Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
This page aggregates tracking information on pending and approved Section 1115 Medicaid waivers. Scroll down or click on the links below to jump to resources such as an overview map and figure, detailed waiver topic tables, and explanatory briefs.
Landscape of Approved vs. Pending Section 1115 Medicaid Demonstration Waivers, June 13, 2019
Tracker contents:
- Detailed Topic Tables:
- Map: All Approved and Pending Waivers by Topic
- State Tables:
- Definitions and Other Notes
- Related Briefs and Resources
1. Populations, exemptions, penalties or consequences, and other details vary significantly by waiver. ME: On December 21, 2018, CMS approved a Section 1115 waiver for Maine that included a work requirement and other eligibility restrictions. On January 22, 2019, the new Governor Janet Mills informed CMS that the state is not accepting the terms of the approved waiver.
2. Other groups such as Transitional Medical Assistance (TMA), family planning only, or former foster care youth, may be included in some states.
3. Arizona requested an exemption from the work requirement for all American Indian/Alaska Native beneficiaries. CMS approved a narrower exemption for only beneficiaries who are members of federally recognized tribes.
4. On March 27, 2019, the court set aside the Arkansas Works waiver amendment, approved by CMS March 5, 2018. Implementation of the work requirement and the reduction of retroactive eligibility from 3 months to 30 days prior to the date of application coverage is stopped unless and until HHS issues a new approval that passes legal muster or prevails on appeal.
5. While Indiana began implementation of the work requirement in 2019, no hours are required in the first 6 months. The phase-in of required hours begins in months 7-9 with a requirement of 5 hours per week.
6. On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect.
7. For non-exempt parents or caretakers whose incomes exceed the eligibility threshold as a result of meeting the work requirement, but who continue to fulfill the requirement, Mississippi would extend Medicaid coverage for a 12-month transitional medical assistance period. These beneficiaries would then qualify for an additional 12 months of coverage contingent upon continued work/community engagement participation.
8. While New Hampshire began implementation of the work requirement on March 1, 2019, beneficiaries who were determined eligible for Medicaid as of March 1 are not required to report work hours or qualify for an exemption until June 2019.
9. SC’s waiver request expands eligibility to parents 67-100% FPL, stating that this expansion would fill the gap between Medicaid and Marketplace premium subsidy eligibility levels and prevent coverage loss under work-related income increases. The pending waiver would also expand eligibility for pregnant and postpartum women and provide a limited coverage expansion for certain childless adults experiencing homelessness, justice system involvement, or need for mental health or SUD treatment. Those in the limited coverage expansion groups would be subject to the work requirement, barring exemption. The work requirement will also apply to the TMA group if SC does not receive requested waiver authority to require enrollment of those individuals in a Marketplace QHP with Medicaid premium assistance. The state indicates that it would average the 80 hour/month requirement by quarter to account for employment that is seasonal or unpredictable.
10. For non-exempt parents or caretakers whose incomes exceed the eligibility threshold as a result of meeting the work requirement, but who continue to fulfill the requirement, South Dakota would extend Medicaid coverage for a 12-month transitional medical benefits (TMB) period. These beneficiaries would then qualify for an additional 12 months of premium assistance (limited to no more than the previous year’s TMB per member per month amount) to pay for employer-sponsored insurance or qualified health plan premiums. Beneficiaries would be responsible for cost sharing and any premium costs exceeding the TMB amount during the premium assistance period.
11. Utah is implementing a Section 1115 waiver, effective April 1, 2019, which will cover childless adults ages 19-64 with income up to 100% FPL and parents/caretakers ages 19-64 with income between 60% FPL up to 100% FPL. The state will not have access to ACA enhanced matching funds. The state may close enrollment for this group if projected costs exceed state appropriations. Non-exempt individuals in this group will be subject to the work requirement. These individuals will be required to complete participation requirements within three months of the demonstration’s approval in order to maintain eligibility for the remainder of their 12-month eligibility period. They must continue to meet such requirements every 12 months to continue to receive Medicaid benefits.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.
Waivers with Eligibility and Enrollment Restrictions:
Approved and Pending as of June 13, 20191
Notes
1. ME: On December 21, 2018, CMS approved a Section 1115 waiver for Maine that included a work requirement and other eligibility restrictions. On January 22, 2019, the new Governor Janet Mills informed CMS that the state is not accepting the terms of the approved waiver.
KY: On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect.
2. “Non-expansion” populations include traditional Medicaid populations (low-income parents, Transitional Medical Assistance, former foster care youth,
medically needy, etc.) but may also refer to narrow/limited populations that gained coverage through the demonstration waiver. For example, WI’s waiver covers childless adults ages 19 to 64 with income up to 100% FPL (without enhanced ACA matching funds). UT is implementing a waiver which will cover childless adults ages 19-64 with income up to 100% FPL and parents/caretakers ages 19-64 with income between 60% FPL and 100% FPL (without enhanced ACA matching funds). UT may close enrollment for this group if projected costs exceed state appropriations.
3. IA: Premiums are waived for the 1st year of enrollment. In later years, premiums are waived if beneficiaries complete specified healthy behavior activities.
4. WI: Waiver covers childless adults ages 19 to 64 with income up to 100% FPL (without enhanced ACA matching funds).
5. NH: NH plans to end QHP premium assistance effective January 1, 2019 and transition beneficiaries to Medicaid MCOs.
6. Six other states (DE, MA, MD, RI, TN, and UT) have retroactive coverage waivers that pre-date the ACA and may have been associated with achieving the budgetary savings necessary to expand coverage before federal law authorized the use of Medicaid funds for childless adults. Some of these waivers apply to limited populations, and most have exceptions for seniors and people with disabilities.
AR: On March 27, 2019, the court set aside the Arkansas Works waiver amendment, approved by CMS March 5, 2018. Implementation of the work requirement and the reduction of retroactive eligibility from 3 months to 30 days prior to the date of application coverage is stopped unless and until HHS issues a new approval that passes legal muster or prevails on appeal.
7. Reasonable promptness waivers allow states to delay the start of coverage until after the 1st premium is paid or after the 60-day payment period expires.
8. SC’s waiver proposes to cap enrollment (with the authority to set the cap at zero) for the newly covered childless adults who are eligible due to homelessness, justice system involvement, or need for mental health or SUD treatment. SC also requests authority to limit coverage for these groups to a maximum of 12 months. In a CMS administrator letter to KS on May 7, 2018, CMS rejected KS’s proposal to impose a lifetime limit on Medicaid benefits for eligible beneficiaries.
9. TX’s pending waiver refers to its “Healthy Women” family planning waiver.
10. Requests to limit expansion eligibility to 100% FPL with the enhanced match in AR, MA, and UT were not approved by CMS. According to Utah state legislation and Medicaid expansion implementation plan, the state anticipates submitting a new waiver amendment (in Spring 2019) requesting full ACA enhanced matching funds for partial Medicaid expansion up to 100% FPL, with a limit on federal funding in the form of a per capita cap.
11. SC’s waiver proposes to cap enrollment (with the authority to set the cap at zero) for the newly covered childless adults who are eligible due to homelessness, justice system involvement, or need for mental health or SUD treatment. Utah is implementing a Section 1115 waiver, effective April 1, 2019, which will cover childless adults ages 19-64 with income up to 100% FPL and parents/caretakers ages 19-64 with income between 60% FPL up to 100% FPL. The state will not have access to ACA enhanced matching funds. The state may close enrollment for this group if projected costs exceed state appropriations. Utah’s enrollment cap was authorized under a reasonable promptness waiver.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.
Waivers with Benefit, Copay, and Healthy Behavior Provisions:
Approved and Pending as of June 13, 20191
Notes
1. On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect.
2. “Non-expansion” populations include traditional Medicaid populations (low-income parents, Transitional Medical Assistance, former foster care youth,
medically needy, etc.) but may also refer to narrow/limited populations that gained coverage through the demonstration waiver. For example, WI’s waiver covers childless adults ages 19 to 64 with income up to 100% FPL (without enhanced ACA matching funds). UT is implementing a waiver which will cover childless adults ages 19-64 with income up to 100% FPL and parents/caretakers ages 19-64 with income between 60% FPL and 100% FPL (without enhanced ACA matching funds). UT may close enrollment for this group if projected costs exceed state appropriations.
3. WI: waiver covers childless adults ages 19 to 64 with income up to 100% FPL (without enhanced ACA matching funds).
4. AR: In the waiver set aside by the court, the NEMT waiver in AR applies to ESI premium assistance enrollees only and is not included in this table.
KY: In the waiver set aside by the court, all NEMT services are waived for the expansion population. In addition to this blanket NEMT waiver for the expansion population, NEMT for methadone services only is waived for both expansion and non-expansion populations.
MA: NEMT waiver would not apply to substance use disorder treatment services.
5. Copays exceeding statutory limits are for non-emergent emergency room (ER) use. KY: In the waiver set aside by the court, charge for non-emergent use of the ER assessed as a deduction from enrollee’s healthy behavior incentive account rather than as a direct fee/copayment.
6. KY: In the waiver set aside by the court, charge for missed appointment assessed as a deduction from enrollee’s healthy behavior incentive account rather than as a direct fee/copayment.
7. OR has an EPSDT waiver as part of its demonstration testing an alternative delivery system model that allows the state to cover treatment services according to a priority list; the OR waiver is not included in this table.
UT: EPSDT treatment services are waived for 19- and 20-year olds who are low-income (traditional) parents, Adult Expansion group (parents & childless adults) and Targeted Adults (childless adults to 5% FPL who are homeless or criminal justice-involved with behavioral health needs).
8. SC: South Carolina’s pending waiver proposes to add additional specifications and qualification requirements for family planning providers.
TX: pending waiver refers to its “Healthy Women” family planning waiver.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.
1. In July 2015, the CMS issued a state Medicaid director letter describing new service delivery opportunities for individuals with substance use disorder under Section 1115. In November 2017, the CMS issued a state Medicaid director letter revising the 2015 guidance.
2. In November 2018, CMS issued new guidance allowing states to obtain Section 1115 waivers of the federal IMD payment exclusion for services for individuals with serious mental health conditions.
VT: Vermont is required to submit a phase-down schedule for their IMD expenditures for individuals residing in an IMD who are there only to receive mental health (MH) treatment.
3. NY: New York’s pending waiver amendment also would move its existing financial eligibility expansion for children with behavioral health and HCBS needs who currently meet an institutional level of care from Section 1915 (c) to Section 1115 authority.
VA: The coverage expansion under the Virginia Governor’s Access Plan (GAP) and Addiction and Recovery Treatment Services (ARTS) Demonstration will be subsumed under Virginia’s Medicaid expansion.
4. MD: While no specific waiver authority is granted, Maryland’s approved waiver commits the state to developing and implementing a physical/behavioral health integration model for individuals with substance use disorders by January 1, 2019 as part of its IMD payment waiver.
MI: Michigan’s integration model currently exists under Section 1915 (b)/(c) authority that the state is seeking to convert to Section 1115.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.
Section 1115 Medicaid Waivers: Approved and Pending as of June 13, 2019
Source: Kaiser Family Foundation, State Health Facts, Approved Section 1115 Medicaid Waivers and Pending Section 1115 Medicaid Waivers, June 13, 2019.
Notes
GENERAL NOTES: “MLTSS” = Managed long-term services and supports, “BH” = Behavioral health. This table does NOT include family planning or CHIP-only waivers. Some states have multiple waivers, and many waivers are comprehensive and may fall into a few different areas. This table does NOT include/capture states mandating managed care through Section 1115 (since waiver authority is not generally required for these initiatives) and does not capture delivery system reform, behavioral health, or LTSS initiatives that do not require Section 1115 expenditure authority/federal funds. For additional details on what is included in each category, see category-specific notes and definitions.
1. On December 21, 2018, CMS approved a Section 1115 waiver for Maine that included a work requirement and other eligibility restrictions. On January 22, 2019, the new Governor Janet Mills informed CMS that the state is not accepting the terms of the approved waiver.
2. On March 27, 2019, the court set aside the Arkansas Works waiver amendment, approved by CMS March 5, 2018. Implementation of the work requirement and the reduction of retroactive eligibility from 3 months to 30 days prior to the date of application coverage is stopped unless and until HHS issues a new approval that passes legal muster or prevails on appeal.
3. Four states (CA, NY, RI & TX) have concurrent Section 1115A authority for financial alignment demonstrations that integrate Medicare and Medicaid benefits for dual eligible beneficiaries in a single health plan.
4. Kansas administers MLTSS through concurrent Section 1115/1915 (c) waivers.
5. On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect.
6. Pennsylvania was granted authority to use Medicaid funds to provide services to adults residing in institutions for mental diseases (IMDs) for short-term acute substance use disorder (SUD) treatment. The state received this authority through an amendment to the state’s only active Section 1115 waiver that specifically targets former foster care youth (FFY) who aged out of foster care while residing in a different state (FFY were previously covered under state plan and due to a change in CMS policy, they have been shifted to coverage under waiver authority). (This waiver tracker does not include/track FFY coverage waivers.) The IMD authority applies to all Medicaid-eligible individuals with SUD (not just former foster care youth).
7. On April 12, 2019, CMS approved a 10-year extension of Wisconsin’s SeniorCare demonstration. SeniorCare is the first non-family planning demonstration and third overall to receive approval for a 10-year extension.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.
Notes
GENERAL NOTES: “MLTSS” = Managed long-term services and supports, “BH” = Behavioral health. This table does NOT include family planning waivers (with the exception of Texas’ Healthy Women waiver) or CHIP-only waivers. Some states have multiple waivers, and many waivers are comprehensive and may fall into a few different areas. Pending waivers include new applications, amendments to existing waivers, and renewal/extension requests. State waiver renewals that do not propose changes and amendments that are technical in nature are excluded. Pending waiver applications are not included in this table until they are officially accepted by CMS and posted on Medicaid.gov. This table does NOT capture states mandating managed care through Section 1115 (since waiver authority is not generally required for these initiatives) and does not capture delivery system reform, behavioral health, or LTSS initiatives that do not require Section 1115 expenditure authority/federal funds. For additional details on what is included in each category, see category-specific notes and definitions.
1. SC’s Community Engagement waiver proposes to cover TMA enrollees using Medicaid as premium assistance to purchase coverage in a Marketplace Qualified Health Plan for up to 24 months instead of providing direct coverage through Medicaid.
SOURCE: KFF analysis of approved and pending waiver applications posted on Medicaid.gov.