State of Ohio flags waving in front of the Statehouse in Columbus, OH

States continue to innovate with their Medicaid programs through 1115 waiver demonstrations, which allow states to “waive” specific requirements of Medicaid and use federal Medicaid funds to support program changes in eligibility and service delivery components to improve Medicaid care quality and cost. In this blog post, we review recent developments related to waiver use to combat specific health challenges, states use of policy innovation to expanding and funding Medicaid, as well as the latest actions on Medicaid work requirements.

In response to the growing interest of combating the nation’s opioid epidemic, states have been rapidly adopting SUD 1115 waivers to assist in this health effort. CMS recently approved Ohio and Alaska’s SUD 1115 waiver proposal, totaling the number of states utilizing this demonstration at 26. CMS also approved an 1115 waiver uniquely focused on increasing access though a dental pilot program in Maryland. Meanwhile, Rhode Island is aiming their recent approved 1115 waiver demonstration extension to “expand eligibility to individuals who are not otherwise Medicaid or CHIP eligible, offer services that are not typically covered by Medicaid, and use innovative service delivery systems that improve care, increase efficiency, and reduce costs.” 

            States’ successes in their 1115 waiver evaluation continued through the use of policy innovation. Utah faced a significant challenge when the Trump Administration denied their request for partial Medicaid funding last month. This unprecedented move placed Medicaid recipients in their state at significant risk, as the status of Utah’s Medicaid program was unknown. In response, Utah submitted a request for full Medicaid expansion. Tennessee is taking an innovative policy approach to their 1115 waiver program by proposing to block grant its federal Medicaid funding. This legislation would make Tennessee the first state in the nation to move to a true block grant format for Medicaid funding. In another form of legislative innovation, New Jersey, Arizona, and Massachusetts successfully utilized Managed Long Term Services and Supports 1115 waivers in order to promote integrated care networks for dual eligibles. 

            There has also been a flurry of movement around Work Requirement 1115 waivers. Michigan submitted a waiver to require people enrolled in the state’s Healthy Michigan program to work or go to school for 80 hours per month in order to receive benefits. Importantly, if CMS denies the waiver, Michigan will end the Health Michigan program all together. Relatedly, state lawmakers in Idaho recently passed a bill requiring 19-55 year old Medicaid recipients to work at least 20 hours a week to maintain their eligibility. While this provision to their 1115 Work Requirement waiver still needs to be approved by CMS, many opponents believe it would create a “one-strike-your-out” policy, and would serve as one of the nation’s most restrictive waiver demonstrations. Meanwhile, a recent report from the Arkansas Center for Health Improvement examines efforts by Arkansas state officials and their partners to communicate the state’s work and community engagement requirement to affected Medicaid enrollees, as well as the experiences and capacity of community organizations in helping enrollees meet the requirement. And while Arizona quietly suspended their Work Requirement 1115 waiver, South Dakota has proposed a Work Requirement 1115 waiver to be approved by CMS. 

These and other issues continue to be an area of focus for the AcademyHealth-led Medicaid Demonstration Evaluation Learning Collaborative. These evaluation researchers examine the critical policy questions, as well as study designs, methodologies, data sources and metrics used in Medicaid waiver initiatives to demonstrate the effectiveness of the waiver programs as designed. Learn more about the collaborative here.

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