Georgia and the ACA’s Medicaid expansion

Key takeaways

Georgia has not expanded Medicaid under the Affordable Care Act.
Enrollment in Georgia Medicaid has surged during the Covid-19 pandemic.
As of May 2020, 23 percent of people in Georgia do not have health insurance coverage.

Medicaid expansion in Georgia

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Georgia enacted legislation (SB106) in 2019 that allows the state to seek federal permission to expand Medicaid, but only to people earning up to 100 percent of the poverty level (as opposed to 138 percent, as called for in the ACA).

In November 2019, the state unveiled an 1115 waiver proposal that calls for partial Medicaid expansion, effective in July 2021, that would cover adults age 19-64 with income up to 100 percent of the poverty level, as long as they work at least 80 hours per month (the work requirement can also be fulfilled via various other “community engagement” activities, including job training, higher education, or community service, although the program does have time limits on vocational training and job readiness programs).

Georgia’s proposal includes asking CMS to provide the state with full Medicaid expansion funding (i.e., covering 90 percent of the cost), despite the fact that the state is proposing only a partial expansion of Medicaid. A similar request from Utah was rejected by the Trump Administration earlier in 2019. And although the Trump Administration supports Medicaid work requirements and has approved them for several other states, their legal future is uncertain — they’ve been blocked by court rulings in Arkansas, Kentucky, and New Hampshire, and some other states have suspended their work requirements as a result.

Under Georgia’s proposal, dubbed Georgia Pathways, enrollees must report their community engagement on a monthly basis. But if they comply with the community engagement requirement (including reporting) for at least six consecutive months, they’ll be exempt from the reporting requirement and will only have to report changes, if applicable. Eligibility will continue to be redetermined annually.

The proposal also calls for Georgia Pathways enrollees to have cost-sharing and monthly premiums for those enrollees with income above 50 percent of the poverty level (the premiums will range from $7 to $11/month, with a lower additional rate for a spouse, plus a tobacco surcharge if applicable). Members will also be able to earn reward points for certain healthy behaviors and use the points to receive dental and vision care, over the counter drugs, and to cover copays for medical care.

Eligible residents who meet the work requirement rules will have to select a plan and pay their initial premium (if applicable) in order to enroll, with coverage taking effect the first of the following month (i.e., no retroactive effective dates or coverage effective the first of the month in which a person applies). People deemed eligible for Georgia Pathways who also have access to employer-sponsored health coverage will be required to enroll in the employer-sponsored plan, with financial assistance from the Georgia Medicaid program, if this option is deemed cost-effective for the state.

Georgia Medicaid is currently only available to non-disabled, non-pregnant adults if they are caring for a minor child and have a household income that doesn’t exceed 35 percent of the poverty level (for a household of two in 2019, which amounts to less than $6,000 in total annual income). Non-disabled adults without dependent children are not eligible for Medicaid in Georgia regardless of how low their income is. The Georgia Pathways program would expand coverage to both parents and non-parents with household income under the poverty level, as long as they comply with the various provisions (work requirement, premiums, etc.) in the program.

The state estimates that about 25,000 people would gain coverage in the first year, and that enrollment would grow to more than 52,000 people by the fifth year of the program. It’s noteworthy, however, that the Kaiser Family Foundation estimates that there are 267,000 people in Georgia who are in the Medicaid coverage gap, which means their household incomes are below the poverty level (so they’re not eligible for subsidies in the exchange) and yet they are not eligible for Medicaid under the state’s current rules. Presumably, it’s expected that the majority of these individuals wouldn’t comply with the premiums and/or the work requirement.

It’s also noteworthy that if Georgia were to fully expand Medicaid as called for in the ACA, the state would be guaranteed to receive 90 percent federal funding (i.e., no waiver approval necessary), and an estimated 400,000 to 500,000 people would gain coverage. Instead, the state is proposing a program that they expect to cover only a fraction of those individuals — and it is unlikely to garner the enhanced federal funding available to states that expand Medicaid under the ACA. It’s also possible that the work requirement could face the same legal challenges that have hindered similar programs in other states.

Georgia’s full proposal can be viewed here. The state sought public comments on the proposal, and most who commented did not support it.

Georgia’s history with Medicaid expansion

As of May 2020, 23 percent of Georgia residents were uninsured — the state has the fourth highest uninsured rate in the U.S. Georgia is leaving billions of dollars on the table and nearly half a million people without Medicaid coverage by passing up federal funding to expand Medicaid.

Two laws designed to make expansion difficult were enacted during the 2014 legislative session. HB 990 prohibits Medicaid expansion without legislative approval (the 2019 legislation that triggered the Georgia Pathways proposal expressly allows for Medicaid expansion for those earning up to the poverty level), while HB 943 prohibits state and local employees from advocating for Medicaid expansion.

By the spring of 2016, Medicaid expansion began to seem within reach in Georgia, fueled in part by support from hospitals facing severe financial challenges. The state has raised Medicaid reimbursement rates for providers, including OB-GYNs in the state, in an effort to keep providers solvent and able to accept Medicaid patients. And Republican lawmakers began indicating that they might be open to a privatized version of Medicaid expansion, like the model used in Arkansas.

Although then-Governor Nathan Deal has long been opposed to Medicaid expansion, he began to express a willingness to consider a modified version of expansion, as did more GOP lawmakers in Georgia. In June 2016, talking about the possibility of Medicaid expansion during the 2017 legislative session, Deal said “I still have the same concerns. And you won’t see anyone advocating a wholesale Medicaid expansion. But I do think there will be variations that will be discussed, and I look forward to talking to members of the General Assembly.”

However, there was no real progress on Medicaid expansion in Georgia until the partial expansion proposal was announced in 2019. Governor Brian Kemp, who took office in 2019, has been steadfastly opposed to full Medicaid expansion, although he views the Georgia Pathways program as a conservative compromise aimed at helping people who are working but not able to afford health coverage.

Against the backdrop of Covid-19, Georgia Democrats renewed calls for Medicaid expansion during the 2020 legislative session. Even without expansion of the program under ACA provisions, Medicaid enrollment in Georgia grew substantially in 2020 with Covid-19 related significant job losses driving down household income, which in turn made more people eligible for Georgia Medicaid under existing enrollment criteria.

Who is eligible for Medicaid in Georgia?

As of April 2020, criteria for enrollment in Georgia Medicaid are set at the following levels:

Children up to age 1 with family income up to 205 percent of FPL
Children ages 1-5 with family income up to 149 percent of FPL
Children ages 6-18 with family income up to 133 percent of FPL
Pregnant women with family income up to 220 percent of FPL
Parents of minor children with family income up to 35 percent of FPL
Individuals who have a disability or a family member in their household with a disability: see income and resource limits

How Medicaid supports 1 in 5 Medicare beneficiaries
How do I enroll in Medicaid in Georgia?

There are several way you can apply for Medicaid in Georgia:

Complete an online application at either Georgia Gateway or
Call the Division of Family and Children Services (DFCS) information line at 1-877-423-4746. You will be directed to a local office that can help you.
Complete a paper application. Contact your DFCS county office and ask them to mail you an application. You can return it by mail, fax, or in person.

Georgia Medicaid history

The federal legislation authorizing Medicaid was enacted in 1965, and Georgia implemented its program in October of 1967. The Georgia Medicaid program is managed by the Georgia Department of Community Health (DCH).

A major trend in state Medicaid programs has been the move from fee-for-service to managed care arrangements. In fee-for-service, the doctor, hospital or clinic is reimbursed for each visit, test or procedure performed. In managed care, the health care provider gets a set fee each month for each person covered, regardless of the actual services provided.

Georgia Medicaid first adopted managed care in 1993 and transitioned to a statewide Medicaid managed care system called Georgia Families in 2006. Nearly all Medicaid beneficiaries — including low-income adults and children, foster care children, and pregnant women —must enroll in Georgia Families. However, individuals with disabilities or long-term care needs do not receive services through Georgia Families.

Despite the fact that Georgia has not expanded Medicaid, enrollment in Medicaid/CHIP in Georgia has grown by about 18 percent since late 2013. Enrollment was 1,535,090 as of September 2013. As of July 2019, enrollment had grown to 1,808,764. The new enrollees are all eligible based on Georgia’s existing eligibility guidelines, but enrollment has still increased fairly significantly, due in large part to the outreach and enrollment efforts of Navigators and enrollment assisters, and marketing associated with the ACA’s exchanges.

According CMS, nearly 1.7 million people are enrolled in Georgia Medicaid as of May 2020. Eligibility for and enrollment in Georgia Medicaid have grown rapidly in 2020 driven by the Covid-19 pandemic.



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