CMS: Trump Administration Approves Innovative State-Led Health Reform to Expand and Strengthen Coverage for Georgia Residents

BALTIMORE, Maryland, Oct. 16 -- The U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services issued the following news release on Oct. 15:

Today, the Centers for Medicare & Medicaid Services (CMS), under the leadership of President Trump, announced action it has taken to advance an innovative package of state-led reforms that were crafted in response to the guidance and unprecedented flexibility offered by the Trump Administration. As a result of the state and CMS's actions, thousands of uninsured Georgians will gain access to coverage.

Specifically, CMS announced the approval of Georgia's new Medicaid section 1115 demonstration called "Pathways to Coverage." The demonstration is designed to create a pathway for working-age Georgia adults who are ineligible for Medicaid to opt into Medicaid coverage by participating in qualifying activities like work and education, as well as meeting premium and income requirements.

"President Trump has long understood that states should have maximum flexibility over their own healthcare programs, because innovative leaders like Governor Kemp know their states and have good ideas worth testing," said CMS Administrator Seema Verma. "I'm thrilled to support this comprehensive state-led reform that will help thousands of working adults in Georgia gain access to coverage for the first time in a way that addresses both their health and socio-economic needs."

Georgia's Medicaid section 1115 demonstration "Pathways to Coverage" applies to individuals who are between the age of 19 through 64, with income up to and including 100 percent of the federal poverty level (FPL) and is effective today through September 30, 2025, with implementation beginning July 1, 2021. Those who already qualify for Medicaid today will not be directly affected, and it is estimated that over 30,000 individuals will receive Medicaid coverage during the first year of the demonstration and nearly 65,000 Georgians will enroll in Medicaid or receive Medicaid premium assistance for coverage through Employer Sponsored Insurance (ESI) over the five-year demonstration.

In order to qualify for this program, individuals must comply with specific requirements, including participating in 80 hours a month of work or other qualifying activities. Most individuals with income between 50 and 100 percent of the FPL will be required to make initial and ongoing monthly premium payments. Applicants and beneficiaries with disabilities requiring reasonable accommodation will have options available to complete and report their qualifying activities and hours. The state is providing support to those not already working to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities.

The "Pathways to Coverage" demonstration leverages many of the flexibilities outlined in the Healthy Adult Opportunity (HAO) guidance that CMS released earlier this year. The HAO was designed to give states a broad suite of flexibilities in exchange for meeting certain performance and spending targets. For example, while the demonstration program affords the state a great deal of flexibility, it also requires Georgia to report on a range of key quality measures and CMS will monitor the state's performance. The state will also be required to develop a rigorous evaluation design and submit evaluation reports to CMS to assess the effectiveness of testing these policies. Additionally, as with all section 1115 demonstrations, Georgia will be financially accountable to an agreed-upon budget neutrality test for this demonstration.

Georgia is also pursuing complementary reforms of its individual health insurance market through a section 1332 State Relief and Empowerment Waiver, also referred to as a section 1332 waiver. CMS has completed its review of Georgia's 1332 waiver request and is working with the state and federal partners to finalize the terms and conditions for approval. This waiver is designed to put Georgia on a path to change the systemic issues with the state's individual health insurance market--with the goal of reducing premiums, providing greater access and promoting a more competitive private insurance marketplace.

Like many other states, Georgia's individual market has faced severe challenges under the Patient Protection and Affordable Care Act (PPACA). As a result, many Georgians who are eligible for federal premium subsidies remain uninsured in Georgia, and people who do not qualify for such subsidies continue to be priced out of the market. In just one year from 2016 to 2017, total individual market enrollment in Georgia dropped substantially, with approximately 94,000 Georgians fleeing the market and enrollment declining by 22% between 2016 to 2019. Georgia continues to have one of the highest uninsured rates in the country at 14.8 percent with approximately 1.4 million people uninsured across the state. The state attributes the high numbers of uninsured individuals to a variety of factors, including high premiums, unaffordable out-of-pocket expenses, and low insurer competition in the individual market.

In its waiver, the state has proposed a two-phase approach to address these challenges. The first phase seeks to implement a state-based reinsurance program starting in Plan Year (PY) 2022. The reinsurance program is expected to reduce premiums for everyone in the individual market by an average of 10 percent, and will target savings to rural areas hardest hit by the lack of competition and choice due to the PPACA. The second phase seeks to transition the state's individual market enrollment to a private sector platform called the Georgia Access Model in plan year 2023.

Under the Georgia Access Model, consumers will shop for and compare available plans through private sector partners, including web brokers, health insurance companies, and traditional agents and brokers. This will drive expanded access to enrollment options and improvements in the consumer shopping experience as the market innovates to meet consumer preferences. Consumers will continue to have access to and be able to enroll in the full array of metal-level plans, including subsidy-eligible qualified health plans, and be assessed for Medicaid and CHIP eligibility.

The state projects that the combined impact of the Reinsurance Program and the Georgia Access Model will result in more affordable premiums and increase enrollment, particularly across rural areas of the state.

To view the approved Georgia section 1115 Demonstration, click here: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ga/ga-pathways-to-coverage-ca.pdf