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Medicaid 1115 Waiver Elements

Medicaid 1115 waivers request modification of various elements of Medicaid coverage, often attempting to reduce access. Click on an element below to understand these approaches and learn how to fight back.

Asset Tests

Provision that determines Medicaid eligibility based on both income and assets, as opposed to just income.

Beneficiary Accounts

Accounts in Medicaid adult coverage waivers that include state and enrollee contributions. Enrollee contributions are typically in the form of cost-sharing or premium payments. When an individual enrolls, the state funds the account, and enrollee contributions are added as they accrue. Costs higher than balance of the account are covered by Medicaid.

Cost Sharing

Amount Medicaid enrollees pay aside from premiums when they receive a service. Not all states implement this, as it can be financially burdensome.

Drug Testing

Provision requiring Medicaid applicants to be tested for the use of illegal drugs and using the result of this to approve or deny Medicaid.

EPSDT

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) – Medicaid benefit that provides all enrollees under 21 with a comprehensive set of prevention, screening, diagnostic, and treatment services-such as eye and dental checkups.

Lock-outs

Provisions that prevent people from re-enrolling in Medicare when they lose coverage as a result of failing to comply with conditions like work requirements, paying premiums, or reporting a change in income.

Non-emergency Medical Transport

Transportation offered to all Medicaid enrollees to and from scheduled Medicaid-covered services.

Partial Expansion

Limits expanded Medicaid coverage to a sub-group of the Affordable Care Act’s (ACA) adult expansion category-homeless people or those at or below 100 percent of the poverty level-rather than covering everyone up to 133 percent of the poverty level as envisioned by the ACA.

Premiums

Amount Medicaid enrollees pay for receiving a service. These costs make it hard for low-income individuals to afford Medicare.

Private Option

When a state Medicaid program buys private insurance for some of its Medicaid population instead of providing coverage directly through the state’s Medicaid program.

Retroactive Coverage

Provision requiring Medicaid coverage to begin three months prior to an individual’s Medicaid application if the individual would have been eligible during these months. Medicaid covers unpaid medical bills incurred during this time.

Time Limits

Limit on how long an individual is eligible for Medicaid or may receive Medicaid coverage.

Wellness Programs

Programs that give Medicaid health plan enrollees incentives to engage in healthy behaviors-such as annual checkups-to reach certain benchmarks.

Work Requirements

Provision linking an adult’s eligibility for Medicaid to their work status. Adds a work or community service requirement to Medicaid enrollment.

Provisions Affecting Oral Health Care

Tools for Advocates

A waiver is a state request that the Secretary of Health and Human Services waive certain federal health care program requirements, usually in Medicaid (Section 1115 waivers) or the marketplaces (Section 1332). 

Contact Us

Our partners in the states are our best resource. If you learn about a waiver being developed in your state, please let us know. Contact Us