Georgia: Sen. Warnock & Rep. McBath ask CMS to slow the hell down on approving GA's state-based exchange

In February, I wrote about how the state of Georgia, in an eyebrow-raising move, announced that they were moving from the federal ACA exchange (HealthCare.Gov) onto their own state-based ACA exchange.

While numerous other states have already done the same thing (and several more are in the process of doing so as well), Georgia's move to their own enrollment platform was especially noteworthy for two reasons:

First, because it represents as complete 180-degree turn from their prior attempts (over the course of several years) to eliminate any formal ACA exchange (federal or state-based) in favor of outsourcing it to private insurance carriers & 3rd-party web brokers.

Secondly, because of the timeframe involved:

The State conducted an analysis to determine the gaps between the Georgia Access Model as originally designed under the 1332 Waiver and the federal regulatory requirements for SBEs. The analysis concluded that the original Georgia Access Model under the 1332 Waiver met nearly all federal regulations for SBEs either as designed or with minor modifications. There are four program areas that were not part of the original Georgia Access design that are new requirements for an SBE: a state consumer portal, a Navigator program, a Certified Application Counselor (CAC) program, and a Small Business Health Option Program (SHOP). The State is committed to expediting the standup of these programs and is confident it can successfully implement for PY 2024.

"PY" is "Plan Year." In other words, Georgia is saying that not only do they now want to transition over to a fully state-based ACA exchange platform, they want to do it starting this fall.

As I noted in February:

Holy cats. If they're really that far along (and assuming the plan is approved by CMS), Georgia will be moved directly from HealthCare.Gov onto their own technical platform this fall. I believe every other state which has made the move from the federal exchange to a state-based exchange (Pennsylvania, New Jersey, Maine, etc.) has taken at least two years to do so (the first year operating as a "federally-facilitated" SBM).

While several activities are still in progress, many of those activities are almost complete. The State is making significant progress toward meeting all SBE requirements and is confident it can implement an SBE for a go-live date of November 1, 2023.

My overall takeaway so far has been quiet skepticism on both their motives in making the move itself as well as on the extremely tight timeframe involved. However...I don't live in Georgia and I have no idea what's been going on behind the scenes:

As I noted earlier, the current Georgia Access website is essentially a simple informational site with links to a bunch of 3rd-party insurance brokers & carrier sites. According to this letter, however:

• The State’s website was ready to launch for PY 2023 in compliance with all Exchange website requirements except for the items listed below. The following changes will be incorporated for the website launch for PY 2024:
• Consumers will have the ability to apply for, receive eligibility determinations, shop, compare, and select a QHP via a self-service State consumer portal. The State’s technology vendor will build this consumer portal, leveraging the existing single, streamlined application (SSApp) for the Agent Portal.
• The State will post the required Exchange financial information and reports to the website.
• The website will provide information on additional consumer assistance information available under the Exchange, including Navigators and CACs.
• The Georgia Access Eligibility System eligibility calculator has been developed and will be available to consumers at the start of Open Enrollment (OE) 2024.

So...y'know, OK: If they're really able to pull this off just seven months from now, good for them. We'll see.

However, U.S. Senator Raphael Warnock and U.S. Representative Lucy McBath, both of Georgia, are far more concerned about the move...and for a whole other reason I hadn't even thought about before (thanks to Kenya Hunter of Capital B Atlanta for the heads up):

Dear Administrator Brooks-LaSure,

We write to request that you not approve Georgia’s plan to operate its own state-based health insurance exchange for plan year 2024 if the Centers for Medicare and Medicaid Services (CMS) has reason to believe this approval could result in coverage losses for Georgia families. Approving this request may not comply with federal rules, which require a state seeking to set up a state-based exchange to submit an Exchange Blueprint at least 15 months before the state-based exchange’s first open enrollment period and to have an approved or conditionally approved Blueprint and operational readiness assessment at least 14 months prior to launching. We are concerned that an exception for Georgia at this time would put Georgians at higher risk of coverage loss.

The timeline always seemed way too short to me, but I didn't know what the rules were. According to Sen. Warnock and Rep. McBath, there's supposed to be at least a 15 month period from the waiver request until the point that the state-based exchange launches, which helps explain the 2-year transitional phase other states have gone through. Apparently CMS is set to give Georgia expedited approval for whatever reason...or at least they expect that to happen.

Update: Louise Norris reminded me that eliminating the 14-month lead time requirement is actually part of the pending 2024 NBPP rule, expected to be formally approved soon, so I guess this isn't really a major factor after all...but it's still surprising that Georgia, of all states, would be the test case.

It's the next three paragraphs which get to the heart of the matter, however: Medicaid unwinding and other changes to the state's Medicaid program:

This fall and in early 2024 when Georgia proposes to launch its exchange, the unwinding of the Medicaid “continuous coverage” provision will be well underway. Georgia will be in the midst of reviewing the eligibility of millions of enrollees and terminating Medicaid coverage for those who are no longer eligible, or who are eligible but do not complete paperwork requirements or are otherwise unable document their eligibility. Many Georgians could be eligible for health coverage through the federal healthcare.gov insurance exchange, and we are concerned that a new, state-based exchange in Georgia would only add to the confusion and complexity for people who are terminated from Medicaid coverage and who will become uninsured unless they take action to transition to an exchange plan.

This summer, the state is also planning to implement a new section 1115 waiver program that will require certain low-income adults to meet a work-reporting requirement in order to obtain and keep Medicaid, further complicating the coverage landscape in Georgia and straining the state’s operations during unwinding. Maintaining the federally-run healthcare.gov exchange in Georgia, which successfully provides coverage to more than 800,000 people today, will create greater stability and consistency for Georgians.

Even without major changes to the state’s exchange, coverage losses during this tumultuous period are predicted to be significant. National projections show that children, young adults, and communities of color are likely to be hardest hit. According to the U.S. Department of Health and Human Services’ own analysis, nearly 15 percent of those projected to lose coverage during unwinding are Black and one-third are Latino.

They make sure to remind CMS of the curious about-face that GA Gov. Kemp and his administration made here from their prior efforts:

Georgia’s state leadership previously pursued a section 1332 waiver that would have eliminated healthcare.gov entirely and replaced this one-stop shop with a requirement for Georgians to enroll in coverage directly through an insurer, agent, or broker. We opposed this waiver and were relieved to see it suspended. Now, state officials argue that work done to advance that waiver should allow it to quickly set up a state-based exchange. We disagree. The State of Georgia should meet the specific requirements related to establishing a state-based exchange meant to safeguard Georgians from coverage loss, including federal rules designed to make this a deliberate and careful process.

This is exactly the concern that I've been having.

We believe CMS’s first priority should be to ensure health coverage for Georgians, and we are committed to doing what we can in Congress to expand health care coverage to all Georgians and to prevent coverage losses for Georgia families. As such, we encourage you not to permit Georgia to transition to a state-based exchange on an accelerated and hasty timeline that could result in the loss of health care coverage for Georgia families. Sincerely,

Raphael Warnock, United States Senator

Lucy McBath, Member of Congress

I was under the impression that CMS had already signed off on the move, but it sounds like perhaps they haven't. If not, that tight timeline is getting even tighter. November 1st is just 215 days away.

On the other hand, I find it very difficult to believe that the same CMS officials who flatly denied allowing Georgia to scrap their exchange participation entirely last year (after doing so had been previously approved by the Trump administration a year or two earlier) would turn around and approve them moving to their own exchange this quickly unless they were convinced that it was completely on the up & up both technically and administratively.

We'll see...