A Medicaid waiver program is a special program that allows a state to vary from the standard Medicaid rules so that it can offer more targeted services to specific populations. Waiver programs are thus an alternative to the services in the State Medicaid Plan. While a state must provide the entire service array to anyone who meets the criteria of its Medicaid program, by using a waiver it can provide them only to certain groups (such as those with Traumatic Brain Injury, or those members who can get services inside their home and avoid a nursing home. Waivers must be approved by CMS, and have a capped funding amount.
What are the types of waivers available?
Each of the waiver types are commonly referred to by the part of the Social Security Act that governs them. See below for information on the most commonly used waivers:
Section 1115 waivers- also known as demonstration waivers. These allow a state to test out a new financing model, cover a new population or a new service delivery model.
Section 1915b waivers- also known as managed care waivers. These waivers allow a state to contract with health plans to deliver services to members.
Section 1915c waivers- also known as home and community-based services (HCBS) waivers. These waivers allow states to offer services in the community to members that otherwise would need facility-level care.
Waiting lists are used to ration services for severely disabled Medicaid members who need them. These waiting lists have long been a controversial mechanism to allocate services funded under a Medicaid waiver program.
How is it used in Medicaid?
Since states get a specific amount of funding approved for waivers, and there are more individuals who need services than can be funded under the waiver, waiting lists are used to control utilization. There are hundreds of thousands of people who have been determined to need the services, but can not get them.
It is important to note that traditional (non-waiver) Medicaid services are funded in an-capped model, and states do not use waiting lists for those services. Waiver services typically are more targeted for specific, more severe needs.
Waiting lists fluctuate over time, and from state to state. Medicaid expansion in 2014 caused a resurgent focus on waiting lists, because states were now spending billions more on generally healthy individuals (the expansion group), while thousands of severely disabled members still wait for the services they need.
Medical Loss Ratio is the proportion of premium revenues spent on clinical services and quality improvement. It is commonly referred to as MLR.
How is it used in Medicaid?
In recent years as with many things, CMS has brought new regulations for Medicaid Managed care related to MLR. These new regulations require states to monitor the MLR for MCOs and establish criteria from this data for setting future MLR. The minimum MLR has also been set by CMS at 85% and establishes that noncompliant MCOs can have rates lowered in the future.