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

Appendix A

How Have States Used Section 1115 Demonstration Waivers in the Past?
From Medicaid’s beginning in 1965 through the early 1990s, waivers were small in scope. Beginning in the 1990s, there was an increase in waiver activity, and waivers became broader in scope. General periods of waiver activity are discussed below:

Broad Expansion Waivers (Mid-1990s-2001). In the mid-90s through the early part of this decade most waivers focused on expanding coverage (this was pre-ACA – before statutory authority/federal funds directly authorized for coverage expansion to childless adults). Many began as state efforts to implement broader managed care systems than were permitted under federal law. States used savings from mandatory managed care or redirected disproportionate share hospital (DSH) funds to offset expansion costs, and flush economic times during the mid- to late-90s helped support expansion efforts. Two of the largest waivers approved during this time (Oregon Health Plan and Tenncare) also restructured coverage for existing beneficiaries in ways that were considered very controversial at the time.

HIFA Waivers (2001 Forward). In August 2001, under President Bush, the administration announced the Health Insurance Flexibility and Accountability (HIFA) waiver initiative, which promoted the use of waivers to expand coverage within “current-level” resources and offered states increased flexibility to reduce benefits and charge cost-sharing to offset expansion costs. However, states had limited interest and success in expanding coverage under HIFA, and waivers instead began to increasingly focus on cost control as the nation moved into an economic downturn. Expansions that did move forward under HIFA waivers were generally limited, particularly when compared to the larger expansions of the 1990s.

Reform Waivers (2005 Forward). Beginning in 2005, some broad waivers were approved that restructured Medicaid financing and other key program elements, for example, by setting a global cap on federal funds.1 These waivers stemmed from continued federal emphasis on and interest by some states in controlling and increasing predictability of program costs as well as ideas about reshaping Medicaid to promote personal responsibility and reflect private market trends. However, during this same period, Massachusetts obtained a waiver that provided support for its efforts to provide universal coverage without significantly restructuring its Medicaid program.

Pre-ACA Expansion Waivers (2010-2013). Six states (California, Colorado, the District of Columbia, Minnesota, New Jersey, and Washington) used waivers to expand Medicaid coverage to adults after the enactment of the ACA to prepare for 2014.

Emergency Waivers (periodic over time in response to emergencies). Beyond these themes, waivers have also helped states quickly provide Medicaid support during emergency situations, for example, by enabling a vastly streamlined enrollment process in New York in the wake of the September 11th attacks, and by assisting states in providing temporary Medicaid coverage to certain groups of Hurricane Katrina survivors.

Appendix B

Approved Section 1115 Medicaid Waivers, as of September 2017
Waiver Name Waiver Expiration Date Delivery System Reform BH MLTSS* Other Targeted Populations Medicaid Expansion Work Requirements Eligibility and Enrollment Restrictions Benefit Restrictions, Copays, Healthy Behaviors
Total active, approved waivers: 41 (across 33 states)   16 12 12 16 7 0 7 5
AL Alabama Medicaid Transformation** 3/31/2021 X
AR Arkansas Works 12/31/2021 X X
AR Arkansas’ Tax Equity and Fiscal Responsibility Act (TEFRA-like) 12/31/2017 expands eligibility for children with disabilities
AZ Arizona Health Care Cost Containment System 9/30/2021 X X X X X X
CA California Medi-Cal 2020 12/30/2020 X X X
DE Delaware Diamond State Health Plan 12/31/2018 X X
FL Florida Managed Medical Assistance 06/30/2022 X X
FL Florida MEDS-AD 12/31/2017 expands eligibility for seniors and people with disabilities
HI Hawaii QUEST Integration 12/31/2018 X X
IA Iowa Wellness Plan 12/31/2019 X X X
IN Healthy Indiana Plan (HIP) 2.0 1/31/2018 X X X
IN Indiana End Stage Renal Disease (ESRD) 12/31/2020 expands eligibility for Medicare-enrolled people with ESRD
KS KanCare 12/31/2017 X X X^
MA MassHealth 6/30/2022 X X
MD Maryland Health Choice 12/31/2021 X
ME Maine Section 1115 Demonstration for Individuals with HIV/AIDS 12/31/2017 expands eligibility and provides limited benefit package for people with HIV/AIDS
MI Healthy Michigan 12/31/2018 X X X
MI Flint MI 2/28/2021 expands eligibility and provides additional services to pregnant women & children
MN Minnesota Reform 2020: Pathways to Independence 6/30/2018 expands eligibility for HCBS
MN Minnesota Prepaid Medical Assistance Project Plus 12/31/2020 expands eligibility for one-year-old children
MO Missouri Gateway to Better Health 12/31/2022 expands eligibility and provides limited benefits to nonelderly adults in St. Louis area
MS Healthier Mississippi 9/30/2018 expands eligibility and offers limited benefit package to capped number of seniors and people with disabilities
MT Montana Health Economic Livelihood Partnership (HELP) 12/31/2020 X X
MT Montana Additional Services and Populations 12/31/2017 X
NH New Hampshire Health Protection Program Premium Assistance Demonstration 12/31/2018 X X
NH Building Capacity for Transformation 12/31/2020 X X
NJ New Jersey Comprehensive Waiver 6/30/2022 X X X provides HCBS to targeted groups of people with I/DD
NM Centennial Care 12/31/2018 X X
NV Nevada Comprehensive Care 6/30/2018 provides primary care case management to high-cost/high-need people w/ certain chronic conditions
NY New York Medicaid Redesign Team 3/31/2021 X X X
OK Oklahoma SoonerCare 12/31/2017 expands eligibility to certain populations (working people with disabilities, college students, working foster parents, nonprofit employees), varies benefits and cost-sharing, and authorizes federal funds for primary care case management
OR Oregon Health Plan 6/30/2022 X
RI Rhode Island Comprehensive Demonstration 12/31/2018 X X
TN TennCare II 6/30/2021 X X
TX Texas Healthcare Transformation and Quality Improvement Program 12/31/2017 X X
UT Primary Care Network 12/31/2017 expands eligibility and provides limited benefit package to nonelderly adults
VA Virginia Governor’s Access Plan (GAP) and Addiction and Recovery Treatment Services (ARTS) Demonstration 12/31/2019 X
VT Vermont Global Commitment to Health 12/31/2021 X X
WA Washington Medicaid Transformation Project 12/31/2021 X expands eligibility and offers limited HCBS benefit package targeted to seniors with unpaid family caregivers
WI Badger Care Reform 12/31/2018 expands eligibility and establishes sliding scale premiums for nonelderly adults
WI Wisconsin SeniorCare 12/31/2018 authorizes pharmacy benefits and cost-sharing for seniors
NOTES: “MLTSS” = Managed long-term services and support, “BH” = Behavioral health. Delivery system reform includes states with DSRIP initiatives (CA, KS, MA, NH, NJ, NM, NY, RI, TX, WA), and states that receive federal dollars for other (i.e., non-DSRIP), smaller delivery system reform initiatives (AL, AZ, OR, VT), and states with uncompensated care pools (AZ, CA, FL, KS, MA, NM, TN, and TX). Delivery System Reform does not include/capture states mandating managed care through Section 1115. Medicaid Expansion includes states implementing the ACA Medicaid expansion through alternative models. MLTSS includes only capitated MLTSS. Behavioral health includes states providing enhanced behavioral health services to targeted populations (e.g., SMI or SUD) and/or states implementing initiatives focused on the integration of physical and behavioral health care. Other targeted includes narrow waivers focused on specific populations and/or services. This table does NOT include family planning or CHIP-only waivers. *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. **Alabama is no longer moving forward with this demonstration and is in the process of standing down the demonstration. ^Kansas administers MLTSS through concurrent Section 1115/1915 (c) waivers.

Appendix C

Pending Section 1115 Medicaid Waivers, as of September 2017
Waiver Name New, Amendment, Extension Delivery System Reform BH MLTSS Other Targeted Populations Medicaid Expansion Work Requirements Eligibility and Enrollment Restrictions Benefit Restrictions, Copays, Healthy Behaviors
Total pending waivers: 21 (across 18 states)   3 12 3 3 1 6 8 6
AR Arkansas Works Amendment X X
AZ Arizona Health Care Cost Containment System Amendment X
FL Florida Managed Medical Assistance Amendment X
IA Iowa Wellness Plan Amendment X
IL Illinois Behavioral Health Transformation New X
IN Healthy Indiana Plan (HIP) 2.0 Extension + Amendment X X X
KY Kentucky HEALTH New + Amendment  X X X X X
MA MassHealth Amendment X
ME MaineCare New X X X
MI Michigan Pathway to Integration New X X
MI Michigan Brain Injury Waiver New Would provide specialized rehabilitative services to limited number of adults with brain injuries
MO Missouri Mental Health Crisis Prevention Project New X
NC North Carolina’s Medicaid Reform Demonstration New X X X
RI Rhode Island Comprehensive Demonstration Amendment Would establish pilot program for cortical integrative therapy for brain injuries
TX Texas Healthcare Transformation and Quality Improvement Program Extension X
TX Healthy Women New X X
UT Primary Care Network Extension + Amendment X Would cover limited groups of childless adults X X X
VA Virginia Governor’s Access Plan (GAP) and Addiction and Recovery Treatment Services (ARTS) Demonstration Amendment X
VA Virginia Delivery System Transformation New X X
WI Badger Care Reform Amendment X X X X
WV WV Creating a Continuum of Care for Medicaid Enrollees with SUD New X
NOTES: State waiver renewals that do not propose changes and amendments that are technical in nature are excluded from this table. Family planning waivers are excluded with the exception of Texas’ Healthy Women waiver.
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