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In July 2023, Georgia will begin enrollment into its new Medicaid Pathways to Coverage (“Pathways”) program, with coverage expected to begin in September 2023. The program would offer coverage to a subset of low-income adults who meet a work reporting requirement and, depending on their income, pay a monthly premium. Georgia will become the only state with a work reporting requirement in Medicaid, and one of only two to ever implement such a policy. Arkansas briefly implemented a work reporting requirement in 2018, but the program was halted after 18,000 individuals lost coverage and federal courts intervened.

Pathways Program and Coverage Requirements

Georgia’s Pathways program is a limited Medicaid expansion, offering the possibility of coverage to parents and childless adults with incomes below the poverty line who meet work reporting requirements and, in some cases, pay a premium. Georgia currently covers parents up to 31 percent of the federal poverty line (no more than $642 a month for a family of three); adults with income above that but below the poverty line do not qualify for federally subsidized coverage in the Marketplace and thus fall into a coverage gap—as do all adults without dependent children in Georgia with incomes below the poverty line. The partial expansion is authorized through a section 1115 demonstration; full expansion would cover adults below 138 percent of the federal poverty line and would not require a Section 1115 waiver.

To become eligible and retain health coverage, individuals must successfully report at least 80 hours of work or other qualifying activities each month. Additionally, individuals with incomes at or above 50 percent FPL will have to pay an initial premium to be enrolled in coverage and then pay monthly premiums to retain coverage. Premium amounts range from about 1 to 1.5 percent of household income.

The Pathways program also includes federal waivers allowing the state to eliminate the following for people enrolled through the Pathways partial expansion:

• Non-emergency medical transportation for most enrollees;
• 90-day retroactive coverage;
• Wrap-around benefits for individuals receiving employer-sponsored insurance; and
• Hospital presumptive eligibility coverage.

Coverage Estimates and Financing  

Georgia and the federal Centers for Medicare and Medicaid Services (CMS) estimated in 2020 that approximately 64,000 people would be enrolled in coverage through the demonstration.^[2] About 408,000 uninsured Georgians could become eligible if the state implemented partial expansion to 100% FPL without barriers to coverage,^[3] while full Medicaid expansion would cover as many as 447,000 to 536,000 Georgians.^[4]

Initial state funding authorized in 2021 was $65.5 million; subsequently the funding was increased by $52.2 million, to a total of $153.2 million.^[5] It is unclear how many people are budgeted for in these funds, if it includes administrative dollars necessary to implement the program, or how the state would handle additional applicants once the funding limit is reached.

Because it is implementing a partial expansion, Georgia will receive its default federal matching rate for covering this population – 65.89 percent—rather than the 90 percent match states receive for full expansion. Federal CMS has stipulated that states cannot receive the enhanced expansion rate for partial expansions.^[6] Furthermore, a full expansion would now entitle Georgia to additional federal funding (pursuant to the American Rescue Plan Act of 2021) during the first two years of coverage; CMS has estimated this would be an additional $1.1 billion dollars for Georgia.^[7] The lower matching rate for the Pathways program and forfeiting the ARPA dollars means that the state will be paying significantly more per person covered that it would under a full expansion. In fact, the cost to the state on a per capita basis in the first year of Pathways will be five times higher than the first year of full Medicaid expansion ($2,490 per person versus $496 per person, respectively).^[8]

Coverage Limits, Rules, and Processes

To become eligible for Pathways, individuals will be required to report their 80 hours of work or other qualifying activity hours on a monthly basis, including providing documentation (online or in-person) of compliance upon initial application. If the monthly reporting requirement is not documented, individuals will be initially suspended from coverage and then terminated after a 90-day suspension period. (See Appendix B.)

The Georgia Pathways program has no exemptions for meeting the work reporting requirement, which is unlike any other state that pursued a Medicaid work reporting requirement. (See Appendix A.) According to the official approval documents, individuals who self-attest to having a disability will be “considered for a reasonable accommodation,” but no other support is provided nor accommodations made for other eligibility groups.^[9] The program allows individuals to request temporary exceptions from meeting the work reporting requirement. These exceptions include serious illness of the enrollee or immediate family member, birth or adoption of an immediate family member, or family emergency or other life event. However, an enrollee may only request up to 120 hours of good cause exceptions from the work requirement (approximately a month and half) over a 12-month period.

Most individuals with incomes at or above 50 percent FPL will also be required to pay an initial premium within 90 days of their eligibility determination or they will not be enrolled.^[10] Following enrollment, premiums must be paid on a monthly basis; after any two months of missing premium payments, an individual will have their coverage suspended and will subsequently be disenrolled if premium payments are not made within 90 days of suspension. (See Appendix B for a simplified version of Pathways eligibility rules.)

Premiums will be deposited into an individual’s “member rewards account,” a new account created by the Pathways program. Copayments for non-primary care services including prescriptions and non-emergent use of the emergency department will be deducted from the account while “rewards” for healthy behaviors, like attending annual well visits, will be credited to these accounts. If an individual accrues a certain amount of healthy behavior credits in their member reward account, they can use their account for “bonus” services like vision and dental benefits and over-the-counter drugs.

Impacts on Coverage

If the state’s assumptions for the Section 1115 agreement are accurate, Georgia’s Pathways program will cover around 64,000 people out of the approximately 447,000 to 536,00 that could enroll under a full expansion—approximately 12 to 14 percent of the population. Groups that are likely to face barriers to qualifying for Pathways include:

Workers: The design of Pathways is likely to leave out many workers who are unable to keep up with the monthly reporting requirements. The data from the brief Arkansas experience showed that most people did not know about the work reporting requirement^[11] and it was clear that many who should have been exempt were not able to obtain an exemption.^[12] Low-wage uninsured workers in Georgia disproportionately work in sectors that are less likely to offer employment insurance or paid leave benefits, specifically in retail, hospitality, or construction industries (see Figure 1).^[13] These individuals are also more likely to have fluctuating work hours and informal work arrangements, making work reporting very difficult. In addition, research finds that the majority of Medicaid adults are already working without a work requirement in place; those that are not working have barriers to work such as caregiving responsibilities, illness, or school attendance.^[14]

Parents: Many parents will likely remain uninsured under the Pathways program especially parents of babies and toddlers who are preschool age because they are unlikely to be able to meet the program requirements. Barriers such as the lack of affordable child care are not addressed by the proposal. Georgia’s Medicaid program currently provides coverage only to parents with incomes at or below 31 percent FPL ($642 per month for a family of three). Analysis of work reporting requirements in the 19 states that were approved for or developed a formal proposal for the policy show that Georgia is the only state to propose a work reporting requirement without any exemption for parents with dependent children (See Appendix A). Child care services are unaffordable for many low-income families^[15}, so many parents will be unable meet the requirements for Georgia’s new program due to the lack of child care accommodations or exemptions.

Potential Georgia barriers to enrollment for parents in Pathways:

• Child care availability – Forty-four percent of people in Georgia live in a child care desert. The lack of child care is especially prevalent among families living in rural areas and in the lowest-income neighborhoods.^[16]
• Child care costs – The cost of child care in Georgia ranges from around $6,500 to $8,900 depending on a child’s age or type of facility,^[17] which is up to 32 percent of the annual income of a parent at 50 percent of the poverty line.
• Inadequate parental leave policies – Many low-wage workers are employed in jobs that lack sick or parental leave. Without these policies, parents may put their jobs at risk or at least lose hours needed to meet the work requirement if their child is sick, has a day off from school, or needs to stay home for any reason.
• Difficulties reporting qualifying activities – Parents may have trouble providing documentation for certain activities like community service or reporting compliance in general.

Populations experiencing obstacles to work and/or reporting: Other groups may face similar barriers to enroll. The Pathways program does make some accommodations for people with disabilities; however, it is unclear if these will be sufficient. Many people may also not be identified for accommodation, thus blocking enrollment. The proposal designs in Arkansas and New Hampshire both included exemptions for people with disabilities and people in treatment for mental health and/or substance use disorders, and yet those individuals were often not identified.^[18] The program’s good cause exemption is not available to new applicants, so those with disabilities that prohibit compliance with the work reporting requirement would not be eligible for initial enrollment. For those who are enrolled in coverage, the temporary exception limit of a month and a half may not be long enough to address their life event (such as an injury or natural disaster). Some other groups, such as students, individuals in job training, or those doing community service, could meet the qualifying criteria and be eligible, but may have difficulties documenting compliance, making them vulnerable to denial or termination.

Conclusion: Issues to Monitor Going Forward

Will unemployment rates go up or down? There is uncertainty as to how Pathways will affect employment if at all. While Medicaid expansion has been shown to support work,^[19] Medicaid work requirements, on the other hand, had minimal to no effect on employment—and possibly increased unemployment for those who lost access to health care services needed to support their ability to work.^[20] Previous studies on work requirements in other programs (such as TANF) have found negligible evidence of lasting increases in employment.^[21] 

How many people will get coverage and for how long? Low wage workers with Medicaid coverage often experience temporary changes in income that result in moving on and off coverage within short periods of time. Pathways enrollees could experience even greater coverage disruptions— individuals with fluctuating work hours or gaps in monthly work reporting may repeatedly cycle on and off coverage, suspension, and termination. In addition, the complex rules of the Pathways design (see Appendix B flowchart), may lead to more confusion and coverage instability. It will be important to monitor who is getting coverage and whether parents— especially those with preschool age children—are able to enroll at all.

What are the cost implications for the state of Pathways structure? The cost effectiveness of Pathways will need to be closely monitored—including both administrative costs given its complex structure, and coverage costs—especially how much the state is paying per beneficiary—given the lower match rate in the Section 1115 agreement and the state’s ineligibility for additional ARPA funds.

Acknowledgements

This brief was written by Allexa Gardner, Joan Alker, and Leo Cuello. The authors would like to thank Laura Harker of the Center on Budget and Policy Priorities and Catherine Hope for comments on the draft. Design and layout provided by Nancy Magill.

Appendix A: State Exemptions for Parents Proposed for Medicaid Work Requirements

Appendix B: Pathways to Pathways Coverage

[1] Joan Alker and Tricia Brooks, “Millions of Children May Lose Medicaid: What Can Be Done to Prevent Them From Becoming Uninsured” Georgetown University Center for Children and Families, February 17, 2022), available at https://ccf.georgetown.edu/2022/02/17/millions-of-children-may-lose-medicaid-what-can-be-done-to-help-prevent-them-from-becoming-uninsured/.

[2] Center for Medicare and Medicaid Services, “Georgia Pathways to Coverage Approval Letter & Standard Terms and Conditions,” October 15, 2020, available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ga/ga-pathways-to-coverage-ca.pdf.

[3] Georgia Department of Community Health, “Waiver Project: Georgia Environmental Scan Report,” July 8, 2019, available at https://medicaid.georgia.gov/document/publication/georgia-environmental-scan-report-posted-71819/download.

[4] Georgia Department of Audits and Accounts, Fiscal Note: House Bill (LC 26 0015), January 18, 2019, available at https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHla3I3Y7_AhWfF1kFHWSDArIQFnoECBcQAQ&url=https%3A%2F%2Fopb.georgia.gov%2Fdocument%2Ffiscal-notes-2019-health-and-human-services%2Flc-46-0015-hb-37%2Fdownload&usg=AOvVaw20q6mDuKmqd-nPrPO6AU3T.

[5] FY 2024 Conference Committee Bill (HB 19), March 29, 2023, available at https://www.legis.ga.gov/api/document/docs/default-source/house-budget-and-research-office-document-library/2024_fiscal_year/fy_2024_conference_committee_bill_(hb_19).pdf?sfvrsn=a6423ac9_2.

[6] Letter from CMS Administrator Seema Verma to Utah Governor, August 16, 2019, available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita-cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf.

[7] CMS, All-State Medicaid & CHIP Call, March 30, 2021, available

at https://www.medicaid.gov/state-resource-center/downloads/allstatecall-20210330.pdf.

[8] Leah Chan, “Money Matters: Comparing the Costs of Full Medicaid Expansion to the Pathways to Coverage Program” (Georgia Budget and Policy Institute, January 11, 2023), available at https://gbpi.org/money-matters-comparing-the-costs-of-full-medicaid-expansion-to-the-pathways-to-coverage-program/.

[9] CMS Pathways Approval, op. cit.

[10] The two groups exempted from premiums are: Beneficiaries with employer-sponsored insurance enrolled in HIPP and some beneficiaries enrolled in (or recently graduating from) vocational education programs of highly sought-after trades.

[11] Benjamin D. Sommers, et al., “Medicaid Work Requirements – Results from the First Year in Arkansas,” The New England Journal of Medicine, June 18, 2019, available at https://static.politico.com/8d/24/6ef0e361444 bb034aabc884b2606/sommers-arworks.pdf; MaryBeth Musumeci, et al., “Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees” (Kaiser Family Foundation, December 2018), available at https://files.kff.org/attachment/Issue-Brief-Medicaid-Work-Requirements-in-Arkansas-Experience-and-Perspectives-of-Enrollees; Ian Hill, et al., “New Hampshire’s Experience with Medicaid Work Requirements” (Urban Institute, February 2020), available at https://www.urban.org/sites/default/files/publication/101657/new_hampshires_experience_with_medicaid_ work_requirements_v2_0_7.pdf.

[12] Jennifer Wagner and Jessica Schubel, “States’ Experiences Confirm Harmful Effects of Medicaid Work Requirements” (Center on Budget and Policy Priorities, November 18, 2020), available at https://www.cbpp.org/research/health/states-experiences-confirm-harmful-effects-of-medicaid-work-requirements.

[13] United States Census Bureau, “Public Coverage Increased for All Workers, Private Coverage Declined for Full-Time, Year-Round Workers,” September 13, 2022, available at https://www.census.gov/library/stories/2022/09/private-health-coverage-declines-for-full-time-workers.html; U.S. Bureau of Labor Statistics, “Table 6. Selected paid leave benefits: Access, March 2022,” available at https://www.bls.gov/news. release/ebs2.t06.htm.

[14] Madeline Guth, et al., “Understanding the Intersection of Medicaid & Work: A Look at What the Data Say” (Kaiser Family Foundation,

April 24, 2023), available at https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-work-a-look-at-what-the-data-say/.

[15] Gina Adams, et al., “Child Care Challenges for Medicaid Work Requirements” (Urban institute, September 2019), available at https://www.urban.org/sites/default/files/publication/101094/medicaid_work_ reqs_child_care_0.pdf; ChildCare Aware of America, “Appendices: Demanding Change: Repairing our Child Care System,” available at  https://info.childcareaware.org/hubfs/Demanding%20Change%20Appendices.pdf?utm_campaign=Budget%20Reconciliation%20Fall%20 2021&utm_source=website&utm_content=22_demandingchange_ append.

[16] Center for American Progress, “Child Care Access in Georgia,” https://childcaredeserts.org/2018/?state=GA&urbanicity=Rural.

[17] ChildCare Aware of America, “Demanding Change: Repairing Our Child Care System,” https://info.childcareaware.org/hubfs/Demanding%20Change%20Appendices.pdf?utm_campaign=Budget%20Reconciliation%20Fall%202021&utm_source=website&utm_content=22_demandingchange_append.

[18] MaryBeth Musumeci, “Disability and Technical Issues Were Key Barriers to Meeting Arkansas’ Medicaid Work and Reporting Requirements in 2018” (Kaiser Family Foundation, June 11, 2019), available at https://www.kff.org/medicaid/issue-brief/disability-and-technical-issues-were-key-barriers-to-meeting-arkansas-medicaid-work-and-reporting-requirements-in-2018/; Wagner and Schubel, op. cit.

[19] The Ohio Department of Medicaid, “2018 Ohio Medicaid Group VIII Assessment: A Follow-Up to the 2016 Ohio Medicaid Group VIII Assessment,” August 2018, available at https://medicaid.ohio.gov/static/Resources/Reports/Annual/Group-VIII-Final-Report.pdf.

[20] Benjamin Sommers, et al., “Medicaid Work Requirements In Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care,” Health Affairs (Vol. 39, No. 9), September 2020, available at https://www-healthaffairs-org.proxy.library.georgetown.edu/doi/full/10.1377/hlthaff.2020.00538.

[21] LaDonna Pavetti, “TANF Studies Show Work Requirements Proposals for Other Programs Would Harm Millions, Do Little to Increase Work” (Center on Budget and Policy Priorities, November 13, 2018), available at https://www.cbpp.org/sites/default/files/atoms/files/11-13-18tanf.pdf.