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Health Reform In Georgia

Until November 16, 2012, Georgia was making plans for its state health insurance exchange, using a committee of 25 members including insurers, state officials, brokers, business representatives, providers, and consumers. This group, the Georgia Health Insurance Exchange Advisory Committee, was investigating how a health insurance exchange should be carried out in the state, though they eventually decided it best to leave the federal government in charge. At the end of 2011, the Committee provided the governor with suggestions as to the creation of a small group health insurance marketplace, as well as two separate risk pools for individuals and businesses, though their reports stated nothing about creating an individual exchange. Going forward, the exchange will be run by the federal government, with minimal responsibilities to be executed by the state.

Georgia did not elect to move forward with Medicaid expansion. With only two aspects of the law being somewhat optional for states, many conservative states decided against adding a new group to the state’s Medicaid program, claiming it would be too costly. Some red states changed their mind, however, making Medicaid available to more low-income residents.

The Affordable Care Act affects Georgia insurers and plan members in a variety of important ways. During the health reform transition period from 2010-2013, some new regulations were introduced, allowing policyholders better access to care, and prohibiting insurers from being restrictive. As of Jan. 1, 2014, the individual market has largely changed between mandatory coverage and new requirements for insurers, such as accepting all applicants even if they’re sick.


Early Reforms In Georgia

Since 2010, the ACA has been planting seeds in private insurance to change the face of it completely. Firstly, insurers are no longer allowed to terminate your coverage for health reasons, if you have been truthful on your application. Your policy can still be rescinded if you are attempting fraud or not paying your monthly premiums, but if you become unexpectedly ill, the health plan must keep you insured. Insurers are also regulated by the medical loss ratio, or 80/20 rule, which ensures each private carrier spends 80-85 percent of premium dollars on patients, and the remainder on company expenses.

Consumers are also protected by parts of the law granting coverage to dependent children up to age 26 on their parent’s health plan. So far, this change has shown the largest impact on the uninsured young adult population, which has diminished by more than 11 million people over the past few years. As an introduction to the 2014 provisions, children with pre-existing conditions cannot be declined coverage for their health. While insurers may still increase their rates on an individual plan, they cannot refuse to insure someone under 18.

To offer more fair coverage to Georgians, the health care law made preventive services free when using your health plan’s network. Although because you pay for coverage it is not entirely free care, insurers and providers cannot ask you to pay a copay, deductible, or coinsurance for such services. These include well child care, well woman care, routine exams, cancer screenings, and certain vaccinations. The government also approved several new services for women which are now included for at no cost.

The ACA also added a temporary risk pool, the Pre-Existing Condition Insurance Plan (PCIP) as an interim health plan for people with conditions. The PCIP was created by the federal government in order to offer more comprehensive coverage to adults with conditions who are unable to get insured privately. These plans were effective through the end of 2013, as each current PCIP member is now able to buy a health plan without being turned down.


Full Implementation of Georgia Health Reform

On the topic of conditions, insurers are required to cover all Georgia residents, no matter what medical problems they have had in the past. You are likely to still include accurate personal information on your application, insurers cannot collect your medical history. They are also unable to increase rates based on health problems, nor can they exclude benefits or refuse to sell you a plan. This reform to the individual and small group market will drastically change how insurers operate in Georgia, and make it easier for more residents to get covered.

Insurance will also be more comprehensive in Georgia, offering a wide range of benefits across various health plans, as the law requires ten different types of services to be covered. Essential health benefit (EHB) categories include emergency care, maternity, hospital, preventive care and disease management, and prescriptions, among others. Many comprehensive individual plans in Georgia already offer these services, with the exception of immediate access to maternity coverage. In the future, it will be a requirement to cover these services.

October 1, 2013 marked the opening date for Georgia’s federally-run health insurance exchange, the online marketplace for insurance. HealthCare.gov and other insurance sites sell marketplace plans designed for individuals and small businesses, and also provide information and applications for Medicaid and Medicare. The intent of this organization is to make sure everyone in Georgia knows their health insurance options and gets insured, especially those without access to affordable coverage. Health plans through the exchange are sold by private health insurers and the organization is run by the federal government. Plans are offered in varying coverage levels as with typical private insurance plans, yet they’re required to have an actuarial value of at least 60 percent.

Exchanges open the door to coverage for those with a low-to-moderate income, for whom insurance is too expensive, but their wages are too high to qualify for Medicaid. This is a large group in Georgia and nationwide, and the exchange has the potential to help these people get coverage by issuing subsidies to help pay premiums. Subsidies will be offered to individuals who earn between 100 to 400 percent of the federal poverty level. According to a report by Families USA, over 800,000 Georgians will qualify for these tax credits.

Georgia decided against offering Medicaid to more low-income residents, thoughdoing so would help the state immensely. Medicaid expansion under health reform offers coverage to childless, non-disabled adults whose income is less than 138 percent of FPL. This is a large group, especially considering that only parents and disabled adults between 19-64 in Georgia are able to join Medicaid currently.






1. Kaiser Health Reform. State Exchange Profiles: Georgia.

2. Atlanta Daily World. More Than 800,000 in Georgia Eligible For Health Insurance Tax Subsidies – Report.