Brief Issue Description
This document outlines the challenges that states have faced when reporting waiver-related information on the WAIVER-PARTICIPATION-ELG00012 segment and recommends best practices for accurately reporting the waiver identifier and the waiver type consistently across T-MSIS files. The guidance in this document applies to all files in which WAIVER-TYPE and WAIVER-ID are reported. In addition, in specific cases a waiver identifier will be reported in the AFFILIATED-PROGRAM-ID on the Provider File (see table 1 for all data element numbers affected by this guidance).
Table 1. Data Element Numbers Affected by Waiver ID and Waiver Type Guidance
|IP File||LT File||OT File||RX File|
The widespread use of waivers in the design of state Medicaid managed care programs has made waivers increasingly important to policy-makers who rely on Transformed Medicaid Statistical Information System (T-MSIS) data to monitor state Medicaid programs, making it imperative for states to report reliable data to its T-MSIS waiver fields. In T-MSIS, all waivers in which a beneficiary is enrolled are expected to be reported in the eligible file. Waiver information is separated into its own record segment (WAIVER-PARTICIPATION-ELG00012 in the T-MSIS Eligible File) to allow states to create as many records as necessary to fully document all waivers applicable to each beneficiary. The waiver participation record segment captures the waiver type, the federal waiver identifier, and the period in which the beneficiary is enrolled in the waiver.
The WAIVER-TYPE data element includes values for five broad waiver categories based on their statutory authorities: Social Security Act (SSA) Section 1115 demonstrations, SSA Subsection 1915(b) waivers, SSA Subsection 1915(c) waivers, Patient Protection and Affordable Care Act (PPACA) Section 1332 waivers, and concurrent SSA Subsection 1915(b) and 1915(c) waivers. Each of these waiver authorities has a distinct purpose and distinct requirements. These same waiver categories were reported in MSIS; however, instead of 10 valid values available under MSIS, T-MSIS allows states to report valid values at a more granular level in the T-MSIS WAIVER-TYPE field to distinguish among the different waivers under which an eligible individual is covered under Medicaid. The most noticeable difference in T-MSIS is the expanded options for classifying 1915(c) waivers, although the 1115 demonstration waiver types and 1915(b) waiver types were also expanded.
The WAIVER-ID formats reported in T-MSIS have been inconsistent across states. At times, T-MSIS submissions have not included the federal waiver identifier or included a modified version that does not completely match the crosswalk submitted during the T-MSIS source-to-target-mapping process. Examples of modified waiver identifiers submitted to T-MSIS that don't match the crosswalk include: truncating the federal waiver identifier and appending the federal waiver identifier with additional characters to show regional waiver operations. Further, some states have mapped incorrect waiver type codes to their waiver IDs or were unclear about how to determine the correct waiver type assignment. These scenarios lead to data quality issues that prevent CMS from validating an eligible beneficiary's waiver enrollment with the waivers approved for the state and identifying the volume of waiver beneficiaries for the time period indicated. They also prevent linking services and payments reported in the claims to enrollment in the waiver.
Additionally, some states faced challenges when attempting to populate the WAIVER-TYPE field. States identified that multiple waiver type valid values would apply to a specific waiver program. Selecting which waiver type should have priority is a challenge for the states reporting eligibility files. This impacted the data quality when comparing waiver reporting across states.
The WAIVER-ID field should be populated with the appropriate federal identifier, which is assigned during the waiver approval process. The WAIVER-ID field and the WAIVER-TYPE field from the Eligible File are used to cross-reference waiver ID and waiver type reporting on the claims file as well as the managed care file.
Each state submitted a waiver crosswalk during the T-MSIS source-to-target-mapping process that included a list of all waivers, their federal waiver identifiers, and the statutory authority (Sections 1115, 1915(b), or 1915(c)). States must ensure that their assignment of WAIVER-TYPE to WAIVER-ID in T-MSIS is updated, if necessary, to reflect the expanded list of waiver type options available (see Table 5) and that all subsequent submissions are consistent with that list. Additionally, states must ensure that beneficiaries are only enrolled in the waiver during the periods that the waiver is active.
Waiver ID Guidance
States should ensure that they are only reporting the appropriate federal waiver ID in the WAIVER-ID field. For 1115 demonstrations, the appropriate waiver ID is the full federal waiver ID in the WAIVER-ID field. Both 1915(b) and 1915(c) waivers should be reported with core federal waiver ID in the WAIVER-ID field. The waiver ID reported in T-MSIS should include all periods, hyphens and backslashes as these are part of the official waiver ID. The waiver ID can be found on the approval letter for the waiver or on the approved application of the waiver. State assigned waiver IDs should never be reported in the waiver ID field.
Federal waiver IDs have two different formats depending upon the waiver type (Examples in Table 2):
- 1115 demonstrations are assigned a federal demonstration ID that begins with “11-W-“ or “21-W-“ and is followed by a 5 digit number, a slash, then another number representing the CMS region of the state. The 1115 demonstration ID does not include a renewal number or amendment number.
- 1915(b) waivers and 1915(c) waivers are assigned a waiver ID in which the first two positions are the state abbreviation, followed by a unique waiver ID number for that state, then a renewal number (preceded by an “R”) and ending in an amendment number. However, only the “core” ID consisting of the state abbreviation and the number unique to the state should be reported in the WAIVER-ID field. No renewal or amendment numbers should be reported.
|Waiver Name||Waiver Authority||Assigned Waiver ID||Core Waiver ID (Reported in T-MSIS)|
|New Jersey Comprehensive Waiver Demonstration||1115 Demonstration||11-W-00279/2||11-W-00279/2|
|MT Passport to Health||1915(b)||MT.0002.R02.00||MT.0002|
|OR Medically Involved Children’s Waiver||1915(c)||OR.0565.R02.00||OR.0565|
Waiver Type Guidance
States should review their methodology for assigning WAIVER-TYPE values to ensure that it reflects the correct mapping for each of the state’s waivers. Information regarding the waiver type can be found in the approved waiver application and approval letter documentation. Validating the waiver type assignment can be done by revisiting the state’s waiver crosswalk, as well as waiver applications and approval letters that provide details about the types of waivers approved for each state under the different authorities.
The WAIVER-TYPE valid values reported in the data dictionary will be updated to capture the new valid values. The valid values reported in table 5 below should be used in the WAIVER-TYPE field on the WAIVER-PARTICIPATION-ELG00012 file segment and in the WAIVER-TYPE fields reported on the claims file. Table 5 below includes two sections of waiver types; current waiver type values and waiver type values to be phased out.
When states implement a new 1915(b) or 1915(c) waiver or 1115 demonstration or a previous 1915(b) or 1915(c) waiver or 1115 demonstration is renewed, states should update the WAIVER-TYPE to reflect the “Current T-MSIS WAIVER-TYPES” shown in Table 5a. Table 5b contains a list of the 1915(b) and 1915(c) waiver types that should be phased out. States can continue to use the “T-MSIS WAIVER-TYPE valid values to be Phased Out” shown in Table 5b on waivers until they are renewed. When a waiver is renewed, then a new record segment should be created to capture the updated waiver type. An example is provided in table 3 below, where 1915(c) WAIVER-ID XX.0040 is first reported with WAIVER-TYPE=”06” and is updated to the new 1915(c) WAIVER-TYPE value of “33”. As the “Waiver/Demonstration Renewal Schedule” column of Table 5b indicates, the approval or renewal of all 1915(b) waivers, 1915(c) waivers, and 1115 demonstrations are expected to expire within the next five (5) years. Therefore, CMS is prospectively end dating the WAIVER-TYPE values being phased out according to Table 5b. All T-MSIS segments containing the WAIVER-TYPE values that are being phased out according to Table 5b must be end dated by the end date of the valid value. If a new waiver or demonstration has been approved or existing waiver or demonstration has been renewed at any point between now and the end date of the valid value, states are encouraged to begin reporting new T-MSIS segments with the updated WAIVER-TYPE from that point forward, converting all applicable segments to the new WAIVER-TYPE values by the time the old WAIVER-TYPE valid values have been end dated. Any segment with a WAIVER-TYPE that is being phased out with a segment end date greater than the end of the WAIVER-TYPE value will trigger validation rule errors.
Waiver type valid values are being updated to improve on CMS’s ability to perform program oversight and policy improvement. The WAIVER-TYPE valid values for 1115 demonstrations have been updated to reflect the current subtypes of 1115 demonstrations that may vary from person to person for the same waiver. The 1915(b) waiver type values are being consolidated into one valid value each because they are never expected to vary from person to person for the same waiver. The 1915(c) waiver valid values are being consolidated because the information conveyed by the values being phased out can and should be reported as a person’s HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE.
After a 1915(b) waiver is renewed or implemented, a new record should be reported with the WAIVER-TYPE value ”32”. Similarly, after a 1915(c) waiver is renewed or implemented, a new record should be reported with the WAIVER-TYPE value ”33”.
Some 1915(c) waivers operate concurrently with 1915(b) waivers or with 1115 demonstrations that authorize managed care operating authority. The 1915(c) waivers that operate concurrently with a 1915(b) waiver or 1115 demonstration should be reported with a WAIVER-TYPE of “20”, which indicates a 1915(c) waiver operating concurrently with a managed care authority. For example, the 1915(c) waiver XX.0312 operates concurrently with the 1915(b) waiver XX.0567. The 1915(c) waiver XX.0312 would be reported with the WAIVER-TYPE valid value of “20” and the 1915(b) waiver XX.0567 would be reported with a WAIVER-TYPE valid value of “32”. Similarly, if the 1915(c) waiver XX.0313 is concurrent with the 1115 delivery system reform demonstration with WAIVER-ID 11-W-00568/4, the 1915(c) waiver XX.0312 would be reported with the WAIVER-TYPE valid value of “20” and the 1115 demonstration WAIVER-ID 11-W-00568/4 would be reported with a WAIVER-TYPE valid value of “30” for delivery system reform.
When reporting 1115 waivers, all applicable waiver type values should be reported for each WAIVER-ID value on the eligible file. If a WAIVER-ID has more than one applicable WAIVER-TYPE value, then a record segment will reported for each WAIVER-TYPE under that waiver ID. For example, if waiver 11-W-00568/4 has three applicable waiver types that apply to a given enrollee, three WAIVER-PARTICIPATION-ELG00012 record segments will be reported for the enrollee with the with WAIVER-ID field populated with 11-W-00568/4, and each record segment reported with a different WAIVER-TYPE (Table 4).
Only one WAIVER-TYPE type can be reported per WAIVER-ID on the claims file. The “other” WAIVER-TYPE values should be reported on a claim instead of the more granular values in cases where a WAIVER-ID is associated with more than one WAIVER-TYPE. For example, if a claim is reported with a WAIVER-ID that has associated WAIVER-TYPE values of “25”, “29’, and “30” on the eligible file (for the 1115 substance use demonstration, managed long term services and support, and delivery system reform), then the “other” 1115 WAIVER-TYPE value of “01” should be reported in the WAIVER-TYPE field of the claim.
|MSIS IS||WAIVER-ID||WAIVER-TYPE||Waiver Description|
|123||11-W-00568/4||25||1115 Substance use demonstration|
|123||11-W-00568/4||29||1115 Managed long term services and support|
|123||11-W-00568/4||30||1115 Delivery system reform|
Waiver Effective and End Dates
The WAIVER-ENROLLMENT-EFF-DATE (ELG174) and WAIVER-ENROLLMENT-END-DATE (ELG175) are used to capture the period the beneficiary is enrolled in the specific waiver. The WAIVER-ENROLLMENT-EFF-DATE should be reported to capture the first date on which the beneficiary is enrolled in the waiver. The WAIVER-ENROLLMENT-END-DATE should capture the date in which the beneficiary is no longer enrolled in the waiver program.
If there is a gap in the beneficiary’s enrollment in a waiver program, then a new record will need to be added to the waiver participation record segment to capture the gap in enrollment. For example, if a beneficiary enrolled in a 1915(c) waiver loses Medicaid coverage on January 31st of 2017 and becomes eligible for Medicaid and the 1915(c) waiver program in June, then a second record will need to be created. The record for the waiver enrollment for the prior period of Medicaid enrollment will be reported with A WAIVER-ENROLLMENT-END-DATE=20170131. A new record for with the same WAIVER-ID will be reported with a WAIVER-ENROLLMENT-EFF-DATE=20170601. These two records will capture the beneficiary’s gap in coverage.
|01||1115 Other demonstration|
|22||1115 Pharmacy demonstration|
|23||1115 Disaster-related demonstration|
|24||1115 Family planning demonstration|
|25||1115 Substance use demonstration|
|26||1115 Premium Assistance demonstration|
|27||1115 Beneficiary engagement demonstration|
|28||1115 Former foster care youth from another state|
|29||1115 Managed long term services and support|
|30||1115 Delivery system reform|
|20||1915(c) waiver concurrent with an 1115 or 1915(b) managed care authority|
|WAIVER TYPE||Description||Waiver/Demonstration Renewal Schedule|
|02||1915(b)(1) – These waivers permit freedom-of-choice or mandatory managed care with some voluntary managed care.||1915(b): – Approved for 2 years; 2-year renewal period; 5-year approval and/or renewal period for waivers serving dual eligible enrollees|
|03||1915(b)(2) – These waivers allow states to use enrollment brokers.|
|04||1915(b)(3) – These waivers allow states to use savings to provide additional services that are not in the State Plan.|
|05||1915(b)(4) – These waivers allow fee for service selective contracting.|
|06||1915(c)—Aged and Disabled||1915(c): – Approved for 3 years; 5-year renewal period; 5-year approval and/or renewal period for waivers serving dual eligible enrollees|
|10||1915(c)—Intellectual and Developmental Disabilities|
|13||1915(c)—Technology Dependent or Medically Fragile|
|15||1915(c)—Enrolled in 1915(c) waiver for unspecified or unknown populations|
|16||1915(c)—Autism/Autism spectrum disorder|
|18||1915(c)—Mental Illness—Age 18 or Older|
|19||1915(c)—Mental Illness—Under Age 18|
|21||1115 Health Insurance Flexibility and Accountability (HIFA) demonstration||1115: – Approved for 5 years; 3-year renewal period; 5-year approval and/or renewal period for demonstration serving dual eligible enrollees|
 If a provider is affiliated with a waiver program, then that information should be captured in the provider file. Specifically, if the PRV119 - AFFILIATED-PROGRAM-TYPE=3 (waiver), then a waiver ID will be expected in the PRV120 - AFFILIATED-PROGRAM-ID field.
 In MSIS reporting, states were only able to report up to three waivers per beneficiary each month.
 T-MSIS Data Dictionary V2.0 Appendix A
 For 1115 demonstrations, end users identified that both WAIVER-TYPE and WAIVER-ID were important to perform analysis. End users identified that when analyzing 1915(b) and 1915(c) waivers, the WAIVER-ID is the primary data element used in their analysis
 WAIVER-TYPE has been updated to be reported as a key field for identifying unique records on WAIVER-PARTICIPATION-ELG00012. The “The Rec Segment Keys & Constraints” tab of the T-MSIS data dictionary will be updated to capture this information.
 Section 1915(b) waivers are generally approved for an initial two years with two-year renewal periods. For those serving individuals who are dually enrolled in Medicare and Medicaid, five-year approval and renewal periods are available. Please see the following resource for more information: Medicaid and CHIP Payment and Access Commission (MACPAC): Waivers, Medicaid and CHIP Payment and Access Commission (MACPAC): 1915(b) Waivers
 HCBS waivers are generally approved for three years though five years may be provided for those serving persons dually enrolled in Medicaid and Medicare with five-year renewal periods. Please see the following resources for more information: Medicaid and CHIP Payment and Access Commission (MACPAC): Waivers, Medicaid and CHIP Payment and Access Commission (MACPAC): 1915(c) Waivers, Social Security Administration: Sec. 1915
 Section 1115 demonstrations include a research or evaluation component and usually are approved for a five-year period, with a possible three-year renewal period after the first five years. CMS has approved 10-year demonstration extensions in a small number of cases. Please see the following resources for more information: Medicaid and CHIP Payment and Access Commission (MACPAC): Waivers, Medicaid and CHIP Payment and Access Commission (MACPAC): Section 1115 research and demonstration waivers