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Georgia House of Representatives
Rural Development Council
Blake Fulenwider
Deputy Commissioner
Chief, Medical Assistance Plans
Overview of
Section 1115 and 1332 Waivers
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Mission
The Georgia Department of Community Health
We will provide Georgians with access to
affordable, quality health care through
effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.
2
Topics to Cover
• Federal and State Medicaid
Coordination Overview
• 1115 Medicaid Waiver Overview
• 1332 Waiver Overview
3
Federal and State Medicaid Authorities
• Medicaid State Plan:
– Contract between CMS and DCH
governing Medicaid funding and
administration.
– Changed through State Plan
Amendments (SPAs)
– SPA submissions are routine
– Provisions are not typically time-
limited
• Social Security Act (SSA) Waiver
Authority:
– 1915(b): Managed Care
– 1915(c): Home and Community-
Based Services (HCBS) for Long
Term Services and Supports (LTSS)
– 1915(b)/(c): HCBS Services through
Managed Care
– 1115: Medicaid Demonstration
Waivers
Centers for Medicare and Medicaid Services (CMS)
Georgia Department of Community Health (DCH)
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1115 Waivers
• Secretary of Health and Human Services (HHS) authority to approve
experimental, pilot or demonstration projects likely to promote objectives of the
Medicaid program.
• 1115 Authority established in 1960’s and applies to major federal health and
welfare programs, including Medicaid and the Children’s Health Insurance Program
(PeachCare for Kids®).
• Utilized routinely for large-scale program changes (i.e., Managed Care, CHIP
expansion, Benchmark Benefit design, post-ACA program design).
• Also an authority available to assist with response to significant emergency
situations
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CMS 1115 Waiver Objectives
1. Improve access to high-quality, person-centered services that produce positive
health outcomes for individuals;
2. Promote efficiencies that ensure Medicaid’s sustainability for beneficiaries over
the long term;
3. Support coordinated strategies to address certain health determinants that
promote upward mobility, greater independence, and improved quality of life
among individuals;
4. Strengthen beneficiary engagement in their personal healthcare plan, including
incentive structures that promote responsible decision-making;
5. Enhance alignment between Medicaid policies and commercial health insurance
products to facilitate smoother beneficiary transition; and
6. Advance innovative delivery system and payment models to strengthen provider
network capacity and drive greater value for Medicaid.
https://www.medicaid.gov/medicaid/section-1115-demo/about-1115/index.html
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Current National 1115 Landscape
0
5
10
15
20
25
30
35
40
45
Medicaid
Expansion
Eligibility and
Enrollment
Restrictions
Work/Community
Engagement
Requirements
Benefit
Restrictions,
Copays, Healthy
Behaviors
Behavioral
Health
Delivery System
Reform
MLTSS Other Targeted
Waivers
Approved vs. Pending Section 1115 Medicaid Demonstration Waivers
as of August 29, 2018
Approved Pending
Source: Kaiser Family Foundation, 9/13/18, http://files.kff.org/attachment/Landscape-of-Approved-
vs-Pending-Section-1115-Medicaid-Waivers
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Affordable Care Act-related 1115 Waivers:
Approved and Pending
• Expansion of Medicaid Eligibility:
– Arizona
– Arkansas
– Indiana
– Iowa
– Michigan
– Montana
– New Hampshire
– Utah (pending approval)
• Work and Community Engagement
Provisions:
– Arizona
– Arkansas
– Indiana
– Kansas (pending)
– Maine (pending)
– Mississippi (pending)
– New Hampshire
– Ohio (pending)
– South Dakota (pending)
– Utah (pending)
– Wisconsin (pending)
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Section 1332 Waiver Authority
• Affordable Care Act §1332 (42 USC 18052)
• Waives provisions of the Internal Revenue Code
• State Innovation Waivers must:
– Provide access to coverage that is at least as comprehensive and as would be
provided absent the Waiver
– Provide coverage that is at least as affordable as would be provided without the
Waiver
– Provide coverage to a comparable number of residents
– Not increase the Federal deficit
• Applies to Individual and Small Group Commercial Insurance Markets (Exchange
products)
• High-Risk Pools/State-Operated Reinsurance Programs
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State Action on Section 1332 Waivers
Source: National Conference of State Legislators (NCSL), 9/11/2018,
http://www.ncsl.org/research/health/state-roles-using-1332-health-waivers.aspx
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Waiver-Based Approaches
• 1115 Waiver Authority used by selected states to:
– Implement Premium Assistance Programs
– Require Nominal Premiums/Cost-Sharing Requirements
– Drive Wellness Incentives
– Waive Benefit Requirements (NEMT, Family Planning
Services for targeted enrollees)
– Waive Retroactive Eligibility
– Implement Work and Community Engagement
Requirements as a Condition of Eligibility
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1115 and 1332 Waiver Submission and Approval
Process
Legislature Approves
Waiver Submission
DCH Board Approves
Waiver Submission
Public Notice Period
DCH Submits Waiver to
CMS
CMS Q&A/Negotiation
Period
CMS Approves Waiver
Waiver Operation,
Oversight and Reporting
Waiver Amendment
Submission (if necessary)
to conform with policy
changes
Before Waiver Expiration,
Seek Extension,
Reapplication or Approval
of Close-Out Plan from
CMS
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Georgia’s Current Waiver Programs
Waiver Authority
Program
1115
Georgia Planning for Healthy Babies (P4HB)
1915(c)
Elderly and Disabled Waiver (Includes CCSP and SOURCE programs)
1915(c)
New Options Waiver (NOW)
1915(c)
Comprehensive Supports Waiver Program (COMP)
1915(c)
Independent Care Waiver Program (ICWP)
Full details available on CMS’ website, https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-
waiver-list/index.html
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Georgia’s existing 1115 Waiver
• Known as “Planning for Healthy Babies” or P4HB
• Limited benefit package for target population
– Provides family planning and interpregnancy care services only
• Eligibility Criteria:
– Women ages 18 to 44 who are at or below 200% Federal Poverty Level (FPL) household income
and not otherwise eligible for Medicaid or PeachCare for Kids®
• Goals:
– Reduce Georgia’s rate of Low Birth Weight (LBW) and Very Low Birth Weight (VLBW) infants
– Reduce the number of unintended pregnancies in Georgia
– Reduce Medicaid costs by reducing the number of unintended pregnancies by women who
otherwise would be eligible for Medicaid pregnancy-related care
– Provide access to Interpregnancy Care (IPC) for women who have previously delivered a VLBW
infant
– Increase child spacing intervals through appropriate contraceptive use
• Implemented on January 1, 2011; Current expiration is March 30, 2019
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Legislative Requirements – 1115 Waivers
• § 49-4-142.1:
On and after May 3, 2006, neither the department, the board, nor any
other representative of the state shall submit any request to the United
States Department of Health and Human Services Centers for Medicare
and Medicaid Services for a waiver pursuant to Section 1115 of the
federal Social Security Act without legislative notification.
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Legislative Requirements – Increasing Eligibility
Limits
• § 49-4-142.2:
On and after July 1, 2014, neither the department, the board, nor
any other representative of the state shall expand Medicaid eligibility
under this article through an increase in the income threshold
without prior legislative approval; provided, however, that this shall
not apply to any increase resulting from a cost-of-living increase in
the federal poverty level. The legislative approval required under
this Code section shall be by Act of the General Assembly or the
adoption of a joint resolution of the General Assembly.
