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November 6, 2019

Georgia gov. proposes partial Medicaid expansion, work requirements

Daily Briefing

    Georgia Gov. Brian Kemp (R) on Monday announced a proposal to seek the federal government's permission to implement a partial Medicaid expansion with work requirements in the state.

    Slide deck: Medicaid 101

    According to the Atlanta Journal-Constitution, the partial Medicaid expansion proposal is intended to work in partnership with a proposal Kemp unveiled last week that seeks to revamp the state's individual health insurance market and lower premiums for such coverage.


    Proposal details

    The proposed Medicaid expansion would fall short of a total expansion under the Affordable Care Act (ACA) because it would not expand Medicaid coverage to state residents with annual incomes up to 138% of the federal poverty level (FPL), which is about $17,236 for an individual, The Hill reports.

    Instead, Kemp's proposal, called Georgia Pathways, would expand Medicaid coverage to adults in the state with annual incomes up to 100% FPL, which is about $12,490 for an individual. Under the proposed program, the state would provide Medicaid coverage to qualifying individuals who do not have health insurance, and would help to pay premiums for qualifying individuals who are enrolled in employer-sponsored health plans if they remain enrolled in that coverage.

    The proposal would require qualifying adults to be enrolled full time in post-secondary education, participate in job training, volunteer or participate in certain community service, work, or participate in certain other activities for at least 80 hours per month in order to keep their coverage. Under the proposal, caring for a sick relative would not count as an activity that meets the requirements. Beneficiaries would have to report their time in accordance with state guidelines. According to Inside Health Policy, the proposal would require individuals to prove they are meeting the work requirements before the state would enroll them in coverage.

    The proposal also would require certain beneficiaries with annual incomes between 50% and 100% of FPL to pay monthly premiums that are based on income and range from $7 to $11. According to Inside Health Policy, the proposal includes a three-month grace period for beneficiaries who miss a premium payment to make the payment before they are removed from the program. The proposal also includes some copayment requirements, Inside Health Policy reports.

    But Kemp said Georgia Pathways beneficiaries could earn some of their premiums and copayments back by engaging in certain healthy behaviors and logging them through an app. Kemp said those funds could be used to cover additional services, such as prescription drugs, vision care, hygiene products, and more.

    Kemp's office has estimated that about 408,000 Georgia residents would be eligible for Medicaid coverage under the partial expansion, and that about 50,000 would be enrolled in the program after its first five years of implementation. Kemp's administration projected that Georgia Pathways would cost $128 million in the first year, with the state paying about $36 million and the federal government funding the remaining cost.

    Approval unclear

    The proposal is open to public comments until Dec. 3. Kemp said he intends to submit the proposal to CMS by the end of this year, and CMS then must decide whether to approve the plan. If approved, the proposal would take effect in July 2021.

    But it is unclear whether CMS would approve the proposal, as the agency in August rejected a similar request from Utah, The Hill reports. Utah officials had asked CMS to pay the ACA's enhanced federal funding rate of 90% for beneficiaries enrolled in the state's partial Medicaid expansion, but CMS so far has declined to approve the enhanced rate for partial expansions.

    According to the Journal-Constitution, Kemp's aides said they have been in contact with federal officials and expect the Trump administration to approve the proposal.

    If CMS does approve the proposal, Georgia would be the first state to receive approval for a plan that would implement a partial Medicaid expansion and work requirements at the same time, as other states have sought to apply work requirements to programs they already had expanded, Axios' "Vitals" reports.


    Kemp said the proposed expansion would help some Georgia residents who cannot afford health coverage obtain insurance. "Right now in Georgia there are hundreds of thousands of Georgians working, training, or volunteering and they can't afford needed coverage but have run out of realistic options," he said.

    However, Kemp said, "Unlike Medicaid expansion, which will literally cost billions of dollars, Georgia Pathways will not bankrupt our state or raise taxes on our families or our businesses." He continued, "This is not a free handout," adding, "Hard-working Georgians who qualify will have skin in the game."

    State Sen. Chuck Hufstetler (R), said the proposal represents "a great opportunity to help people get training and to get out of poverty. … As well as getting them insurance."

    But Eliot Fishman, a Medicaid expert at Families USA, said some of the proposal's provisions could create barriers for some low-income residents to access health coverage. "The proposal incorporates work requirements, premiums, and a variety of barriers to actually getting people covered. It's going to limit the number of people who can benefit from this," Fishman said.

    According to the Journal-Constitution, individuals who support fully expanding Georgia's Medicaid program have said Kemp's proposal could leave disabled and homeless residents, as well as residents with mental illness and many others, without coverage.

     Laura Colbert, director of Georgians for a Healthy Future, said, "If there are really 408,000 people who could qualify for coverage and in five years the majority of those people are not expected to be covered, then there's something wrong with the plan" (Hellmann, The Hill, 11/4; Hart/Bluestein, Atlanta Journal-Constitution, 11/4; Owens, "Vitals," Axios, 11/5; Livingston, Modern Healthcare, 11/4; Cirruzzo, Inside Health Policy, 11/4 [subscription required]).

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