GHF's public comment flags gaps in health exemptions and public outreach in Georgia's new Medicaid work requirement rule
Earlier this month, GHF submitted comments to the Georgia Department of Community Health on its proposed amendment to the Georgia Pathways to Coverage Section 1115 demonstration waiver, which asks the federal government for a 90 percent federal match for the Pathways population beginning January 1, 2027.
Our comments urge DCH to maintain coverage for Georgians with low incomes regardless of CMS’s decision, and to publish the enrollment projections, cost estimates, and actuarial analysis that Georgians, the Board of Community Health, and federal policymakers need to evaluate the request. Read our full comment letter below:
Re: Public Comment on the Proposed Amendment to the Georgia Pathways to Coverage Section 1115 Demonstration Waiver to Obtain Enhanced Federal Funding
Dear Ms. Hicks:
Georgians for a Healthy Future (GHF) respectfully submits the following comments regarding the Department of Community Health’s (DCH) proposed amendment to the Georgia Pathways to Coverage Section 1115 Demonstration Waiver, which requests an enhanced federal medical assistance percentage of 90 percent for the demonstration population effective January 1, 2027.1
GHF is a nonprofit health policy and advocacy organization working to ensure all Georgians have access to high-quality, affordable health care. Through policy research and community education and assistance, we work to improve health outcomes, expand coverage, and reduce barriers to care for Georgians.
GHF has engaged with DCH about the Georgia Pathways to Coverage program since the introduction of the Patients First Act in 2019 and employs a full-time enrollment assister who helps Georgians enroll, renew, and troubleshoot their Medicaid applications and coverage, including for the Pathways program. Our comments are informed by the experiences of our enrollment assister and our clients, as well as our previous engagements with DCH regarding the Pathways program.
These comments address the information the notice provides, and the information Georgians, the Board of Community Health, and CMS would need to evaluate the proposed amendment. Our comments fall into the following categories: 1) describing the likely impacts of this proposal on Georgia adults with low incomes and urging DCH to expand, rather than eliminate or narrow, coverage opportunities for this group; and 2) identifying information and evidence that is missing from DCH’s request and must be provided for full consideration of this request by Georgians, stakeholder groups, and federal policymakers.
1. DCH should not consider eliminating or narrowing coverage options for Georgia adults with low incomes.
This amendment requests a change in the federal matching rate for the Pathways demonstration population. It does not propose a change in eligibility. DCH states that the community engagement conditions of Public Law 119-21 (commonly known as H.R.1 or “The One Big Beautiful Bill Act”) are unwaivable,2 and estimates that the covered group will grow to nearly 120,000 by June 30, 2028.3 Nothing in the notice indicates that the number of covered Georgians would differ depending on the outcome of this request.
However, the notice does not indicate whether Georgia will cover the projected population if CMS denies the state’s request. DCH states that “[t]he financial burden of this federally-mandated coverage expansion is simply not sustainable for Georgia in the long run,” and that Georgia “does not have the financial capacity at its federal fiscal year 2027 FMAP of 66.86% to fund this expanded scope without additional federal dollars.”4 It further states that without additional federal funding, “the long-term viability of the program . . . will be threatened and the state will have no alternative but to make decisions that imperil health policy goals around personal responsibility and healthy choices.”5
The notice does not identify the decisions that DCH may make. It does not state whether Georgia would end the demonstration, decline to pursue its pending extension, seek to narrow eligibility, or take another course. Most concerningly, it does not state what would happen to the coverage of any Georgians enrolled in Pathways when a decision is made. Over 19,000 Georgians are currently covered by the program.6
The demonstration’s current federal authority expires December 31, 2026, and Georgia’s five-year extension application remains pending before CMS.7 Georgians enrolled in Pathways cannot determine from the notice whether their coverage depends on the outcome of this request. They do not know if their coverage will continue, be terminated, or change in some other way. This uncertainty will make it difficult for them to plan for their health care needs and for other aspects of their lives.
As indicated by DCH in its notice and enrollment projections, more Georgians will likely be eligible to enroll in Pathways on or after January 1, 2027 because of the federally-required transition from the program’s current extremely narrow eligibility criteria and exemptions policy to the moderately more flexible federal work reporting requirement and exemption structure. Georgians who may become newly eligible in January include individuals whom GHF has previously had to counsel and turn away from applying for Pathways, including parents and family caregivers, people with serious chronic illnesses or disabilities (who cannot or have not yet qualified for federal disability status), and others. These Georgians are also harmed by the lack of clarity offered in DCH’s notice. Will they have the opportunity to enroll in coverage in 2027 or will they be forced to continue piecing together health care through charity programs and other less comprehensive and uncoordinated offerings?
Georgia already has one of the highest uninsured rates in the nation, and Georgians with low incomes have demonstrably struggled to enroll in Pathways under its current structure.8,9 It is untenable to consider eliminating the only coverage option available to Georgia adults with low incomes, just as that program becomes available to more of them.
Absent a commitment from the state legislature and Governor to establish a replacement or more expansive program, Georgians for a Healthy Future recommends that Georgia maintain the Pathways program and move forward with its planned transition to the federal version of work reporting requirements in January, regardless of CMS’s decision about the requested enhanced funding.
2. Publish comparable enrollment and fiscal projections so that Georgians and Georgia policymakers can easily compare policy options.
DCH’s waiver amendment request states that Georgia has declined to pursue full Medicaid expansion; that the Patients First Act authorizes DCH to submit a demonstration reaching a maximum of 100 percent of the federal poverty level (FPL); and that Georgia law requires legislative approval for Medicaid expansion.10
Georgia therefore has two available paths for covering adults with low incomes: 1) its current approach, which covers adults up to an income threshold below the Affordable Care Act’s new adult group income limit (133% FPL); and 2) Medicaid expansion, so that adults with incomes up to 133 percent FPL would largely be eligible. DCH’s notice provides enrollment and fiscal projections for only the first of these options, even though the most straightforward way for Georgia to earn the enhanced funding being requested is to expand its Pathways eligibility threshold up to 133 percent FPL.
The notice does not estimate how many Georgians would be covered, or the state cost of a program that covers Georgia adults up to 133 percent FPL through Medicaid expansion. Without that estimate, the Board of Community Health and the General Assembly cannot compare the cost and coverage implications of the state’s policy options.
GHF recommends that DCH publish side-by-side projections comparing enrollment and cost projections of: 1) the Pathways program as it will look under the federal work requirement and reporting structure required by Public Law 119-21; and 2) Medicaid expansion. Projections should use the same 18-month time period referred to in DCH’s notice and comparable actuarial assumptions, and be substantiated with information about methodology and assumptions.
Following publication of this information, GHF urges the state to re-open public comment for no fewer than 30 days.
3. DCH should fully and publicly substantiate its enrollment and fiscal projections.
Enrollment projections
In DCH’s notice, it estimates that Pathways enrollment will grow to nearly 120,000 by June 30, 2028.11 (As of July 31, 2026, reported Pathways enrollment was 19,397.12) The notice attributes this enrollment projection to “Georgia Department of Community Health, internal enrollment data.” The notice does not include the assumptions or methodology underlying this projection or any explanation of how this estimate was produced, including quarterly (or similar) enrollment projections, what portion of this enrollment growth is expected to be driven by the federally-required exemption structure compared to other factors, or other essential information. The enrollment estimate is offered without justification or evidence of its validity.
Since the program’s launch in 2023, Pathways enrollment has not met enrollment estimates or targets published by DCH.13,14,15,16,17 Without demonstrating how or why the current estimate is more reliable than past projections, Georgians and other key decisionmakers (including the federal government) cannot reasonably assess DCH’s estimates or its funding request.
GHF recommends that DCH publish the methodology and assumptions used to produce its enrollment projection, including projected quarterly enrollment, assumed application and approval rates, and the estimated number of Georgians enrolled through major work reporting and exclusion categories.
Fiscal estimates
The notice projects $227,500,000 in total costs for SFY2027 and $1,205,700,000 for SFY2028, and the amendment request states an 18-month total of $1.4 billion for the period of January 1, 2027 through June 30, 2028.18 Those figures reflect a 90 percent federal share. At Georgia’s federal fiscal year 2027 FMAP of 66.86 percent, which DCH states in the amendment request, the state share of the same total would be approximately $475 million rather than the approximately $143.3 million reflected in the notice.19
The notice does not include a per member per month cost, projected member months, or other assumptions that informed DCH’s fiscal estimates. Applying a linear enrollment ramp to the figures DCH published implies approximately $1,100 to $1,200 per member per month, or approximately $13,100 to $14,200 per enrollee per year.20 MACPAC reports FY2024 Medicaid benefit spending of $8,677 per full-year-equivalent enrollee for newly eligible adults nationally and $6,720 across all Georgia Medicaid enrollees.21
The amendment request refers to “current actuarial estimates” and an “actuarially-conservative evaluation.”22 No actuarial analysis accompanies the notice. Without more complete information about how DCH’s fiscal projections were determined, Georgians and other key decisionmakers (including the federal government) cannot reasonably assess DCH’s estimates or its funding request.
GHF recommends that DCH publish the actuarial analysis supporting these projections, including the per member per month assumptions and projected member months by state fiscal year, along with other figures needed to replicate or verify DCH’s estimates. GHF further recommends that DCH clearly state whether it has submitted or intends to submit an FY2028 budget request to the Governor’s Office of Planning & Budget and/or legislative appropriators reflecting these costs.
Following publication of the requisite information about DCH’s enrollment and fiscal projections, GHF urges the state to re-open public comment for no fewer than 30 days.
4. Reconciliation with the July 9, 2026 public notice
On July 9, 2026, DCH published a public notice for a State Plan Amendment implementing the community engagement requirement. That notice projected $181,400,000 in total costs for SFY2027, comprising $60,642,020 in state funds and $120,757,980 in federal funds, an implied federal share of approximately 66.6 percent.23 The August waiver amendment request projects $227,500,000 for the same state fiscal year, the same population, and the same January 1, 2027 effective date, at a 90 percent federal share. The two totals differ by $46.1 million. If they are additive rather than alternative, the combined SFY2027 projection is $408.9 million. The August 13 notice cites the July 9 notice but does not state the relationship between the two projections.
GHF recommends that DCH state whether the SFY2027 figures in the July 9 notice and in this notice overlap, are additive, or whether one supersedes the other, and publish a reconciliation of the two before the Board is asked to act.
5. Allocation between administrative costs and medical assistance
The notice does not allocate the projected costs between administrative costs and medical assistance. The two are matched under different authorities. Administrative costs are matched at 50 percent for general administration, 75 percent for systems operation and skilled professional medical personnel, and 90 percent for the design, development, and installation of eligibility systems approved through an Advance Planning Document.24 Public Law 119-21 also appropriated $200 million to states for implementation of the community engagement requirement in FY2026. CMS has stated that half of that amount is divided equally among the 50 states and the District of Columbia, and half is distributed according to each state’s share of individuals subject to the community engagement requirement as of March 31, 2025. CMS has not published state-by-state allotments.25
The Government Accountability Office reported that as of April 2025 the Pathways demonstration had incurred approximately $54.2 million in administrative costs compared with approximately $26.1 million in medical assistance spending.26 Because administrative and benefit costs are matched at different rates, the state and federal shares shown in the notice depend on how the projected total is allocated between them.
GHF recommends that DCH publish the allocation of projected costs between administrative costs and medical assistance for each state fiscal year, state whether Georgia has sought or received Advance Planning Document approval for enhanced systems funding, and identify Georgia’s allocation under section 71119 of Public Law 119-21 and how those funds have been applied.
6. Budget neutrality under section 1115(g)
Public Law 119-21 added section 1115(g) to the Social Security Act. Beginning January 1, 2027, the Secretary may not approve an application for, or an amendment or renewal of, a section 1115 demonstration unless the CMS Chief Actuary certifies that the project is not expected to result in an increase in federal expenditures compared with what those expenditures would be absent the project. CMS has stated that the certification is based on federal expenditures only; that administrative costs are included in the determination; and that where the Chief Actuary has not previously certified a demonstration, an amendment requires certification of the entire demonstration.27
DCH requests an effective date of January 1, 2027. The notice does not address section 1115(g).
GHF recommends that DCH’s submission to CMS address how the proposed amendment satisfies section 1115(g), and state which review standard DCH expects CMS to apply given the requested effective date.
Conclusion
GHF appreciates the opportunity to comment on this proposal. The recommendations above are offered so that Georgians, the Board of Community Health and other Georgia policymakers, and CMS have the information needed to evaluate the proposed amendment and its effect on coverage for Georgians. We would welcome the opportunity to discuss any of our comments directly.
Respectfully submitted,
Whitney Griggs Director of Health Policy Georgians for a Healthy Future
Laura Colbert Executive Director Georgians for a Healthy Future
Ga. Dep’t of Cmty. Health, Public Notice, “Proposed Amendment to Georgia Pathways to Coverage Section 1115 Demonstration Waiver to Obtain Enhanced Federal Funding” (issued August 13, 2026) (hereinafter “Public Notice”), and the accompanying “Georgia Section 1115 Demonstration Waiver Amendment Request” (hereinafter “Amendment Request”). ↩
Amendment Request at 4 (“Georgia is prohibited from continued operations of its current Pathways program because under Public Law 119-21, the conditions are unwaivable.”). ↩
Amendment Request at 3 (“Georgia has estimated that new population required from Public Law 119-21 and the current population covered under Pathways will total nearly 120,000 by June 30, 2028.”) and at 4 (“The State is now being forced to expand the program to 100,000 new individuals in order to maintain the coverage of approximately 20,000 hard-working Georgians.”), citing “Georgia Department of Community Health, internal enrollment data.” ↩
Amendment Request at 3 (“The financial burden of this federally-mandated coverage expansion is simply not sustainable for Georgia in the long run.”) and at 4 (“Georgia does not have the financial capacity at its federal fiscal year 2027 FMAP of 66.86% to fund this expanded scope without additional federal dollars . . . .”). ↩
Amendment Request at 3 (“In turn, the long-term viability of the program serving as the foundation of the community engagement requirements in Public Law 119-21 will be threatened and the state will have no alternative but to make decisions that imperil health policy goals around personal responsibility and healthy choices.”). ↩
Georgia Budget & Policy Institute analysis of Pathways to Coverage program enrollment. Obtained through Open Records Requests to Department of Community Health. Available at GeorgiaPathways.org/datatracker. [hereinafter “GBPI Pathways Data Tracker”] ↩
The Pathways demonstration’s current federal authority expires December 31, 2026. Georgia’s five-year extension application was filed April 28, 2025 and remains pending before CMS. Amendment Request at 2. ↩
Amendment Request at 2-3 (“Georgia has declined to pursue full Medicaid expansion and must obtain legislative approval for any Medicaid expansion, consistent with a 2014 state law,” and describing the Patients First Act as authorizing a demonstration that “may include an increase in the income threshold up to a maximum of 100% of the FPL (95% plus a 5% income disregard)”); Public Notice at 1 n.2 (citing O.C.G.A. § 49-4-142.3). ↩
Amendment Request at 3 (“Georgia has estimated that new population required from Public Law 119-21 and the current population covered under Pathways will total nearly 120,000 by June 30, 2028.”) and at 4 (“The State is now being forced to expand the program to 100,000 new individuals in order to maintain the coverage of approximately 20,000 hard-working Georgians.”), citing “Georgia Department of Community Health, internal enrollment data.” ↩
GBPI Pathways Data Tracker (enrollment data through July 31, 2026). ↩
GBPI Pathways Data Tracker (enrollment data through July 31, 2026). ↩
Public Notice at 1 (SFY2027: $22,750,000 state, $204,750,000 federal, $227,500,000 total; SFY2028: $120,570,000 state, $1,085,130,000 federal, $1,205,700,000 total); Amendment Request at 4 (eighteen-month total of $1,433,200,000 for the period beginning January 1, 2027 and ending June 30, 2028). ↩
Amendment Request at 4. At 66.86 percent, the state share of $1,433,200,000 is approximately $475 million; at 90 percent it is approximately $143.3 million. ↩
GHF analysis of figures published in DCH’s notice. DCH projects total expenditures of $1,433,200,000 over the eighteen months beginning January 1, 2027 and ending June 30, 2028, and projects that the population will grow from approximately 20,000 to nearly 120,000 over that period. A linear enrollment ramp across eighteen months yields approximately 1,210,000 to 1,310,000 member months, depending on whether enrollment is measured at the beginning or the end of each month, implying approximately $1,094 to $1,184 per member per month. ↩
MACPAC, MACStats: Medicaid and CHIP Data Book, Medicaid benefit spending per full-year-equivalent enrollee, FY2024. ↩
Amendment Request at 3 (referring to “current actuarial estimates” and an “actuarially-conservative evaluation”). ↩
Ga. Dep’t of Cmty. Health, Public Notice, “Medicaid Community Engagement Requirement for Certain Adults: State Plan Amendment” (issued July 9, 2026) at 1 (projecting $181,400,000 total for SFY2027, comprising $60,642,020 in state funds and $120,757,980 in federal funds). The August 13 notice cites the July 9 notice. See Public Notice at 1 n.4. ↩
Social Security Act § 1903(a); 42 C.F.R. § 433.15(b) (50 percent for general administration; 75 percent for skilled professional medical personnel and mechanized systems operation; 90 percent for the design, development, and installation of mechanized claims processing and information retrieval systems). Enhanced systems funding requires an approved Advance Planning Document. 45 C.F.R. Part 95, Subpart F. ↩
Pub. L. No. 119-21, § 71119. CMS, Informational Bulletin (Dec. 8, 2025), https://www.medicaid.gov/federal-policy-guidance/downloads/cib12082025.pdf ($100 million distributed equally among all 50 states and the District of Columbia, and $100 million distributed to the 50 states and the District of Columbia based on their share of individuals subject to community engagement relative to the total number of such individuals across all 50 states and the District of Columbia, as of March 31, 2025). The equal-share portion is approximately $1,960,784 per jurisdiction. CMS has not published a state-by-state allotment table. ↩
U.S. Gov’t Accountability Office, GAO-25-108160 (Sept. 2025). ↩
Pub. L. No. 119-21, § 71118 (adding Social Security Act § 1115(g)); SMD # 26-003, supra note 18. ↩
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