Georgia — one of 10 states that has not expanded Medicaid under the Affordable Care Act (ACA) — recently implemented a new Medicaid waiver, called Georgia Pathways to Coverage. The program expands eligibility to individuals with incomes up to the federal poverty level ($1,215 per month for an individual), a population previously ineligible in Georgia. The waiver applies to nonelderly “able-bodied” adults and differs from the ACA’s Medicaid expansion in two ways: 1) people with incomes between 101 percent and 138 percent of the federal poverty level are ineligible and 2) applicants must document 80 hours of work or other “qualifying activities” in the month before application; once eligible, they must continue to satisfy these requirements to maintain coverage. These restrictions have implications for the number of people who will gain coverage in Georgia and their ability to stay enrolled. In this post we focus specifically on what it means for people with disabilities. Medicaid is the primary source of health insurance coverage for many disabled people; the Georgia waiver creates a new pathway to eligibility for this population.
People with disabilities qualify for Medicaid based on their disability status or their income. Some people who receive federal Supplemental Security Income (SSI) benefits (a national cash assistance program for people who are poor and meet strict disability requirements) qualify for Medicaid based on their disability. However, many people with disabilities do not meet the SSI criteria. In fact, nearly half of nonelderly adults with disabilities in Georgia’s Medicaid program didn’t receive SSI as of 2019. Instead, they qualified for Medicaid based solely on their income. Georgia’s waiver expands Medicaid income limits and thus could cover more people with disabilities who don’t receive SSI.
Georgia’s work requirement waiver indicates the state will provide reasonable accommodations for people with disabilities. Reasonable accommodations are required by federal laws to prohibit disability-based discrimination. They are modifications to policies, practices, or procedures that enable people with disabilities to participate in state programs. Examples in Georgia’s waiver include assistance with documentation, eligibility, and appeals; reductions in required hours; and other changes agreed to by enrollees and employers. Georgia will refer people with disabilities who cannot satisfy the work requirement to state vocational rehabilitation programs, which are intended to help people with disabilities find employment. They can then qualify for Medicaid if they meet the rehabilitation program’s requirements. The waiver doesn’t address programs’ capacity to handle these referrals, how quickly services are available, or how the state will coordinate referrals and prevent people from falling through the cracks.
Despite the importance of reasonable accommodations for people with disabilities, Georgia isn’t required to report the number or type of these requests or whether requests were approved. Instead, Georgia must provide “general assurances” to the Centers for Medicare and Medicaid Services that it:
- makes “good faith efforts” to connect people with disabilities with necessary supports to meet the work requirement
- maintains a system that provides reasonable accommodations for people with disabilities to meet the work requirement
- provides written notice to people with disabilities about their right to receive reasonable accommodations, including examples of such accommodations
- assesses whether people with disabilities have limited job opportunities and, if so, considers further exceptions from the work requirement.
It remains to be seen if people with disabilities can access coverage under Georgia’s waiver. Arkansas was the first state to impose work requirements in its Medicaid waiver. During the seven months the waiver was in effect, more than 18,000 people lost coverage for failing to meet work and reporting requirements. The state provided reasonable accommodations to only 17 people and exempted 577 people from the work and reporting requirement. More than one-third of these exemptions were based on a disability or health issue. Arkansas’s experience aligns with studies of other benefit programs that show people with disabilities are more likely to be penalized for failing to meet a work requirement.
In Georgia, one issue to watch is whether people receive accessible information about the new waiver. A 2022 state website review found that Georgia included a general statement about reasonable accommodations, but access to braille or large-print materials, sign language interpreters, and a phone number to enable communication with deaf people were not readily available. The state is simultaneously renewing the eligibility of its 2.8 million Medicaid enrollees for the first time since 2020, owing to the end of the pandemic. In the state’s first phase of review, more than 1,500 of 12,526 people were disenrolled; most lost coverage because the state couldn’t contact them. It is unclear how effective Georgia will be in contacting existing enrollees who are up for renewal and potentially eligible under the new waiver. Only 265 people enrolled in coverage in July 2023, the waiver’s first month; more than 100,000 people have lost Medicaid in Georgia since the state restarted eligibility renewals in April. The narrow coverage pathway created by Georgia’s waiver could mean the difference between coverage or going uninsured, but much depends on outreach and implementation efforts in the coming weeks.