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Georgia is planning to run its own exchange starting in the fall of 2023, for coverage effective in 2024 and future years. This is outlined in the state’s letter of intent and its exchange blueprint, both of which were submitted to CMS in February 2023. Georgia also enacted legislation in 2023 that grants the Office of Commissioner of Insurance and Safety Fire the ability to create and run a state-based exchange (this is a reversal of 2014 legislation that had prohibited the state from running its own exchange). And the state has hired an executive director for the new exchange.
If CMS approves Georgia’s proposals, the state’s Georgia Access platform would become a full-fledged state-run exchange by the fall of 2023. Currently, Georgia Access is just an informational website that the state debuted in late 2022, with links to various insurers and health insurance brokers.
But the state’s exchange blueprint confirms that “consumers will have the ability to apply for, receive eligibility determinations, shop, compare, and select a QHP (qualified health plan) via a self-service State consumer portal.”
Consumer and patient advocates have expressed reservations about Georgia’s ability to operate a successful exchange, given the state’s previous efforts to dismantle the exchange altogether. A group of patient advocacy organizations wrote a letter to CMS in March 2023, asking them to reject Georgia’s proposal to operate a state-run exchange, particularly given the accelerated timeframe Georgia had proposed.
But one of their objections is no longer relevant: CMS used to require states to submit an exchange blueprint at least 15 months before a state-run exchange would be in use. But under the federal rules for 2024, CMS no longer requires that. Instead, a state just has to have its blueprint approved prior to the open enrollment when they plan to begin using the state-run exchange. In Georgia’s case, that would be anytime prior to November 1, 2023, when open enrollment begins for 2024 coverage.
Here’s the backstory on Georgia’s health coverage reform progress:
Georgia enacted SB106, the Patients First Act, in March 2019. The legislation authorized the state to submit an 1115 waiver proposal to the federal government with a proposal to partially expand Medicaid to cover people with income up to 100% of the poverty level (the legislation allowed the proposal to go up to that amount, but not above it). SB106 also authorized the state to submit a 1332 waiver to the federal government with a proposal or proposals for modifying the state’s individual health insurance market.
The Trump administration ultimately approved both the 1115 waiver (for partial and conditional Medicaid expansion with a work requirement) and the 1332 waiver (for a reinsurance program effective in 2022 and the “Georgia Access Model” for the exchange starting in 2023; this would have involved the state no longer having a health insurance exchange, and relying instead on a network of web brokers and insurers to enroll people in coverage).
As of early 2023, only the reinsurance program was fully in effect in Georgia. But the state did still set up its own insurance platform in addition to HealthCare.gov, and is planning to convert that into a fully state-run exchange by the fall of 2023. Georgia is also planning to move ahead with partial Medicaid expansion (and a work requirement) in mid-2023.
Georgia Access Model
The Biden administration ultimately suspended the Georgia Access Model in 2022, so the state still uses HealthCare.gov for the 2023 plan year. However, the state still rolled out its new Georgia Access platform in late 2022, described as an “informational website” and run by the Georgia Office of Insurance. The page makes no mention of HealthCare.gov or the significant subsidies that most people can receive when they enroll in coverage through HealthCare.gov.
Instead, it provides links to 17 “healthcare partners” that consumers can use to enroll in health coverage. These partners are a mix of web brokers (like HealthSherpa and Via Benefits) and insurers (like Aetna and UnitedHealthcare). The majority of them are approved enhanced direct enrollment entities, which means that they can enroll applicants directly in coverage through the exchange, with subsidies, even though the consumer doesn’t actually use the exchange website.
But some of the “healthcare partners” included on the Georgia Access site are not enhanced direct enrollment entities, which means they cannot enroll people directly in on-exchange plans. And the majority of the partners are insurers, which means they will show consumers only their own plans, instead of the full range of plans available in each area.
Some of the partner web brokers also offer non-ACA-compliant health coverage, such as short-term health insurance. Unless a consumer is quite savvy and understands exactly what they need and what’s available to them, there are concerns that people could be confused and inadvertently purchase a non-ACA-compliant plan without fully understanding the drawbacks.
But Georgia is planning to convert Georgia Access into a fully state-run exchange in time for the 2024 plan year. The state submitted its letter of intent and exchange blueprint in February 2023, and will go live with the exchange in the fall of 2023 if CMS approval is granted. Although the current site does not provide any way for consumers to compare plans or enroll in coverage (just links to other websites that can be used for those purposes), Georgia’s blueprint letter indicates that they plan to make those changes and roll out the new platform in the fall of 2023.
Partial Medicaid Expansion with a work requirement in 2023
In early 2022, Georgia officials opted to cease implementation of the state’s planned partial Medicaid expansion after the Biden administration revoked approval for the work requirement (as had been the case for every other state where a Medicaid work requirement was previously approved by the Trump administration). But Georgia also filed a lawsuit in early 2022 against the Biden administration in response to the rule changes.
In August 2022, a judge sided with Georgia, allowing the state to move forward with the Georgia Pathways program. And the Biden administration had not appealed that decision as of early 2023. In late 2022, Gov. Kemp announced that the Pathways program would begin in July 2023
Although only the reinsurance program was in effect as of the 2023 plan year, the partial Medicaid expansion is expected by mid-2023 and Georgia has rolled out its new Georgia Access website, although HealthCare.gov is also still in use in the state. Here’s an overview of what was included in Georgia’s 1115 and 1332 waivers:
1115 waiver: Partial expansion of Medicaid (delayed, but expected in July 2023)
Georgia is one of 12 states where Medicaid has not yet been expanded as of early 2023 (South Dakota will expand Medicaid in July 2023, and North Carolina is expected to expand Medicaid by late 2023). Under the 1115 waiver that was approved by the Trump administration, Georgia planned to partially expand Medicaid as of mid-2021, granting coverage to non-elderly adults earning up to 100% of the poverty level.
As described above, this was postponed by two years, and is now expected to take effect in mid-2023. The state only anticipates that 50,000 people will gain coverage under the partial Medicaid expansion, and there are an estimated 269,000 people stuck in Georgia’s coverage gap (only Florida and Texas currently have more people in the coverage gap). The low coverage projection under Georgia’s proposal is due in large part to the fact that the program calls for a work requirement, as well as premiums for some enrollees.
The details of Georgia’s proposed 1115 waiver were unveiled in November 2019. It called for a partial expansion of Medicaid, and would cover people with income under the poverty level — as long as they are compliant with a work requirement, and in some cases, paying premiums for their coverage. Georgia’s proposed partial expansion of Medicaid and Medicaid work requirement were approved by CMS in October 2020, although the Trump administration rejected the state’s proposal for the enhanced federal funding that can only be obtained if a state fully expands Medicaid, covering people with income up to 138% of the poverty level.
Instead, Georgia will receive its normal federal matching rate for the newly eligible population, and people with income over the poverty level will continue to be eligible for premium subsidies to offset the cost of private individual market coverage. It’s projected that if Georgia were to fully expand Medicaid, the expansion would cover at least 400,000 low-income Georgia residents. But the state’s modified expansion is expected to cover only a fraction as many people.
(Wisconsin provides Medicaid coverage for people with income up to the poverty level, but they do not receive the enhanced federal funding for that population, since they haven’t fully expanded Medicaid up to 138% of the poverty level. Utah took a similar approach for most of 2019; CMS rejected Utah’s proposal for full federal Medicaid expansion funding despite partial expansion, so Utah transitioned to full Medicaid expansion as of 2020.)
1332 waiver: Reinsurance (implemented) and the Georgia Access Model (not implemented, but website in use as of late 2022 and transition to fully state-run exchange planned for late 2023)
Georgia also unveiled its 1332 waiver proposal in November 2019, calling for a variety of changes that would affect the state’s individual insurance market. SB106 had included a few examples of changes that could be proposed with a 1332 waiver, the most likely of which was reinsurance, which is what numerous other states have implemented via 1332 waivers (this is the primary recommendation from the Georgia Budget and Policy Institute, although they also had additional recommendations for ways the state could utilize a 1332 waiver).
On November 1, 2020, CMS granted approval for Georgia’s 1332 waiver proposal. Georgia’s 1332 waiver includes a reinsurance program, but while most states that have thus far implemented 1332 waivers have used them only for reinsurance programs, Georgia’s 1332 waiver went beyond that. Under the terms of the 1332 waiver, Georgia had planned to transition away from HealthCare.gov as of 2023, and simply not have an exchange. That has not happened, but Georgia now has its own “Georgia Access” website in addition to HealthCare.gov. And by the fall of 2023, Georgia plans to be operating a fully state-run exchange.
Georgia’s reinsurance program took effect in 2022, covering a portion of high-cost medical claims between $20,000 and $500,000 (the proposal initially called for the reinsurance program to take effect in 2021, but the state announced in mid-2020 that the program was being delayed by one year and this was approved by CMS in November 2020).
The reinsurance program targeted a 10% reduction in overall average premiums across the state, but like a model that has been successfully implemented in Colorado, Georgia uses the reinsurance program to offset a higher percentage of claims in areas of the state where premiums are the highest, in order to bring down premiums the most in those areas. Reinsurance programs are a tried and true way of bringing down premiums for people who have to pay full price for their coverage, and they can serve to boost enrollment in the ACA-compliant market by making coverage affordable for that segment of the population.
While the American Rescue Plan’s subsidy enhancements are in effect (through 2025, due to an extension under the Inflation Reduction Act), reinsurance is not as important as it used to be. That’s because the American Rescue Plan eliminated the “subsidy cliff” and increased the number of people who are eligible for subsidies. So there aren’t as many people who have to pay full price for their coverage. But if the ARP’s subsidy enhancements aren’t extended by Congress, reinsurance will once again be an important tool for keeping coverage affordable as of 2026, for people who earn more than 400% of the poverty level (the normal cap for subsidy eligibility, which was temporarily eliminated by the ARP).
Georgia Access Model (web brokers instead of HealthCare.gov) — suspended by the Biden administration in 2022, but Georgia is pursuing a fully state-run exchange by the fall of 2023
As noted above, Georgia is planning to debut a fully state-run exchange in the fall of 2023, which residents will use (instead of HealthCare.gov) to enroll in coverage for 2024. The state plans to use the existing Georgia Access platform, but it will be upgraded to include plan comparison and enrollment functionality (it’s currently just an informational website that directs visitors to other websites where they can view plans and sign up for coverage).
But it’s also important to understand what Georgia was initially proposing, and what they would have implemented if the Biden administration hadn’t suspended the initial approval.
Under the terms of the Trump administration’s approval of Georgia’s proposal, the Georgia Access Model — in which the state relies on web brokers, agents, brokers, and insurance companies to enroll people in health coverage, instead of using HealthCare.gov — was slated to take effect for the 2023 plan year. Georgia had initially proposed a 2022 start, and that was still the proposal after the state made some significant modifications to the proposal as of mid-2020. But CMS noted that in order to ensure a smooth transition, and after communication with Georgia officials, the program had been pushed to 2023.
Moving away from HealthCare.gov without creating a centralized state-run exchange would have gone well beyond what other states have done with 1332 waivers. The Georgia Access Model faced a lawsuit within a few months of gaining federal approval, and the Biden administration began reconsidering the Georgia Access Model in the fall of 2021, ultimately suspending it in August 2022.
However, Georgia did debut its Georgia Access website in late 2022. The website directs visitors to 17 “healthcare partners” that include insurers and web brokers. The Atlanta Journal-Constitution notes that the state spent $31 million on the Georgia Access program, including the website and marketing.
Before the Biden administration suspended the state’s transition away from HealthCare.gov, there were concerns that what Georgia planned to do would simply not meet the ACA’s requirements for 1332 waivers, despite the approval from CMS under the Trump administration. It’s also noteworthy that nearly all of the initial public comments that were submitted regarding the Georgia Access Model were negative, and encouraged the state to keep the HealthCare.gov platform. The new round of public comments, submitted in late 2021 and early 2022, were also overwhelmingly opposed to the idea of jettisoning the exchange.
Georgia’s proposal initially called for the state to receive the same federal funding that would have been used for subsidies via HealthCare.gov, but with the money instead being distributed by the state to help residents cover the cost of qualified health plans (ie, the same sort of plans that are currently available on HealthCare.gov) as well as “non-QHPs” which would have lesser benefits but would still be part of the same risk pool and not medically-underwritten. But the modifications made to the proposal in mid-2020 scaled this back considerably.
The state planned to stop using HealthCare.gov and switch to a system that would have relied on web brokers and insurers, but it planned to let the federal government continue to handle premium subsidies. The state’s system would have sent subsidy eligibility information to the federal government, which would have continued to issue premium subsidies just as it already did, only for QHPs. Consumer advocates noted that while there were still concerns, the modifications the state made during the waiver approval process “will reduce the harmful impacts that consumers would have felt under the original proposal.”
The entities that would have been enrolling people in health coverage in Georgia — in lieu of a health insurance exchange — would have included some that also offer non-QHPs (such as short-term health plans, fixed indemnity plans, etc), which could have potentially led to consumer confusion. And while it’s true that many of these web brokers already use the enhanced direct enrollment pathway to enroll people in on-exchange health plans via their own websites, that would have essentially been the only option as of 2023, rather than simply being an alternative to HealthCare.gov.
Without the HealthCare.gov platform — where only QHPs can be offered — residents would have potentially had a harder time ensuring that the coverage they’re buying is actually compliant with the ACA. The waiver approval noted that brokers in Georgia earn an average of “only” $8.42 per member per month in commissions when they sell short-term health plans, versus an average of $6.88 per member per month when they sell QHPs. The CMS Office of the Actuary notes that “as long as there is not a major change in commission structure [they] would not expect broker behavior to change drastically.” But even at those amounts, brokers are earning 22% more by selling short-term health insurance, which is not an inconsequential difference.
It may be true that broker behavior wouldn’t “change drastically,” but consumers in Georgia would have lost access to HealthCare.gov, leaving them with only web brokers, agents, brokers, and insurers as their means of enrolling in coverage. In short, this would have been a subtraction rather than an addition: The web brokers, agents, brokers, and insurers already exist, and many do an excellent job of helping people enroll in plans via the enhanced direct enrollment pathway. But Georgia’s 1332 waiver wouldn’t have added anything new to the mix — it would have simply taken away the current exchange platform and the services it provides.
There were also concerns that people who qualify for Medicaid would have been lost in the shuffle under the new system. Georgia has not yet expanded Medicaid, but the HealthCare.gov platform does still direct people to Medicaid and CHIP if they’re eligible under the state’s current rules. But there are no commission payments for enrolling someone in Medicaid, and brokers/agents only get paid on commission. So there is little incentive for them to help people enroll in Medicaid or CHIP.
Federally-funded Navigators work with HealthCare.gov in Georgia, but would no longer be available once the state no longer has the HealthCare.gov platform available for consumers to use; states that run their own exchanges must also fund and operate their own enrollment assistance programs. And the state’s waiver approval included some negativity about the existing Navigator program, noting that “the Navigator program has simply had limited impact on reducing the overall uninsured rate in Georgia, suggesting there may be a more effective way to reach and engage consumers. In fact, one of the key criticisms of HealthCare.gov and the implementation of the Navigator program is that it has squeezed local agents and brokers out of the market with government-funded competition.” But it’s worth noting here that a big part of the reason for Georgia’s stubbornly high uninsured rate has been the state’s failure to expand Medicaid under the ACA.