Georgia 1115 Waiver Application

On March 27, 2019, Governor Brian Kemp of Georgia signed and enacted Senate Bill 106, otherwise known as the Patients First Act. This legislation authorizes the Georgia Department of Community Health to submit a Section 1115 Demonstration waiver to the Centers for Medicare and Medicaid Services (CMS) to expand the income threshold for Medicaid eligibility up to a maximum of 100% of the federal poverty level (FPL). It is worth noting, that this is not a full expansion and Utah was previously denied enhanced funding for their partial Medicaid expansion. On December 23, 2019, the Department officially submitted its proposal to CMS, requesting approval to launch Georgia’s “Pathways to Coverage” initiative. Georgia seeks a 5 year demonstration approval period and intends to implement the demonstration on July 1, 2021. The application is currently pending CMS review and CMS is accepting comments on the application from January 8, 2020 through February 7th, 2020.
Below please find our summary of key points of the waiver.

Expanding Eligibility

Through the 1115 waiver, Georgia is proposing to provide a pathway to Medicaid coverage for certain ineligible residents who have incomes up to 100% of the FPL).  The eligible population for ‘Georgia Pathways’ includes parents, caretakers, or guardians with household incomes from 35% to 100% of the FPL who are not currently eligible for Medicaid and adults without dependent children with household incomes up to 100% of the FPL.  All eligible individuals must currently be ineligible for Medicaid, a current resident of Georgia and a US citizen, not incarcerated in a public institution, and between the ages of 19 and 64.

Eligibility in ‘Georgia Pathways’ is prospective only.  Before enrollment in the Medicaid program, an individual must meet the activity requirements, pay their monthly premium, and select a plan or choose to be auto-assigned.  Enrollment will begin at the start of the month following the initial premium payment.  (Work requirements and premiums are discussed in more detail below.)

Work Requirements

In order for an individual to be eligible for coverage under ‘Georgia Pathways’, the individual must work or participate in community engagement activities for a minimum of 80 hours per month.  Activities that satisfy this requirement include unsubsidized employment, subsidized private sector employment, subsidized public sector employment, on-the-job training, job readiness programs, community service, vocational training, and enrollment in an institution of higher education.

In order to maintain eligibility in ‘Georgia Pathways’, a beneficiary must continue to meet the community engagement threshold of 80 hours per month and report their hours monthly.  If a beneficiary does not meet the community engagement threshold, they will be suspended from Medicaid and no longer able to receive the Medicaid benefit.  The individual beneficiary has three months to come in compliance with ‘Georgia Pathways’ in order for the suspension to be lifted.  If the beneficiary is unable to comply with the community engagement requirement after three months of suspension, the beneficiary will be disenrolled in Medicaid.  The beneficiary can regain eligibility at any time after suspension or disenrollment if they meet the community engagement threshold in a single month.

Members who have previously been in compliance will receive a short-term exception for failure to meet the hours and activities threshold in the event that any of the following occur: a family emergency, birth or death of a family member, serious illness or hospitalization, severe inclement weather, temporary homelessness, and other good reasons as defined and approved by the state.

Premiums and Cost Sharing

Certain beneficiaries enrolled in ‘Georgia Pathways’ will be required to pay monthly premiums on a sliding scale, not to exceed 2% of household income.  Beneficiaries with incomes between 50% and 84% of the FPL will pay a monthly premium of $7, while beneficiaries with incomes between 85% and 100% of the FPL will pay a monthly premium of $11.  If two spouses in the same household are enrolled in ‘Georgia Pathways’, the associated premium for the second enrolled spouse will be discounted.  Additionally, the state will assess a premium surcharge between $3 and $5 for members who use tobacco.  Premiums paid will be deposited into a Member Rewards Account.

The Member Rewards Account is a tool designed to help beneficiaries pay copayments and afford other services not covered by Medicaid.  Premiums paid by enrollees will be deposited into the Member Rewards Account and the State will set a series of criteria for awarding points (healthy incentive points), which will translate to dollars upon use, such as completing an annual well care visit. If the enrollee has value in their account, the cost of copayments will be withdrawn from the account.  In the event that there are insufficient funds, copayments will still be deducted from the account and any future premium payment or healthy incentive point will be applied to this negative balance.  When the value in the account exceeds $200, enrollees may use the account for other medical expenses not covered by Medicaid.  If a beneficiary becomes ineligible for Medicaid due to their income exceeding 100% of the FPL, the remaining value in the Member Rewards Account will be made accessible to the member for future medical expenses.

Beneficiaries who are required to pay premiums include adults without dependent children and parents with household incomes between 50% and up to 100% of the FPL who were previously ineligible for Medicaid but became eligible and are enrolled in ‘Georgia Pathways.

Beneficiaries who miss a premium will have a three-month period to retain their ‘Georgia Pathways’ eligibility without being disenrolled. If a beneficiary fails to make a premium payment for one month, the beneficiary enters a one-month grace period and remains enrolled.  Upon missing a premium payment for the second consecutive month, the beneficiary is placed in a suspended status.  If the enrollee pays their missed premium within this month, the beneficiary’s enrollment suspension will be lifted at the point of payment.  If the beneficiary does not pay the missed premiums by the end of the third month, the beneficiary will be disenrolled.

‘Georgia Pathways’ will not assess copayments at the point of use, but instead will be assessed retroactively for services already received.  Beneficiaries will be sent monthly invoices for the copayment amounts which will include information about the amount owed and the amount paid out of the members Member Rewards Account.  If the State is made aware that a member’s income has changed during their current enrollment period, the State will evaluate whether the member is still required to make copayments.

Beneficiaries who are required to make monthly premium payments will also be required to make copayments for services used.


Georgia will maintain the State Plan benefits for the ‘Georgia Pathways’ population with the exception of non-emergency medical transportation, which will not be covered.  The state plan benefits include early and periodic screening, diagnostic and treatment services for enrollee’s ages 19 and 20.

Beneficiaries enrolled in employer sponsored insurance will have a different benefit package based on the insurance offered by their employer.

Additional benefits such as vision and dental can be purchased through the Member Rewards Account.