Medicaid Waivers Overview Kathryn Smith, RN, DrPH

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  • Medicaid Waivers OverviewKathryn Smith, RN, DrPH

    2010 CHLA - All Rights Reserved

  • What is a Medicaid WaiverA waiver is a document that asks the Federal government to waive a Medicaid rule in order to deliver care in a different wayEach state has a State Medicaid Plan that defines for the Federal government how the state will operate its Medicaid programThere are certain rules that each state must follow in its Medicaid program, for instance statewidenessIf a state wants to experiment with a different way of delivering or paying for services, it must either submit a new State Medicaid Plan, or ask for one of the Medicaid rules to be waivedWaivers are typically used when the requested changes are not in alignment with current Medicaid rules*

  • Types of Medicaid WaiversSection 1115 Research and Demonstration WaiversSection 1915 (b) Managed Care WaiversSection 1915 (c) Home and Community Based Services WaiversConcurrent Section 1915 (b) and 1915 (c) Waivers


  • Section 1115 Research and Demonstration Projects

    States can apply for program flexibility to test new or existing ways of providing or financing carePotential uses of an 1115 waiver by a state:Expand eligibility to individuals who are not otherwise eligibleProvide services not typically covered by MedicaidUse innovative service delivery methods to increase efficiency and decrease costExample is the CA Bridge to Health Reform, transitioning Healthy Families children and youth into Medi-Cal


  • Section 1915(b) Managed Care WaiversStates can apply to provide services through managed care organizations or otherwise limit peoples choices of providersThese can be used to:Implement managed care that restricts providersAllow a county or local government to aid people in choosing a managed care planUsing the savings from managed care to provide additional servicesRestrict the number of type of providersAn example is the CA HIV/AIDS waiver that provides enhanced case management and services to those with HIV/AIDS*

  • Section 1915(c) Home and Community Based Services WaiversStates can apply to provide long term care services in the home or community settings, rather than institutionsStates can offer a variety of services including standard medical services and non medical services including: case management, home health aide, homemaker, personal care, adult day health care and respite, as well as other services that would divert a person from an institution to homeAn example in CA: the CA HCBS Waiver for Californians with Developmental Disabilities providing a full range of services to those with developmental disabilities*

  • Concurrent Section1915(b) and 1915(c) WaiversStates can apply to implement two waivers at the same time to provide comprehensive services to the elderly and those with disabilitiesStates can provide traditional long term care services in the context of a managed care environment*