Federal Authorities and Waivers
Waivers and
Federal Authorities

Federal Authorities and Waiver Consulting and Support Services

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.

Partnering with State and Federal Government Healthcare Agencies

For more than 43 years, Myers and Stauffer has assisted local and state government clients by supporting strategic planning, implementation, monitoring, and evaluation activities related to the delivery and financing of health care and social service programs. We are one of a small number of firms that has direct, hands-on experience assisting states with the operational aspects of health care reform and modernization efforts, including various waiver authorities and State Plan Amendments (SPAs). As such, we are recognized as a national leader in Medicaid transformation consulting initiatives. We routinely work with clients to determine the appropriate legal authorities available to support both targeted and sweeping program changes. 

We have experience with all waiver types and federal authorities:

Waiver services we provide include, but are not limited to:

Amy Perry, CPA
Member
aperry@mslc.com

816.945.5342

Managed Care Waiver and Authorities – §1915(a), §1915(b), §1932, and §1115 

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States have several options available to implement a risk-based managed care delivery system. Specifically, states may restrict Medicaid enrollees from receiving services within a contracted managed care network; allow a locality to act as a “central enrollment broker” in assisting beneficiaries to choose among competing health care plans; use cost-savings to provide additional services to beneficiaries; and/or restrict providers from who a beneficiary may obtain services. Under a §1915(b) waiver, states may exclude certain populations from the managed care delivery system, are not required to ensure that the same benefits are available to all persons eligible, or to everyone throughout the state. Myers and Stauffer has the depth of knowledge and experience to assist our state clients in developing and implementing a managed care waiver and authority solution.

Home and Community Based Services (HCBS) Waivers – §1915(c)

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Allows states to provide disability services to individuals in their homes, as an alternative to institutional care. This model is designed to ensure individual dignity, independence, and self-determination, while at the same time lessening the burden and cost of institutional care. Eligible beneficiaries must meet state requirements to receive services in an institution; however, services may be tailored to a particular population. States can also provide HCBS services through a managed care delivery system with a combined or concurrent §1915(b) waiver. Opportunities on the horizon for HCBS programs include:

  • Incorporating service innovations that support greater community integration and opportunities for independence, such as supportive employment or by improving participant choice regarding service delivery.
  • Transitioning toward value based purchasing or alternative payment models that emphasize achieving outcomes over paying for tasks and time.
  • Restructuring payment structures and reimbursement rates to reflect changes to wages and demographics of direct support professionals who have been impacted by economic changes, as well as public health emergencies (e.g., COVID-19, natural disasters).

State Plan Amendments under §1915(i), §1915(j), and §1915(k) 

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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 options that may assist in transitioning individuals from institutional settings into their homes and community. Myers and Stauffer has significant experience in working with State Medicaid Agencies on all aspects of HCBS waivers and authorities.

  • 1915(i) allows states to provide HCBS via the Medicaid State Plan, as opposed to a waiver. While offering similar flexibility as a waiver, the §1915(i) SPA does not require that eligible beneficiaries meet institutional level of care. This authority is often used to implement services such as respite or adult day health, which help to support families who wish to continue caring for their family member but need assistance during the day. §1915(i) SPAs may also be used to implement specific services like dental services for people with chronic conditions such as diabetes.
  • 1915(j) allows states to provide self-directed personal assistance services (PAS) via the Medicaid State Plan and/or an existing §1915(c) waiver. Participation in self-directed PAS is voluntary, and typically requires that individuals seek out and employ their own direct support professionals, which may include a spouse or other family member.
  • 1915(k), the “Community First Choice (CFC) Option,” was created by the Affordable Care Act and allows states to provide HCBS to beneficiaries in an eligibility group entitled to nursing facility services under the State plan or who are not in an eligibility group entitled to nursing facility services but have income below 150 percent of the federal poverty level. Similar to §1915(c) waivers, the CFC option offers considerable flexibility; however, services must be provided statewide and must cover the Categorically Needy eligibility groups without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires in order to lead an independent life. States that select this option receive a six percent increase in federal matching funds.

Demonstration Waivers – §1115 and §1332

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Provides states with flexibility to shape their Medicaid programs to improve care, increase efficiency, and reduce costs. Many states have used these types of waivers to expand beneficiary eligibility, provide services not typically covered by Medicaid, and/or to craft innovative service delivery systems designed to improve care and increase efficiency. In recent years, states have used §1115 waivers to:

  • Expand access to residential substance use disorder (SUD) services that are not covered if they fall within the Institutions for Mental Disease (IMD) exclusion. These types of waivers require states to commit to also providing community-based SUD treatment as well as to meet specific milestones, follow certain guidelines, and track measurable outcomes.
  • Expand access to integrated behavioral and physical health care by creating comprehensive service delivery systems for people with complex physical and behavioral health care needs. These integrated behavioral health systems seek to provide ongoing support to individuals to improve recovery and community based stabilization while reducing the use of emergency departments or psychiatric hospitals.

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 expertise to help our clients evaluate and navigate state innovation waiver opportunities.

System Redesign and Innovation

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Waiver services include developing innovative service delivery systems that consider social determinants of health when developing and providing services to individuals with chronic or complex conditions. Potential services include housing-related services and supports, non-medical transportation, home-delivered meals, educational services, employment, community integration and social supports, and case management. Myers and Stauffer has the depth of knowledge and technical resources to lead and/or support the design, implementation, and maintenance of your demonstration and innovation waiver program.

Waiver Program Development

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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 agencies in the design, negotiation, and implementation of programs requiring federal authorities. We support the development of waiver programs from the beginning evaluation stage through working with CMS to obtain approval. 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 target the most appropriate policy authorities to the desired state goals.
  • Consulting on the review, planning, and design of waiver programs, including policy analysis, critical policy decision making, and development of concept papers and applications.
  • Managing both internal and external stakeholder engagement activities, including compliance with state and federal transparency requirements.
  • Supporting state negotiations with CMS during the waiver application process, including direct discussions with CMS and drafting responses to CMS requests for additional information.
  • Visit the HCBS page for more information. 

Waiver Program Implementation and Operationalization 

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Myers and Stauffer will support the implementation and operationalization of waiver programs. This includes developing operational policies and procedures, evaluating payment methodologies, and calculating payment rates to support waiver programs. Our services include, but are not limited to:

  • Supporting program fiscal projections including, but not limited to: modeling various solutions to achieve budget and cost neutrality; modeling methods to accurately demonstrate cost effectiveness; development of alternative payment models; and assessment of managed care pass-through payment options.
  • Working with the state Medicaid agency to develop quality metrics relevant to the waiver program objectives.
  • Improving care access, delivery, and reimbursement; enhancing accuracy of beneficiary eligibility decisions; building system security; and protecting sensitive health data and/or other confidential information.

Rate Methodology Review and Redesign

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Rate Setting and Development

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Health Care Financing Strategies

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Alternative Payment Models (APM) and Value Based Purchasing (VBP)

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Waiver Monitoring and Evaluation Services

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Ongoing waiver program monitoring is critical to measuring the performance of waiver programs, and to assure ongoing compliance to CMS. With the expansion of waiver programs, states need to establish reporting requirements and review reported data to determine if a program is meeting state goals and objectives, or should be modified. Our services include, but are not limited to:

  • 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, evaluation of health outcomes, and benefit/program integrity assurance.
  • Facilitating state fund allocation by reducing fraud, waste, and abuse expenditures, and highlighting financial integrity and controls.
  • Visit the HCBS page for more information.