Medicaid eligibility and enrollment in Georgia

If a person is no longer eligible for Medicaid, they should understand what their coverage options will be once their Medicaid coverage terminates (note that this might not come for several months, as the eligibility redeterminations will be spread over several months). Other coverage options might include an employer-sponsored plan, Medicare, or a plan purchased through the exchange/marketplace. In all of those cases, there is normally a limited window to enroll in the coverage. But for people who end up needing to purchase their own replacement coverage (ie, they aren’t eligible for Medicare or an employer’s plan), HealthCare.gov is offering an extended enrollment opportunity, from March 31, 2023 through July 31, 2024, for anyone who loses Medicaid at any time during that window.

Since Georgia does still have a coverage gap due to the state’s refusal to expand Medicaid under the ACA, it’s important for low-income residents to be aware of how to avoid this coverage gap. Some people might have become eligible for Georgia Medicaid during the pandemic due to something like pregnancy, but could find themselves in the coverage gap if their income is not at least the poverty level once the eligibility redeterminations resume.

Georgia’s partial Medicaid expansion set to take effect in July 2023, with a work requirement and premiums for some enrollees

In July 2023, Georgia plans to implement a partial Medicaid expansion, covering adults with household income below the poverty level as long as they work at least 80 hours per month. The implementation of Georgia’s partial Medicaid expansion has been a complicated legal and regulatory process, and Georgia will be the only state in the country with a Medicaid work requirement once it takes effect. Here’s the story of how all of this came to be:

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).

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 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, as people with income at or above the poverty level are eligible for subsidies in the marketplace/exchange.

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 noted 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.

In 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 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. In August 2022, a judge sided with Georgia, clearing the way for the state to move forward with the Georgia Pathways program. And the Biden administration had not appealed that decision as of early 2023.

Implementation of the state’s partial Medicaid expansion was paused while the lawsuit made its way through the court system. But by late 2022, Georgia Governor Brian Kemp announced that the Pathways program would begin in July 2023. The program, including the work requirement, will be administered via the state’s existing Georgia Gateway website for social services benefits.

The state has long anticipated between 50,000 and 64,000 enrollees in the program, but Georgia Medicaid is seeking funding in the state budget to cover up to 100,000 people. That is only a small fraction of the number of people who would be covered if Georgia simply accepted the ACA’s expansion of Medicaid, but the work requirement and premium requirement are designed to ensure that enrollment is fairly minimal.

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

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.

(Note that states have been receiving additional federal Medicaid funding during the COVID pandemic, but that will be phased out over the course of 2023. However, the American Rescue Plan provides states that newly expand Medicaid with two years of boosted federal Medicaid funding, and Georgia would be eligible to receive that if the state were to fully expand Medicaid.)

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. As described above, the federal government has provided states with additional Medicaid funding to address the pandemic, but a condition of receiving the funding was that coverage could not be terminated during the COVID public health emergency (that continuous coverage requirement ends March 31, 2023, regardless of whether the public health emergency continues or not). So throughout the pandemic, the Medicaid continuous coverage requirement would have rendered a work requirement meaningless. But the continuous coverage requirement will no longer be in place when Georgia’s partial Medicaid expansion and work requirement take effect in the summer of 2023.

Under the Georgia Pathways program, enrollees must report their community engagement on a monthly basis. But the waiver terms note that 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 will also have to pay monthly premiums for their Georgia Pathways coverage. Members will 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 roughly 27% of the poverty level. (Note that this percentage decreases each year as the federal poverty level increases, unless Georgia increases its eligibility limit. This is because Georgia is one of the states that use a flat dollar limit, rather than a percentage of the poverty level, to determine Medicaid eligibility for parents.) For a household of three 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 allows for expansion of coverage to both parents and non-parents with household income under the poverty level, as long as they comply with the work requirement (and for those with income above 50% of the poverty level, payment of premiums).

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, or possibly as many as 100,000. But in general, 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 and administrative reporting.

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 planning 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 is also forfeiting the American Rescue Plan’s two years of additional federal funding for states that newly expand Medicaid, which would have amounted to $1.3 billion in additional federal funding.

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.

As of September 2022, total Medicaid/CHIP enrollment in Georgia was 58% 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). As noted above, this will end as of April 2023, when states will once again start to conduct regular Medicaid eligibility redeterminations.

Who is eligible for Medicaid in Georgia?

The 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 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 www.healthcare.gov.
• 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 58% since late 2013. Enrollment was 1,535,090 as of September 2013. As of September 2022, enrollment had grown to 2,420,983. 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.

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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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.