Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers?
These states are using (or seek to use) Section 1115 authority to: use Medicaid funds to pay for inpatient substance use and/or mental health services for nonelderly adults in “institutions for mental disease” (IMDs); fund other behavioral health or supportive services for people with behavioral health needs (such as supportive housing, supported employment, peer supports, and/or community-based mental health or SUD treatment services); expand Medicaid eligibility to cover additional people with behavioral health needs who are otherwise uninsured; or request waiver funding for delivery system reform initiatives (such as physical/behavioral health integration, value-based purchasing, and workforce development initiatives).
CMS Guidance: In July 2015, the CMS issued a state Medicaid director letter describing new service delivery opportunities for individuals with substance use disorder under Section 1115. In November 2017, the CMS issued a state Medicaid director letter revising the 2015 guidance.
These states are implementing (or seeking approval to implement) the ACA Medicaid expansion through alternative models that differ from federal law. Expansion waivers typically include eligibility and enrollment restrictions for the ACA expansion population (see “Eligibility and Enrollment Restrictions”).
These states are implementing (or are seeking approval to implement) waivers that would require work as a condition of eligibility, for most ACA expansion adults and/or traditional populations. Note: States do not need Section 1115 waiver authority to implement voluntary work referral programs.
CMS Guidance: On March 14, 2017, the CMS sent a letter to state governors that signaled a willingness to use Section 1115 authority to “support innovative approaches to increase employment and community engagement.” On January 11, 2018, CMS posted new guidance for state Section 1115 proposals to condition Medicaid on meeting a work requirement. On June 29, 2018, the DC federal district court issued a decision in Stewart v. Azar. The court invalidated the waiver approval and sent it back to HHS to reconsider the Kentucky HEALTH Section 1115 waiver program.
Eligibility and Enrollment Restrictions
These states are implementing (or are seeking approval to implement) certain eligibility and enrollment restrictions as part of ACA Medicaid expansion waivers or for traditional populations. Provisions approved by CMS to date include: charging premiums beyond what is allowed under federal law (invalidated by court in KY); eliminating retroactive eligibility (invalidated by court in KY); making coverage effective on the date of the first premium payment (instead of the date of application) (invalidated by court in KY); disenrollment and lock-out for unpaid premiums (invalidated by court in KY); imposing a lock-out for failure to timely renew eligibility and/or lock-out for failure to timely report a change in circumstance that would affect eligibility (invalidated by court in KY); and imposing a tobacco premium surcharge. Provisions in pending waivers not approved by CMS to date include: eliminating hospital presumptive eligibility; requiring asset tests for poverty-related eligibility pathways; waiving MAGI requirements; requiring drug screening and testing; and imposing time limits on coverage. In a CMS administrator letter to Kansas on May 7, 2018, CMS rejected Kansas’ proposal to impose a lifetime limit on Medicaid benefits for eligible beneficiaries. Requests to limit expansion eligibility to 100% FPL with the enhanced match in Arkansas and Massachusetts were not approved by CMS.
Benefit Restrictions, Copays, and Healthy Behaviors
These states are implementing (or seeking approval to implement) certain service-use related waiver provisions as part of ACA expansion waivers or for traditional populations including: eliminating non-emergency medical transportation (NEMT) (invalidated by court in KY), implementing healthy behavior incentives (tied to premium or cost sharing reductions) (invalidated by court in KY), and charging copays in excess of the federal maximum for non-emergent use of the emergency room (invalidated by court in KY).
These states are using (or seek to use) Section 1115 waivers to authorize the delivery of Medicaid long- term services and supports (MLTSS) through capitated managed care. These states need waiver authority to require seniors and people with disabilities to enroll in managed care, and most are choosing to use Section 1115 waivers instead of separate Section 1915 (c) waivers to authorize home and community-based services.
These states operate (or seek to operate) Section 1115 waivers that affect targeted populations (e.g., persons with HIV/AIDS, seniors and people with disabilities, uninsured nonelderly adults in non-expansion states). These targeted waivers may provide limited benefit coverage and/or include cost-sharing. “Other Targeted” waivers for seniors and people with disabilities may include eligibility and/or acute care benefits and/or FFS home and community-based services (HCBS) expansions. (States implementing (or seeking to implement) capitated HCBS under Section 1115 authority are captured under “MLTSS.”) “Other Targeted” does NOT include family planning waivers (with the exception of Texas’ Healthy Women waiver).
Delivery System Reform
These states are using (or seek to use) Section 1115 waiver authority to use federal Medicaid funding on delivery system reforms that otherwise would not be available under current law. This includes states using Section 1115 waivers to: implement Delivery System Reform Incentive Payment (DSRIP) initiatives, to invest in delivery system reform initiatives other than DSRIP, and to operate Uncompensated Care Pools (also called “Low Income Pools” in some states).
Some states have multiple waivers, and many waivers are comprehensive and may fall into a few different areas. Pending waivers include new applications, amendments to existing waivers, and renewal/extension requests. State waiver renewals that do not propose changes and amendments that are technical in nature are excluded from this tracker and the accompanying tables. This map/table does NOT include/capture states mandating managed care through Section 1115 (since waiver authority is not generally required for these initiatives) and does not capture delivery system reform, behavioral health, or LTSS initiatives that do not require Section 1115 expenditure authority/federal funds. Pending waiver applications are not included in this tracker until they are officially accepted by CMS and posted on Medicaid.gov.Which States Have Approved and Pending Section 1115 Medicaid Waivers?