Federal Authorities
and Waivers

Federal law provides a number of authorities that enable states to restructure Medicaid health care delivery and payment systems to meet the needs of their specific populations. These “federal authorities” include, but are not limited to, state plan amendments (SPAs), managed care waivers, home and community based services (HCBS) waivers, demonstration waivers, and state innovation waivers. Once approved by the Centers for Medicare & Medicaid Services (CMS), these authorities allow states to modify existing programs, expand services, and develop and test new approaches in Medicaid that differ from federal program rules.

With a deep understanding of the public health insurance system, Myers and Stauffer’s multi-disciplinary team helps clients consider state-specific options and develop viable SPAs and waivers that support their strategic goals. Our expertise in delivery system and payment transformation, strategic planning, financial analysis, rate setting, and project management enables us to help our clients evaluate their needs and the appropriate federal authorities necessary to achieve their objectives. We have demonstrated experience assisting our clients with gaining CMS’ approval for the design and implementation of a variety of state initiatives.

Our legislation and regulation services include:

Amy Perry, CPA


Federal Authority and Waiver Services

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Myers and Stauffer is one of a small number of firms with the national experience and resources available to support state Medicaid programs in the design, negotiation, and implementation of programs requiring federal authorities. We help states to fully explore their options through Medicaid SPAs, as well as to consider and utilize waiver authorities and coordinate waiver applications. Our services include, but are not limited to:

  • Working with states to develop data-driven program design options and preparing key design considerations and analyses for leadership consideration and decision-making.
  • Evaluating current state efforts, patient demographics, and Medicaid expenditures in order to determine the most appropriate policy authorities to achieve state goals.
  • Consulting on the review, planning, and design of waiver programs, including policy analysis, critical policy decisions consultation, concept paper development, and application development.
  • Supporting program fiscal projections including, but not limited to, budget neutrality, cost effectiveness, cost neutrality, development of alternative payment models, and assessment of managed care pass through payment options.
  • Assisting with, or taking responsibility for, project management activities, including strategic planning; development of work plans outlining required activities and timelines; preparing, submitting, and archiving all waiver documents; developing communications and supporting materials; ensuring the timely and accurate preparation of CMS-required waiver reports; etc.
  • Managing both internal and external stakeholder engagement activities, including compliance with the state and federal transparency requirements.
  • Working with the state to develop quality metrics relevant to the waiver’s objectives.
  • Supporting state negotiations with CMS during the waiver application process, including direct discussions with CMS and drafting responses to CMS requests for additional information.
  • Designing sustainable reimbursement methodologies and associated data collection methods to facilitate rate setting activities for 1915 HCBS waiver services.
  • Supporting the implementation and post-implementation evaluation of programmatic changes and their effectiveness in reaching the state’s objectives.
  • Monitoring and project oversight including quality program strategy design, measure development, data collection, and benefit/program integrity assurance.
  • Facilitating state fund allocation by reducing fraud, waste, and abuse expenditures; improving care delivery and reimbursement; enhancing accuracy of beneficiary eligibility decisions; building system security and protecting health and/or other confidential information; and highlighting financial integrity and controls.

HCBS Waivers and Authorities 1915(c), 1915(i), 1915(j), and 1915(k)

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Several options exist to meet the needs of people who prefer to receive long-term care services and supports (LTSS) in a home or community setting, rather than in an institution. State HCBS programs can provide access to a number of services beyond those which are permissible in the state plan, serve individuals who would not otherwise be eligible for Medicaid, and allow additional unique features such as beneficiary self-direction. States can also propose other options that may assist in transitioning individuals from institutional settings into their homes and community. Myers and Stauffer has significant experience with all aspects of HCBS waivers and authorities.

Demonstration and Innovation Waivers 1115 and 1332

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Section 1115 waivers offer the greatest degree of flexibility for states to design and implement innovative Medicaid program options ranging from offering an alternative benefit plan to a subset of Medicaid beneficiaries, to restricting enrollees to a specific network of providers, or to extending coverage to groups beyond those defined in Medicaid law. More recently, states are using 1115 waivers to enact Medicaid community engagement requirements, substance use disorder (SUD) program enhancements, and reinsurance programs to support private markets. We can help with the design, implementation, and maintenance of your demonstration and innovation waiver program.

Section 1332 state innovation waivers give states the opportunity to waive a variety of provisions related to the health insurance market created under the Affordable Care Act in exchange for implementing innovative strategies that provide access to high-quality, affordable health care. States can use this option to tailor their health insurance market to better meet the needs and expectations of its citizens and businesses. Myers and Stauffer has the experience to help our clients evaluate and navigate state innovation waiver opportunities.

Managed Care Waivers and Authorities 1915(a), 1915(b), 1115, and 1932

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Several options exist for implementing a Medicaid managed care delivery system, each dependent on a state’s overall priorities and program design considerations. Regardless of the federal waiver or authority selected, states must comply with the federal regulations that govern managed care delivery systems. These regulations include, but are not limited to, requirements for a managed care plan to have a quality program and provide appeal and grievance rights, reasonable access to providers, and the right to change managed care plans, among others. We can assist your state in developing and implementing a managed care waiver and authority solution.

State Plan Amendments

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The state plan is the operational agreement between the state and CMS governing the administration of the state’s Medicaid program. While much more limited than Medicaid waivers, some degree of flexibility can be obtained within the state plan authority through SPAs. Myers and Stauffer has the experience and expertise to help states investigate the appropriateness of a SPA to accomplish the necessary changes. Our firm also supports states through assistance with drafting and negotiating SPAs with CMS.