual health insurance market – with the goal of reducing premiums, providing greater access and promoting a more competitive private insurance marketplace.

Due to challenges with Georgia's individual market, many Georgians who are eligible for federal premium subsidies remain uninsured, and people who do not qualify for such subsidies are priced out of the market, according to CMS. From 2016 to 2017, total individual market enrollment in Georgia dropped substantially, with approximately 94,000 Georgians fleeing the market and enrollment declining by 22% between 2016 to 2019. 

Georgia continues to have one of the highest uninsured rates in the country at 14.8%, with roughly 1.4 million people uninsured across the state. The state attributes the high numbers of uninsured individuals to a variety of factors, including high premiums, unaffordable out-of-pocket expenses, and low insurer competition in the individual market.

In its waiver, the state has proposed a two-phase approach to address these challenges. The first phase seeks to implement a state-based reinsurance program starting in Plan Year 2022. The reinsurance program is expected to reduce premiums for everyone in the individual market by an average of 10%, and will target savings to the hardest hit rural areas. The second phase seeks to transition the state's individual market enrollment to a private-sector platform called the Georgia Access Model in plan year 2023.

Under the Georgia Access Model, consumers will shop for and compare available plans through private-sector partners, including web brokers, health insurance companies and traditional agents and brokers. This is intended to expand access to enrollment options and improvements in the consumer shopping experience as the market innovates to meet consumer preferences.  Consumers will continue to have access to and be able to enroll in the full array of metal-level plans, including subsidy-eligible qualified health plans, and be assessed for Medicaid and CHIP eligibility.
The state projects that the combined impact of the Reinsurance Program and the Georgia Access Model will result in more affordable premiums and increase enrollment, particularly across rural areas of the state.


"President Trump has long understood that states should have maximum flexibility over their own healthcare programs, because innovative leaders like Governor Kemp know their states and have good ideas worth testing," said CMS Administrator Seema Verma. "I'm thrilled to support this comprehensive state-led reform that will help thousands of working adults in Georgia gain access to coverage for the first time in a way that addresses both their health and socio-economic needs."

Twitter: @JELagasse
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