Section 1115 of the Social Security Act allows the Secretary of the Department of Health and Human Services to approve state Medicaid demonstration projects that promote the objectives of the program but may not otherwise be allowed under the Medicaid statute. CHA provides an overview of the current approved Section 1115 demonstration waiver landscape and identifies whether these waivers are consistent with CHA's Section 1115 waiver principles for children's coverage, which assess how waivers impact children.
CHA highlights four categories of waivers: delivery system reform, multi-component, adult expansion, and targeted population and/or services waivers. The map shows the key themes of existing waivers in each state and includes links to brief waiver summaries. The map does not highlight nor include summaries of pending waivers or amendments and approved demonstrations with a focus on family planning services, HIV/AIDs or services for senior citizens.
State waiver summaries
State waiver categories and themes by state
Delivery system/payment reform Specific population/services Adult Medicaid expansion
Multi-component No approved waiver
*Arkansas has a second specific population/services waiver that directly addresses coverage for children via the TEFRA or "Katie Becket" eligibility pathway. Michigan has a second and third waiver both focused on specific populations and/or services. Minnesota has a second specific population/services waiver. New Hampshire has a second adult Medicaid expansion waiver and a third specific population/services waiver. Alabama's Medicaid Transformation demonstration was terminated before its implementation at the request of the state.
Hawaii and Alaska, not visible on the map, have approved multi-component and specific population/services waivers, respectively.
Waiver category descriptions
The following are four broad categories that CHA has identified as common topics across approved Section 1115 demonstrations. Each waiver has been identified by one of these categories:
- Adult Medicaid Expansion - Waiver authority is used to implement the adult Medicaid expansion under the Affordable Care Act.
- Delivery system/ payment reform - Waivers with a delivery system reform incentive payment (DSRIP) or value-based delivery system and/or payment reform initiative.
- Multi-component - Long-standing, comprehensive waivers and, for multiple states, reflect the creation and management of the state's entire Medicaid program.
- Specific population/services - Waivers that modify coverage requirements for particular populations or coverage of particular services, including, but not limited to the expansion of Medicaid coverage to specific populations or for specific services.
Waiver theme descriptions
The following are key themes found in approved waivers. These themes are not necessarily specific to kids. We have highlighted changes made to these themes through Section 1115 waiver authority:
- Behavioral health - Mental health and/or substance use disorder services or integration of physical and behavioral health services.
- Delivery System Reform Incentive Payment Program (DSRIP) - Programs that encourage providers to engage in delivery system reform efforts and tie payments to health outcome improvements for Medicaid beneficiaries.
- Eligibility/enrollment - Eligibility or enrollment provisions, including but not limited to, retroactive eligibility, presumptive eligibility, enrollment caps, lock-out periods or coverage expansions.
- EPSDT - Provision affecting EPSDT requirement for children up to age 21.
- Home and Community-based Services (HCBS) - Addresses HCBS for individuals with disabilities or chronic conditions.
- HSA-lookalike - Program operated similar to a health savings account.
- Innovative pediatric initiative - Includes child-only pilot program(s) or other initiative(s).
- Long-term Services and Supports (LTSS) - Delivers or impacts LTSS or managed LTSS.
- Managed care - Waiver authority used to implement managed care delivery system.
- Premium assistance - Impacts Medicaid provisions that allow state programs to pay private insurance premiums for beneficiaries.
- Premiums/cost-sharing - Modifies premium and/or cost-sharing requirements or limits authorized in the federal Medicaid statute.
- Supplemental payments - Payments to hospitals that are not tied to a particular service (e.g., payments from a provider tax, low-income/uncompensated care pool).
- Value-based model - Delivery system and/or payment reform initiative outside of DSRIP that may include components such as care coordination, provider performance incentive payments, quality improvement metrics, and/or address social determinants of health.
- Wellness incentive - Incentive payments or reductions used to offset cost-sharing requirements for beneficiaries who engage in recommended healthy behaviors.
- Work requirements - Establishes work or community engagement activity requirements as defined by the state, such as employment, education and job skills training, as a condition of receiving benefits.