Providers in Georgia could see more insured as partial Medicaid expansion gets green light

Ingrid Stiver Senior Manager, Health Research Institute, PwC US October 22, 2020

CMS has approved a waiver for Georgia that allows the state to partially expand Medicaid under Section 1115 of the Social Security Act with some provisions, including work requirements, that could pave a path for other states that have not yet made the leap to expansion.

Under the approved Section 1115 waiver, Georgia will expand Medicaid coverage to individuals age 19 to 64 with incomes up to 100% of the federal poverty level if they meet requirements for work and make monthly premium payments. The waiver runs from July 1, 2021, through Sept. 30, 2025. All individuals eligible for Medicaid under the waiver will be enrolled in a plan through a managed care organization (MCO) contracted with the state.

According to the approved waiver, the state of Georgia estimates that more than 30,000 people will enroll in Medicaid coverage during the first year of the waiver and that nearly 65,000 will enroll in Medicaid or receive financial assistance from the state for employer coverage during the five-year waiver period. CMS acknowledges that no individuals eligible for Medicaid will lose coverage because of the work requirements or premium payments, as those will apply only to the Medicaid expansion population in Georgia.

But the Section 1115 waiver falls short of full Medicaid expansion in Georgia without work requirements or premium payments. The Kaiser Family Foundation estimates that 518,000 Georgians would be eligible for Medicaid if the state fully expanded the program without any stipulations.

The Trump administration has been encouraging states to apply for Section 1115 waivers for programs imposing certain requirements on some Medicaid beneficiaries, including proof that they are engaged in work or worklike activities. States have applied for Section 1115 waivers for a variety of proposed deviations from the traditional Medicaid program, including eligibility and enrollment restrictions, benefit and copay provisions, healthy behavior provisions, behavioral health provisions and delivery system reform initiatives.

The legality of work requirements has been challenged across the US. Work requirements in Arkansas, Kentucky, Michigan and New Hampshire have been set aside by the courts. Kentucky’s premium payment requirement also was set aside by the courts. Gov. Andy Beshear ended the state’s Section 1115 waiver when he took office in December 2019.

Under the Georgia waiver, individuals not already eligible for Medicaid will be required to complete 80 hours of qualifying activities—such as employment, self-employment, education or training, and certain volunteer activities—before coverage will begin. Then they will have to meet these requirements each month. Beneficiaries must report compliance with the requirement monthly in person, over the phone, online or by mail. Most individuals will also be required to make initial premium payments within 90 days of being determined to be eligible for Medicaid. They will have to continue to pay the monthly premiums to keep coverage active.

The waiver also requires employed individuals eligible for Medicaid based on their income who have access to employer-sponsored insurance to instead enroll in that employer coverage and have it subsidized by the state, if the state considers the employer coverage cost-efficient. The state will determine if the employer coverage is cost-efficient by comparing the state’s cost if the individual were enrolled in a managed Medicaid plan to the cost of premiums and cost sharing on the employer plan that the state would cover.

Coverage will not take effect for those who fail to meet the initial work requirements or do not pay the initial premium payment. Those who fail to meet ongoing work requirements, including reporting compliance with those requirements, or fail to pay their monthly premiums will be disenrolled after a grace period. Individuals who do not meet the initial requirements for coverage or who are disenrolled for failure to comply with work requirements and reporting or to keep up with premium payments can reapply at any time.

A decade after the passage of the Affordable Care Act, 12 states have not expanded Medicaid under the law. Many of these states have higher rates of uninsured residents, a challenge for local providers. Providers in Georgia could benefit from the Section 1115 waiver as more people gain Medicaid coverage, rather than going uninsured. Payers running Medicaid managed care organizations in Georgia also stand to benefit from increased enrollment, since all individuals eligible for Medicaid under the waiver will be enrolled in an MCO. Pharmaceutical and life sciences companies may also benefit, albeit modestly, as the number of insured individuals in the state climbs.

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Ingrid Stiver

Senior Manager, Health Research Institute, PwC US

Erin McCallister

Senior Manager, Health Research Institute, PwC US

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