Blog

November 12, 2026

Re: Georgia Section 1332 Waiver Amendment Comment

Dear Commissioner King:

Georgians for a Healthy Future (GHF) respectfully submits these comments regarding the Office of the Commissioner of Insurance and Safety Fire’s (OCI) draft amendment to Georgia’s Section 1332 State Innovation Waiver.¹ Beginning in plan year 2028, the amendment would replace federal premium tax credits with a state-defined Predictable Fixed Credit (PFC), deliver that credit through new Health Expense Accounts (HEAs), and replace the Navigator program with the Community Partners Program (CPP).

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 monitors and reports on Georgia Access enrollment, premiums, and affordability. GHF also employs a full-time enrollment assister who helps Georgians enroll in, renew, and troubleshoot their coverage. Our comments are informed by that work and by the experiences of the consumers our assister serves.

The amendment aims to solve the real coverage affordability problem for unsubsidized consumers in the individual market and projects lower gross premiums for this group; however, it would shift the risk of premium growth onto subsidized consumers, raise costs for older and low-income consumers, add new steps that could cause coverage loss, and end the Navigator program. It would do so in the same period that H.R. 1’s Marketplace changes take effect, under federal rules that are not yet final.

The amendment would change how nearly 880,000 Georgians buy and pay for individual market coverage, including the 795,767 that OCI projects will receive financial help.² Several of its provisions protect consumers; however, the application’s projections show that the benefit to subsidized consumers shrinks each year, and the application omits analyses needed to show that older and lower-income consumers would not be made worse off.³

If OCI moves forward with the request, the comments below identify changes that would better protect consumers and information OCI should publish so that Georgians, policymakers, and the Departments of Health and Human Services and the Treasury (the Departments) can evaluate the amendment. They fall into three groups: 1) provisions OCI should keep; 2) design changes that would protect affordability and coverage for subsidized consumers over the life of the waiver; and 3) information OCI should publish before submitting a final application.

1. Provisions to preserve

If OCI moves forward with the amendment, GHF supports keeping several provisions that protect consumers:

• State reimbursement of cost-sharing reductions for Silver plan enrollees from 100 to 200 percent of the federal poverty level (FPL), delivered at the point of service, with cost-sharing protections for American Indian and Alaska Native consumers unchanged.⁴
• The commitment that credit amounts used for premiums or other permitted expenses are final and will not be recovered when a consumer’s circumstances later change.⁵
• The Year-One Baseline, which raises any 2028 credit that falls below the premium tax credit a consumer would have received absent the waiver.⁶
• Publication of the credit schedule before open enrollment, so consumers can compare plans against a known amount of assistance.⁷

2. Credit growth and budget adjustments

Under the amendment, the PFC would grow each year by a measure of the Consumer Price Index for All Urban Consumers: Medical Care (CPI-U Medical Care), not by changes in premiums. The actuarial analysis assumes the credit grows 3 percent per year while premiums grow 5.6 percent per year. The application describes this divergence as intended.⁸

The state’s own projections show the effect on subsidized consumers. In 2028, average net premiums for subsidized consumers are $25 per member per month lower under the amendment than under the current reinsurance waiver ($169 compared with $194). By 2037, the difference is zero ($288 under both).⁹ Over the same period, supplemental reinsurance funded from the gap between the credit and premiums grows from $0 to $2.1 billion per year.¹⁰

Recent premium growth in Georgia has been well above the analysis’s baseline. The application itself uses an 11.9 percent premium trend from 2025 to 2026, compared with 5.6 percent in later years.¹¹ The actuarial analysis tested a scenario with 7.6 percent premium growth and 1 percent CPI-U Medical Care growth. In that scenario, subsidized consumers’ net premiums exceed the without-waiver level by 2030 and are 59 percent higher by 2037 ($493 compared with $311 per month).¹² The actuary states that recalibration would be required to comply with the guardrails and that the scenario does not model the enrollment losses that would likely occur.¹³

The amendment places two more risks on subsidized consumers. First, if waiver costs exceed available pass-through funding, OCI would reduce every credit by the same flat dollar amount, a “budget adjustment factor,” and may keep that reduction in place until funding is sufficient.¹⁴ The 2028 schedule already includes a $34 per member per month reduction, offset in that year only by the Year-One Baseline. Second, the application describes recalibration as an exceptional measure, triggered only when a guardrail is at risk, limited to the minimum adjustment necessary, and applied prospectively. Because the schedule for a plan year is published before insurers file rates for that year, a premium increase cannot be reflected in credits until the following plan year at the earliest.¹⁵

3. Impact on older consumers

Under current law, a subsidized consumer’s net premium for the benchmark plan depends on income, not age. The PFC instead sets target net premiums that rise with age, on a curve of about 4.7 to 1. At the same income, the target net premium for a consumer age 60 to 64 is more than four times that of a consumer age 21 to 24.¹⁶

The application states that the age curve preserves, on average, the net premium position of older enrollees represented by its reference cell. That reference cell is consumers age 65 and older with incomes from 350 to 400 percent FPL, a small group because most Georgians in that age group are eligible for Medicare.¹⁷ The application does not show projected net premiums for consumers age 50 to 64 at lower incomes after the first year.

Gross premiums continue to vary by age on the ACA’s 3 to 1 rating curve.¹⁸ Because the PFC grows more slowly than premiums, the dollar gap between the credit and the premium widens fastest for older consumers, who pay the highest gross premiums. An independent analysis estimates that in 2029 a 64-year-old earning $25,000 would pay about $300 per month for the benchmark Silver plan under the PFC, compared with about $102 under current tax credits.¹⁹ The guardrail standards cited in the application direct the Departments to consider effects on older adults and low-income residents, not only aggregate effects.²⁰

4. $0-premium plans and cost-sharing assistance

Ending silver loading lowers gross Silver premiums, but it also reduces the assistance available to consumers who choose Bronze or Gold plans. For many low-income consumers, silver loading is what makes a Bronze plan available at a $0 net premium today.²¹

An independent analysis estimates that the share of subsidized consumers with a $0-premium Bronze option would fall from 80 percent under current tax credits in 2028 to 61 percent under the PFC in 2028, 46 percent in 2029, and 32 percent in 2032. Among consumers from 100 to 133 percent FPL, the analysis estimates the share would fall from 100 percent to 45 percent by 2032.²² Research from Massachusetts found that when plans went from a $0 premium to a premium of $10 or less per month, enrollment fell 14 percent over the following year.²³

The Out-of-Pocket Exposure Protection (OOPEP) deposit does not offset these changes. The deposit is $6 per member per month in 2028, or $72 per year. Consumers from 100 to 200 percent FPL who choose a Bronze plan receive the same $6 deposit. The actuarial analysis estimates 2028 average annual cost sharing of $669 for consumers in 94 percent CSR plans and $1,044 for consumers in 87 percent CSR plans, compared with $2,722 for Bronze plans. Consumers from 201 to 250 percent FPL who lose access to the 73 percent actuarial value Silver plan would see average annual cost sharing rise by $379 in 2028.²⁴

The application promotes the ability to keep unused credit for other health expenses. The actuarial analysis estimates that 7 to 20 percent of subsidized consumers would have any credit left after paying premiums in 2028, 3 to 10 percent would have $25 or more per month left, and fewer would in later years.²⁵

5. Health Expense Account design

Today, advance premium tax credits are paid directly to insurers, and consumers pay only the remaining balance, if any. Under the amendment, credits would be deposited into an HEA run by a private administrator. HEA funds would not be applied to premiums without the consumer’s authorization, and using HEA funds for past-due premiums would require affirmative action by the consumer.²⁶

Coverage does not take effect until the first month’s premium, the binder payment, is paid.²⁷ A consumer whose entire premium is covered by the tax credit today takes no action to pay–a feature that consumers largely enjoy and perceive as convenient. Under the amendment, that consumer would need to set up account access and authorize payment, or lose coverage. During a grace period, non-premium uses would be frozen, deposits for the second and third months would be subject to recovery, and unresolved accounts could be closed with balances returned to the state. Inactive accounts with no activity for six months would also close.²⁸ In Massachusetts, when $0-premium plans began charging nominal premiums, most of the resulting terminations occurred at the end of January, indicating that many consumers never started paying.²⁹

The implementation timeline is compressed. The application schedules the HEA administrator procurement to be finalized on February 26, 2027, and the administrator’s platform testing to be completed on August 31, 2027, two months before open enrollment.³⁰ Federal pre-open enrollment verification is proposed to begin on August 1, 2027, during the same period.³¹

The application also relies on the state’s assumptions about the federal tax treatment of HEA deposits and transfers, which remain subject to confirmation by Treasury and the IRS.³² Consumers need to know before they enroll whether HEA funds create a tax obligation.

6. Eligibility rules and H.R. 1 interactions

Mid-year changes. The application states that Georgia Access will process changes in income, household composition, and eligibility, but it does not explain how a consumer’s PFC would change during the year. Today, a consumer whose income drops after a layoff, or whose household grows through birth or adoption, can receive a larger tax credit for the rest of the year. The PFC schedule is fixed for each plan year and is not reconciled at year-end.³³

Employer coverage. PFC eligibility is limited to consumers who are not eligible for other minimum essential coverage. Under section 36B, workers and family members offered employer coverage that is unaffordable or does not provide minimum value remain eligible for premium tax credits. The application does not state whether this rule continues under the PFC.³⁴

Interaction with H.R. 1. Public Law 119-21 (H.R. 1) made several changes to Marketplace eligibility and premium tax credits that take effect from 2026 through 2028.³⁵ The actuarial analysis states that it takes H.R. 1 into account, but the application does not explain how these provisions would apply to the PFC or HEAs. The federal rules implementing these provisions are not final. Treasury and the IRS proposed regulations on October 14, 2026, and CMS proposed its rule on October 23, 2026, both after the October 12 date of the state’s draft actuarial analysis.³⁶ No federal guidance addresses how these provisions apply to a state-administered credit under a Section 1332 waiver, so the application rests on the state’s best estimate of rules that may still change. Examples include:

• Pre-enrollment verification. Section 71303 requires Exchanges to verify eligibility before providing financial assistance and ends automatic re-enrollment with assistance, beginning in plan year 2028, the same year the PFC begins. CMS’s proposed implementing rule would open the first verification window on August 1, 2027, while the HEA system is still being tested.³⁷ The application does not address section 71303 or how verification would interact with HEA setup and the first deposit.
• Repayment of excess credits. Section 71305 removed the limits on repayment of excess advance premium tax credits beginning with tax year 2026.³⁸ The application states that PFC amounts are final once used and that the state will handle enrollee-level reconciliation. It also states that the federal reconciliation process, including Forms 1095-A and 8962, would need only minimal changes.³⁹ The application does not say whether a consumer could still owe repayment to the IRS.
• Failure to reconcile. Section 71303 also denies advance credits to consumers who did not file and reconcile prior-year credits.⁴⁰ The application does not say how this rule would apply once credits are no longer reconciled on federal tax returns.
• Immigrant eligibility. Section 71301 narrows premium tax credit eligibility for lawfully present immigrants beginning in 2027.⁴¹ The PFC would rely on existing immigration status verification,⁴² but the application does not state whether PFC eligibility follows the narrower federal rules.

7. Navigator program and enrollment assistance

Georgia Access has already shifted its consumer assistance focus from Navigators to the Community Partner Initiative, launched in plan year 2026. The amendment would complete that shift by ending the Navigator program. Community Partners would provide outreach and education but would not enroll consumers or recommend plans.⁴³

The amendment increases the need for impartial, individualized enrollment help:

• Consumers would need help understanding a new credit schedule, setting up HEAs, authorizing premium payments, and resolving account problems.⁴⁴
• H.R. 1’s pre-enrollment verification and other eligibility changes would take effect in the same plan year.⁴⁵
• Without Navigators, individualized help would come only from the Georgia Access contact center and from agents paid commissions by insurers.⁴⁶ Navigators are the only assisters federal rules require to have no financial ties to insurers and to meet language access and disability access standards.⁴⁷
• The application identifies residents of 120 rural counties and more than 1.7 million Georgians who speak a language other than English at home as hard to reach.⁴⁸ Federal Navigator standards require culturally and linguistically appropriate assistance and accessibility for people with disabilities.⁴⁹

8. Coverage projections

The application projects that the amendment would add 1,670 enrollees compared with the current reinsurance waiver, and 4,814 compared with no waiver, about 0.6 percent of projected enrollment. It projects subsidized enrollment of 795,767 in every year from 2028 through 2037, even though the credit is designed to lose value relative to premiums each year. The analysis does not model enrollment losses from HEA authorization requirements, the loss of $0-premium plans, or the end of the Navigator program, and none of its sensitivity scenarios model enrollment changes.⁵⁰

A small coverage loss would erase the projected gain. The independent analysis cited above estimates that about 275,000 consumers would lose a $0-premium option in 2029. If 1 percent of them dropped coverage, the loss would exceed the 1,670-person gain the application attributes to the amendment.⁵¹

9. Administrative costs

The actuarial analysis states that the costs to administer the amendment are not yet known and uses a proxy minimum of $5 million. Its baseline model holds $16 million in 2028 and $30 million in each later year for administration and contingency reserve.⁵² The application states that credits will be set after accounting for administrative costs, so higher overhead means lower credits.⁵³

The application does not estimate the cost of the HEA administrator contract, account or card fees, or customer service.⁵⁴ It also does not state how balances returned to the state from closed or frozen accounts would be used.⁵⁵

10. Public reporting and comment process

The application commits to annual reports to the Departments and to public notice of recalibration events.⁵⁶ It does not commit to public comment before a recalibration, a budget adjustment, or a change to the CPP. It also omits several measures needed to detect harm to consumers early.

The draft application posted for comment does not include the age, income, and subgroup analyses, administrative cost estimates, or enrollment modeling described above. The Departments and the public cannot evaluate guardrail compliance without them.

Conclusion

GHF appreciates the opportunity to comment and OCI’s work to address premium growth in Georgia’s individual market. GHF urges OCI to withdraw the proposed amendment. If OCI moves forward with the request, the recommendations above are offered so that the amendment keeps coverage affordable for subsidized Georgians over the life of the waiver, not only in its first year, and so that Georgians, policymakers, and the Departments have the information needed to evaluate it. We would welcome the opportunity to discuss any of our comments directly.

Respectfully submitted,