ACA Now

Implementation Status

2012

CMS in early 2012 issued a final rule implementing provisions of section 10201(i) of the Senate Manager’s Amendment relative to transparency and public notice procedures for Medicaid and CHIP experimental, pilot, and demonstration projects approved under section 1115 of the SSA.  CMS subsequently issued a SMD/SHO letter regarding the final rule. To view and comment on pending section 1115 waivers, visit here, and a relevant user guide to assist in the review and comment process is available here.  CMS developed a main webpage for this topic that consolidates relevant information.

2013

On March 29, CMS issued a FAQ document providing guidance on using Medicaid funding to enable beneficiaries to purchase Qualified Health Plans (QHPs) in the Exchange.  In sum, the document suggests that while states likely have flexibility to quantify savings in an array of potential areas – as Arkansas already has taken steps to project – the federal government will not otherwise foot the bill for the delta between Medicaid and private coverage for individuals below 100% of the Federal Poverty Level under these arrangements.  At the same time, CMS implies that more federal funding may be available for those above 100% FPL, because they otherwise would qualify for premium tax credits through Exchange coverage.  This document also addresses related provisions regarding individual market premium assistance demonstrations per the existing section 1115 waiver authority.

On April 25, CMS issued a subsequent round of FAQs to address ongoing questions regarding ACA implementation, including those pertaining to: (1) the availability of the 75% federal match for maintenance and operations; (2) systems issues regarding communication between the Federally-Facilitated Marketplace (FFEs) and Medicaid/CHIP; and (3) further policy guidance regarding the use of section 1115 demonstrations.

on April 30, CCIIO released a single, simplified application for use by individuals beginning on October 1, 2013 to apply for health coverage under the Exchange (including premium subsidies), Medicaid, and CHIP.  The individual short form is available here; the family form, here; and the individual without financial assistance form, here. A CMS press release on the shortened, streamline forms is available here.

 In a related event, on July 18, the GAO published a report raising concerns about HHS’ processes to assure federal budget neutrality under select Medicaid section 1115 demonstrations, referencing this provision of the ACA regarding section 1115 waiver amendments.

On a related note, on July 24, CMS issued an informational bulletin delineating a new fast-track federal review process for Medicaid and CHIP waiver extensions. The new fast-track application process will be available to extend all types of 1115 ((a), (e) & (f)) waivers, and will allow for a 5-year extension period for states with 1115(a) demonstrations.

2016

On May 20, Texas submitted an amendment to accomplish three separate goals: (1) implementing a comprehensive managed care model for children (STAR Kids); (2) amending the demonstration to end the current NorthSTAR behavioral health Medicaid carve-out program effective January 2017; and (3) amending the demonstration to solely apply the spell of illness exemption for beneficiaries admitted due to a diagnosis of Serious and Persistent Mental Illness. The federal public comment period will be open from May 20, 2016, to June 19, 2016.

On June 16, Iowa requested a termination of their Market Place Choice Plan demonstration. Iowa terminated in response to the two QHPs that served this population exiting the market. Beneficiaries in this program were transitioned into another demonstration.

On June 20, Iowa requested a three-year extension of its Wellness Plan demonstration. The state requested an extension of all current federal waivers and expenditure authorities and no program changes were proposed.

Also on June 20, North Carolina requested a new section 1115(a) demonstration to transform and re-organize North Carolina’s Medicaid and NC Health Choice programs, through statewide managed care plans, transforming primary care medical homes (PCMHs) to person-centered health communities (PCHCs), integrating behavioral health and physical health, and lastly, by allowing managed care entities to provide long-term services and supports (LTSS) for Medicaid only individuals.

On June 23, California requested to amend their California Medi-Cal 2020 demonstration by expanding the definition of a Whole Person Care Pilot lead entity to include federally recognized Tribes and Tribal Health Programs operated under a Public Law 638 contract with the Federal Indian Health Services.

On July 7, Ohio requested a new five-year section 1115 demonstration which seeks to modify the existing Medicaid expansion program.

Also on July 7, Michigan submitted a new section 1115 application targeted to children with serious emotional disturbances and individuals with severe mental illness, substance use disorders, intellectual and developmental disabilities.

On July 7, Arkansas submitted an application to extend its 1115 demonstration and make changes to the demonstration in response to the Arkansas Works Act of 2016.

On July 18, Iowa submitted a request to renew their Iowa Family Planning Network demonstration without changes.

On July 15, Arizona submitted revisions to its Delivery System Reform Incentive Payments (DSRIP) proposal to CMS.

On Aug. 3, Massachusetts submitted a section 1115 demonstration project amendment and extension request to implement ACOs throughout the state, implement a Substance Abuse Disorder initiative, among other changes. Comments are due September 3, 2016.

On Aug. 12, Indiana submitted an amendment to its section 1115 demonstration, the Healthy Indiana Plan (HIP) 2.0, pertaining to its non-emergency medical transportation waiver program. Comments are due Sept. 11.

On Aug. 17, New Hampshire submitted an amendment to its section 1115 demonstration program pertaining to work requirements of certain able-bodied adults, among other provisions. Comments are due Sept. 16.

On Aug. 18, Utah submitted an amendment to extend its section 1115 demonstration pertaining to its “Primary Care Network,” among other provisions. Comments are due Sept. 17.

On Aug. 24, Kentucky submitted a section 1115 demonstration titled, Kentucky Health, which seeks to leverage a managed care delivery system (via a high deductible health plan with two health care spending accounts) to serve all non-disabled individuals under age 65. Comments are due Oct. 8.

On Aug. 25, Montana requested an extension of its section 1115 demonstration pertaining to Basic Medicaid for Able-bodied adults, among other provisions. Comments are due Sept. 24.

On Sept. 1, California submitted an amendment to its section 1115 waiver in which it sought to revise the incentive payment methodology under its Dental Transformation Initiative (DTI) program, among other purposes. Comments were due Oct. 1.

On Sept. 1, Oregon submitted an extension of its section 115 demonstration, outlining a number of Medicaid delivery system reforms, including those focused on addressing the social determinants of health to improve health equity. Comments were due Oct. 1.

On a related note, on Dec. 13, 2016, CMS issued an informational bulletin addressing issues pertaining to ensuring program integrity in Medicaid personal care services, a form of HCBS. Also on a related note, on Dec. 15, 2016, CMS released FAQs concerning Medicaid Beneficiaries in Home and Community-Based Settings who exhibit unsafe wandering or exit-seeking behavior.

2017

On Mar. 1, 2017, New Jersey submitted a revised section 1115 waiver extension application. Comments are due Apr. 10, 2017.

On Mar. 2, California requested to amend the California Medi-Cal 2020 Demonstration. Comments are due Apr. 2, 2017.

On Mar. 16, CMS Administrator Seema Verma and HHS Secretary Tom Price sent a cosigned letter to state governors indicating that they will seek to facilitate expedited approval of Section 1115 demonstration waiver applications to reshape Medicaid. Also on Mar. 16, Texas submitted a proposal to amend its existing section 1115 waiver. Comments are due Apr. 15, 2017.

On July 6, Kentucky submitted modifications to its pending Kentucky HEALTH section 1115 waiver, seeking to align Supplemental Nutrition Assistance Program (SNAP) and Medicaid employment requirements. Comments were due Aug. 2.

On July 24, Massachusetts submitted an amendment to its section 1115 waiver regarding the following changes: (1) the authority to discontinue the assurance of providing non-emergency medical transportation for individuals enrolled in MassHealth’ CarePlus program except for transportation to SUD services; (2) discontinuing provisional eligibility for certain adult applicants; and (3) to continue coverage for former foster care youth through the demonstration. Comments were due Aug. 24.

On July 28, Alabama submitted a request to amend its section 1115 Alabama Medicaid Transformation demonstration to phase-in the implementation of a managed care delivery system, run by provider-based Regional Care Organizations, over a two-year period with statewide implementation by October 1, 2018. Comments were due Aug. 11.

On July 28, Indiana submitted a slightly revised version of its section 1115 amendment that addresses public comments received on the original proposed amendment submitted on May 25, 2017. The application requests, along with other technical revisions, to (1) require beneficiaries to participate in Gateway to Work, the Healthy Indiana Plan (HIP) 2.0 job training and employment services program, (2) change the monthly premium contributions from two percent of a beneficiary’s income to income tiers that are about two percent of income, (3) phasing out the HIP Employer Link employer sponsored insurance program. Comments were due Aug. 24.

On Aug. 3, citing a “new era of state flexibility,” CMS approved a five-year extension of Florida’s Managed Medical Assistance (MMA) section 1115 waiver (approval letter; add’l details). Under the demonstration, Florida will continue to require most beneficiaries to enroll in a managed care plan, while also continuing to operate a Low-Income Pool (LIP) to support safety-net providers furnishing uncompensated care.

On Aug. 8, Minnesota and Iowa requested to extend and modify their respective section 1115 demonstrations. Comments on both waivers – titled “Minnesota Reform 2020” and “Iowa Wellness Plan” – were due Sept. 7. See here and here, respectively.

On Aug. 15, Kansas requested a one-year extension of its KanCare section 1115 waiver with no changes. Comments were due Sept. 10.

On Aug. 22, Maine requested approval to implement Medicaid work requirements, monthly premiums, eligibility tests and more under section 1115 waiver authority. Comments were due Sept. 16.

On Aug. 22, Oklahoma submitted an amendment to its section 1115 waiver, “SoonerCare,” to fund health care workforce development at public universities. Comments were due Sept. 16.

On Sept. 19, New York submitted an amendment to its section 1115 demonstration, Medicaid Redesign Team (MRT) Plan. The state seeks to provide specialized Health Homes to individuals with intellectual and developmental disabilities (I/DD). Comments were due Oct. 16.

On Sept. 20, Massachusetts submitted a request to amend its section 1115 Medicaid demonstration, entitled “MassHealth,” to, among other changes, restructure coverage for non-disabled adults to align with commercial plans, to adopt widely used commercial tools to lower drug prices and enhanced rebates, and strengthen its behavioral health care and addiction treatment systems. Comments were due Oct. 20.

In November, at the 2017 Fall Conference of the National Association of Medicaid Directors (NAMD), CMS Administrator Seema Verma delivered a speech in which she unveiled a new vision for the Medicaid program, under which new policies will “encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability.”

2018

On Jan. 11, CMS released highly anticipated guidance (press release; FAQs) on how states can implement work and “community engagement” requirements through Medicaid section 1115 waivers. CMS says that such programs may apply to beneficiaries who are non-elderly, non-pregnant, and eligible for Medicaid on a basis other than disability. CMS’ State Medicaid Director letter is being issued as 10 states seek to implement such work and community engagement requirements, including Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah, and Wisconsin. CMS addressed parameters that may lead to states’ successful applications, as well as design, eligibility, and other considerations.

On Jan. 12, a day following CMS’ guidance on section 1115 waivers with work and “community engagement” requirements, CMS approved the Kentucky HEALTH waiver that includes such requirements. Under Kentucky’s approved waiver, non-disabled adults ages 19-64 are required to demonstrate 80 hours per month of such activities, which include “employment, education, job skills training, and community service.” A fact sheet is available here.

On Jan. 23, Mississippi submitted a new Medicaid Workforce Training Initiative 1115 Demonstration waiver application to CMS. Specifically, Mississippi proposes to implement workforce training activities for non-disabled adults currently covered under traditional Medicaid, including low-income parents and caretakers eligible under Section 1931 and individuals eligible for transitional medical assistance (TMA). Comments were due Feb. 22. See also Wisconsin’s 1115 waiver application, submitted the same day, which sought to impose work requirements, time limits, impose premium payments and more for its childless adult population. Comments were also due Feb. 22.

On Feb. 2, Indiana became the second state to receive approval from CMS to implement its section 1115 Medicaid waiver to impose work requirements. The Health Indiana Plan (HIP) waiver is an extension of the state’s previous Medicaid expansion demonstration, with a number of notable changes including the imposition of a “community engagement” requirement for certain adult beneficiaries.

On Feb. 27, MACPAC released an issue brief describing the features of the CMS guidance on Section 1115 waiver authority to impose work and community engagement requirements as a condition of Medicaid eligibility. Specifically, it describes the populations subject to the requirements, the allowable work and community engagement activities, and the penalties associated with non-compliance, as  well as the implementation considerations CMS has requested that states take into account. MACPAC concludes by outlining some of the concerns raised regarding the imposition of such requirements.

On Mar. 5, CMS approved Arkansas’ section 1115 Medicaid waiver application to add 80 hours of monthly work requirements to its current Medicaid waiver, which provides premium assistance for QHP coverage to beneficiaries up to 138 percent FPL. CMS did not approve the state’s request to reduce eligibility to 100 percent FPL, though added that it was not approving that request “at this time.”

On Mar. 28, Senate Finance Committee Ranking Member Ron Wyden (D-OR) and House Energy and Commerce Committee Ranking Member Frank Pallone (D-NJ) called on the GAO to study the “administrative waste” – in terms of costs, as well as onerous burdens on beneficiaries – of the Trump Administration’s recently-approved “harmful” section 1115 Medicaid waivers. The lawmakers’ concerns follow recent guidance from the Trump Administration that seeks to impart additional flexibility to the states, including through work requirements (details). A copy of their letter is available here.

On Apr. 10, President Trump issued an Executive Order (EO) on “Reducing Poverty in America by Promoting Opportunity and Economic Mobility” (text; fact sheet), which the Administration calls “the first steps toward welfare reform in America.” The EO directs all federal agencies that administer public assistance programs to produce a report to the President on current regulations and guidance relating to work requirements and how they might be strengthened.

On April 30, MACPAC released updated issue briefs and fact sheets delineating information on newly approved state Medicaid expansion waivers, Medicaid’s role in emergency response, and the program’s role in delivery system transformation.

On July 20, CMS announced that it will open a second 30-day comment period on the State of Kentucky’s Section 1115 Medicaid waiver application proposing to institute work requirements in its Medicaid program. Public comments were due Aug. 18. CMS’ move follows a recent decision by the DC federal district court which vacated the Administration’s previous approval of the waiver on the grounds that HHS did not consider Medicaid’s central objective of providing affordable health coverage, and ignored public comments, which were overwhelmingly against the plan (details). CMS Administrator Seema Verma said that CMS plans to proceed with implementation of the waiver, and will again invite public feedback on how CMS might address the judge’s concerns. Medicaid work requirements have been approved in three other states thus far: Arkansas, Indiana, and New Hampshire. Arizona, Maine, Wisconsin and Utah currently have work requirement waiver proposals pending before CMS, with Michigan and Virginia expected to follow.

On Aug. 22, CMS issued a letter to state Medicaid agencies clarifying, for the first time, the agency’s current approach to calculating budget neutrality expenditure limits for Section 1115 demonstration waiver programs. Among other things, the letter describes a new mandatory monitoring tool to ensure states have a “streamlined and standardized approach to expenditure reporting” (see p. 9, including footnotes), and discusses the approach to budget neutrality in demonstration extensions and renewals (see p. 7).  See CMS’ press release for further details.

On Aug. 24, Tennessee submitted an 1115 waiver application to CMS proposing to amend its demonstration by establishing state-specific criteria for providers of family planning services and to exclude from the demonstration providers that perform elective abortions. Comments were due Sept. 23.

2019

For an up-to-date listing of section 1115 waivers, see here.