Tag: 1115 waiver
Background: In 2019, Georgia submitted a plan to the Centers Medicare and Medicaid Services (CMS) to expand Medicaid to a certain subset of Georgians. Under the plan, called the Georgia Pathways waiver, the state planned to allow individuals aged 19-64 making up to 100% of the federal poverty line (FPL) ($12,880 for an individual and $17,420 for a family of 2) to apply for Medicaid coverage. The Georgia Pathways plan also required these newly eligible adults to complete and document 80 hours of work or other “qualifying activities” each month to enroll in and maintain coverage. The plan further required some enrollees (those making 50-100% FPL) to pay a monthly premium to maintain their coverage, which is not required for traditional Medicaid.
In late 2020, the Trump Administration approved the Georgia Pathways plan and implementation was slated for the following July. In spring 2021, the Biden Administration changed the status of Georgia’s plan from “approved” to “pending” and stated they needed to review the plan, specifically the work and premium requirements, to ensure they were in keeping with the spirit, goals, and intent of the Medicaid program. You can learn more about the Georgia Pathways program and the approval timeline here.
On December 23rd, 2021, CMS approved the Georgia Pathways plan and will allow Georgia to extend Medicaid coverage to Georgians making up to the poverty line (or 100% FPL). However, CMS denied the state’s request to include work requirements and premium payments as a condition of enrolling in and maintaining Medicaid coverage. CMS cited concerns about the devastating impact the COVID-19 pandemic has had on both the health and economic security of Georgians as the reason for denying these provisions.
Now that CMS has issued its decision, Governor Kemp and the Georgia legislature must decide how to proceed, choosing one of these four options:
- Do nothing. Even though CMS approved a modified version of the Georgia Pathways waiver, Georgia is under no obligation to implement it. This action would mean the coverage gap remains in place and vulnerable low-income Georgians would largely remain uninsured.
- Appeal CMS’s decision on the work and premium requirements. On Jan. 22, 2022, Gov. Kemp initiated an appeal beginning a lengthy process with CMS (a process made even slower by the pandemic). While the state pursues the appeal, thousands of Georgians will remain without coverage. State leaders can move forward with the following two options even while the appeal is in process.
- Move forward with the Georgia Pathways plan as approved. Under this option, Georgians making less than 100% FPL would be eligible for Medicaid. An estimated 269,000 uninsured Georgians would gain coverage. This plan would cost the state 2.5 times more to implement than the following option.
- Expand Medicaid to cover more people at a lower cost. Under a full Medicaid expansion, individuals and families making up to (138% FPL) would be eligible for coverage. As many as 500,000 Georgians would be covered and the state would qualify for a 90% cost match from the federal government. Georgia would save millions of dollars annually over the Pathways waiver and earn a $1.3 billion bonus in the first two years.
With CMS’s approval of the Georgia Pathways program, the state is at a crossroads. Our state leaders can choose to meet the pressing health care needs of the state through Medicaid expansion, or they can choose to help fewer Georgians at a higher cost under the Pathways program.
Our state leaders cannot and should not choose to do nothing because Georgians can’t wait. Too many Georgians are without health coverage and the positive effects that come with coverage. It is far past time to act and the onus lies with our state leaders to decide the way forward. Click HERE to take action!
In December 2019, Georgia’s Governor asked federal officials to approve changes to the state’s Medicaid program. Medicaid is a public health insurance program that currently covers half of Georgia’s children, some low-income seniors and people with disabilities, low- and moderate-income pregnant women, and very low-income parents.
The Affordable Care Act (ACA) gave states the option to expand Medicaid to cover adults making slightly more than poverty-level wages (about $16,700 for an individual and $35,900 for a family of four). Unfortunately, Georgia is one of only 14 states who have so far refused to extend health insurance to these low-income Georgians. That leaves 408,000 uninsured Georgians ineligible for Medicaid, and at the same time, their incomes remain too low to qualify for financial help to buy coverage through the ACA’s health insurance marketplace.
Governor Kemp’s plan to change Medicaid, called Georgia Pathways, will do little to close this coverage gap. The state estimates the plan will cover only about 50,000 low-income Georgians because of the unwarranted complications that it puts in place. The Governor’s plan ultimately leaves thousands of low-income Georgians uninsured and ignores the most cost-effective solution available: Medicaid expansion.
Some low-income Georgians would be allowed to enroll in Medicaid
This change, sometimes called a “partial Medicaid expansion,” falls short of the ACA’s Medicaid expansion which envisioned that states would cover adults making slightly more than poverty-level income. Under the Governor’s plan, 408,000 Georgians could qualify for coverage—if they can meet the stringent requirements described below. Under a full Medicaid expansion, Georgia could cover 567,000 low-income adults.
Georgians would be subjected to illegal paperwork requirements to enroll in coverage
Under the Governor’s plan, Georgia adults who may qualify for coverage must prove they are working or performing certain activities for at least 80 hours a month. Work and qualifying activities include full or part-time employment, community service, vocational readiness, certain education activities, or job readiness. Qualifying activities do not include caregiving and participating in substance use recovery programs; Georgians who are homeless or have limited access to the internet would not be excused from the reporting requirements.
If the Governor’s plan is approved, Georgians would be required to complete bureaucratic paperwork to prove they are spending 80 hours a month participating in an eligible activity before they can enroll in Medicaid coverage. They must continue to prove their work or other activities to Georgia’s government for at least three months. After that, they would be subject to random requests for proof of continued work.
Other states have attempted to implement similarly burdensome “work requirements.” In those states, thousands of qualified people lost their health care coverage because they were unable to successfully report their work due to technology barriers, insufficient notice from the state about the requirements, bureaucratic mistakes, and other issues. As a result, work requirements are currently the subject of a federal lawsuit and have been deemed illegal by three federal courts.
Low-income Georgians must pay premiums and copays to Georgia’s government
The current proposal requires that Georgians making between 50 – 100% of the federal poverty line (between $6300-$12,700 annually for an individual) would be required to pay monthly premiums of $7-$11 per month. If an enrollee misses two months of premium payments, their coverage would be suspended and after three months of missed payments, the person would lose their coverage. When accessing health care services, enrollees would be required to additionally pay copays of up to $30 per visit.
Traditionally, Medicaid members have not been required to pay premiums or co-pays because their incomes are so low. While the state caps enrollees’ cost-sharing at 5% of a person’s income, that could add up to as much as $600 for an individual and $1300 for a family of four per year, who are surviving on poverty-level wages.
The plan eliminates the option for low-income Georgians to get transportation to their health appointments
Under the Governor’s plan, Georgians who enroll in coverage would not have access to some traditional Medicaid benefits like non-emergency medical transportation. Non-emergency medical transportation (NEMT) is a free service that provides transportation to people who are covered by Medicaid who do not have their own way to get to and from health appointments or the pharmacy. The program is especially important for people with disabilities, seniors, rural residents, and people of color.
Adequate transportation is important to the health of Georgians because in most cases people need to go to a location outside of their homes to receive medical care. Without access to reliable, safe transportation, Georgians may be forced to skip health appointments, go without medication and ultimately, experience worse health outcomes.
According to the Georgia and Budget Policy Institute, “Cutting out transportation is not likely to significantly reduce state costs but would deeply impact rural Georgians who may live farther away from health facilities. Non-emergency medical transportation is less than two percent of traditional Medicaid spending in Georgia according to GBPI’s budget calculations. A relatively small investment in Medicaid funding could mean a huge difference to Georgians who don’t have reliable access to safe transportation.”
The plan creates a complicated, expensive bureaucracy
The state’s proposed plan creates complicated restrictions and burdens for low-income Georgians. In addition to the paperwork requirements and required cost-sharing, the Governor’s plan would establish a member rewards account and a point reward system for enrollees. Consumers’ monthly premiums would be deposited into their rewards account, which could be used to pay future copays for health services. The point reward system would “reward” individuals for healthy behaviors and add money to the account based on those behaviors.
Indiana initially operated a similar reward system as part of their version of Medicaid expansion. The state saw limited participation and no benefits to beneficiaries’ health because of the complexity of the system, which mirrors Georgia’s in many ways. Ultimately, these kinds of systems are expensive and ineffective at keeping Medicaid enrollees enrolled in coverage, facilitating access to comprehensive benefits, or achieving better health outcomes.
Governor Kemp’s office has not provided an estimate of the costs to the state to operate the rewards systems, track work requirements or collect premiums. The Atlanta Journal-Constitution reported, “Other states that have tried to implement a work requirement reported costs ranging from $6 million to $272 million, according to the federal Government Accountability Office.” The intricacies of Georgia’s plan would require significant spending by the state that is not currently budgeted for in the Governor’s plan.
Georgia would pay three times more per person than needed
The Governor’s plan only expands coverage to Georgians making up to the poverty line, rather than slightly more than the poverty level (138% of the federal poverty level) as intended by the Affordable Care Act (ACA). Because Georgia is not proposing a full Medicaid expansion, the state will have to pay three times more per person to carry out this plan. When states fully expand Medicaid, the federal government covers at least 90% of the costs of the expansion and the state has to pay only 10% of the costs. If Georgia were to full expand Medicaid coverage the state would be eligible for this “enhanced match”. Instead, Georgia will pay 33% of the costs (and the federal government will pay the remaining 67% ) of the Governor’s plan–three times more than needed.
Governor Kemp’s plan to change Medicaid in Georgia does not work for Georgians. It would exclude most low-income, uninsured adults and subject those who can enroll to illegal, complicated, and expensive requirements. At the same time, the plan passes up the most cost-effective option to provide coverage to low-income adults in Georgia.
Our elected officials have the power to ensure that every Georgian, regardless of income, have access to affordable, comprehensive coverage. Leaders of 34 other states have made the choice to expand Medicaid and their states are reaping the benefits. Georgia can join them, but elected officials need to hear from you. Ask Governor Kemp and your state legislators to expand Medicaid.
Risky Health Proposal Hurtles through Gold Dome
Updated Mar. 25, 2019. Flawed legislation to expand access to health insurance is hurtling through the state legislature, and hundreds of thousands of uninsured Georgians are being left behind. Senate Bill 106, the Patients First Act, passed the Georgia Senate on Feb. 26 and advanced to the House. The proposal could expand health insurance coverage to more Georgians, though an arbitrary restriction in the bill is setting Georgia up for lengthy delays or outright failure. As currently written, the proposal could cost Georgia twice as much as alternate plans while covering only half as many Georgians with health insurance.
Earlier this year, Georgia leaders announced a plan with a risky restriction to seek federal waivers that could extend health care access across the state. Senate Bill (SB) 106, the Patients First Act, aims to partially expand Medicaid in Georgia. This change could impact individuals earning up to 100 percent of the federal poverty level (FPL): about $12,100 a year for an individual or $25,100 for a family of four. About 240,000 Georgians may eventually qualify for Medicaid coverage under the proposal.
However, restricting Medicaid eligibility to those only under the poverty line could strand hundreds of thousands of Georgians without affordable health insurance options while also forfeiting an enhanced funding deal from the federal government. That means SB 106 could cost Georgia twice as much as traditional Medicaid expansion while covering only half as many Georgians. And although the legislation is quickly advancing through the Gold Dome, the state has yet to release any estimates of how many Georgians will gain coverage or how much the plan will cost taxpayers.
How could the Patients First Act cover half as many Georgians while costing twice as much as Medicaid expansion? As part of the Affordable Care Act, the federal government agrees to pay 90 percent of the costs if states expand health care access to people earning less than 138 percent FPL—about $35,000 for a family of four. States can leverage this 9-to-1 funding match through Medicaid expansion or a state plan, called an 1115 waiver, to accomplish similar goals with more tailored approaches. Without the enhanced 90 percent match, states receive a lower funding commitment instead (about 67 percent for Georgia).
By arbitrarily limiting the state’s ability to negotiate coverage, SB 106 represents a risky gamble while Georgia’s worsening health care crisis hangs in the balance. Other states have previously submitted waivers asking for the enhanced funding match while offering to cover people up to 100 percent FPL, similar to SB 106. None were approved. Every 1115 Medicaid waiver approved under the Affordable Care Act for the enhanced match—including the most conservative examples in Arkansas, Indiana and Kentucky—expanded eligibility up to 138 percent of the poverty line. Georgia should too.
State lawmakers can fix SB 106 by allowing Medicaid eligibility up to 138 percent of the federal poverty level.
Senate Bill (SB) 106 is an unnecessarily risky proposal that threatens to leave hundreds of thousands of Georgians out of expanded health coverage and restricts Georgia from negotiating the best possible health plan.
An arbitrary restriction in SB 106 will lock Georgia to a failed approach that deprives state leaders of the flexibility needed to negotiate a strong health plan.
SB 106 may cost Georgia twice as much money while covering half as many people compared to other plans, including traditional Medicaid expansion.
A simple change to SB 106 would give Georgia a clearer, more certain path to success. State lawmakers can amend the bill to allow Medicaid eligibility up to 138 percent of the federal poverty level.
The Patients First Act, Georgia Senate Bill (SB) 106, would authorize the Department of Community Health to negotiate two waivers with the federal government that could improve health care in Georgia.
Senate Bill 106 would allow the Department of Community Health to request waivers to increase Medicaid coverage up to 100 percent of the federal poverty level (FPL)—about $12,000 for an individual or $25,000 for a family of four. This could potentially expand health coverage to about 240,000 Georgians.
SB 106 Leaves Hundreds of Thousands of Georgians Behind
The proposal falls far short of covering all eligible Georgians with incomes up to 138 percent of the federal poverty level (FPL). Many of the Georgians who are left out will remain uninsured and continue to struggle to get the health care they need.
About 230,000 uninsured Georgians earn between 100 to 138 percent FPL and would not receive expanded coverage through Medicaid. Georgians earning more than 100 percent FPL currently qualify for financial support to buy health insurance, but many still struggle to afford coverage.
Georgia has the 4th highest number of uninsured kids in the nation, many of whom are eligible for Medicaid but remain uninsured. When more parents and caregivers are covered, more kids are more likely to be insured too.
Other plans would put health insurance cards in the pockets of almost half a million Georgians while likely still costing less than the plan authorized by SB 106.
The Critical Difference Between 100 and 138 Percent
As part of the Affordable Care Act, the federal government agrees to pay 90 percent of the costs if states expand health care access to people earning less than 138 percent of the federal poverty level (FPL)—about $35,000 for a family of four.
Without this enhanced 90 percent federal match, states receive a lower funding commitment instead. That lower match is about 67 percent for Georgia.
SB 106 Represents Unnecessarily Risky Gamble
SB 106 represents an unnecessarily risky gamble with Georgia’s health crisis in the balance. Georgia’s leaders are putting forward ideas that have previously failed in other states.
Other states have submitted waivers asking for the enhanced match while only proposing to cover people up to 100 percent FPL, similar to SB 106. None were approved.
Every 1115 Medicaid waiver approved under the Affordable Care Act for the enhanced match—including the most conservative examples in Arkansas, Indiana and Kentucky—expanded eligibility up to 138 percent of the federal poverty level. Some states simply expanded Medicaid while others have developed state-specific plans called 1115 waivers to accomplish similar goals with more tailored approaches.
By restricting Medicaid eligibility to 100 percent of the poverty line, the best plan possible will likely cover half as many Georgians while costing twice as much as alternative.
The arbitrary coverage restriction in SB 106 is setting Georgia up for failure. Preventing Georgia’s 1115 waiver from helping Georgians earning up to 138 percent of the federal poverty level (about $35,000 for a family of four) means that our state is unlikely to get a good deal any time soon.
Unclear Proposal Could Result in Massive Changes with Limited Oversight
SB 106 gives Gov. Brian Kemp’s administration broad authority to make extensive changes to health care in Georgia without input from the legislature or public during the drafting stage.
The Governor’s plan offers no guiding principles, assurances of good governance or safeguards for fiscal responsibility.
No fiscal note or cost estimate has been provided for the proposed waivers being authorized even though this bill has been called “the most significant issue” being discussed this year
The governor’s proposal will likely result in covering fewer Georgians at a greater cost to taxpayers.
There’s a simple solution for this unnecessarily risky gamble: change one number. State lawmakers can amend SB 106 to authorize an 1115 waiver up to 138 percent of the federal poverty level, instead of the current 100 percent.
Or lawmakers can include a back-up plan authorizes Medicaid eligibility up to 138 percent if the current approach is rejected.
Key Questions About SB 106
How many Georgians will gain access to health insurance through the waivers authorized by SB 106?
Georgia’s uninsured rate in 2017 was 13.4 percent. How much will the proposed waivers reduce our growing uninsured rate?
About 240,000 Georgians make too little to get financial help to buy health insurance and do not currently qualify for Medicaid. This coverage gap represents people earning below the poverty line. Will the waiver offer Medicaid eligibility to everyone in this gap?
When can Georgians expect to see expanded access to health insurance from this proposal?
When will Georgians finally get a health insurance card in their pocket from this plan?
What guarantee does Georgia have that an 1115 waiver which only covers people up to the federal poverty level will receive approval from the federal government for the enhanced 9-to-1 funding match? All similar plans that were previously submitted by other states have been rejected.
Why should state lawmakers arbitrarily limit Georgia’s flexibility to negotiate the best deal possible, especially when that restriction is likely to cause significant delays or outright rejection?
If Georgia’s 1115 waiver is not approved for the enhanced federal funding match, will state leaders choose to cover half as many Georgians as traditional Medicaid expansion for twice the cost?
Will the waivers from this proposal protect Georgians with pre-existing conditions?
Will the waivers maintain essential health benefits for Georgians?
What opportunities will Georgia’s legislative branch have to review and inform the waiver proposals?
How will locking Georgia into a risky waiver approach that’s destined for long delays or failure help address our state’s pressing health care crisis?