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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- September 16, 2022
In comments to the Department of Health and Human Services, the National Health Law Program urges HHS to ensure that appropriate guardrails are placed on any Medicaid funding for prison, jail, and other institutional re-entry, to ensure that it is used strictly for services that aid in reentry and that is primarily used for home and community based services. We also urge HHS to reject Washington's request to waive the Institutions for Mental Diseases (IMD) exclusion for certain psychiatric and substance use disorder facilities.
- September 7, 2022
In comments to the Department of Health and Human Services, the National Health Law Program urges HHS to ensure that appropriate guardrails are placed on any Medicaid funding for prison, jail, and other institutional reenty, to ensure that it is used strictly for services that aid in re-entry and that is primarily used for home and community based services. We also urge HHS to reject Washington's request to waive the Institutions for Mental Diseases (IMD) exclusion for certain psychiatric and substance use disorder facilities.
- April 14, 2022
NHeLP comments on Oregon’s application for renewal of the Oregon Health Plan § 1115(a) Demonstration Waiver for 2022-2027
In public comments, NHeLP expresses support for Oregon's decision to abandon its waiver of EPSDT. However, NHeLP strongly opposes Oregon's proposal to exclude outpatient prescription drugs approved under the FDA's accelerated approval pathway. Denying Medicaid enrollees access to effective break-through therapies would harm people with serious or life-threatening medical conditions. NHeLP also expresses concern about implementation of the EPSDT waiver withdrawal, and opposes the continued use of the prioritized list for children and adults.
- July 20, 2020
This publication identifies ten actions that advocates can take to maximize eligibility and enrollment in Medicaid during and after the COVID-19 emergency.
- May 24, 2018
Representing children with disabilities, Disability Rights California, National Health Law Program and Western Center for Law and Poverty today filed a class action lawsuit in federal court against California's Medicaid agency (Medi-Cal) for failure to provide sufficient in-home nursing services. Medi-Cal's "deficient policies, practices, and procedures related to arrangement of in-home skilled nursing services violate not only ... provisions of the Medicaid Act, but also provisions of the Americans with Disabilities Act.
- July 23, 2013
Q. My state is considering asking CMS to approve Medicaid coverage of home and community-based (HCB) services through the 1915(i) state plan option. Can you explain what this option is and whether there are any particular issues that advocates should watch for? A. Section 1915(i) enables to states to offer HCB services through a state plan option. This can be good for P & A clients, because it can increase access to HCB services for individuals who are not eligible for Medicaid waiver programs. At the same time, it can be a way for states to limit coverage of services to particular populations. Therefore, advocates need to closely monitor states? plans to offer 1915(i) services. Discussion In 2005, Congress added a new section to the Medicaid Act that authorizes states to provide HCB services to certain individuals through a state plan option.2 Previously, such home and community-based services could be offered only pursuant to an 1115 or 1915 waiver.3 The 1915(i) option enables states to serve individuals with incomes under 150% of FPL who need HCB supportive services but whose disabilities are less severe than those served under HCB waivers. Unlike waivers, individuals…
- July 23, 2013
Q. My state is considering implementing cost sharing for Medicaid beneficiaries, arguing that this will save money. The state wants to implement cost sharing above the nominal amounts listed in federal Medicaid regulations and to make payment of the copayments mandatory. It also wants to impose premiums on some Medicaid populations that exceed the premium amounts currently allowed in the Medicaid laws. We understand that the state is going to ask the federal Medicaid agency for approval of these changes. Are there arguments we can make against these cuts? Can you suggest evidentiary support for our legal position? A. Yes. A recent decision from the Ninth Circuit Court of Appeals casts doubt on the state?s plan to impose the heightened cost sharing. Moreover, numerous studies have demonstrated that Medicaid cost sharing reduces utilization of necessary services and lowers enrollment. The imposition of premiums also implicates the maintenance of efforts requirements of the Affordable Care Act. Discussion Medicaid cost sharing rules Cost sharing requires a patient to pay part of the cost of health care services, such as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar charges. Congress has been very…
- July 23, 2013
Q & A: Recent Medicaid Settlements in Washington and Florida On December 20, 2006, the Federal District Court for the Western District of Washington gave final approval to a far-reaching settlement agreement in a Medicaid home and community based waiver case. Boyle v. Braddock was filed in 2001 on behalf of a class of current and future participants in Washington?s Medicaid Home and Community Based Waiver programs for people with developmental disabilities. The plaintiffs claimed that Washington?s Division of Developmental Disabilities (DD) had violated Medicaid law by failing to advise waiver participants about the range of Medicaid services available; failing to provide services with reasonable promptness and denying waiver participants free choice of service alternatives available under the waiver. In addition, the plaintiffs claimed that they were not given due process when services were reduced, terminated or denied. After several years of litigation, extensive discovery, appeal to the Ninth Circuit, and two separate formal mediation processes, the parties entered into the settlement agreement that was ultimately approved by the district court. The settlement provides that: All waiver participants will have annual comprehensive needs assessments; All waiver participants will have the opportunity to apply…
- July 23, 2013
This powerpoint provides background on three typs of home and community based waivers for individuals who suffer traumatic brain injuries (TBI) or spinal cord injuries (SCI). Topics include available services, beneficiary protections, application of EPSDT, and relevant litigation.