Medicaid Waiver Map

Use this interactive map to help you determine if your state has an 1115 Medicaid waiver and the impact on Medicaid beneficiaries living with or at risk for HIV and hepatitis. Please see NASTAD’s related Medicaid resources: Medicaid 1115 Waivers: Considerations for HIV and Hepatitis Programs and Medicaid 1115 Waivers: Exemptions for People Living with HIV and Hepatitis.

NASTAD’s interactive Private Insurance State Policy Tracker tool is available here.

This map was produced as part of a project supported by the Elton John AIDS Foundation.

Last Updated: November 1, 2019

Waiver Status

Pending

Both

Approved

Pending

Alaska

Approved

Alaska Substance Use Disorder and Behavioral Health Program

  • Status: Approved
  • Provides an enhanced set of mental health, behavioral health, and substance use treatment benefits.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Federal Approval

Alabama

Pending

Alabama Medicaid Workforce Initiative

Arkansas

Approved

Arizona

Both

Arizona Health Care Cost Containment System 

  • Status: Amendment Pending
  • Requires premiums for expansion adults above 100% FPL through contributions to AHCCCS CARE account (similar to a Health Savings Account). Premiums and coinsurance liabilities are billed to members on a quarterly basis. Beneficiaries that make timely payments and engage in specified healthy behaviors related to preventive health and/or chronic disease management will be exempt from premiums for six months. Members may access funds in AHCCCS CARE account upon completion of healthy behaviors. Disenrollment for failure to pay premiums, but no lockout for re-enrollment.
  • Enacts payment and delivery reforms to improve behavioral health services, including incentive payments to providers for increasing physical and behavioral health care integration and coordination, and specialized plans that include acute and behavioral health services for adults with serious mental illness and SUD.
  • “Medically frail” individuals are exempt from premiums. The state has proposed to develop a definition of “medically frail” that specifically includes people living with HIV, but has not yet done so.
  • Proposed amendment would authorize SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • REJECTED: CMS rejected the state’s proposal to impose a five-year lifetime coverage limit for individuals who fail to comply with work requirements.
  • UPDATE—October 17, 2019: Arizona has postponed implementation of work requirements until further notice, citing the “evolving national landscape concerning Medicaid community engagement programs” and ongoing litigation in several other states regarding this topic. Arizona previously received federal approval to implement work requirements for “able-bodied” expansion adults age 19-49, with exemptions for “medically frail” individuals, with disenrollment and two-month lockout for failure to comply. Work requirements were set to take effect no earlier than January 2020.
  • Imposes work requirements on “able-bodied” expansion adults age 19-49, with disenrollment and two-month lockout for failure to comply. Work requirements will go into effect no earlier than January 2020.
  •  “Medically frail” individuals are exempt from work requirements and premiums. The state has proposed to develop a definition of “medically frail” that specifically includes people living with HIV, but has not yet done so.
  • Proposed amendment would authorize SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • REJECTED: CMS rejected the state’s proposal to impose a five-year lifetime coverage limit for individuals who fail to comply with work requirements.

California

Approved

Medi-Cal 2020 Demonstration

  • Status: Approved
  • Waiver began as "Bridge to Reform" to allow for early Medicaid expansion for Medi-Cal beneficiaries as well as payment and delivery reform initiatives. The waiver allowed the state to incorporate people with disabilities into the Medi-Cal managed care system and supported a range of projects aimed at improving care at safety net and public hospitals.
  • "Health home" initiative allows the state to offer care coordination services to beneficiaries with chronic conditions in managed care plans. Health home services may be provided by community health workers.
  • Authorizes pilot program programs to support infrastructure development to integrate services for enrollees with mental health or substance use disorders.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval
  • National Organization Comments on California's 1115 Waiver (October 2011)

Colorado

Pending

Expanding the Substance Use Disorder Continuum of Care

  • Status: Pending
  • Proposal would authorize SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Application (October 2019)

Connecticut

No Waiver

District of Columbia

Pending

D.C Behavioral Health Transformation

  • Status: Pending
  • Proposal would authorize SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Proposal would expand community-based behavioral health benefits.
  • State Resources
  • Federal Application (June 2019)

Delaware

Approved

Diamond State Health Plan 

  • Status: Approved
  • Eliminates retroactive eligibility for most populations.
  • Expands community-based behavioral health services.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

Florida

Pending

Florida Managed Medical Assistance Program 

  • Status: Amendment Pending
  • Provides coverage for individuals diagnosed with AIDS with income at or below 222% FPL and assets not exceeding $2,000 (for an individual).
  • Enrolls people living with HIV or AIDS in specialty plans, where available.
  • Eliminates retroactive coverage.
  • Includes community behavioral health providers as participating providers under the Low Income Pool.
  • Authorizes a pilot program to provide behavioral health and supportive housing assistance services for enrollees age 21 and older with serious mental illness and/or substance use disorder who are homeless or at risk of homelessness due to disability.
  • State Resources
  • Federal Approval
  • Federal Application (August 2019)
  • National Organization Comments on Florida 1115 Waiver Amendment (June 2018)

Georgia

No Waiver

Hawaii

Approved

Hawaii QUEST Integration

  • Status: Renewal Pending
  • Expands community-based behavioral health benefits, including supportive housing services and SUD treatment.
  • Hawaii QUEST Integration 

    • Status: Approved
    • Expands community-based behavioral health benefits, including supportive housing services and SUD treatment.
    • Provides community integration services for qualified beneficiaries who meet the definition of being chronically homeless and who also have a behavioral or physical illness or a substance abuse diagnosis.
    • State Resources
    • Federal Approval

Iowa

Pending

Iowa Wellness Plan 

Idaho

Pending

Idaho Medicaid Reform Waiver

  • Status: Pending
  • Proposal would impose work requirements for non-exempt expansion adults age 19-59, with disenrollment and two-month lockout for failure to comply.
  • State Resources

Illinois

Approved

Illinois Behavioral Health Transformation

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Authorizes 10 SUD pilot projects that provide case management, withdrawal management, peer recovery, tenancy support, and other services to various populations in need of SUD care.
  • Expands community-based behavioral health benefits.
  • State Resources
  • Federal Approval
  • AIDS Foundation of Chicago Comments on Illinois 1115 Waiver (November 2016)

Indiana

Pending

Healthy Indiana Plan (HIP) 2.0 

  • Status: Amendments Pending
  • Establishes premiums through monthly contributions to a Personal Wellness and Responsibility (POWER) account (similar to a Health Savings Account). Disenrollment with 6-month lockout for failure to pay premiums (>100% FPL only). Premiums are optional for beneficiaries with incomes below 100% FPL, but those who do not pay premiums get fewer benefits and must pay cost-sharing charges.
  • Eliminates non-emergency medical transportation.
  • Eliminates retroactive coverage for non-pregnant HIP program enrollees.
  • Allows for waiting periods.
  • Imposes 50% tobacco premium surcharge.
  • Disenrollment with lockout for failure to complete annual redetermination on time. Enrollees have 90 days following disenrollment to submit redetermination paperwork and re-enroll. Failure to complete redetermination during this 90-day period results in additional 3-month lockout.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • HIV and “chronic” hepatitis B and C included in medically frail condition list, but exemption may not be automatic. Medically frail are exempt from work requirements, lockout periods, and NEMT waiver.
  • Proposed amendment would provide a $1,000 account, funded from aggregate remaining balances of HIP $2,500 POWER Accounts, to cover premiums and out-of-pocket costs for a 12-month period for enrollees who must transition from Medicaid to commercial insurance due to an increase in income.

Kansas

Pending

KanCare 2.0 

  • Status: Amendment Pending
  • Authorizes rehabilitation services designed to meet the more intensive needs of individuals with SUD in their community and avoid the need for inpatient hospitalization. Services are prior authorized and include various detox, treatment, and community-based services.
  • Expands community-based behavioral health benefits.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • DEFERRED: The state has asked CMS to defer consideration of proposals to impose work requirements and to limit coverage for TMA enrollees.
  • REJECTED: CMS rejected the state’s proposal to impose a 36-month lifetime coverage limit for individuals who are subject to work requirements.

Kentucky

Approved

Kentucky HEALTH 

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.

Louisiana

Approved

Healthy Louisiana OUD/SUD Demonstration

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Federal Approval

Massachusetts

Pending

MassHealth 

  • Status: Amendment Pending
  • Shifts certain Medicaid populations into 1115 demonstration, including PLWH with income at or below 200% FPL.
  • Expands eligibility, with some limits on benefits, for PLWH with incomes between 133 and 200% FPL who would be eligible for Medicaid expansion but for their income. Enrollees may choose to receive premium assistance for ESI (with wraparound) in lieu of direct coverage.
  • PLWH with income above 133% FPL do not receive EPSDT services or non-emergency medical transportation, and may be subject to waiting list.
  • Discontinues provisional eligibility for certain adults. PLWH with incomes at or below 200% FPL may self-attest to income eligibility and receive 90-day provisional eligibility.
  • Extends Massachusetts’ longstanding 1115 waiver to move to an Accountable Care Organization model. The ACO model incentivizes partnership between ACOs and community-based organizations to improve behavioral care and long-term services and supports in particular.
  • Establishes a DSRIP program to incentivize investment to address social determinants of health.
  • Expands benefits to address the opioid epidemic.
  • Provides subsidies for individuals under 300% FPL who are not eligible for Medicaid and who purchase Marketplace coverage.
  • Allows the state to consider family income and resources “not actually made available to the applicant,” as well as income from any member of the “family unit,” when determining income for eligibility purposes.
  • Limits retroactive eligibility to 10 days prior to application date for most eligibility groups.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands community-based behavioral health benefits.
  • Proposed amendment would expand existing authority to provide services delivered in IMDs to include medically necessary treatment for co-occurring mental health conditions.

Maryland

Pending

Maryland Health Choice

  • Status: Amendment Pending
  • Enacts payment and delivery reform to address substance use disorders, including evidence-based benefit design, requiring providers to meet industry standards of care, implementing a comprehensive care coordination and management strategy, and reporting specific quality measures.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands community-based behavioral health benefits, including supportive housing services.
  • Expands services provided in IMDs to include medically managed intensive inpatient services, and covers services in private IMDs for participants with a primary SUD diagnosis and secondary mental health diagnosis.
  • State Resources
  • Federal Approval
  • Federal Application (June 2019)

Maine

Approved

Maine Section 1115 Demonstration for Individuals Living with HIV/AIDS  

  • Status: Approved
  • Provides coverage for PLWH with incomes at or below 250% FPL.
  • Enrollees with incomes at or below 133% FPL who are eligible for MaineCare receive Medicaid state plan-covered services and case management services.
  • Enrollees with incomes at or below 250% FPL who are not eligible for MaineCare receive a targeted essential set of services. The benefits provided to this group are not recognized as Minimum Essential Coverage under the ACA.
  • State Resources
  • Federal Approval

Michigan

Approved

Healthy Michigan 

  • Status: Approved
  • Imposes work requirements for “able-bodied” adults age 19-62, with disenrollment and one-month lockout for failure to comply for more than 3 months in a 12-month period. Re-enrollment contingent upon proof of compliance. Work requirements go into effect January 2020.
  • Requires compliance with “healthy behaviors” or completion of a health risk assessment as a condition of eligibility for individuals with income above 100% FPL and at least 48 months of cumulative enrollment, with disenrollment for failure to comply. Re-enrollment is contingent upon completion of a health risk assessment.
  • Imposes monthly premiums for enrollees with incomes above 100% FPL in the form of contributions to MI Health Account (similar to a health savings account), with reduced premiums upon completion of “healthy behaviors.” After 48 cumulative months of enrollment, members with income above 100% FPL will no longer be required to pay copayments; however, their premiums will increase, they will not be eligible for healthy behavior premium reductions, and they can be disenrolled for failure to pay. Re-enrollment is contingent upon payment of past due premiums.
  • Imposes targeted cost-sharing for all enrollees in the Healthy Michigan Plan, with reduced copayments upon completion of “healthy behaviors.” Copayment liabilities are billed to members on a quarterly basis. Members with income above 100% FPL and at least 48 months of cumulative enrollment are not required to pay copayments, but their premiums will increase.
  • Allows requests for prior authorization for prescription drugs to be addressed within 72 hours for individuals enrolled in Marketplace premium assistance. A 72-hour supply must still be provided in the event of emergency.
  • Eliminates copayments for services related to treatment of HIV or viral hepatitis.
  • HIV is included in the medically frail condition list. Medically frail are exempt from work requirements, premiums, and the 48-month cumulative enrollment loss of coverage provisions.

 

Michigan 1115 Behavioral Health

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands community-based behavioral health and SUD benefits.
  • State Resources
  • Federal Approval

Minnesota

Approved

Minnesota Pre-Paid Medical Assistance Project Plus

  • Status: Approved
  • Minnesota has a longstanding 1115 waiver that provides Medicaid coverage to otherwise uninsured populations in the state. The current demonstration project provides coverage to children and adults who have higher incomes than federal income thresholds for the program.
  • This demonstration served as a bridge to the “Basic Health Plan.” The demonstration project is no longer necessary to continue the MinnesotaCare program, which transitioned from Medicaid to Basic Health Plan authority in 2015, but is still needed to operate some aspects of Minnesota’s Medicaid program.
  • State Resources
  • Federal Approval

 Minnesota Substance Use Disorder System Reform

  • Status: Approved
  • Authorizes intensive outpatient SUD services not otherwise covered under the state plan.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval (August 2019)

Missouri

Approved

Missouri Gateway to Better Health

  • Status: Approved
  • Authorizes limited outpatient SUD services for the demonstration population.
  • Clarifies that the Medicaid rebate requirements of Section 1927 do not apply to the limited prescription drug benefit provided under Gateway to Better Health.
  • State Resources
  • Federal Approval
  • Federal Application (August 2018)

Mississippi

Pending

Mississippi Medicaid Workforce Training Initiative

  • Status: Pending
  • Proposal would impose work requirements on “able-bodied” adults currently covered under traditional Medicaid, including low-income parents and caretakers and individuals eligible for Transitional Medical Assistance (TMA). Individuals who fail to meet work requirements will be disenrolled with lockout until compliance is achieved.
  • Proposal would provide additional 12 months of coverage for TMA enrollees who comply with work requirements.
  • Proposal would exempt enrollees who are “physically or mentally unable to work” from work requirements.
  • State Resources
  • Federal Application (January 2018 and May 2018)
  • NHeLP Comments on Mississippi Revised 1115 Waiver (August 2018)

Montana

Both

Montana Health and Economic Livelihood Partnership (HELP) 

  • Status: Renewal and Amendment Pending
  • Authorizes 12 months of continuous coverage for the Medicaid expansion population.
  • Imposes premiums for individuals with income 50-133% FPL. Individuals with income above 100% FPL may be disenrolled for failure to pay premiums, with lockout until the end of the calendar quarter or upon payment of outstanding premiums.
  • Uses an Alternative Benefit Plan for the expansion population with defined provider network.
  • Proposed renewal/amendment would impose work requirements for non-exempt expansion adults age 19-55, with disenrollment and six-month lockout for failure to comply.
  • Proposed renewal/amendment would gradually increase premiums based on the length of time an enrollee is enrolled in the program, capped at four percent of aggregate household income.
  • State Resources
  • Federal Approval
  • Federal Application (August 2019)
  • National Organization Comments on Montana HELP Program 1115 Waiver (October 2015)

North Carolina

Approved

North Carolina's Medicaid Reform Demonstration 

  • Status: Approved
  • Includes funding for pilot programs to test evidence-based interventions in four domains of social determinants of health: housing, food, transportation, and interpersonal safety/toxic stress.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • REJECTED: CMS rejected the state’s proposals to impose premiums and work requirements on expansion group adults, on the grounds that the state currently lacks legislative approval to provide coverage to this group.

North Dakota

No Waiver

Nebraska

Approved

Nebraska Substance Use Disorder Section 1115 Demonstration

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

New Hampshire

Approved

New Hampshire Granite Advantage Health Care Program

 

New Hampshire Building Capacity for Transformation 

  • Status: Approved
  • Enacts payment and delivery reforms to improve behavioral health services, including integrating behavioral and physical health, expanding behavioral health provider capacity, and expanding care coordination services.
  • Uses DSRIP funding to form regionally based Integrated Delivery Networks to incentivize partnership between behavioral health care providers and community-based providers.
  • State Resources
  • Federal Approval
  • Federal Application (October 2018)

 

New Hampshire SUD Treatment and Recovery Access

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

New Jersey

Approved

New Jersey FamilyCare Comprehensive Demonstration

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands community-based behavioral health benefits.

New Mexico

Pending

Centennial Care 2.0

  • Status: Amendment Pending
  • Access to expanded benefits for individuals who complete “healthy behaviors.”
  • Imposes premiums on adult expansion group enrollees above 100% FPL, with disenrollment and 90-day lockout for failure to pay. Re-enrollment is contingent upon payment of past due premiums.
  • Reduces retroactive coverage period to one month for the first year of the demonstration, and eliminates retroactive coverage thereafter.
  • Enrollees with incomes above 100% FPL who are required to pay premiums will be enrolled prospectively and will not receive retroactive coverage.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Proposed amendment would eliminate premiums, eliminate copayments for non-emergency use of the hospital emergency department and non-preferred prescription drugs, and reinstate retroactive eligibility.

Nevada

No Waiver

New York

Pending

New York Medicaid Redesign Team 

Ohio

Approved

Ohio Group VIII Work Requirements and Community Engagement Section 1115 Demonstration Waiver

  • Status: Approved
  • Imposes work requirements as a condition of eligibility for expansion adults ages 19-49, with disenrollment for failure to comply. Enrollees may re-enroll at any time with no lockout period.
  • Exempts individuals with chronic conditions participating in the Specialized Recovery Services (SRS) Program, which includes people living with HIV who also have a serious mental illness.
  • State Resources
  • Federal Approval

 

Ohio Section 1115 Demonstration Waiver for Substance Use Disorder Treatment

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

Oklahoma

Pending

Oklahoma SoonerCare 

  • Status: Amendments Pending
  • SoonerCare Choice program: primary care case management delivery system with patient-centered medical home model.
  • Insure Oklahoma: premium assistance program (including Employer-Sponsored Insurance program and Individual Program) for individuals who do not qualify for SoonerCare or SoonerCare Choice.
  • Eliminates retroactive coverage for certain eligibility groups.
  • Eliminates EPSDT for full time college students age 19 through 22 with incomes above 200% FPL.
  • Eliminates non-emergency transportation for certain eligibility groups.
  • Proposed amendment would impose work requirements as a condition of eligibility for low-income parents and caretakers. Individuals who fail to meet work requirements will be disenrolled with lockout until compliance is achieved.
  • Proposal would exempt enrollees who are “physically or mentally unable to work” from work requirements.

Oregon

No Waiver

Pennsylvania

Approved

Pennsylvania Medicaid Coverage Former Foster Care Youth From a Different State SUD Demonstration

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

Rhode Island

No Waiver

South Carolina

Pending

South Carolina Community Engagement

  • Status: Pending
  • Proposal would impose work requirements as a condition of eligibility for non-disabled adults under age 65 in the low-income parents and caretakers and Transitional Medical Assistance (TMA) eligibility groups, with up to three-month lockout for failure to comply.
  • State Resources
  • Federal Application (May 2019)

South Dakota

Pending

South Dakota Career Connector

  • Status: Pending
  • Proposal would impose work requirements as a condition of eligibility for adults age 19-59 in the low-income parents and caretakers and Transitional Medical Assistance (TMA) eligibility groups in two counties. Individuals who fail to meet work requirements will be disenrolled.

Tennessee

Pending

TennCare II

Texas

No Waiver

Utah

Both

Utah Primary Care Network 

  • Status: Amendments Pending
  • Bridge Plan (approved): Authorizes state to implement partial expansion for adults up to 100% FPL, and to close this group to new enrollment if projected costs exceed state appropriations. This plan will remain in effect until one of the other three options—the Per Capita Cap Plan (filed as a separate waiver application), the Fallback Plan, or the Full Expansion Plan—is approved by CMS.
  • Fallback Plan (pending, submitted as an amendment in November 2019): Proposed amendment would replace the Bridge Plan if CMS rejects the Per Capita Cap Plan waiver proposal. The Fallback Plan would expand Medicaid to adults up to 138% FPL at the enhanced federal match rate, and would include work requirements, lockouts, and the cap on enrollment in the Medicaid expansion group.
  • Full Expansion Plan: This would replace the Bridge Plan if neither the Per Capita Cap Plan nor the Fallback Plan is approved by CMS. The Full Expansion Plan would expand Medicaid to adults up to 138% FPL at the enhanced federal match rate, without work requirements, lockouts, or an enrollment cap on the Medicaid expansion group.
  • Imposes work requirement as a condition of eligibility for “able-bodied” expansion adults age 19-64, with disenrollment and lockout for failure to comply. Re-enrollment contingent upon proof of compliance. Work requirements go into effect January 2020.
  • Provides full state benefits for adults without dependent children with income at 0% FPL who are chronically homeless, involved in the criminal justice system, or in need of SUD or mental health treatment (“Targeted Adults” group). State may elect to impose enrollment cap.
  • Eliminates retroactive coverage for certain enrollees.
  • Eliminates EPSDT for 19- and 20-year-olds in certain eligibility groups.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands dental services to certain adults with income at 0% FPL who are receiving SUD treatment.
  • Authorizes clinically managed residential withdrawal management services, referred to as “social detoxification,” to Medicaid-eligible adults in Salt Lake County.
  • Exempts enrollees who are “physically or mentally unable to work” from work requirements.
  • Proposed amendment would impose 5-year lifetime cap on benefits for expansion group and “Targeted Adults” group.
  • Proposed amendment would eliminate presumptive eligibility for certain populations.
  • REJECTED: CMS rejected the state’s request to receive the enhanced federal match rate for partial expansion. The enhanced match is unavailable for waivers that limit enrollment in the new adult group, either by implementing an income cutoff of less than 138% FPL or through an enrollment cap.  

 

Utah Per Capita Cap 1115 Demonstration

  • Status: Pending
  • Proposal would replace the Bridge Plan currently in effect under the Primary Care Network waiver.
  • Proposal would authorize a per capita cap funding mechanism for the expansion group, which will include the “Targeted Adults” group.
  • Proposal incorporates provisions currently authorized or pending approval under the state’s Primary Care Network, including partial Medicaid expansion up to 100% FPL, work requirements, and enrollment caps.
  • REJECTED: CMS rejected the state’s request to receive the enhanced federal match rate for partial expansion. The enhanced match is unavailable for waivers that limit enrollment in the new adult group, either by implementing an income cutoff of less than 138% FPL or through an enrollment cap. 

Virginia

Pending

The Virginia Governor's Access Plan (GAP) and Addiction and Recovery Treatment Services (ARTS) Delivery System Transformation

  • Status: Renewal Pending
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Pending renewal would sunset existing Governor’s Access Plan (GAP) program, which provided behavioral health services to populations not previously eligible for Medicaid, and transitions GAP enrollees to Medicaid expansion group.
  • Pending renewal would provide housing and employment supports for high-need enrollees.
  • Pending renewal would impose work requirements as a condition of eligibility for all Medicaid expansion adults, with lockout until the end of the 12-month eligibility period for failure to comply. Early re-enrollment may be permitted if enrollee complies with opportunities to cure non-compliance, as specified in consumer notices.
  • Pending renewal would establish premiums through monthly contributions to a HWA account (similar to a Health Savings Account) for enrollees with income at or above 100% FPL. Disenrollment for failure to pay premiums with lockout until enrollee makes one premium payment. Premiums will be reduced by 50% for enrollees who comply with healthy behaviors. Account funds can be used to pay for health-related services not covered by Medicaid, but only if enrollee complies with healthy behaviors and contributes a minimum of 10 monthly premiums over the year.
  • Pending renewal would exempt medically frail individuals, including people living with HIV, from work requirements and premiums.

Vermont

Approved

Vermont Global Commitment to Health 

  • Status: Approved
  • Authorizes premium subsidies for individuals enrolled in a QHP with incomes at or below 300% FPL.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • Expands community-based behavioral health benefits.
  • State Resources
  • Federal Approval

Washington

Approved

Washington Medicaid Transformation Project

  • Status: Approved
  • Establishes Accountable Communities of Health (ACHs) comprised of clinical and community service providers to lead projects including capacity building, care delivery redesign, and prevention and health promotion for Medicaid beneficiaries.
  • Expands community-based behavioral health benefits, such as supportive housing and employment services.
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
  • State Resources
  • Federal Approval

Wisconsin

Approved

  • Wisconsin BadgerCare Reform 

    • Status: Approved
    • Authorizes state to implement partial expansion by providing benefits to non-pregnant childless adults ages 19-64 with incomes at or below 100% FPL. “Childless” adults may have children, but do not live with children under age 19.
    • Imposes premiums for individuals with incomes above 50% FPL, with disenrollment and 6-month lockout for failure to comply. Premiums may be reduced for individuals who do not engage in “health risk behaviors,” including alcohol consumption and illicit drug use. Early re-enrollment permitted upon payment of past due premiums.
    • Imposes work requirements as a condition of eligibility for adults ages 19-49.
    • Imposes 48-month enrollment time limit, followed by 6-month lockout, for enrollees subject to work requirements. Months in which the individual meets work requirements do not count towards the 48-month limit.
    • Requires completion of health risk assessment as a condition of eligibility.
    • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD.
    • Enrollees who are “physically or mentally unable to work” are exempt from work requirements and 48-month enrollment time limit.

    Wisconsin Senior Care 

    • Status: Approved
    • Provides comprehensive prescription drug benefits to Wisconsin residents age 65+ with income at or below 200% FPL who are not otherwise eligible to receive full Medicaid benefits.
    • State Resources
    • Federal Approval

West Virginia

Approved

West Virginia Creating a Continuum of Care for Medicaid Enrollees with Substance Use Disorder 

  • Status: Approved
  • Authorizes SUD treatment services for short-term residents in residential and inpatient treatment settings that qualify as an IMD
  • Expands community-based behavioral health benefits.
  • Federal Approval

Wyoming

No Waiver

Guam

No Waiver

Northern Mariana Islands

No Waiver

American Samoa

No Waiver

Puerto Rico

No Waiver

Marshall Islands

No Waiver

Palau

No Waiver

Federated States of Micronesia

No Waiver

Virgin Islands

No Waiver

Premiums

Yes
No

Work Requirements

Yes
No

Enrollment Time Limit/Lifetime Cap

Yes
No

SUD/Behavioral Health

Yes
No

HIV- or Hepatitis-Specific Exemptions

Yes
No

Medicaid Waiver Map – Background Information

What is a Medicaid 1115 Waiver?

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve demonstration projects that promote the objectives of the Medicaid program. To encourage innovative demonstration projects, section 1115 gives states additional flexibility to “waive” certain federal Medicaid requirements.  An 1115 waiver or demonstration project typically lasts for five years (with the option to renew). Demonstration projects must also be “budget neutral” to the federal government, meaning that during the course of the project, the federal Medicaid expenditures cannot be more than federal spending would have been without the project.

What Kinds of Things Can States Do with an 1115 Waiver?

States have used the flexibility provided through 1115 waivers for a number of different purposes, including to:

  • Implement the Medicaid expansion in an innovative way, for instance through purchase of Qualified Health Plans for the Medicaid expansion population
  • Expand services for a particular population, for instance, substance use disorder services to better address the opioid epidemic
  • Test innovative ways to pay for and deliver care, for instance through expansion of the types of providers eligible to seek Medicaid reimbursement or programs that incentivize partnerships between hospital systems and community and public health providers to improve individual and population health 
  • Impose additional eligibility requirements, such as work requirements, increased cost-sharing, monthly premiums, and lifetime enrollment caps
  • Expand eligibility for family planning services, for instance, by increasing the income threshold and expanding the program to men as well as women

How Do Medicaid 1115 Waivers Impact HIV and Hepatitis Prevention Programs?

Because 1115 waivers can be used to develop innovative approaches to population health, with an emphasis on prevention, there may be reimbursement opportunities for HIV prevention services included in these types of waivers. For instance, some waivers have been used to cover services provided by Community Health Workers and other peer workers or to cover HIV linkage services. Waivers are also being used to increase drug user health services and address the opioid epidemic and could include new opportunities for partnerships with HIV and hepatitis public health programs. 

How Can I Weigh in with My State or the Federal Government During the 1115 Waiver Approval Process?

There are a number of transparency and notice and comment requirements that must precede 1115 waiver approval. At the state level, states must post all 1115 waiver applications on the state Medicaid website and provide a public comment period to solicit input from interested parties. This often includes public hearings and listening sessions to discuss the proposal and solicit feedback. Following the state notice and comment process, the application is submitted for federal review by CMS, where it is posted on the CMS website and subject to another notice and comment period from interested parties. Public health stakeholders should weigh in at all stages of the 1115 waiver application process to ensure that proposals protect access to care and prevention services for people living with and at risk for HIV and hepatitis.  

Glossary

  • ACO: Accountable Care Organizations are groups of providers (e.g., doctors, hospitals, community health centers) that receive financial incentives to work together to provide coordinated care across provider types and settings for patients
  • ACH: Accountable Communities of Health are similar to ACOs and bring together clinical providers as well as social services programs and providers to provide patient-centered care that addresses health care needs as well as social determinants of health
  • CHIP: The Children’s Health Insurance Program provides coverage to eligible children through Medicaid or a separate program. Like Medicaid, it is administered by states subject to federal rules and jointly funded by states and the federal government
  • CMS: The Centers for Medicare and Medicaid Services is the federal agency that oversees the Medicaid program
  • DSRIP: Delivery System Reform Incentive Plans are a type of 1115 waiver states may use to restructure the way they deliver and pay for Medicaid and other safety net health services
  • FPL: Federal poverty level, a federal income threshold used to determine eligibility for public programs that are based on financial need
  • MCO: Managed Care Organizations are entities that serve Medicaid beneficiaries through a network of providers through a financial and contractual arrangement with the state Medicaid program
  • Premium Assistance: A Medicaid option that allows states to use Medicaid funding to purchase commercial insurance for eligible beneficiaries on the private market (as opposed to through the traditional Medicaid fee-for-service or managed care systems)

What Other Resources Are There on 1115 Waivers?