An Analysis of Georgia's Section 1115 Medicaid Pathways to Coverage Program by Allexa Gardner, Joan Alker, and Leo Cuello Key Findings zz After litigation, Georgia's limited new Medicaid coverage program known as In July 2023, Georgia will "Pathways" authorized by the Trump Administration under Section 1115 waiver begin enrollment into its new authority in 2020, will begin enrollment July 1 with coverage expected to begin in Medicaid Pathways to Coverage September 2023. The Medicaid work reporting requirement will be the only one ("Pathways") program, with in effect in the nation and is the most restrictive Section 1115 approved during coverage expected to begin in the Trump Administration-with no exceptions for caregiving or high child care September 2023. The program costs. This means it is extremely unlikely that many parents will be able to receive would offer coverage to a subset coverage under this approach. The waiver agreement between the federal and state of low-income adults who meet governments notes that 64,000 Georgians are likely to be covered; this equates a work reporting requirement to about 12 to 14 percent of people who would be covered under a full Medicaid and, depending on their income, expansion. pay a monthly premium. Georgia zz Our analysis finds that uninsured low-wage workers in Georgia most commonly will become the only state with work in retail and hospitality, sectors that often have fluctuating work hours a work reporting requirement in which may make it more difficult for workers to comply with the work reporting Medicaid, and one of only two requirement on a monthly basis. Women make up the majority of the low-wage to ever implement such a policy. uninsured workforce in Georgia. Arkansas briefly implemented a work reporting requirement zz Since the initial approval of Pathways in 2020, Congress has approved new federal in 2018, but the program was financing incentives worth an additional $1.1 billion federal dollars for Georgia to halted after 18,000 individuals take up the full Affordable Care Act (ACA) Medicaid expansion, but the state will lost coverage and federal courts not access those funds with its limited approach. This loss of federal funds comes intervened. on top of the financing structure of the Section 1115 waiver agreement whereby Georgia will pay 34 cents on the dollar to cover fewer people rather than 10 cents on the dollar that the state would pay under a regular ACA Medicaid expansion- where the federal government pays 90 percent of the cost. The cost to the state on a per capita basis in the first year of Pathways will be five times higher than the first year of full Medicaid expansion ($2,490 per person versus $496 per person, respectively). zz Implementation of Pathways will begin as the state embarks on the Medicaid continuous coverage "unwinding" process. As pandemic protections are lifted, all states are checking eligibility for those who have been relying on Medicaid for their health coverage. Separately, we have identified Georgia as a state that poses high risks to eligible children inappropriately losing coverage during this process.1 June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 1 Pathways Program and Coverage Requirements Georgia's Pathways program is a limited Medicaid expansion, qualifying activities each month. Additionally, individuals with offering the possibility of coverage to parents and childless incomes at or above 50 percent FPL will have to pay an initial adults with incomes below the poverty line who meet work premium to be enrolled in coverage and then pay monthly reporting requirements and, in some cases, pay a premium. premiums to retain coverage. Premium amounts range from Georgia currently covers parents up to 31 percent of the about 1 to 1.5 percent of household income. federal poverty line (no more than $642 a month for a family The Pathways program also includes federal waivers allowing of three); adults with income above that but below the poverty the state to eliminate the following for people enrolled through line do not qualify for federally subsidized coverage in the the Pathways partial expansion: Marketplace and thus fall into a coverage gap-as do all adults without dependent children in Georgia with incomes zz Non-emergency medical transportation for most below the poverty line. The partial expansion is authorized enrollees; through a section 1115 demonstration; full expansion would zz 90-day retroactive coverage; cover adults below 138 percent of the federal poverty line and zz Wrap-around benefits for individuals receiving would not require a Section 1115 waiver. employer-sponsored insurance; and To become eligible and retain health coverage, individuals zz Hospital presumptive eligibility coverage. must successfully report at least 80 hours of work or other Coverage Estimates and Financing Georgia and the federal Centers for Medicare and Medicaid population – 65.89 percent-rather than the 90 percent match Services (CMS) estimated in 2020 that approximately states receive for full expansion. Federal CMS has stipulated 64,000 people would be enrolled in coverage through the that states cannot receive the enhanced expansion rate for demonstration.2 About 408,000 uninsured Georgians could partial expansions.6 Furthermore, a full expansion would now become eligible if the state implemented partial expansion to entitle Georgia to additional federal funding (pursuant to the 100% FPL without barriers to coverage,3 while full Medicaid American Rescue Plan Act of 2021) during the first two years expansion would cover as many as 447,000 to 536,000 of coverage; CMS has estimated this would be an additional Georgians.4 $1.1 billion dollars for Georgia.7 The lower matching rate for the Pathways program and forfeiting the ARPA dollars means Initial state funding authorized in 2021 was $65.5 million; that the state will be paying significantly more per person subsequently the funding was increased by $52.2 million, covered that it would under a full expansion. In fact, the cost to a total of $153.2 million.5 It is unclear how many people to the state on a per capita basis in the first year of Pathways are budgeted for in these funds, if it includes administrative will be five times higher than the first year of full Medicaid dollars necessary to implement the program, or how the state expansion ($2,490 per person versus $496 per person, would handle additional applicants once the funding limit is respectively).8 reached. Because it is implementing a partial expansion, Georgia will receive its default federal matching rate for covering this June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 2 Coverage Limits, Rules, and Processes To become eligible for Pathways, individuals will be required to exceptions from the work requirement (approximately a month report their 80 hours of work or other qualifying activity hours and half) over a 12-month period. on a monthly basis, including providing documentation (online Most individuals with incomes at or above 50 percent FPL will or in-person) of compliance upon initial application. If the also be required to pay an initial premium within 90 days of their monthly reporting requirement is not documented, individuals eligibility determination or they will not be enrolled.10 Following will be initially suspended from coverage and then terminated enrollment, premiums must be paid on a monthly basis; after after a 90-day suspension period. (See Appendix B.) any two months of missing premium payments, an individual The Georgia Pathways program has no exemptions for will have their coverage suspended and will subsequently be meeting the work reporting requirement, which is unlike disenrolled if premium payments are not made within 90 days any other state that pursued a Medicaid work reporting of suspension. (See Appendix B for a simplified version of requirement. (See Appendix A.) According to the official Pathways eligibility rules.) approval documents, individuals who self-attest to Premiums will be deposited into an individual's "member having a disability will be "considered for a reasonable rewards account," a new account created by the Pathways accommodation," but no other support is provided nor program. Copayments for non-primary care services including accommodations made for other eligibility groups.9 The prescriptions and non-emergent use of the emergency program allows individuals to request temporary exceptions department will be deducted from the account while "rewards" from meeting the work reporting requirement. These for healthy behaviors, like attending annual well visits, will be exceptions include serious illness of the enrollee or immediate credited to these accounts. If an individual accrues a certain family member, birth or adoption of an immediate family amount of healthy behavior credits in their member reward member, or family emergency or other life event. However, account, they can use their account for "bonus" services like an enrollee may only request up to 120 hours of good cause vision and dental benefits and over-the-counter drugs. Impacts on Coverage If the state's assumptions for the Section 1115 agreement Figure 1: Top Industry Sectors for Low-Wage, are accurate, Georgia's Pathways program will cover around Uninsured Non-Elderly Adult Workers in Georgia 64,000 people out of the approximately 447,000 to 536,00 that Industry Share of Low-Wage, could enroll under a full expansion-approximately 12 to 14 Uninsured Workers percent of the population. Retail Trade 18% Accommodation & Food Services Groups that are likely to face barriers to qualifying for (Hospitality) 16% Pathways include: Construction 9% zz Workers Administrative & Support and Waste Management Services 8% The design of Pathways is likely to leave out many workers Manufacturing 8% who are unable to keep up with the monthly reporting Health Care & Social Assistance 8% requirements. The data from the brief Arkansas experience Transportation & Warehousing 7% showed that most people did not know about the work Other Services, Except Public reporting requirement 11 and it was clear that many who Administration 6% should have been exempt were not able to obtain an Professional, Scientific, and Technical exemption.12 Low-wage uninsured workers in Georgia Services 3% disproportionately work in sectors that are less likely Educational Services 3% to offer employment insurance or paid leave benefits, Workers with no occupation are not listed. specifically in retail, hospitality, or construction industries Source: Georgetown University Center for Children and Families analysis of US Census Bureau American Community Survey (ACS) 2021 Public Use Microdata (see Figure 1).13 Sample (PUMS). June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 3 These individuals are also more likely to have fluctuating work hours and informal work arrangements, making work Potential Georgia barriers to reporting very difficult. In addition, research finds that the enrollment for parents in Pathways majority of Medicaid adults are already working without a work zz Child care availability requirement in place; those that are not working have barriers Forty-four percent of people in Georgia to work such as caregiving responsibilities, illness, or school live in a child care desert. The lack of child attendance.14 care is especially prevalent among families zz Parents living in rural areas and in the lowest-income neighborhoods.16 Many parents will likely remain uninsured under the Pathways program especially parents of babies and toddlers who are zz Child care costs preschool age because they are unlikely to be able to meet the The cost of child care in Georgia ranges from program requirements. Barriers such as the lack of affordable around $6,500 to $8,900 depending on a child care are not addressed by the proposal. Georgia's child's age or type of facility,17 which is up to 32 Medicaid program currently provides coverage only to parents percent of the annual income of a parent at 50 with incomes at or below 31 percent FPL ($642 per month for percent of the poverty line. a family of three). Analysis of work reporting requirements in the 19 states that were approved for or developed a formal zz Inadequate parental leave policies proposal for the policy finds that Georgia is the only state to Many low-wage workers are employed in jobs propose a work reporting requirement without any exemption that lack sick or parental leave. Without these for parents with dependent children (See Appendix A). Child policies, parents may put their jobs at risk or care services are unaffordable for many low-income families,15 at least lose hours needed to meet the work so many parents will be unable meet the requirements requirement if their child is sick, has a day off for Georgia's new program due to the lack of child care from school, or needs to stay home for any accommodations or exemptions. reason. zz Populations experiencing obstacles to work zz Difficulties reporting qualifying activities and/or reporting Parents may have trouble providing Other groups may face similar barriers to enroll. The Pathways documentation for certain activities like program does make some accommodations for people with community service or reporting compliance in disabilities; however, it is unclear if these will be sufficient. general. Many people may also not be identified for accommodation, thus blocking enrollment. The proposal designs in Arkansas and New Hampshire both included exemptions for people with disabilities and people in treatment for mental health and/ or substance use disorders, and yet those individuals were often not identified.18 The program's good cause exemption is not available to new applicants, so those with disabilities that prohibit compliance with the work reporting requirement would not be eligible for initial enrollment. For those who are enrolled in coverage, the temporary exception limit of a month and a half may not be long enough to address their life event (such as an injury or natural disaster). Some other groups, such as students, individuals in job training, or those doing community service, chould meet the qualifying criteria and be eligible, but may have difficulties documenting compliance, making them vulnerable to denial or termination. June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 4 Conclusion: Issues to Monitor Going Forward Will unemployment rates go up or down? XX There is uncertainty as to how Pathways will affect employment if at all. While Medicaid expansion has been shown to support work,19 Medicaid work requirements, on the other hand, had minimal to no effect on employment-and possibly increased unemployment for those who lost access to health care services needed to support their ability to work.20 Previous studies on work requirements in other programs (such as TANF) have found negligible evidence of lasting increases in employment.21 How many people will get coverage and for how long? XX Low wage workers with Medicaid coverage often experience temporary changes in income that result in moving on and off coverage within short periods of time. Pathways enrollees could experience even greater coverage disruptions- individuals with fluctuating work hours or gaps in monthly work reporting may repeatedly cycle on and off coverage, suspension, and termination. In addition, the complex rules of the Pathways design (see Appendix B flowchart), may lead to more confusion and coverage instability. It will be important to monitor who is getting coverage and whether parents- especially those with preschool age children-are able to enroll at all. What are the cost implications for the state of Pathways structure? XX The cost effectiveness of Pathways will need to be closely monitored-including both administrative costs given its complex structure, and coverage costs-especially how much the state is paying per beneficiary-given the lower match rate in the Section 1115 agreement and the state's ineligibility for additional ARPA funds. Acknowledgments This brief was written by Allexa Gardner, Joan Alker, and Leo Cuello The authors would like to thank Laura Harker of the Center on Budget and Policy Priorities and Catherine Hope for comments on the draft. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center based at the McCourt School of Public Policy. CCF conducts research, analyzes data, develops strategies, and offers solutions to improve the health of America's children and families, particularly those with low and moderate incomes. June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 5 Appendix A: State Exemptions to Proposed Medicaid Work Requirements * Note: None of these work requirements are currently in effect. State Exemptions Alabama zz anyone who is a single custodial parent of a child age 12 months or younger; Alabama Medicaid Workforce Initiative zz anyone who is a single custodial parent caring for a child under the age of 6 for whom appropriate childcare is not available; zz anyone required to care for a disabled child or adult Arizona zz a designated caretaker of a child under age 18, or of a child who is 18 and is a full-time AZ AHCCCS Works student in high school or trade school and is expected to graduate before he/she turns 19, with a limit of 1 designated caregiver per child Arkansas zz beneficiary lives in a home with his or her minor dependent child age 17 or younger Arkansas Works Idaho zz a parent or caretaker providing for a dependent under age 18 or persons with a serious Medicaid Reform medical condition Indiana zz beneficiaries who are a primary caregiver of a dependent child under age 13 or a Healthy Indiana 2.0 disabled dependent, including kinship caregivers of abused or neglected children; Kentucky zz primary caregivers of a dependent, including either a dependent minor child or an adult Kentucky HEALTH who is disabled (limited to only one exempt beneficiary per household) Michigan zz a caretaker of a family member under 6 years of age (only one parent at a time can claim Healthy Michigan Plan this exemption); zz a caretaker of a dependent with a disability who needs full-time care based on a licensed medical professional's order (this exemption is allowed one enrollee per household) Mississippi zz the beneficiary is the primary caregiver for: a child under the age of 6 years; a person Mississippi Medicaid Workforce Training diagnosed with a mental illness; a disabled family member Initiative Montana zz a primary caregiver for a person who is unable to provide self-care; HELP Section 1115 Demonstration zz a foster parent Amendment and Extension Nebraska zz individuals who are: a parent, caretaker relative, guardian, or conservator of dependent Heritage Health Adult child; or, a parent, caretaker relative, guardian, or conservator responsible for the care of an elderly or disabled relative (and who are providing care to these individuals in the home) New Hampshire zz beneficiaries who are a parent or caretaker where care of a dependent is considered New Hampshire Granite Advantage Health necessary by a licensed provider; Care Program zz beneficiaries who are a custodial parent or caretaker of a dependent child under 6 years of age (only applies to one parent or caretaker in case of a 2-parent household); zz beneficiaries who are a parent or caretaker of a dependent child of any age with a disability (only applies to one parent or caretaker in the case of a 2-parent household) Ohio zz parent/caretaker/individual residing in same Medicaid household with minor child Ohio Group VIII Work Requirement and (defined as a child under age 19); Community Engagement Section 1115 zz caring for a disabled/incapacitated household member Demonstration Waiver Oklahoma zz a parent or caretaker responsible for the care of a dependent child under the age of 6; Oklahoma SoonerCare zz a parent or caretaker personally responsible for the care of an incapacitated person (as attested to by a Medical or Mental health provider) South Carolina zz primary caregiver of a child, up to age 18, and/or disabled adult South Carolina Medicaid Community Engagement June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 6 State Exemptions South Dakota zz parents of dependent children under one year old living in the parent's residence; South Dakota Career Connector zz primary caregivers of elderly or disabled individuals living in the caretaker's residence Tennessee zz individuals who are the primary caregiver of a child younger than 6 years of age (one TennCare III exemption per household); zz individuals who are providing caregiver services for a household member (child or adult) with a disability or incapacitation, or with a medical frailty that prevents the caretaker from fulfilling the community engagement requirement Utah zz parentsor other members of households with the responsibility of a dependent child Primary Care Network 1115 Demonstration under age 6; Waiver (June 2018 Amendment) zz responsiblefor the care of a person with a disability as defined by the ADA, section 504 of the Rehabilitation Act, or section 1557 of the Patient Protection and Affordable Care Act Virginia zz primary caregiver for a dependent child under age 19 Virginia GAP and ARTS Wisconsin zz the member is a primary caregiver for a person who cannot care for himself or herself Wisconsin BadgerCare Reform June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 7 Appendix B: Pathways to Pathways Coverage Do you have income at or Yes No below 100% FPL? Are you Not Eligible for No currently working? Coverage Yes No Do you have income at or Did you pay above 100% FPL? your initial premium? No Yes Enrolled in Coverage Have you completed 80 hours Yes of work or qualified activities No per month AND reported compliance to the state? Have you paid Suspended/Disenrolled No your monthly premium? from Coverage Have income below Yes 50% FPL Maintain Coverage June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 8 Endnotes 1 Joan Alker and Tricia Brooks, "Millions of Children May Lose Medicaid: 13 Jennifer Wagner and Jessica Schubel, "States' Experiences Confirm What Can Be Done to Prevent Them From Becoming Uninsured" Harmful Effects of Medicaid Work Requirements" (Center on Budget and Georgetown University Center for Children and Families, February 17, Policy Priorities, November 18, 2020), available at https://www.cbpp.org/ 2022), available at https://ccf.georgetown.edu/2022/02/17/millions-of- research/health/states-experiences-confirm-harmful-effects-of-medicaid- children-may-lose-medicaid-what-can-be-done-to-help-prevent-them- work-requirements. from-becoming-uninsured/. 13 United States Census Bureau, "Public Coverage Increased for All 2 Center for Medicare and Medicaid Services, "Georgia Pathways to Workers, Private Coverage Declined for Full-Time, Year-Round Workers," Coverage Approval Letter & Standard Terms and Conditions," October September 13, 2022, available at https://www.census.gov/library/ 15, 2020, available at https://www.medicaid.gov/Medicaid-CHIP- stories/2022/09/private-health-coverage-declines-for-full-time-workers. Program-Information/By-Topics/Waivers/1115/downloads/ga/ga- html; U.S. Bureau of Labor Statistics, "Table 6. Selected paid leave pathways-to-coverage-ca.pdf. benefits: Access, March 2022," available at https://www.bls.gov/news. release/ebs2.t06.htm. 3 Georgia Department of Community Health, "Waiver Project: Georgia Environmental Scan Report," July 8, 2019, available at https://medicaid. 14 Madeline Guth, et al., "Understanding the Intersection of Medicaid georgia.gov/document/publication/georgia-environmental-scan-report- & Work: A Look at What the Data Say" (Kaiser Family Foundation, posted-71819/download. April 24, 2023), available at https://www.kff.org/medicaid/issue-brief/ understanding-the-intersection-of-medicaid-work-a-look-at-what-the- 4 Georgia Department of Audits and Accounts, Fiscal Note: House Bill data-say/. (LC 26 0015), January 18, 2019, available at https://www.google.com/ url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHla3I 15 Gina Adams, et al., "Child Care Challenges for Medicaid Work 3Y7_AhWfF1kFHWSDArIQFnoECBcQAQ&url=https%3A%2F%2Fopb. Requirements" (Urban institute, September 2019), available at https:// georgia.gov%2Fdocument%2Ffiscal-notes-2019-health-and-human- www.urban.org/sites/default/files/publication/101094/medicaid_work_ services%2Flc-46-0015-hb-37%2Fdownload&usg=AOvVaw20q6mDuKm reqs_child_care_0.pdf; ChildCare Aware of America, "Appendices: qd-nPrPO6AU3T. Demanding Change: Repairing our Child Care System,"available at https://info.childcareaware.org/hubfs/Demanding%20Change%20 5 FY 2024 Conference Committee Bill (HB 19), March 29, 2023, available Appendices.pdf?utm_campaign=Budget%20Reconciliation%20Fall%20 at https://www.legis.ga.gov/api/document/docs/default-source/house- 2021&utm_source=website&utm_content=22_demandingchange_ budget-and-research-office-document-library/2024_fiscal_year/fy_2024_ append. conference_committee_bill_(hb_19).pdf?sfvrsn=a6423ac9_2#page=66. 16 Center for American Progress, "Child Care Access in Georgia," 6 Letter from CMS Administrator Seema Verma to Utah Governor, August available at https://childcaredeserts.org/2018/?state=GA&urbanicity=Ru 16, 2019, available at https://www.medicaid.gov/Medicaid-CHIP- ral. Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita- cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf. 17 ChildCare Aware of America, "Demanding Change: Repairing Our Child Care System,"available at https://info.childcareaware. 7 CMS, All-State Medicaid & CHIP Call, March 30, 2021, available org/hubfs/Demanding%20Change%20Appendices.pdf?utm_ at https://www.medicaid.gov/state-resource-center/downloads/ campaign=Budget%20Reconciliation%20Fall%202021&utm_ allstatecall-20210330.pdf. source=website&utm_content=22_demandingchange_append. 8 Leah Chan, "Money Matters: Comparing the Costs of Full Medicaid 18 MaryBeth Musumeci, "Disability and Technical Issues Were Key Barriers Expansion to the Pathways to Coverage Program" (Georgia Budget to Meeting Arkansas' Medicaid Work and Reporting Requirements in and Policy Institute, January 11, 2023), available at https://gbpi.org/ 2018" (Kaiser Family Foundation, June 11, 2019), available at https:// money-matters-comparing-the-costs-of-full-medicaid-expansion-to-the- www.kff.org/medicaid/issue-brief/disability-and-technical-issues- pathways-to-coverage-program/. were-key-barriers-to-meeting-arkansas-medicaid-work-and-reporting- 9 CMS Pathways Approval, op. cit. requirements-in-2018/; Wagner and Schubel, op. cit. 10 The two groups exempted from premiums are: Beneficiaries with 19 The Ohio Department of Medicaid, "2018 Ohio Medicaid Group employer-sponsored insurance enrolled in HIPP and some beneficiaries VIII Assessment: A Follow-Up to the 2016 Ohio Medicaid Group VIII enrolled in (or recently graduating from) vocational education programs of Assessment," August 2018, available at https://medicaid.ohio.gov/static/ highly sought-after trades. Resources/Reports/Annual/Group-VIII-Final-Report.pdf. 11 Benjamin D. Sommers, et al., "Medicaid Work Requirements – Results 20 Benjamin Sommers, et al., "Medicaid Work Requirements In Arkansas: from the First Year in Arkansas," The New England Journal of Medicine, Two-Year Impacts on Coverage, Employment, and Affordability of Care," June 18, 2019, available at https://static.politico.com/8d/24/6ef0e361444 Health Affairs (Vol. 39, No. 9), September 2020, available at https:// bb034aabc884b2606/sommers-arworks.pdf; MaryBeth Musumeci, et al., www-healthaffairs-org.proxy.library.georgetown.edu/doi/full/10.1377/ "Medicaid Work Requirements in Arkansas: Experience and Perspectives hlthaff.2020.00538. of Enrollees" (Kaiser Family Foundation, December 2018), available at 21 LaDonna Pavetti, "TANF Studies Show Work Requirements Proposals https://files.kff.org/attachment/Issue-Brief-Medicaid-Work-Requirements- for Other Programs Would Harm Millions, Do Little to Increase Work" in-Arkansas-Experience-and-Perspectives-of-Enrollees; Ian Hill, et al., (Center on Budget and Policy Priorities, November 13, 2018), available at "New Hampshire's Experience with Medicaid Work Requirements" (Urban https://www.cbpp.org/sites/default/files/atoms/files/11-13-18tanf.pdf. Institute, February 2020), available at https://www.urban.org/sites/default/ files/publication/101657/new_hampshires_experience_with_medicaid_ work_requirements_v2_0_7.pdf. June 2023 CCF.GEORGETOWN.EDU georgia's section 1115 medicaid pathways to coverage program 9