Updated January 10, 2023: In August 2022, a federal judge in Georgia cleared the way for the Pathways Coverage program to proceed. The federal government opted not to make an appeal during the 60-day window, and in October 2022, the Department of Community Health announced that it was moving forward with planning for the implementation of the Pathways to Coverage program.
The passage of the Affordable Care Act a decade ago provided an opportunity to get more Georgians access to health care coverage by 1) giving Georgia the option to expand Medicaid eligibility for more low-income adults; 2) offering premium tax credits that make marketplace coverage more affordable for low- and middle-income Georgians; and 3) creating a federally-facilitated marketplace website (Healthcare.gov) to help make those plans more easily accessible. In 2019, Georgia’s Patients First Act paved the way for Georgia to seek federal approval for two waivers that would partially expand Medicaid coverage and remove the state from Healthcare.gov. This fact sheet provides an update on both those waivers as well as on full Medicaid expansion.
The bottom line is this: Everyone benefits when all Georgians have access to high-quality, affordable health care. The Georgia Pathways to Coverage program and Georgia Access Model program would provide access to coverage for fewer Georgians and be more costly for the state than what is currently offered by full Medicaid expansion and by state participation in Healthcare.gov.
| What would it do? | Who does it help? | How is it funded? |
What’s the status?
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Georgia Pathways to Coverage (1115 Waiver[1]) |
Partially expands Medicaid coverage to Georgians with incomes up to 100% of the federal poverty level and requires that enrollees work and that some pay premiums | More than 50,000 low-income Georgians
|
About 66% of costs covered by federal government with remaining costs covered by state | Initially approved in 2020; approval for premium payments and work requirements withdrawn in 2021; implementation re-started in late 2022 |
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Full Medicaid Expansion
(Affordable Care Act)
|
Expands Medicaid coverage to Georgians with incomes up to 138% of the federal poverty level | Almost 500,000 low-income Georgians | About 90% of costs covered by federal government with remaining costs covered by state | Not yet adopted |
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Georgia Access Model (1332 Waiver[2])
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Removes the state from Healthcare.gov and relies on web brokers and insurers to help consumers enroll in individual market coverage | Undetermined | Mix of federal and state funding and fees | Temporarily suspended |
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Georgia Reinsurance Program (1332 Waiver) |
Establishes a claims-based reinsurance program | Individual health insurance market enrollees who are not eligible for federal premium tax credits
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Mix of federal and state funding
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Approved in 2020 and implementation started in 2022
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[1] Section 1115 waiver: The federal Centers for Medicare and Medicaid (CMS) agency allows states to apply for waivers for experimental projects that test out and evaluate state-specific policy approaches to better serving Medicaid populations.
[2] Section 1332 waiver (also known as state innovation waiver): CMS allows states to apply for waivers for programs that remove certain ACA requirements related to individual markets while continuing to provide access to high quality, affordable health care in a way that meets that state’s unique needs and context.
Visit Cover Georgia for a full timeline.
Full Medicaid Expansion
- Medicaid coverage for adult Georgians with incomes up to 138% of federal poverty level
- About 486,503 Georgians would gain coverage once program reached full enrollment according to state auditor
- Federal government pays about 90 percent of cost for newly eligible enrollees, and state would pay remainder
- Federal government pays additional 5 percentage match on existing enrollees (about 71 percent federal matching) in first two years after expansion—more than offsetting state costs of expansion
- State legislature and Governor have failed to provide approval for full Medicaid expansion—making Georgia one of only 11 states to not fully expand Medicaid
Georgia Pathways to Coverage
- Medicaid coverage for adult Georgians earning up to 100% of federal poverty level
- Eligibility requirements: 1) complete of minimum of 80 hours per month of qualifying activities like employment, community service, higher education, etc. and 2) pay monthly premium payments if income is between 50 – 100% of federal poverty level
- Between 52,000 to 64,000 Georgians would gain coverage over entire 5 years of program according to state estimates
- Federal government pays about 66 percent of cost for newly eligible enrollees, and state would pay remainder
- Initial approval received from federal government in October 2020; approval for premium payments and work requirements withdrawn by federal government in December 2021 under new administration; implementation halted in January 2022 while state pursued legal action in federal court; federal judge ruled in favor of state in August 2022; the state re-started implementation planning in late 2022
Georgia Access Model
- Proposes to leave federal health insurance marketplace (known as Healthcare.gov) without creating a state-based alternative
- Enrollees would be advised to work directly with online agents or brokers
- Enrollment in individual health insurance market would increase through improved customer service, outreach, and education provided by web brokers, insurers, etc. in private market according to state proposal
- However, federal government estimates it would result in loss of coverage for tens of thousands of Georgians[3]
- Would be funded by state general funds, federal funds and fees on insurers and providers
- About $8 million in state funding in AFY22 and about $16 million slated for FY23
- User fee, if implemented, would also be used to fund Reinsurance Program
- Initial approval received from federal government in November 2020; approval suspended by federal government in August 2022
- State can submit a corrective action plan to resume implementation for plan years 2024 – 2026
Georgia Reinsurance Program
- Provides payments to health insurers to help offset costs of enrollees in individual health insurance market who have large medical claims
- Lowers costs for enrollees who are not eligible for federal premium tax credits and pay full out-of-pocket cost for individual market coverage
- Premiums reduced an average of almost 12% statewide and number of insurers in market increased from 6 to 11 in 2022 according to state data
- Funded by state general funds and federal pass-through funding (in other words, amount federal government saves in premium subsidies resulting from reinsurance program)
- About $49,000 in in state funding in AFY22 and about $124 million slated for FY23
- Initial approval received from federal government in November 2020; implementation began in 2022 and can continue through 2026
[3] Over 700,000 Georgians enrolled in marketplace coverage through Healthcare.gov during 2022 open enrollment period—an increase of 36% from 2021 thanks in part to enhanced premium tax credits that are available through 2025.
