Are You Leveraging Medicaid Demonstration Waivers?


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If you’re not taking advantage of Section 1115 waivers yet, the time is now. 

As of June 2021, there are 63 active waivers in 45 states, with 27 pending review. Many of these cover social determinants of health initiatives and make it possible for managed care organizations to work with community-based organizations to address the social needs of high-risk populations. 

Connecticut, for instance, has a Mental Health Waiver, which gives health plans the opportunity to provide home-delivered meals, non-medical transportation, and peer support services to members with mental illness who are 22 years old or older. This simple demonstration can make a significant difference. 

Understanding the history and purpose of Section 1115

Established in 1962 by the Kennedy administration, Section 1115 was added to the Social Security Act to allow welfare programs more flexibility to adapt their services to meet local needs. Authorized by the U.S. Secretary of Health and Human Services, these Medicaid demonstration waivers have a complicated history, having evolved significantly from administration to administration. 

When the Affordable Act Act (ACA) was established in 2010, during the Obama administration, the purpose of these waivers changed, as Medicaid began to cover individuals with incomes at or below 138 percent of the federal poverty level. Individuals who wouldn’t have been covered by Medicaid, such as childless adults, were covered, though seven states received approval to offer alternative approaches to the expansion. 

Under the Trump administration, numerous waivers were fast-tracked, and some of them included work requirements, time limits for coverage eligibility, and coverage lockouts, which posed barriers to certain individuals who would have otherwise benefited from the programs. At this time, many waiver extensions have been approved for an additional ten years, as opposed to the typical three to five years. 

The stipulations surrounding the demonstration waivers have certainly changed and are actively changing under the Biden administration, but their purpose -- to support high-risk populations -- remains the same. And they have proven beneficial. 

Amidst the COVID-19 pandemic, Medicaid Emergency Authorities were approved in every state across the country, which helped to address immediate needs during the public health emergency. Some of the approved actions have included: extended coverage for testing to uninsured individuals, temporary coverage for non-residents of the state, and delay or extend the timeframe for families to complete CHIP renewals. 

Meeting the needs of high-risk populations

Section 1115 waivers grant MCOs the funding and flexibility to expand beyond their typical scope and address prevalent needs within their high-risk populations. Adults with disabilities, children in low-income families, and individuals who are housing insecure may benefit from these programs, depending on the demonstration and its stipulations.

MCOs can use the waivers to offer a specialized benefit package to members and if a program is effective and successful, it can help inform policy changes. However, the program must prove its value to CMS and the public at large, which is often challenging to do, but certainly doable, especially with a prioritization on data collection and measurement. 

Any MCO that has the opportunity to take advantage of a Section 1115 waiver in their state should. However, it’s important to have an actionable plan to ensure that the program serves members in the best, most effective way. Establishing valuable and strategic partnerships with CBOs can help achieve desired results.

To learn more about Section 1115 waivers and how to take advantage of them, download our white paper today: Leveraging Medicaid Section 1115 Waivers to Address Social Determinants of Health

Download here.

Topics: Medicaid managed care value-based care SDoH data sdoh

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