Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
Published: May 29, 2020
Section 1115 Medicaid demonstration waivers provide states an avenue to test new approaches in Medicaid that differ from federal program rules. While there is great diversity in how states have used waivers over time, waivers generally reflect priorities identified by states and the Centers for Medicare and Medicaid Services (CMS). 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. The map and tables do NOT include/capture states mandating managed care through Section 1115 (since waiver authority is not generally required for these initiatives) and do 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.
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; eliminating retroactive eligibility; making coverage effective on the date of the first premium payment (instead of the date of application); disenrollment and lock-out for unpaid premiums; 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; and imposing a tobacco premium surcharge.
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.
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), implementing healthy behavior incentives (tied to premium or cost sharing reductions), and charging copays in excess of the federal maximum for non-emergent use of the emergency room.
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. In November 2018, the CMS issued a state Medicaid director letter describing a new demonstration opportunity for adults with serious mental illness (SMI) or children with serious emotional disturbance (SED).
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).
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.
Other Targeted Eligibility Changes
These states operate (or seek to operate) Section 1115 waivers that affect targeted populations. Many of these targeted waivers may provide limited benefit coverage and/or include cost-sharing. Targeted waivers for seniors and people with disabilities may include eligibility or benefit expansions provided through Section 1115 authority; however, capitated HCBS Section 1115 waivers are captured under “MLTSS.” “Other Targeted Eligibility Changes” also includes eligibility policy changes that are not captured in the “Eligibility and Enrollment Restrictions” category which affect targeted waiver populations (e.g., 12 month continuous eligibility). This category does NOT include family planning waivers.
Section 1115 waivers that include financing changes contain provisions that alter (or seek to alter) federal Medicaid financing rules or structures. Such provisions include block grant and/or per capita cap financing mechanisms that may affect the level of federal Medicaid funding available to states.