Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve their programs.
Secretary may waive multiple requirements under §1902 of the Social Security Act if waivers promote the objectives of the Medicaid law and intent of the program.
Standardized application requirements found at: 431.412(a)(1): https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html
Depending on the nature and scope of the 1115 application, different processes may apply.
It is advisable for states to contact CMS to discuss application intentions prior to submission.
Initial application: 5 years
Renewal: 5 years
Monthly progress calls, quarterly and annual progress reports and other reports as required in the approved STCs.
Administered by the Single State Medicaid Agency (SSMA).
Certain provisions may be operated by other entities as approved by CMS.
Required unless otherwise stipulated in the approved standard terms and conditions and approved waiver authorities.
State defines eligibility categories and may expand or propose modified eligibility within the 1115 demonstration.
The approved Special Terms and Conditions as approved by the Secretary set forth the eligibility requirements for benefit packages and/or services.
States must provide at least a 30-day public notice and comment period for applications for new demonstrations and extensions of existing demonstrations. This process is followed by a federal public comment period.
Information about the process can be found at https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-transparency-requirements/index.html.
State must operate in accordance with the approved Special Terms and Conditions.
Cannot cover: Room & Board costs.
State estimates numbers served.
Operates as an entitlement to all who are eligible.
Budget neutrality must be maintained. Caps or benefit limits may apply pursuant to approved STPs.
State decides what services are covered, subject to CMS approval.
Determined by state, subject to CMS approval.
Subject to specific requirements set forth in the approved STPs.
Subject to specific requirements set forth in the approved STPs.
Permitted subject to the approved STCs.
Required (state may offer options that can be utilized voluntarily by providers to meet this requirement) unless otherwise stipulated in approved STCs.
Payment rates and methodologies subject to the provisions approved within the STCs.
Budget neutrality. Federal spending under the waiver cannot exceed what it would have been spent in absence of the waiver.
Extensive data collection and evaluation plans to assess the effectiveness of the project or demonstration as established within the state’s approved STCs.
HCBS requirements apply if the 1115 contains HCBS.
State defines relationship to state plan, waivers, and amendments, subject to CMS approval.
If HCBS are included in 1115, COI provisions will apply subject to approved STCs.
If HCBS are included in 1115, provisions will apply subject to approved STCs.