COVID-19: 1115 Waiver Demonstrations
On January 31, 2020, the Secretary of Health and Human Services (HHS) declared a public health emergency, effective as of January 27, 2020, for the entire United States to aid the nation’s healthcare community in responding to the 2019 novel Coronavirus. On March 13, 2020, the President declared the ongoing Coronavirus Disease 2019 (COVID-19) pandemic of sufficient severity and magnitude to warrant an emergency declaration for all states, tribes, territories, and the District of Columbia pursuant to section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-5207 (the “Stafford Act”).
In an effort to assist states with addressing the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services (CMS) developed a section 1115 demonstration opportunity available to states under title XIX (Medicaid) of the Social Security Act (the Act). Under this demonstration opportunity, effective retroactively to March 1, 2020 states may select from a variety of options to deliver the most effective care to their beneficiaries as a result of the COVID-19 public health emergency.
The COVID-19 section 1115 demonstration opportunity makes available a number of authorities to assist states in enrolling and covering beneficiaries in Medicaid and to focus agency operations on addressing the COVID-19 pandemic.
Healthy Adult Opportunity Section 1115 Demonstration Application Template
On January 30, 2020 the Centers for Medicare & Medicaid Services (CMS) announced a new opportunity to support states with greater flexibility to improve the health of their Medicaid populations. The Healthy Adult Opportunity (HAO) Demonstration emphasizes the concept of value-based care while granting states with extensive flexibility to administer and design their programs within a defined budget.
To offer states this option, the HAO will involve the use of section 1115(a)(2) authority to provide coverage to individuals not eligible for benefits under the state’s Medicaid state plan, while affording states maximum flexibility in the administration of benefits for such individuals. The HAO demonstration is available to states for a limited population – adults under age 65 who are not eligible for Medicaid on the basis of disability or need for long term care services and supports, or are not eligible under a state plan.
- Healthy Adult Opportunity Section 1115 Demonstration Application Template
- State Medicaid Director Letter – Healthy Adult Opportunity
- Healthy Adult Opportunity Overview
Application Template for New Section 1115 Demonstrations
States have the option of using an interim template to develop their own applications. States are also encouraged to use the accompanying budget neutrality template to develop their own applications. States are also encouraged to use the accompanying in developing their applications. States may either download and complete the template, or simply use it as guide as they develop the application. States may submit completed applications to firstname.lastname@example.org.
Application Template for Extending Section 1115 Demonstrations – Fast Track Reviews
CMS established a new “fast track” process for reviewing proposals from states to extend established Medicaid and Children's Health Insurance Program (CHIP) 1115 demonstrations that reauthorize longstanding policies with proven program outcomes. States that want to be considered for the fast track process must use the streamlined extension application for the 1115 extension pathway it is requesting to be extended under.
Download and complete the fillable application template for:
- Section 1115(a) extensions
- Section 1115(e) extensions
- Section 1115(f) extensions
- Fast Track Extension Template
States may submit completed applications to email@example.com. For more information on the fast track review process, please review the CMCS Informational Bulletin released July 24, 2015.
Section 1937 of the Social Security Act as in Effect in 2009
This document provides the statutory language in effect as of December 1, 2009, and may be helpful to section 1115 demonstration states analyzing benefits provided to certain demonstration eligible as of that date.
Benchmark Standards in Effect on December 1, 2009
More About the State Section 1115 Application Process
Effective April 27, 2012, in accordance with section 10201(i) of the Affordable Care Act that set forth transparency and public notice requirements for section 1115 demonstrations, states will need to include the following components in demonstration applications for CMS to consider the application submission complete for the purpose of initiating federal review.
Initial 1115 Submissions
- A comprehensive program description of the demonstration, including the goals and objectives to be implemented under the demonstration project
- A description of the proposed health care delivery system, eligibility requirements, benefit coverage and cost sharing (premiums, copayments, and deductibles) required of individuals who will be impacted by the demonstration to the extent such provisions would vary from the state’s current program features and the requirements of the Social Security Act
- An estimate of the expected increase or decrease in annual enrollment, and in annual aggregate expenditures, including historic enrollment or budgetary data, if applicable
- Current enrollment data, if applicable, and enrollment projections expected over the term of the demonstration for each category of beneficiary whose health care coverage is impacted by the demonstration
- Other program features that the demonstration would modify in the state’s Medicaid program and/or CHIP
- The specific waiver and expenditure authorities that the state believes to be necessary to authorize the demonstration
- The research hypotheses that are related to the demonstration’s proposed changes, goals, and objectives; a plan for testing the hypotheses in the context of an evaluation; and, if a quantitative evaluation design is feasible, the identification of appropriate evaluation indicators
- Written documentation of the state’s compliance with the public notice requirements, with a report of the issues raised by the public during the comment period, which shall be no less than 30 days, and how the state considered those comments when developing the demonstration application
Extensions of Existing Demonstrations
- A historical narrative summary of the demonstration project, which includes the objectives set forth at the time the demonstration was approved, evidence of how these objectives have or have not been met, and the future goals of the program
- If changes are requested, a narrative of the changes being requested along with the objective of the change and the desired outcomes
- A list and programmatic description of the waivers and expenditure authorities that are being requested for the extension period, or a statement that the state is requesting the same waiver and expenditure authorities as those approved in the current demonstration
- Summaries of External Quality Review Organization reports, managed care organization and state quality assurance monitoring, and any other documentation of the quality of and access to care provided under the demonstration
- Financial data demonstrating the state’s historical and projected expenditures for the requested period of the extension, as well as cumulatively over the lifetime of the demonstration. This includes a financial analysis of changes to the demonstration requested by the state
- An evaluation report of the demonstration, including evaluation activities and findings to date, plans for evaluation activities during the extension period, and if changes are requested, identification of research hypotheses related to the changes and an evaluation design for addressing the proposed revisions
- Documentation of the state’s compliance with the public notice process, with report of the issues raised by the public during the comment period and how the state considered the comments when developing the demonstration application
States should review the full content of section 42 CFR 431.412 of the CMS Final Rule to confirm that it has met all of the pre-submission application requirements outlined in this subpart. Please note that while the Final Rule left open the applicability of public notice requirements to proposed amendments, to ensure that the public is afforded the same degree of transparency and input on proposed amendment requests, CMS applies application "completeness" requirements to state applications for amendments as well as posts and accepts public comments on all amendments.
Final Rule-Review and Approval Process for Medicaid and CHIP Section 1115 Demonstrations
Guidance for Former Foster Care Youth Section 1115 Demonstrations
On November 21, 2016, CMS announced a section 1115 opportunity to allow Medicaid coverage of former foster care youth who have moved to a different state. To assist states in pursuing section 1115(a) demonstration authority to cover former foster care youth who currently reside in a different state than the state in which they were in foster care as of age 18 or when they “aged out” of foster care, CMS has developed two different guidance documents for states—one for states that provide Medicaid coverage under the new adult group and one for states that do not provide coverage under the new adult group. These guidance documents are structured so that states can be sure to include the necessary programmatic elements for providing coverage of former foster care youth under a section 1115 demonstration in alignment with federal transparency requirements.