States can use Medicaid's Section 1115 waivers to try out new healthcare approaches that go beyond regular Medicaid services. In this article, we explore how 1115 waivers work and what they mean for caregivers and their loved ones.
Section 1115 waivers let states try new ways of delivering and paying for healthcare services. These waivers give states flexibility to experiment with programs that aren't typically covered under standard Medicaid rules, helping them address unique needs or challenges in their communities.
1115 waivers can change who is eligible for Medicaid services. Sometimes, they make it easier for people with specific health conditions or financial situations to qualify, which can be a huge relief for caregivers struggling to find affordable care options for their loved ones.
1115 waivers are a collaborative effort between state Medicaid agencies and the federal government to allow states to tailor Medicaid programs to local needs while still complying with federal guidelines. Before submitting a waiver application, states typically gather public input to make sure that the community has a voice in shaping the waiver.
Caregivers can advocate for programs that better support their families by participating in these public comment periods when new 1115 waivers or updates are proposed. During these periods, you can share personal stories and feedback on how the changes will affect you and your loved ones.
To apply, states propose an implementation plan to the Centers for Medicare & Medicaid Services (CMS) outlining how they will roll out the waiver and monitor its impact. CMS reviews the application to make sure it aligns with federal guidelines, improves care, reduces health disparities, and stays cost-effective.
Waivers are initially approved for a five-year period, with the option for extensions in three- to five-year increments if they demonstrate success after the initial demonstration period.
States are required to monitor and evaluate the waiver's performance, providing regular reports to CMS. These reports assess whether the waiver meets its goals, such as enhancing care delivery and cost-effectiveness.
Federal matching funds, known as the Federal Medical Assistance Percentage (FMAP), help states implement 1115 waivers without needing to take on the full financial burden. States can test new initiatives—like expanding home- and community-based services (HCBS) or caregiver compensation—using partial federal funding. However, states must prove that the waiver will be budget neutral, meaning the federal government won't spend more on the waiver than it would on standard Medicaid services.
Each state uses its waiver authority differently, tailoring services to meet the needs of their residents. Below are a few examples of how states use 1115 waivers to expand coverage and improve care for vulnerable populations.
Georgia's Pathways to Coverage program is under the 1115 waiver authority to extend Medicaid benefits to low-income adults who meet specific work or activity requirements. Unlike traditional Medicaid expansions, this waiver ties eligibility to fulfilling particular activities such as employment or volunteering. The goal is to offer healthcare coverage to people who previously fell into a coverage gap—making too much for Medicaid but still not enough for private insurance—while encouraging economic participation and community involvement.
Oregon’s Health Plan Substance Use Disorder 1115 Demonstration focuses on improving care for individuals with substance use disorders by expanding access to critical treatment services to reduce the burden on emergency rooms and inpatient care. By addressing these gaps, Oregon hopes to improve health outcomes and reduce the social and economic impacts of untreated substance use disorders.
Missouri's 1115 waiver for former foster care youth ensures continuous Medicaid coverage for young adults previously in foster care, up until the age of 26. This waiver is unique because it extends coverage regardless of where the person lives, whether they remain in Missouri or move out of state. This national portability aspect provides stability and support to a vulnerable population as they transition into independent adulthood.
Alaska's Behavioral Health Reform, through its 1115 waiver, aims to improve access to care for individuals with mental health and substance use disorders. The waiver strives to address gaps in the state's behavioral health system by integrating primary and behavioral health services, promoting early intervention, and enhancing long-term recovery support for individuals in need.
1115 waivers have a significant impact on long-term care options, as they allow states to tailor Medicaid programs to better meet the needs of individuals who require ongoing care. These waivers often focus on expanding home- and community-based services (HCBS), which enable individuals to receive care at home rather than in institutional settings like nursing homes.
In addition to expanding home-based care, 1115 waivers can change the eligibility criteria for long-term care services. This flexibility allows states to offer more comprehensive coverage to individuals who may not traditionally qualify for Medicaid but still require long-term care. In some cases, waivers also promote innovative care models that focus on care coordination and managed care, which help streamline services for people with complex medical needs.
Ultimately, 1115 waivers provide more personalized care options, giving families the chance to choose whether their loved ones remain at home or enter facility-based care. The ability to cover a broader range of services under Medicaid helps reduce the financial burden on families while ensuring that their loved ones receive the care they need, no matter where that care is delivered.
Caregivers and their loved ones can apply for Medicaid services that may be expanded or created through an 1115 waiver:
Here are some helpful resources to better understand 1115 waivers and their impact on Medicaid:
We understand how important it is for family caregivers to have access to flexible, high-quality services. Section 1115 waivers provide states with the ability to expand and enhance Medicaid in ways that directly benefit caregivers, their loved ones, and other vulnerable populations.
