Medicaid Waivers

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Federal authorities (Waivers and State Plan Amendments)

1115(a) States can apply for a Section 1115 waiver to test experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs.

1902(a)(70) NEMT States can use Section 1902(a)(70) statutory authority to amend their Medicaid state plans to establish non‐emergency medical transportation (NEMT) brokerage programs without regard to the statutory requirements for comparability, geographic region served, and freedom of choice.

1905(t) States can use Section 1905(t) statutory authority to create voluntary primary care case management (PCCM) managed care programs.

1915(a) States can use Section 1915(a) statutory authority to enter into a voluntary contract with an entity to provide State plan services. Enrollment is voluntary.

1915(b) States can use Section 1915(b) waivers to mandate enrollment of special populations into managed care delivery systems or otherwise limit beneficiaries’ choice of providers.

1915(c) States can use Section 1915(c) waivers to provide long-term services and supports (LTSS) in home and community settings rather than institutional settings. By using 1915(c) waivers concurrently with 1915(a), 1932(a), or 1915(b) authorities, states can provide LTSS through managed care. Without a concurrent waiver allowing a state to deliver these services through managed care, 1915(c) waiver services are paid fee-for service.

1915(i) States can use Section 1915(i) statutory authority to offer a variety of home and community-based services through the state plan, regardless of whether enrollees meet the institutional level of care. By using 1915(i) authority concurrently with 1915(a), 1932(a), or 1915(b) authorities, states can provide LTSS through managed care.

1915(j) States can use Section 1915(j) statutory authority to offer self- directed personal assistance services provided under the state plan and/or section 1915(c) waivers. By using 1915(j) authority concurrently with 1915(a), 1932(a), or 1915(b) authorities, states can provide LTSS through managed care.

1915(k) States can use Section 1915(k) statutory authority to provide home and community based attendant services and supports (the "Community First Choice Option") under their state plan. By using 1915(k) authority concurrently with 1915(a), 1932(a), or 1915(b) authorities, states can provide LTSS through managed care.

1932(a) State can use Section 1932(a) statutory authority to mandate enrollment of Medicaid beneficiaries in managed care entities without section 1915(b) or 1115 waiver authority. However, certain groups are exempt from mandatory enrollment (for example, Medicare-Medicaid dual enrollees, Native Americans and children with special health care needs), and with exceptions for rural areas, the state must offer at least two managed care options.

1937 Alternative Benefit Plan States can use Section 1937 statutory authority to provide alternative benefits tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan. The Affordable Care Act of 2010 amended Section 1937 by requiring states to provide an alternative benefit package to the newly eligible adult (Section VIII) Medicaid expansion population, which must cover 10 essential health benefits described in ACA Section 1302(b).

1945 Health Homes States can use Section 1945 statutory authority to coordinate care for Medicaid beneficiaries who have chronic conditions. Although Medicaid Health Homes are not a managed care system, states can combine 1945 authority with a managed care authority such as 1915(a), 1932(a), or 1915(b) to provide health home services through managed care entities.