Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending, and Program Policies

Molly O'Malley Watts, MaryBeth Musumeci, and Petry Ubri
Published: Jan 31, 2017

Appendix Table 1: Key Provisions in § 1115 Capitated MLTSS Waivers, as of December, 2016
State	Initial § 1115 MLTSS Approval	Current Waiver Expires	Populations Covered				Duals Included	Level of Care		Statewide	Mandatory Enrollment	Services Included
State	Initial § 1115 MLTSS Approval	Current Waiver Expires	Seniors	Phys. Dis.	I/DD	Serious Mental Illness	Duals Included	Instit.	At Risk of Instit.	Statewide	Mandatory Enrollment	Instit.	HCBS	Physical health	Behav. health
AZ	1989	9/30/21	X	X	X		Yes	X	X	Yes	Yes	X	X	X	X
CA	2014	12/31/20	X	X			Yes	X		No	Yes	X	X	X	X
DE	2012	12/31/18	X	X			Yes	X	X	Yes	Yes	X	X	X	some
HI	2008	12/31/18	X	X			Yes	X	X	Yes	Yes	X	X	X	some
NJ	2012 (enrollment effective July 2014)	6/30/17	X	X			Yes	X		Yes	Yes	X	X	X	X
NM	2014	12/31/18	X	X			Yes	X		Yes	Yes	X	X	X	X
NY	2012	11/15/16	X	X	X	X	Yes	X		Yes	Some	X	X	some	some
RI	2013	12/31/18	X	X	X		Yes	X	X	Yes	No	X	X	X	X
TN	2009 (enrollment effective March 2010)	11/30/16	X	X	X		Yes	X	X	Yes	Yes	X	X	X	X
TX	2011	12/31/17	X	X			Yes	X		Yes	Yes	X	X	X	X
VT	2005	12/31/21	X	X	X	X	Yes	X	X	Yes	Yes	X	X	X	X
NOTES: Table omits KS, which has joint § 1115/1915 (c) waivers, and NC and VA, which have capitated MLTSS § 1115 applications pending with CMS. AZ: limits at-risk services to those who no longer meet institutional level of care at renewal; uses state entity to serve people with I/DD. CA: includes Medicaid state plan HCBS, in-home supportive services, community-based adult services, multipurpose senior services, and NF services but not other § 1915 (c) waiver HCBS. DE: also includes those with HIV/AIDS, TEFRA children, and working people with disabilities buy-in; limited number of MCO behavioral health visits with remainder FFS. HI: MCOs provide standard behavioral health services, with separate managed care carve out for specialized behavioral health services. NJ: also includes people with TBI and AIDS; MLTSS enrollment for those in NFs limited to those eligible for Medicaid after July 1, 2014. NM: also includes working people with disabilities buy-in, people with HIV/AIDS and those who are medically fragile; previously offered MLTSS to duals and those requiring NF LOC through a § 1915 (b)/(c) waiver that was converted to § 1115; § 1115 waiver also phased in HCBS from § 1915 (c) waivers for self-direction, AIDS, and medically fragile populationsBShCB over 6 months, beginning Jan. 2016. NY: managed LTC plans provide limited Medicaid state plan benefits including institutional and HCBS for beneficiaries who need more than 120 days of LTSS, with other services provided FFS; people with SMI included as of Aug. 2015, and may enroll in specialized MCOs providing mainstream Medicaid managed care benefits and BH HCBS, which are non-risk for 1^st 2 years; people with I/DD enrolled as of 2016; seeking waiver extension through Dec. 2019. RI: also includes adults ages 19 to 21 with significant disabilities below 250% FPL who aged out of TEFRA coverage, need services, and are otherwise ineligible. TN: MLTSS enrollment was statewide as of Aug. 2010; MLTSS enrollment for people with I/DD receiving HCBS is as of 2016 and limited to new Medicaid applicants – those receiving HCBS through § 1915 (c) I/DD waivers remain there, but those waivers are closed to new enrollment; ICF/DD services are FFS; seeking 5-year waiver extension. TX: MLTSS began in 1998 under a § 1915(b)/(c) waiver, which was converted to § 1115; MLTSS expanded statewide as of Sept. 2014; all NF services added to MCO benefit package as of March 2015; mandatory MLTSS enrollment for children with disabilities in STAR KIDS as of Nov. 1, 2016; seeking 5-year waiver extension. VT: state entity operates as a non-risk-bearing PIHP; I/DD population included as of 2015; also includes people with TBI. SOURCE: KFF analysis of waiver special terms and conditions.

Appendix Table 2: Provisions That May Affect Access to HCBS in § 1115 Capitated MLTSS Waivers, 2015
State	Same Income Limit for HCBS and NF	Higher Asset Limit for HCBS than NF	Provide HCBS to Those At Risk of Instit.	Financial Incentives to Encourage Health Plan Use of HCBS	Benefit Package Includes HCBS and NF	Offers Self-Direction	Allows Payments to Family Caregivers	HCBS Utilization Controls	Requires Health Plan Nursing Facility Diversion Program
AZ	X		X	X	X	X	X	X	X
CA				X	X	X		X
DE			X	X	X	X
HI			X	X	X	X			X
NJ	X			X	X	X		X	X
NM	X				X	X		X
NY				X	X	X
RI	X	X	X		X	X			X
TN	X		X	X	X	X		X	X
TX	X				X	X		X
VT	X	X	X		X	X	X
TOTAL	7 states	2 states	6 states	7 states	11 states	11 states	2 states	6 states	5 states
NOTES: NJ eliminates the 5-year asset transfer look-back period for LTSS applicants at or below 100% FPL. RI allows access to a limited HCBS benefit package for 90 days via self-attestation of financial eligibility. NY’s health plan benefit package has limited Medicaid state plan benefits, including LTSS. TN allows payments to family caregivers for beneficiaries with I/DD as of 2016. Utilization controls include maximum cost and/or maximum hours per beneficiary. VT does not use private health plans and instead delivers MLTSS through a state entity. SOURCE: KFF survey of § 1115 Medicaid MLTSS waivers (2016).

Appendix Table 3: Beneficiary Protections in § 1115 Capitated MLTSS Waivers, 2015
State	Independent Enrollment Options Counseling	Change Plans Outside Open Enrollment	LTSS Quality Measures	Health Plan Advisory Committee	State-Level Advisory Committee	Ombudsman Program
AZ		X	X	X
CA	X	X	X			X
DE	X	X			X	X
HI	X	X	X			X
NJ	X	X	X	X	X
NM	X	X	X	X	X	X
NY	X	X	X		X	X
RI	X		X
TN	X	X	X	X		X
TX	X	X	X	X	X	X
VT	N/A		X			X
TOTAL	9 states	9 states	10 states	5 states	5 states	8 states
NOTES: TN and AZ allow plan changes outside open enrollment based on hardship or to ensure continuity of care; other states allow changes if an LTSS provider leaves the plan network. LTSS quality measures include those related to rebalancing and/or quality of life. SOURCE: KFF survey of § 1115 Medicaid MLTSS waivers (2016).

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