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Medicaid Waiver Regulations

Medicaid waivers allow states to use federal funds in ways that don't currently conform to state and federal standards. Section 1115 permits the use of research and demonstration projects within the Medicaid system. Section 1915(b) grants states the ability to limit people's provider choices. Under section 1915(c), Medicaid strives to provide community-based long-term care as opposed to institutional care.

  1. Section 1115---Research & Demonstration Projects

    • Section 1115 of the Social Security Act lays forth provisions that allow for experimental, pilot and demonstration projects that probably will advance the objectives of the Medicaid statute. The Secretary of Health and Human Services is the one to authorize these projects. There's enough flexibility in section 1115 to allow individual states to experiment with new ideas of policy merit that haven't been demonstrated in a more widespread way. To some, this waiver is advantageous because it allows states to attempt to provide coverage for people who are otherwise ineligible under the Medicaid program. This expanded coverage not only includes broader individual coverage, but also services that aren't usually covered by Medicaid. To give states ample time to adapt and adjust to the new programs, the projects are generally approved on a five-year basis with the possibility for renewal. For these projects to meet approval, they must be "budget neutral" and not cost the federal government more than it would without the waiver.

    Combined 1915(b)/(c) Waivers

    • A waiver combination of sections 1915(b) and 1915(c) are being adopted by states in order to provide continuous services to elderly and disable individuals. Combining the two, states have the option of including community-based services such as homemaker services and respite care in combination with more traditional long-term care services. When combining the two, states are still required to treat each waiver separately and must meet individual regulations for both 1915(b) and 1915(c)---balancing 1915(c)'s cost neutrality with 1915(b)'s cost effectiveness requirements. Approval periods are also at odds that requires states to ensure all renewal applications are in on time for individual services.

    Section 1915(c) Home and Community-Based Services Waivers

    • The section 1915(c) waivers allow consumers to combine traditional medical services such as skilled nursing with non-medical services like respite care within their coverage program. Since some of these services are non-traditional, so long as they meet provider qualifications, in some instances family members and friends can act as providers of these waiver services. Generally, though, spouses and parents of minor children aren't able to become paid waiver service providers. It's left to an individual state's discretion to decide how many consumers serve in a home and community-based service waiver program.

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