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Section 1115 Medicaid Demonstration Waivers: A Look at the Current Landscape of Approved and Pending Waivers

Issue Brief
  1. not including family planning or CHIP-only waivers

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  2. Pending waivers include new waivers, waiver extensions/renewals, and waiver amendments. State waiver renewals that do not propose changes and amendments that are technical in nature are excluded from the count of pending waivers. Family planning waivers are excluded with the exception of Texas’ Healthy Women waiver.

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  3. Some states have multiple waivers, and many waivers are comprehensive and may fall into a few different areas.

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  4. Kaiser Commission on Medicaid and the Uninsured, The New Review and Approval Process Rule for Section 1115 Medicaid and CHIP Demonstration Waivers, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2012), http://kff.org/health-reform/fact-sheet/the-new-review-and-approvalprocess-rule/.

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  5. Indiana filed an amendment to its pending extension on May 25, 2017 and Kentucky filed an amendment to its pending application on July 3, 2017. Neither state held a state-level public comment period before submission to CMS. Although the final regulations involving public notice do not require a state-level public comment period for amendments to existing/ongoing demonstrations, CMS has historically applied these regulations to amendments. However, these amendments were not to ongoing demonstrations but to a new waiver request (KY) and extension request (IN).

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  6. Robin Rudowitz, MaryBeth Musumeci, and Alexandra Gates, Medicaid Expansion Waivers: What Will We Learn? (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2016), http://kff.org/medicaid/issue-brief/medicaid-expansion-waivers-what-will-we-learn/.

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  7. Some of these states have Section 1115 waivers that utilize managed care; however, many types of managed care delivery systems could be implemented without waiver authority (although states do need Section 1115 authority to mandate managed care for certain groups including children with special needs, foster care kids, and duals). A number of other states are engaged in delivery system reform efforts outside of this group, through Medicaid initiatives that do not receive funding under Section 1115.

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  8. Centers for Medicare and Medicaid Services (CMS), Medicaid & CHIP Strengthening Coverage, Improving Health, (Baltimore, MD: Centers for Medicare and Medicaid Services, January 2017), https://www.medicaid.gov/medicaid/program-information/downloads/accomplishments-report.pdf.

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  9. DSRIP states: California, Kansas, Massachusetts, New Hampshire, New Jersey, New Mexico, New York, Rhode Island, Texas, and Washington

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  10. Originally, DSRIP initiatives were more narrowly focused on funding for safety net hospitals and often grew out of negotiations between states and HHS over the appropriate way to finance hospital care.

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  11. These principles specifically establish that 1) uncompensated care pool funding should not pay for costs that would be covered in a Medicaid expansion, 2) Medicaid payments should support services provided to Medicaid beneficiaries and low-income uninsured individuals, and 3) provider payment should promote provider participation and access, and should support plans in managing and coordinating care.

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  12. Florida Managed Medical Assistance Program (MMA), Special Terms and Conditions, #11-W-00206/4, approved August 3, 2017, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/fl/fl-medicaid-reform-ca.pdf.

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  13. Under Florida’s LIP, funding was set at $1 billion in SFY 2016 and $608 million in SFY 2017. CMS indicated the new LIP funding amount approved as part of the state’s extension request reflects “the most recent available data on hospitals' charity care costs.” Florida’s LIP funds may be used for health care costs incurred by the state or by providers (hospitals, medical school physician practices, and FQHCs/RHCs) to furnish uncompensated medical care for uninsured low-income individuals up to 200% FPL.

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  14. IN renewal pending

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  15. Pending waivers include new waivers, waiver extensions/renewals, and waiver amendments. State waiver renewals that do not propose changes and amendments that are technical in nature are excluded from the count of pending waivers. Family planning waivers are excluded with the exception of Texas’ Healthy Women waiver.

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  16. IN and WV also note the addition of community-based behavioral health services but do not appear to request or require waiver authority to do so.

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  17. Cost-sharing waiver approved under Section 1916(f), not Section 1115

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  18. MaryBeth Musumeci, Robin Rudowitz, Petry Ubri, and Elizabeth Hinton, An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana, (Washington, DC: Kaiser Family Foundation, January 2017), https://www.kff.org/medicaid/issue-brief/an-early-look-at-medicaid-expansion-waiver-implementation-in-michigan-and-indiana/.

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  19. Natoshia M. Askelson et al., “Iowa’s Medicaid Expansion Promoted Healthy Behaviors But Was Challenging To Implement And Attracted Few Participants,” Health Affairs 36, no. 5 (May 2017): 799-807, http://content.healthaffairs.org/content/36/5/799.abstract.

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  20. Arizona previously sought similar changes, which were denied by the Obama Administration in September, 2016, but state law requires Arizona to request these components annually.

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Appendices
  1. The State Health Access Data Assistance Center (SHADAC) (a program of the Robert Wood Johnson Foundation), Medicaid Block Grants: Lessons from Rhode Island’s Global Waiver, (Minneapolis, MN: The State Health Access Data Assistance Center, June 2013) (citing “Rhode Island also purposefully built a cushion into its fiscal projections and the Global Waiver was much more generous than typical block grant proposals.”), http://www.shadac.org/sites/default/files/publications/RI_Global_Waiver_Brief_FINAL.pdf.

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