Section 1115 Medicaid waivers allow states to explore new options for providing health coverage to persons who would otherwise not be eligible and allow states to examine innovative ways to deliver care by waiving certain requirements of the Medicaid Act.
While waivers can be important tools that can help states respond to the needs of low-income individuals, they also present concerns for health advocates working to protect the rights of Medicaid enrollees and promote transparency in state waiver processes.
Sec. 1115 of the Social Security Act allows the Secretary of Health and Human Services to waive some requirements of the Medicaid Act so that states can test novel approaches to improving medical assistance for low-income people.
Under the current administration, several states are seeking waivers to impose harmful cuts and restrictions. The first set of harmful waivers have been approved for Kentucky and Arkansas, with a number of states seeking to enact similar changes to Medicaid. Learn more about Medicaid waivers and how the National Health Law Program is combating the Trump administration’s illegal use of waivers to weaken Medicaid.
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- January 6, 2022
In 2017, the Centers for Medicare & Medicaid Services issued a policy announcing its intent to “approve the extension of routine, successful, non-complex” section 1115 waivers for a period of up to 10 years. Thereafter, CMS extended a number of projects for 10 years. This issue brief explains how the policy and the subsequent approvals are contrary to section 1115 and calls on the Biden administration to rescind the policy, reconsider the approvals, and adhere to the text of section 1115 moving forward.
- November 11, 2021
In comments to the Department of Health and Human Services, NHeLP explains that the ARHOME project raises serious legal concerns. The application does not include a sufficient level of detail to allow for meaningful comment on several features of the project. What is clear from the application is that Arkansas is seeking permission to implement a number of policies - imposing premiums, waiving retroactive coverage, and restricting access to services through various mechanisms - that conflict with the core objective of the Medicaid Act and serve no experimental purpose.
- November 1, 2021
In comments to the Department of Health and Human Services, the National Health Law Program explains that the initial purpose of the Primary Care Network project, which started nearly 20 years ago as a way to expand coverage to population groups that were not described in the Medicaid Act at that time, has been lost. Currently, the project is a hodgepodge of features, many of which restrict coverage and access to care. As a result, we recommend that CMS take the following steps in response to Utah’s application: Where possible, CMS should require Utah to implement elements of the project through other authorities (the state plan or non-demonstration waiver authorities). CMS should then evaluate the remaining elements of the project in accordance with section 1115.
- July 15, 2021
In 2020, the COVID-19 pandemic plunged the United States into a public health crisis. This situation was not entirely unprecedented. Local crises had previously been triggered by events such as hurricanes (e.g., Katrina in 2005, Irma in 2017), wildfires (e.g., California in 2017 and 2018), lead contamination (Flint, Michigan in 2016), and terrorist attacks (New York City after 9/11). During these events, the Secretary of the Department of Health and Human Services (HHS) used waiver authority to allow affected states to ignore otherwise mandatory Medicaid requirements so that they could use Medicaid as part of the emergency response. These crises, and particularly the COVID-19 pandemic, have made it clear that the current statutes do not give HHS sufficient emergency waiver authority. This paper: Outlines legal authorities that allow HHS and states to adjust their Medicaid programs during an emergency; Identifies deficiencies in these authorities; and Makes recommendations that, if implemented, will better prepare Medicaid programs for the next crisis. The two authorities that HHS and states have turned to the most during emergencies are Section 1115 and Section 1135 of the Social Security Act.
- June 16, 2021
Tension and confusion can arise over how HHS allows states to change their Medicaid programs, whether through a state plan amendment (SPA) or a Section 1115 project. To help guard against the improper use of Section 1115 waivers, advocates must know the distinctions between Section 1115 waivers and SPAs. This primer outlines these distinctions.
- May 20, 2021
Tension and confusion can arise over how HHS allows states to change their Medicaid programs, whether through a state plan amendment (SPA) or a Section 1115 project. To help guard against the impoper use of Section 1115 waivers, advocates must know the distinctions between Section 1115 waivers and SPAs. This primer outlines these distinctions.
- February 16, 2021
Comments on Utah 1115 Primary Care Network Demonstration Waiver Amendment Request: In Vitro Fertilization and Genetic Testing for Qualified Conditions
In comments to the Department of Health and Human Services, the National Health Law Program asks HHS to reject Utah's proposal to restrict coverage of in vitro fertilization (IVF) services and preimplantation genetic diagnosis (PGD) for Medicaid-enrolled individuals who: (1) have been diagnosed by a physician as having a genetic trait associated with one of five specified conditions; and (2) intend to get pregnant with a partner who also has been diagnosed by a physician as having a genetic trait associated with the same condition. First, Utah's application does not contain a sufficient level of detail to allow for meaningful comment. Second, Utah’s proposal is not likely to assist in promoting the objectives of the Medicaid Act and does not propose an actual experiment. And finally, Utah’s proposal is at best arbitrary, and at worst motivated by the discriminatory motive of trying to avoid providing medical assistance to people with disabilities.
- July 24, 2020
In comments to the Department of Health and Human Services, the National Health Law Program asks HHS to reject Oklahoma's proposed project, which would impose a number of unlawful conditions on coverage and access to care. Oklahoma also requested permission to shift to per capita cap funding for the Medicaid expansion population.
- December 6, 2019
In comments to the Department of Health and Human Services, the National Health Law Program urges HHS to reject Utah's proposed project, which would impose a number of unlawful conditions on coverage and access to care. Utah requested a number of restrictions, including: capping enrollment in the expansion population; imposing work requirements; charging premiums (and terminating coverage and imposing a lockout penalty for failure to pay); charging an amount higher than otherwise permitted for non-emergency use of the emergency room; eliminating hospital presumptive eligibility; imposing a lockout penalty for an "intentional program violation;" eliminating EPSDT for people ages 19 and 20; cutting services for parents; and ignoring various managed care protections. The comments explain why the proposed project does not comply with the requirements of § 1115 of the Social Security Act.
- November 26, 2019
In comments to the Department of Health and Human Services, the National Health Law Program urges HHS to reject Idaho's request to require individuals to obtain a referral from their primary care provider before receiving family planning services from a different provider. The comments explain why the proposed project would reduce access to medically necessary preventive care, leading to worse health outcomes for low-income people in Idaho.