Last week, the Centers for Medicare & Medicaid Services (CMS) approved Georgia’s Pathways to Coverage Section 1115 waiver request, allowing for a limited expansion of Medicaid that provides coverage to individuals ages 19 to 64 earning up to 100 percent of the federal poverty level (FPL).
Through its 1115 waiver, the state had asked permission to expand Medicaid eligibility only up to 100 percent of FPL at the enhanced federal match rate that is provided for the Affordable Care Act (ACA) adult Medicaid expansion group. CMS denied a similar request from Utah to receive enhanced federal matching funds for its partial expansion of Medicaid last August, and it rejected Georgia’s request as well. Georgia will receive its regular Medicaid match rate for the demonstration group. CMS did approve these following components of Georgia’s waiver.
- Eligible individuals: Individuals ages 19 to 64 who are not currently eligible for Medicaid who have incomes up to 100 percent of the FPL.
- Work requirements: As a condition of eligibility, individuals would be required to demonstrate they are working or engaged in other approved activities (e.g., community service, job training) for at least 80 hours per month, unless they meet a good cause exemption. Individuals will be required to report on a monthly basis, but enrollees who demonstrate compliance for six consecutive months will be exempt from reporting until they are reevaluated for eligibility, although they must inform the state if their employment status changes.
- Employer-sponsored insurance (ESI) premium assistance program: If an eligible individual has access to ESI, the individual will be required to enroll in that coverage instead of Medicaid and the state will provide premium and cost-sharing assistance through Georgia’s health insurance premium program (HIPP) if it is deemed cost effective for the state.
- Premiums: Some individuals will be required to pay premiums, and these premiums will be deposited in a Member Rewards Account.
- Individuals required to pay premiums:Individuals in the demonstration program who have incomes of 50 to 100 percent of the FPL will have income-based monthly premiums ($7/month for individuals with incomes between 50 to 84 percent of the FPL and $11/month for individuals with incomes between 85 to 100 percent of the FPL). For coverage to begin, individuals must make an initial premium payment within 90 days of being determined eligible.
- Exempt individuals:Individuals with incomes below 50 percent of the FPL; individuals with ESI enrolled in HIPP; and individuals who are enrolled in and two months after graduation from certain vocational education training programs of highly sought-after trades.
- Penalties for nonpayment:If an enrollee misses one or two premium payments after the initial payment, there is a 60-day grace period for each missed payment. Enrollees who accrue three missed payments will be suspended from the demonstration in the following month, and they will have 90 days to make a minimum of one payment in order to regain coverage.
- Copayments: With the exception of individuals participating in the ESI premium assistance program, all demonstration enrollees will be required to make copayments for certain services. These payments will be assessed retrospectively and are consistent with the state plan, with the addition of a copayment for non-emergency use of the emergency department. The copayments are not to exceed 5 percent of an individual’s household income when combined with any premium payments.
- Member Rewards Accounts: All enrollees except those who are receiving premium assistance for ESI coverage will have a Member Rewards Account (MRA), and enrollees’ premium payments will be deposited in these accounts. Individuals can earn non-monetary credits in their accounts by engaging in healthy behavior activities, such as smoking cessation classes or annual well visits. Funds in the MRA accounts can be used for copayments or to pay for additional services that are not covered, such as vision or dental care.
- Benefit package and delivery system: Most enrollees will receive a benefit package that aligns with the benefits provided through the Medicaid state plan, with the exception of non-emergency medical transportation (NEMT). However, individuals ages 19 and 20 will receive Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, which will include NEMT. For individuals for whom the state is covering the cost of ESI, wraparound benefits are not covered, and their benefits are limited to those covered by their ESI plan. The demonstration program will use a managed care delivery system for all enrollees, although individuals participating in the ESI program are exempt from this requirement.
- Other key elements: Through the demonstration, CMS is permitting the state to waive retroactive eligibility, and to have eligibility begin the month following the determination of eligibility and the payment of any premium required. Also, CMS is allowing the state to not provide hospital presumptive eligibility for individuals in the demonstration.
- Implementation timeline: CMS is permitting the state to implement the demonstration beginning July 1, 2021, and it is approved through Sept. 30, 2025.
Legal challenges to the work requirements in the approved waiver are expected, as was acknowledged by CMS Administrator Seema Verma. While other states have received federal approval to implement Medicaid work requirements, currently there are no states with active work requirements. This is due to some states not having yet implemented them, legal challenges that have vacated some waiver approvals, and states’ decisions to suspend implementation. Explore the National Academy for State Health Policy’s A Snapshot of State Proposals to Implement Medicaid Work Requirements Nationwide for additional information.