Trump Administration Approves Georgia’s Limited Expansion of Medicaid and Work Requiremen

King & Spalding

CMS approved Georgia’s Section 1115 demonstration project to partially expand Medicaid coverage for adults not otherwise eligible for Medicaid coverage with incomes up to 95 percent of the Federal Poverty Line (FPL)—short of the Affordable Care Act’s effective minimum threshold of 138 percent of the FPL. Most individuals with incomes from 50 percent up to 95 percent of the FPL who choose to opt-in to this Medicaid coverage will be required to pay monthly premiums. CMS also approved an eighty-hour “qualifying activities” requirement as a condition of eligibility. The changes were effective October 15, 2020.

Enrolled individuals who are also eligible for employer-sponsored insurance may be required to enroll in such insurance with premium and cost-sharing assistance from the State if this alternative will be cost effective to the State. Enrollees will be provided a Member Rewards Account (MRA) to be used to deduct beneficiary copayments, reflect accrued premium payment amounts as credits, and deposit incentive points with a dollar-value equivalent for completing healthy behavior activities, such as attending smoking cessation classes and annual well visits. Enrollees may use credits in the MRAs to access dental services, glasses, contacts and over-the-counter drugs not covered by Medicaid.

Notably, CMS rejected Georgia’s request for an enhanced federal match for the state’s limited Medicaid expansion. CMS clarified that it would continue its existing policy of providing the enhanced match only to states that expanded Medicaid to the ACA threshold. Accordingly, Georgia will not receive the Affordable Care Act’s 90 percent federal match for full expansion and will instead continue to receive its existing 67 percent match.

In addition to the limited Medicaid expansion, Georgia added a qualifying activities requirement for Medicaid eligibility, with limited exceptions due to disability or other good cause reasons. The activities requirement may be satisfied by certain specified activities, including subsidized private sector employment (including self-employment), unsubsidized employment, specified job readiness activities, on-the-job training, certain community service activities, specified vocational educational training, and enrollment in an institution of higher education. The Supreme Court is expected to take up the issue of Medicaid work and activity requirements sometime soon. King & Spalding will continue tracking this issue.

Georgia has also submitted a Section 1332 State Innovation Waiver Application for the “Georgia Access Model,” a plan to exit, the federal health insurance exchange for ACA plans. Under the waiver, Georgia would not establish a state-run clearinghouse for ACA plans. Instead of using the federal or a state-run exchange website to purchase ACA plans, Georgians would purchase plans directly from private insurers and web brokers.

In its Section 1332 State Innovation Waiver Application, Georgia also requests a waiver to develop a state reinsurance program to attempt to stabilize the individual insurance market and reduce premiums. This would be contingent on a waiver of the ACA requirement that all individual market enrollees be members of a single risk pool. Georgia estimates the total cost for the reinsurance program would be $398 million in 2022. Of this $398 million, the federal government would contribute approximately $306 million via pass-through funding, and Georgia would contribute the remaining $92 million from the state general fund. The State estimates that the waiver would decrease premiums by approximately ten percent, as compared to premiums if no waiver were in place. The estimated premium reduction is expected to have the greatest impact for those individuals over 400% of the FPL, who are not eligible for federal subsidies for premiums.

If approved, Georgia’s plans to exit the federal exchange and implement a reinsurance program would be in effect from 2022 through 2026. Last Thursday, Seema Verma, the CMS Administrator, announced that approval of the Section 1332 Waiver would be officially announced in a few days. King & Spalding will continue tracking this issue as well.

A copy of the Section 1115 demonstration project approval is available here. Georgia’s Section 1332 State Innovation Waiver Application, as submitted to CMS on July 31, 2020, is available here.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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