Filling the need for trusted information on national health issues…

Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers

Issue Brief
  1. “About Section 1115 Demonstrations,” CMS, accessed December 6, 2017, https://www.medicaid.gov/medicaid/section-1115-demo/about-1115/index.html.

    ← Return to text

  2. Not including family planning or CHIP-only waivers.

    ← Return to text

  3. 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.

    ← Return to text

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

    ← Return to text

  5. This CMCS Information Bulletin also outlines changes to the “fast track” federal review process for Section 1115 waiver extension requests, removing the requirement that states must have at least one full extension cycle without “substantial program changes” before they are eligible to be considered for the “fast track” review process. (The “fast track” process was designed to expedite the federal review of certain Section 1115 waiver extensions requests that meet specified criteria.)

    ← Return to text

  6. On December 28, 2017, CMS approved the Mississippi Family Planning Medicaid Waiver extension for a 10-year period. Mississippi is the first state to receive a 10-year Section 1115 waiver extension under the new policy.

    ← Return to text

  7. 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/.

    ← Return to text

  8. 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).

    ← Return to text

  9. However, CMS recently relieved Montana from the requirement to evaluate its expansion waiver based on its participation in a cross-state federal evaluation.

    ← Return to text

  10. 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/.

    ← Return to text

  11. The November 6, 2017 CMCS Information Bulletin (found at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib110617-2.pdf) on Section 1115 demonstration process improvements also signaled CMS’s interest in moving toward reducing the frequency of reporting required for states to semi-annually or annually for certain demonstrations.

    ← Return to text

  12. CMS’s August 2017 renewal of Florida’s Managed Medical Assistance Section 1115 waiver allows the state to submit annual reports (and semi-annual reports at CMS’s request) instead of quarterly reports.

    ← Return to text

  13. State waiver renewals that do not propose changes and amendments that are technical in nature are also excluded from the count of pending waivers.

    ← Return to text

  14. The previous Administration issued policy guidance, consistent with its legal interpretation of the ACA, indicating that states cannot receive enhanced federal ACA expansion funding unless they cover all newly eligible adults through 138% FPL.

    ← Return to text

  15. Arkansas requested authority for a partial expansion to 100% of the FPL using the ACA enhanced match in its June 2017 amendment request to CMS. The amendment was approved on March 5, 2018, however, CMS did not make a decision on the state’s partial expansion request.

    ← Return to text

  16. More details about curing eligibility suspensions due to non-compliance with work requirements can be found in work requirement sections of appendix tables in Kentucky and Indiana waiver summaries.

    ← Return to text

  17. CMS does not consider the assessed fee for non-emergency use (operationalized as a deduction from beneficiary incentive accounts) of the emergency room to be a copayment, deduction, or similar charge under 42 U.S.C. §§ 1396o and 1396o-1, which carry certain other requirements and preconditions.

    ← Return to text

  18. Cost-sharing waivers are subject to Section 1916 (f), not Section 1115.

    ← Return to text

  19. 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/.

    ← Return to text

  20. 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.

    ← Return to text

  21. Under the previous administration, CMS denied Iowa and Indiana’s requests to waive the provision of EPSDT services for newly eligible 19- and 20-year-olds. Oregon 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.

    ← Return to text

  22. 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.

    ← Return to text

  23. 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.

    ← Return to text

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

    ← Return to text

  25. 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.

    ← Return to text

  26. Texas Healthcare Transformation and Quality Improvement Program, Special Terms and Conditions, # 11-W-00278/6, approved January 1, 2018 through September 30, 2022, https://hhs.texas.gov/sites/default/files//documents/laws-regulations/policies-rules/1115-waiver/waiver-renewal/1115renewal-cmsletter.pdf.

    ← Return to text

  27. 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.

    ← Return to text

  28. 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.

    ← Return to text

  29. 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 federally qualified health centers (FQHCs)/rural health centers (RHCs)) to furnish uncompensated medical care for uninsured low-income individuals up to 200% FPL.

    ← Return to text

  30. Texas Healthcare Transformation and Quality Improvement Program, Special Terms and Conditions, # 11-W-00278/6, approved January 1, 2018 through September 30, 2022, https://hhs.texas.gov/sites/default/files//documents/laws-regulations/policies-rules/1115-waiver/waiver-renewal/1115renewal-cmsletter.pdf.

    ← Return to text

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.

    ← Return to text

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.