This document discusses trends in Medicaid Section 1115 waivers. It provides an overview of the National Association of Medicaid Directors (NAMD), which supports state Medicaid directors. The rest of the document summarizes key topics discussed in a NAMD presentation on Section 1115 waivers, including why states use them, operational aspects like stakeholder engagement and budget neutrality, and trends in waiver policies around community engagement, pharmacy benefits, delivery system reform, and behavioral health integration. The document concludes by providing additional NAMD resources on these topics.

1. Trends in Medicaid 1115
Waivers
Jack Rollins
Senior Policy Analyst
October 26, 2018

2. National Association of Medicaid Directors
(NAMD): Who are we?
• Created in 2011 to support the 56
state and territorial Medicaid Directors
• Standalone, bipartisan, & nonprofit
• Core functions include:
• Developing consensus on critical
issues and leverage Directors’
influence with respect to national policy
debates;
• Facilitating dialogue and peer to peer
learning amongst the members; and
• Providing effective practices and
technical assistance tailored to
individual members and the challenges
they face.
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3. National Association of Medicaid Directors 3
Topics to Cover
• What 1115 Waivers Are and Why States Use
Them
• Operational Aspects of 1115 Waivers
• Stakeholder engagement
• Budget Neutrality
• Trends in 1115 Waiver Policies
• Community Engagement
• Pharmacy
• Delivery System and Payment Reform
• Behavioral Health Integration

4. National Association of Medicaid Directors 4
Why Use Waivers?
• Medicaid statute lays out mandatory covered
populations; mandatory and optional benefits
• States may seek various waivers from CMS to
operate their programs in different ways than
those laid out in statute
• All states operate some type of waiver, no state limits
their program to the basic statutory elements
• 1115 waivers are the broadest waiver authority
available, intended to test new and innovative
approaches to Medicaid coverage and benefit
design
• Generally approved for 5-year periods

5. National Association of Medicaid Directors 5
Sequences/Elements of 1115s
• Negotiation: States negotiate with CMS on the
terms of the waiver.
• Unlike other Medicaid waivers, there is no time limit
on this negotiation period.
• There are both state and federal public notice and
comment periods for an 1115.
• 1115s must be budget neutral.
• Implementation: States implement the waiver
over the course of its demonstration period, per
terms negotiated with CMS.
• Evaluation: All 1115 waivers must include an
evaluation component to assess the outcomes
of the hypothesis behind the waiver.

6. National Association of Medicaid Directors 6
Deeper Dive: Stakeholder
Engagement
• 1115 conceptualization and design often occurs
prior to entering the formal public notice and
comment process
• States may publish working papers or other design
documents that indicate the direction of a waiver
• States and CMS must respond to public
comments, like any other rulemaking process
• Stakeholder input can also inform waiver
evaluation design by emphasizing study of
waiver’s impact on specific populations

7. National Association of Medicaid Directors 7
Deeper Dive: Budget Neutrality
• Statute requires 1115 waivers to cost the federal
government no more than what would have
been spent in absence of a waiver
• Depending on what states are seeking to do,
budget neutrality calculations can be lengthy or
require creative solutions
• CMS recently revised 1115 budget neutrality
rules
• Impact is mostly felt for long-standing 1115 waivers
with multiple approval cycles

8. National Association of Medicaid Directors 8
Community Engagement
• Signature policy of the Administration is approval of
community engagement waivers
• Guidance issued in January 2018
• Currently, approvals are only for expansion
populations
• AR implemented; KY, IN, NH approved; several more
states negotiating
• Non-expansion states are seeking these waivers, none yet
approved
• Emphasis on building linkages with other state
programs (SNAP; TANF) and building in appropriate
exemptions for at-risk populations
• Significant administrative lift associated with
implementation; inter-agency collaboration is key

9. National Association of Medicaid Directors 9
Pharmacy
• Massachusetts proposal for commercial payer-like
flexibility in Medicaid pharmacy benefit
• Note Medicaid required to cover all FDA-approved drugs in
exchange for mandatory rebates (Medicaid Drug Rebate
program, or MDRP)
• Sought to cover only 1 – 2 drugs in a therapeutic
class, with robust exceptions process
• Sought ability to exclude coverage of a therapy if
and only if a national PBM or the state employee
health insurance benefit also excluded coverage
• CMS did not approve this waiver
• Stated that participation in MDRP is either all in or all out
• Despite this, state interest in this concept remains strong

10. National Association of Medicaid Directors 10
Delivery System and Payment
Reform
• Like all payers, Medicaid is seeking to reward value
over volume in the health care system
• 1115 waivers are the strongest tool available to test
new payment models and approaches
• Diverse array of models:
• Bundled payments (TN, AR, OH)
• ACOs
• All-payer global budgets (MD)
• Other areas states eager to address include social
determinants (housing, food security, justice-
involved individuals, etc.) and risk-based payments
to safety net providers

11. National Association of Medicaid Directors 11
Additional Resources and Contact
Info
• NAMD Publications
• Blog post on Commonwealth Fund’s “To the
Point” series on alternative payment models
• Issue brief on 1115 trends
• NAMD Staff
• Jack Rollins, Senior Policy Analyst:
jack.rollins@medicaiddirectors.org
• Lindsey Browning, Program Director for Medicaid
Operations:
lindsey.browning@medicaiddirectors.org

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Questions?