Health Reform WK-EDGE Georgia’s request to expand Medicaid approved
Friday, October 23, 2020

Georgia’s request to expand Medicaid approved

By Gregory Kane, J.D., M.B.A.

CMS approved the Georgia Department of Community Health’s request to expand Medicaid coverage with certain work requirements for eligibility.

CMS approved Georgia’s request to extend Medicaid coverage to individuals who meet additional requirements beyond those described in the state plan through a section 1115 demonstration projected entitled, "Georgia Pathways to Coverage" (Pathways). The approval is effective October 15, 2020 through September 30, 2025. The program is designed to extend Medicaid coverage to individuals with incomes up to 95 percent of the federal poverty level (FPL) (effectively 100 percent with the 5 percent income disregard) who meet the qualifying hours and activities and premium payment requirements as a condition of initial and continued eligibility (CMS Letter, October 15, 2020).

Background. As of December 2019, Georgia’s Medicaid program had over 1 million individuals enrolled through its Georgia Families Medicaid managed care program with some 470,500 aged, blind and disabled low-income individuals enrolled in the state’s fee-for-service Medicaid program. Georgia has not expanded Medicaid coverage to adults with income up to 133 of FPL under the Patient Protection and Affordable Care Act (ACA).

New coverage. The Pathways program will provide coverage to low income adults ages 19 through 64 with incomes up to 95 percent of the FPL who are not otherwise eligible for Medicaid coverage. Applicants and beneficiaries must complete a minimum of 80 hours of qualifying activities in order to qualify for the program. Qualified activities may include unsubsidized employment, subsidized private sector employment, on-the-job training, specified job readiness activities, or enrollment in an institution of higher learning. Most applicants with incomes at 50 percent up to 95 percent of the FPL will be required to make initial and ongoing monthly premium payments. Most beneficiaries in Pathways will receive benefits consistent with the Medicaid state plan except for non-emergency medical transportation.

Georgia’s request to allow individuals who are disenrolled from Medicare because their income exceeds 95 percent of the FPL to access the balance of their Medicaid benefits is the subject of ongoing discussions.

CMS did not authorize Georgia’s request to receive enhanced Federal Medical Assistance Percentage because the state did not cover the entire adult expansion group, those adults with income up to 133 percent of the FPL.

Approval of Pathways was based on the goal of expanding coverage to individuals who would not otherwise be eligible for Medicaid. While there were considerable public comments criticizing the qualifying hours and activities requirement for coverage, the Pathways program will provide an opportunity for uninsured Georgians who were previously ineligible for Medicaid to gain health coverage. CMS stated its confidence that Georgia will implement sufficient guardrails to address concerns about the potential impact to people with health issues and to other groups like low-income families and people who are lesbian, gay, bisexual and transgender.

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