Georgia responds to CCIIO: They're PO'd but will accept the FF-SBE deal if given reassurances...

Back 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 policy 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:

...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 at the time:

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).

...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.

I've been skeptical all along that Georgia would be able to pull off all of the complexities required to successfully transition from the federal exchange to their own full state-based ACA exchange in just 8-9 months...but without having any knowledge of the behind-the-scenes developments, I've tried to keep my doubts in check.

In addition to this, as GA Senator Raphael Warnock & Rep. Lucy McBath noted in March, there are several other reasons to be concerned about making such a significant move in such a short time period...especially right now, including:

  • The short timeframe in general
  • Making the transition in the middle of the ongoing Medicaid Unwinding process, and...
  • Making the transition in the middle of the launch of Georgia's new Medicaid work requirement program

In the end, however, a week or so ago the Center for Consumer Information and Insurance Oversight (CCIIO) division of the Centers for Medicare & Medicaid Services (CMS) told Georgia to cool their heels a bit:

Dear Director Gardner:

Thank you for submitting an Exchange Declaration of Intent on February 13, 2023 and Blueprint Application on February 14, 2023, seeking approval for the State of Georgia (“Georgia” or “the State”) to establish and operate a State-based Exchange (“SBE”) within Georgia’s Office of Commissioner of Insurance and Safety Fire (“OCI”). This letter conditionally approves Georgia’s Blueprint Application to operate an SBE for plan year (“PY”) 2025, and to operate a State-Based Exchange on the Federal Platform (SBE-FP) for PY 2024.

In other words, Georgia is gonna have to follow the 2-step procedure for moving to their own full ACA exchange just like the other 18 states which have previously done so:

  • For 2024 they'll operate as a separate legal entity (with their own board of directors, marketing team/budget, advisory board and so forth), but will still utilize the federal technical platform (HealthCare.Gov) for Open Enrollment and off-season enrollment for the 2024 calendar year.
  • Then, assuming CMS is satisfied that the state-based exchange has complied with all of the other regulatory requirements, they'll be allowed to move to their own enrollment platform ( starting in November 2024.

CCIIO went through a lengthy list of reasons which included the bullets noted in the letter from Sen. Warnock & Rep. McBath, along with several others.

Well, today Georgia Insurance Commissioner John King issued his response to CCIIO's decision. The short version: He's pissed as hell but has little choice but to suck it up given the short timeframe between now and the start of the 2024 Open Enrollment Period on November 1st. HOWEVER, he's also concerned that CCIIO is gonna make like Lucy with the football next year as well, and wants some assurances about that:

Dr. Ellen Montz
Deputy Administrator and Director
Center for Consumer Information and Insurance Oversight (CCIIO) Centers for Medicare & Medicaid Services (CMS)

Dear Director Montz,

We are in receipt of your letter dated July 27, 2023, and are surprised by the agency’s decision not to grant Georgia approval to implement a State-based Exchange (SBE) for Open Enrollment (OE) 2024 as Georgia requested. Instead, the agency granted only conditional approval to operate a State-based Exchange on the Federal Platform (SBE-FP) for 2024 and an SBE for 2025. Georgia is clearly ready to implement an SBE for OE 2024 and has continually demonstrated that readiness. Since Georgia first notified CMS of its intention to transition off the federal Exchange under its 1332 Waiver submitted December 23, 2019, we have been steadfast in our desire to bring the individual insurance marketplace into the State. We believed then, as we believe now, that Georgia is best positioned to serve the needs of its residents, just like the other 18 states that currently operate SBEs.

After CMS suspended approval of Georgia Access under the 1332 Waiver, which would have transitioned Georgia’s health insurance plans from for OE 2023, the State pivoted and operated in good faith to build an SBE. The State has consistently demonstrated operational and technical readiness and is tracking closely with the readiness level of the Commonwealth of Virginia, also transitioning off the federal Exchange for OE 2024. From the submission of Georgia’s SBE Blueprint Application on February 14, 2023, the State has actively collaborated with CCIIO to demonstrate readiness and respond to feedback and questions. We have been transparent about our progress, including the management of risks and delays that all states experience transitioning from the federal Exchange. Additionally, we provided all requested demonstrations of the State’s systems and incorporated required feedback from CCIIO. We were also told CCIIO’s go/no-go decision to grant conditional SBE approval for Georgia for OE 2024 was going to be August 4, 2023, in alignment with the timeline for all states moving off the federal Exchange this year. The letter provided on July 27, 2023, requiring a response from Georgia by August 4, 2023, is a last-minute change in direction from the agency.

The entire response letter is 9 pages long and gets pretty wonky; he basically reiterates the timeline of what actions have been taken by Georgia, the responses by CCIIO, etc etc., again insists that Georgia is fully prepared to go fully live this November, stresses that there's no logical reason to put it off for another year, and basically claims that CMS keeps jerking them around on the issue.

In the end, however, especially given that the clock is ticking and healthcare coverage for hundreds of thousands of people is at stake...

Despite our disagreement with CCIIO’s assessment and decision based on the reasons outlined above, we believe it is in the best interest of Georgia residents and our partners to have clarity for how consumers will shop for and enroll in coverage this fall. The requested SBE-FP Blueprint is being submitted concurrently with this letter. The State is prepared to be amenable to the phased SBE approach.


However, since CCIIO waited until only a few months prior to OE 2024 to deny Georgia’s request to be an SBE, the state would request that CCIIO give a number of assurances with respect to the state’s readiness for OE 2025.

After once again accusing CCIIO of not acting in good faith, King issues his list of demands:

We are hesitant to move forward in good faith, continue to expend state resources for a third time, or ask our partners to do the same, without the following assurances from CCIIO for SBE readiness for OE 2025:

  • CCIIO will honor the readiness activities and demonstrations completed by Georgia to date and acknowledge that the State currently meets Blueprint requirements for eligibility determinations for qualified health plans (QHPs) and Advance Payments of the Premium Tax Credit (ATPCs), as well as assessments for Medicaid and PeachCare for Kids® (the State’s Children’s Health Insurance Program (CHIP)) per the latest ORR tracker shared with the State on 7/21/2023. Indicative of this, CCIIO will not require the State to repeat these completed ORR activities for OE 2025.
  • CCIIO will acknowledge that the SBE Single Streamlined Application with the required changes identified by CCIIO on 7/21/2023 for the SBE meets the Blueprint requirements and no further gap analysis or demonstrations will be required.
  • CCIIO will share a definitive list of mandatory, regulatory operational and technical deficiencies for Georgia Access that exist as of 7/27/2023. This is critical for the State to be able to close any gaps that may exist and ensure alignment with how other states have met the same requirements. To date, CCIIO has not cited any concrete deficiencies of this nature that would prevent State’s ability to go-live as an SBE for OE 2024.
  • CCIIO will not introduce any new requirements for Georgia’s readiness for OE 2025 that have not already been shared and agreed upon as of 7/27/2023.
  • CCIIO and the IRS will grant a 3-year Authority to Connect (ATC) effective 8/1/2023 based on current compliance with all requirements and readiness.
  • Completed Federal Data Services Hub (FDSH) testing performed in 2023 in preparation for OE 2024 will be accepted as fulfilling the Blueprint requirement for OE 2025.
  • CCIIO will limit any future review and approval of SBE readiness to items specifically under the Exchange’s authority, rather than continue to request that Georgia Access make changes to Medicaid systems, notices, or outreach that are outside the authority of the SBE and CCIIO.

My read of this one is that they're basically saying that the Medicaid Unwinding situation, which is kind of a mess in a lot of other states as well, shouldn't be used as a reason to deny approval of Georgia shifting to a full state-based exchange.

  • CCIIO will provide Georgia a definitive list of federal requirements as they exist today for outreach activities and spending that a State must meet for SBE readiness for OE 2024 and OE 2025. This must include transparency regarding the federal government’s total spend and activities in Georgia specifically for the Exchange outreach for 2022 and 2023 for comparative purposes. It must also include examples from other state’s outreach plans which were granted federal approval and clearly identify how those plans differ from Georgia’s proposed plan and where the gaps are in Georgia’s plans under federal regulations.
  • CCIIO will provide Georgia a definitive list of required regulatory items that CCIIO believes the website was not in compliance with based on the demonstration last provided on 7/24/2023 under 45 CFR 155.205(b) rather than continue to provide feedback based on the personal opinions of staff. This is necessary to ensure Georgia meets regulatory requirements and is held to the same standards as other states, rather than continue to chase a never-ending feedback loop of opinions in which readiness can never be granted.

Finally, we are seeking a significant reduction in the user fee collected by CCIIO for PY 2024 for Georgia Access as an SBE-FP. This is necessary to recoup the significant resource and financial investments made by the State to demonstrate readiness for an SBE for OE 2024. CCIIO has not been transparent from the beginning that it would not grant approval of the SBE based on the timing of the Blueprint submission and the result has been costly to the State.

We can arrange a time in the coming week to discuss the terms of the potential transition.

I obviously have no idea what the actual technical, legal, testing, compliance, etc. status is of any of the above, so I can't really definitively state whether most of Georgia's wish list items are reasonable or not, though most of them sound reasonable to me at face value.

The last one, however, sounds like a long shot to me. They're saying that the state has gone through a tremendous amount of time & effort to make this move and that they should therefore be compensated for the expense they racked up in doing so.

I can't speak for CCIIO, of course, and I have no idea whether they'll agree to doing so...but my problem with this is that no one asked them to go through the effort to begin with.

It was Governor Kemp's administration which tried to pull the plug on any official ACA exchange in the first place, and it was then Gov. Kemp's administration which, when that attempt was shot down, then suprisingly decided to pull a 180 and move to a full SBE instead. Finally, it was the Kemp administration which insisted on making that move in less than a single year instead of going through the normal 2-year, 2-phase process like every other state has done so far.

Again, there's nothing wrong with Georgia moving to a SBE; I honestly hope they do a great job with it...but if they had just gone the standard 2-year route in the first place, their partners/other stakeholders wouldn't have been put in this position.

Anyway, stay tuned...