Medicaid Waivers OverviewKathryn Smith, RN, DrPH

What is a Medicaid Waiver

• A waiver is a document that asks the Federal government to waive a Medicaid rule in order to deliver care in a different way

• Each state has a State Medicaid Plan that defines for the Federal government how the state will operate its Medicaid program

• There are certain rules that each state must follow in its Medicaid program, for instance “statewideness”

• If 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 waived

• Waivers are typically used when the requested changes are not in alignment with current Medicaid rules

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Types of Medicaid Waivers

• Section 1115 Research and Demonstration Waivers• Section 1915 (b) Managed Care Waivers• Section 1915 (c) Home and Community Based Services

Waivers• Concurrent Section 1915 (b) and 1915 (c) Waivers

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Section 1115 Research and Demonstration Projects

• States can apply for program flexibility to test new or existing ways of providing or financing care

• Potential uses of an 1115 waiver by a state:– Expand eligibility to individuals who are not otherwise

eligible– Provide services not typically covered by Medicaid– Use innovative service delivery methods to increase

efficiency and decrease cost• Example is the CA Bridge to Health Reform, transitioning

Healthy Families children and youth into Medi-Cal

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Section 1915(b) Managed Care Waivers

• States can apply to provide services through managed care organizations or otherwise limit people’s choices of providers

• These can be used to:– Implement managed care that restricts providers– Allow a county or local government to aid people in

choosing a managed care plan– Using the savings from managed care to provide additional

services– Restrict the number of type of providers

• An example is the CA HIV/AIDS waiver that provides enhanced case management and services to those with HIV/AIDS

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Section 1915(c) Home and Community Based Services Waivers

• States can apply to provide long term care services in the home or community settings, rather than institutions

• States 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 home

• An example in CA: the CA HCBS Waiver for Californians with Developmental Disabilities providing a full range of services to those with developmental disabilities

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Concurrent Section1915(b) and 1915(c) Waivers

• States can apply to implement two waivers at the same time to provide comprehensive services to the elderly and those with disabilities

• States can provide traditional long term care services in the context of a managed care environment

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