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Analysis

CMS Approves Georgia's New Medicaid Section 1115 Demonstration

By Jack O'Brien  
   October 16, 2020

The "Pathways to Coverage" demonstration was borne out of the Health Adult Opportunity guidance released by CMS earlier this year.

The Centers for Medicare & Medicaid Services (CMS) announced that Georgia's new Medicaid section 1115 demonstration called "Pathways to Coverage" was approved Thursday afternoon.

According to a CMS press release, the Pathways to Coverage creates an opportunity for working-age Georgians who are ineligible for Medicaid to opt into through program through "qualifying activities like work and education, as well as meeting premium and income requirements."

Specifically, the policy applies to adults between the ages of 19 and 64, with income up to 100% of the federal poverty line.

Participating adults must work 80 hours per month or complete other "qualifying activities," and CMS added that most participants will be required to "make initial and ongoing monthly premium payments."

Related: Medicaid Block Grant Savings Varies from State to State

The program will be implemented on July 1, 2021 and run through September 30, 2025.

CMS projected that 30,000 Georgians will gain access to Medicaid coverage in the first year, while almost 65,000 will enroll or receive Medicaid premium assistance for coverage through employer-sponsored coverage during the entirety of the program.

"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," CMS Administrator Seema Verma said in a statement.  "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."

The Pathways to Coverage demonstration was borne out of the Health Adult Opportunity (HAO) initiative released by CMS earlier this year.

Related: CMS Releases Medicaid Block Grant Plan: Healthy Adult Opportunity

The HAO, first announced in January, allows states that have expanded Medicaid under the Affordable Care Act to transition state Medicaid programs into a block grant program.

The guidance marked the culmination of a decades-long goal by Republicans to transition state Medicaid programs into block grants as a way to cap spending and increase flexibility in managing the programs.

Both provider and payer associations criticized the Trump administration's Medicaid block grant announcement, arguing that the initiative would reduce access to care for beneficiaries and alter long-standing prescription drug formularies.

Many healthcare organizations publicly opposed the guidance, including the American Medical Association, the American College of Physicians, the Association of American Medical Colleges, and the Leadership Conference on Civil and Human Rights.

Related: Stakeholders Pan CMS' Health Adult Opportunity

CMS noted that Georgia will be "financially accountable" for a budget neutrality test related to the demonstration.

Additionally, CMS said the agency 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.

Jack O'Brien is the finance editor at HealthLeaders, a Simplify Compliance brand.

Photo credit: MARIETTA, GA- SEPTEMBER 25, 2020: President Donald Trump greets Georgia Governor Brian Kemp and Georgia First Lady Marty Kemp upon exiting Air Force One at Dobbins Air Reserve Base. / Editorial credit: Evan El-Amin / Shutterstock.com


KEY TAKEAWAYS

Participating adults must work 80 hours per month or complete other "qualifying activities," and CMS added that most participants will be required to "make initial and ongoing monthly premium payments."

The program will be implemented on July 1, 2021 and run through September 30, 2025.

Additionally, CMS said the agency 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.


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