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Georgia and the ACA’s Medicaid expansion

Georgia postponed a planned a partial expansion of Medicaid that called for a work requirement, would not have received enhanced federal funding, and would have covered far fewer people than full expansion.

Key takeaways

Georgia’s partial Medicaid expansion has been delayed; CMS has revoked approval for work requirement and premiums; Georgia has filed a lawsuit in response

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

Federal poverty level calculator

In November 2019, the state unveiled an 1115 waiver proposal that called for partial Medicaid expansion, effective in July 2021, that would cover adults age 19-64 with income up to 100% of the poverty level, as long as they were working (or participating in other “community engagement” activities) at least 80 hours per month.

Georgia’s full proposal, called Georgia Pathways, can be viewed here. The state sought public comments on the proposal in late 2019, and most who commented did not support it. The state submitted the proposal to CMS in late December 2019, and approval was granted in October 2020. The state’s partial expansion of Medicaid was initially slated to take effect July 1, 2021. Although it would have been only a partial expansion of Medicaid and would have had a work requirement, it would have technically eliminated the coverage gap that currently exists in Georgia.

The approved waiver also allowed for Georgia Pathways enrollees with income above 50% of the poverty level to have cost-sharing and monthly premiums (ranging from $7 to $11/month, with a lower additional rate for a spouse, plus a tobacco surcharge if applicable).

Although the Trump administration was open to states’ Medicaid work requirement proposals (and approved Georgia’s), the Biden administration has expressed that work requirements do not mesh with the overall mission of Medicaid, which is to provide health coverage to low-income Americans. So CMS notified Georgia in February 2021 that the work requirement approval was being reconsidered (CMS sent a similar letter to every state where Medicaid work requirements had been approved by the Trump administration).

In March 2021, Georgia officials replied, explaining that they believe the work requirement is an essential part of their plan to partially expand Medicaid. Shortly thereafter, Georgia also notified CMS that the partial expansion of Medicaid was being delayed until at least the end of 2021, while Georgia and CMS officials worked out the details.

As of late 2021, CMS notified Georgia officials that the approval for the work requirement provision had officially been revoked, along with the premium requirement that Georgia had been included in the Georgia Pathways program. At that point, the partial expansion of Medicaid was still allowed to move forward, but without a work requirement or a premium requirement for participants. (The Biden administration has also revoked Medicaid work requirement approvals in all of the other states where the Trump administration had approved them.)

In January 2022, the state of Georgia filed a lawsuit against CMS/HHS, alleging an “unlawful regulatory bait and switch” and asking a judge to allow the state to proceed with the Georgia Pathways program as it was initially approved in 2020. Implementation of the state’s partial Medicaid expansion has been paused while the lawsuit makes its way through the court system.

Georgia Pathways would be costly for the state and complicated for enrollees

Although Georgia Pathways is currently on hold due to the legal dispute over the work requirement and premiums, it could still be implemented at a later date. Let’s take a look at what the state wants to do in terms of partial Medicaid expansion.

As part of the waiver proposal, Georgia asked CMS to provide the state with full Medicaid expansion funding (i.e., covering 90% of the cost), despite the fact that the state would only be implementing a partial expansion of Medicaid. A similar request from Utah was rejected by the Trump administration in 2019, and CMS followed the same process for Georgia: The federal government will not provide the 90% funding match for Georgia’s partial Medicaid expansion, but will instead pay the state’s normal federal matching rate of 67%. This means it will cost Georgia more to cover the expanded Medicaid population than it would if the state were to simply expand Medicaid fully, as called for in the ACA.

As of 2020, due to the COVID pandemic, Medicaid work requirements had been suspended in all states that had implemented them or been in the process of implementing them. The federal government is providing states with additional federal Medicaid funding to address the pandemic, but a condition of receiving the funding is that coverage cannot be terminated during the COVID public health emergency. This would render a work requirement meaningless for the time being, but Georgia’s lawsuit against HHS makes it clear that they wish to proceed with the work requirement (and partial expansion of Medicaid) once the pandemic public health emergency period ends.

(Georgia’s waiver approval was granted in late 2020, after the pandemic had been underway for several months and states had stopped terminating Medicaid enrollees’ coverage. The waiver approval noted that if necessary due to the pandemic, modifications could be made to the work requirement when the Georgia Pathways program was implemented.)

Under the Georgia Pathways program, 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.

As noted above, enrollees with income above 50% of the poverty level would have to pay monthly premiums for their Georgia Pathways coverage. 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). 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 36% of the poverty level (for a household of two in 2022, this amounts to about $550 in monthly 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 called for expansion of 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.

But again, that’s up in the air as of 2022: The Biden administration has revoked authorization for the work requirement and premiums, and Georgia has paused implementation of Georgia Pathways and filed a lawsuit against HHS/CMS in response.

The Kaiser Family Foundation estimates that there are 269,000 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. But the state of Georgia only expects about 50,000 people to gain coverage under Georgia Pathways. Presumably, it’s expected that the majority of the people currently in the coverage gap 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% federal funding (i.e., no waiver approval necessary), and an estimated 600,000 to 700,000 people would gain coverage. Instead, the state is attempting to implement a plan that will cover only a fraction of those individuals, and they’re forfeiting the enhanced federal funding match that would be provided if they fully expanded Medicaid.

Georgia’s history with Medicaid expansion

As of May 2020, 23% of Georgia residents were uninsured — the state had the fourth-highest uninsured rate in the U.S. at that point. Georgia is leaving billions of dollars on the table and over 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 in Georgia. 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.

As of mid-2021, total Medicaid/CHIP enrollment in Georgia was 43% higher than it had been in 2013, despite the fact that the state has not expanded Medicaid. The increase is due in large part to the COVID pandemic and the fact that eligibility redeterminations are not being done during the COVID public health emergency (so enrollment has tended to only increase, nationwide, with no downward fluctuations).

Georgia has not accepted federal Medicaid expansion

  • 2,195,640 – Number of Georgians covered by Medicaid/CHIP as of July 2021
  • 678,000 – Number of additional Georgia residents who would be covered if the state accepted expansion
  • 269,000 – Number of people who have NO realistic access to health insurance without Medicaid expansion
  • $3.5 billion – Federal money Georgia is leaving on the table in 2022 by not expanding Medicaid

Who is eligible for Medicaid in Georgia?

As of April 2020, criteria for enrollment in Georgia Medicaid are set at the following levels for non-disabled adults (note that these income limits include a built-in 5% income disregard that’s used for MAGI-based Medicaid eligibility determinations):

  • Children up to age 1 with family income up to 210% of federal poverty level (FPL)
  • Children ages 1-5 with family income up to 154% of FPL
  • Children ages 6-18 with family income up to 138% of FPL
  • Pregnant women with family income up to 225% of FPL
  • Parents of minor children with family income up to 36% of FPL

How does Medicaid provide financial help to Medicare beneficiaries in Georgia?

Many Medicare beneficiaries receive assistance from Medicaid with Medicare premiums, prescription drug costs, and expenses not covered by Medicare – including long-term care.

Our guide to financial assistance for Medicare enrollees in Georgia includes overviews of these programs, including Medicaid nursing home benefits, Extra Help, and eligibility guidelines for assistance.

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 43% since late 2013. Enrollment was 1,535,090 as of September 2013. As of July 2021, enrollment had grown to 2,195,640. 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, marketing associated with the ACA’s exchanges, and the effects of the COVID pandemic.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Apply for Medicaid in Georgia

Online at either Georgia Gateway or; in person (Call 1-877-423-4746 for directions to a local office.) Submit a paper application by mail, fax or in person. (Contact your DFCS county office for an application.)

Eligibility: Children up to age 1 with family income up to 205% of FPL; children 1-5 with family income up to 149% of FPL; children 6-18 with family income up to 133% of FPL; pregnant women with family income up to 220% of FPL; parents with family income up to 35% of FPL; individuals who are elderly, blind and disabled (See income and resource limits.)

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