Advocates puzzled after HIV is left off of Georgia’s ‘medically frail’ list for Medicaid work rules

The new proposed state policy is aimed at aligning Georgia’s Pathways to Coverage, a partial Medicaid-expansion with work requirement components, with new federal changes to Medicaid eligibility that were included in President Donald Trump’s tax break and spending cuts package that passed last year. A waiver authorizing the Pathways to Coverage program’s work requirement is set to expire at the end of this year, and the new federal work requirement takes effect early next year.

States gird for new Medicaid ‘medically frail’ rule

Under Centers for Medicare and Medicaid Services guidance released in June, able-bodied adults must complete 80 hours of work, community service or education per month to keep their healthcare coverage, something that is already required in Georgia. 

But now the state will have to provide exemptions to people deemed “medically frail,” with the federal government’s guidance specifically citing HIV/AIDS alongside cancer, end-stage renal disease and sickle cell disease as potential examples of medical conditions states could include.

The Georgia Department of Community Health released its proposed rule in July, with one list of conditions that automatically qualifies a recipient and another list of conditions that will be considered on a more case-by-case basis. 

When Georgia Equality executive director Jeff Graham saw the proposal, he said he was perplexed. He said in an interview that the state’s program that helps people living with HIV access their medication struggles financially, and ensuring this population has access to Medicaid could help lower those costs. He also said that excluding HIV could worsen health outcomes with increased hospitalizations and emergency care.

“Ultimately the state of Georgia would save money by having more people living with HIV having access to Medicaid,” Graham said. “And again, by being able to ensure that there are the needed exemptions from the community engagement criteria or the work requirements, as people really know it, is not just good for people living with HIV, it would clearly be in the best interest financially for the state of Georgia.”

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A public comment period ended on July 21, and the DCH board will consider those comments at its Aug. 13 meeting, where they can make changes to the rule before voting to approve it.

In a letter submitted during the public comment period, Metropolitan Atlanta HIV Health Services Planning Council, an advisory body established by federal law, asked the state agency to add HIV to the list of conditions that automatically exempt a person from work requirements.

“We do not raise this as a question of state policy preference. We raise it as a question of the correct application of a federal standard,” Graham and Daniel Griffin, chair of the Metro Atlanta HIV Health Services Planning Council, wrote in the letter.

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According to the letter, “Georgia continues to be at the epicenter of the ongoing epidemic in the United States,” with 2,485 people newly diagnosed with HIV in 2024, the most recent year with available data. A total of 66,896 Georgians are living with HIV.

Fiona Roberts, spokesperson for the department, said they “are reviewing the public comments and will address any changes to the public notice at our next Board meeting.” 

Despite these concerns, changes to the state program under the new federal law may still lead to more Georgians being covered by Medicaid.

While the new federal changes could decrease coverage in states that have fully expanded Medicaid, especially for the ill and disabled, those changes could actually expand coverage in Georgia, according to Leah Chan, director of health justice at the left-leaning Georgia Budget and Policy Institute.

The state’s Pathways to Coverage program, which has only enrolled about 30,000 Georgians since 2023, according to a GBPI tracker, currently doesn’t have exemptions for those considered medically frail. Its current exemptions for work requirements, like being a parent to a Medicaid-enrolled child under the age six, are more narrow than the federal guidance. Under the new exemptions, parents of Medicaid-enrolled children under 13 are exempt from work requirements, as well as those who were formerly in foster care.

“One of the biggest opportunities for more Georgians to get access to healthcare is some of these other exclusions that are more broad,” Chan said. “Those are just broader categories that more people fit under.”

Laura Colbert, executive director for Georgians for a Healthy Future, a patient advocacy group that advocates for full Medicaid expansion, said that some of the changes the state proposed will decrease some of the paperwork challenges people face, calling those “smart choices” by state officials. 

But she said she is worried about what the state has not included in its proposal, like information about the process the state used to update the medically frail list or how the department will communicate with people affected by these changes.

“Right now, the public has not seen that plan,” Colbert said. “DCH’s board will vote on this rule without knowing whether and how the people it affects will receive the information they need.”

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