The ACA and Medicaid Expansion Waivers
Issue Brief
Kaiser Family Foundation State Health Facts, Status of State Action on the Medicaid Expansion Decision. Data Source: KCMU tracking and analysis of state executive activity (Nov. 2, 2015), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.
Section 1115 waivers are intended to allow for “experimental, pilot, or demonstration projects” that, in the view of the HHS Secretary, “promote the objectives” of the Medicaid program. 42 U.S.C. § 1315(a).
Budget neutrality is established using a cap on federal matching funds over the life of the waiver.
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) https://www.kff.org/health-reform/fact-sheet/the-new-review-and-approval-process-rule/.
Centers for Medicare and Medicaid Services, Healthy Michigan Section 1115 Demonstration, Special Terms and Conditions at p. 5, section III.7.a (Dec. 30, 2013), http://www.michigan.gov/documents/snyder/Healthy_Michigan_1115_Demonstration_Approval_12302013_443466_7.pdf; Centers for Medicare and Medicaid Services, Montana Health and Economic Livelihood Partnership Program Demonstration, Special Terms and Conditions at p. 7-8, section III.14 (Nov. 2, 2015), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mt/mt-HELP-program-ca.pdf.
Report to Congress. The US Department of Health and Human Services’ First Report on Section 1115(a) Demonstrations: Transparency in the Review and Approval of Medicaid and Children’s Health Insurance Program (CHIP) Section 1115 Demonstrations, http://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/downloads/1115-transparency-rtc.pdf.
Arizona administers its entire Medicaid program through a long-standing Section 1115 demonstration waiver, dating back to 1989, that enables Arizona to deliver Medicaid through capitated managed care. Arizona’s present waiver incorporates the ACA’s Medicaid expansion population but does not include any waiver authorities related to the ACA expansion specifically.
Newly eligible adults in Arkansas include childless adults between 0-138% FPL and parents between 17-138% FPL.
Newly eligible adults in New Hampshire include non-working parents from 38-138% FPL, working parents from 47-138% FPL, and childless adults from 0-138% FPL.
As of October, 2014, Iowa beneficiaries from 101-138% FPL were no longer required to enroll in Marketplace premium assistance as a condition of eligibility because one of the two QHPs covering Medicaid beneficiaries was no longer participating. Instead, these beneficiaries could choose to receive coverage through the state’s Medicaid managed care delivery system or enroll in the remaining QHP with premium assistance. Subsequently, the other QHP informed Iowa that it would no longer accept new members. In September, 2015, Iowa submitted a waiver amendment request seeking to require all beneficiaries from 101-138% FPL to enroll in capitated Medicaid managed care as of January, 2016. Iowa also submitted a Section 1915(b) waiver request to expand its capitated managed care system statewide.
Laura Snyder and Robin Rudowitz, Premiums and Cost-Sharing in Medicaid: A Review of Research Findings (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, February 2013), https://www.kff.org/medicaid/issue-brief/premiums-and-cost-sharing-in-medicaid-a-review-of-research-findings/.
Arizona proposes not charging co-payments for preventive or wellness services, services to manage chronic illness, any services (well or sick visit) at PCP or OB/GYN office, specialist services with PCP referral, behavioral health services/people with serious mental illness, or prescription drugs (except for opioids other than for people with cancer or who are terminally ill and brand name drugs unless doctor has determined that generic is ineffective).
42 U.S.C. § § 1396a(a)(8).
Letter from Cindy Mann, Director, CMCS, CMS to Julie Lovelady, Interim Medicaid Director, State of Iowa (Dec. 30, 2014), http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ia/ia-marketplace-choice-plan-ca.pdf.
42 U.S.C. § 1396a(a)(34); 42 C.F.R. § 435.914.
Montana also is expected to amend its other Section 1115 demonstration waiver to implement 12-month continuous eligibility for other populations.
Kaiser Commission on Medicaid and the Uninsured, Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Jan. 2015), available at https://www.kff.org/report-section/modern-era-medicaid-enrollment-and-renewal-processes/.
CMS Special Terms and Conditions, New York Partnership Plan Medicaid Section 1115 Demonstration, No. 11-W-00114/2, at 10 (§ IV. 4) (Sept. 30, 2015), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ny/ny-partnership-plan-ca.pdf.
Letter from Cindy Mann to Thomas Betlach, December 15, 2014. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/az-hccc-ca.pdf
Letter from Marilyn Tavenner, CMS Administrator, to Secretary Beverly Mackereth (Aug. 28, 2014), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/pa/pa-healthy-ca.pdf.
Press release: CMS and Indiana Agree on Medicaid Expansion (Jan. 27, 2015), http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-01-27.html; see also Letter from CMS Administrator Marilyn Tavenner to Medicaid Director Joseph Moser (Jan. 27, 2015), http://www.in.gov/fssa/hip/files/IN_HIP_2.0_CMS_Approval_Ltr_1_27_15.pdf.
Kaiser Commission on Medicaid and the Uninsured, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/; MaryBeth Musumeci. Medicaid Expansion Through Marketplace Premium Assistance (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Sept. 2013), http://www.kff.org/medicaid/fact-sheet/medicaid-expansion-through-marketplace-premium-assistance/.
news release
Also of Interest
- Medicaid Expansion in Arkansas
- Medicaid Expansion in Iowa
- Medicaid Expansion in Michigan
- Medicaid Expansion in Montana
- Medicaid Expansion in New Hampshire
- Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage
- Medicaid Expansion in Indiana
- Proposed Medicaid Expansion in Tennessee
- Proposed Medicaid Expansion in Utah