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States may request Section 1915(b) waiver authority to operate programs that impact the delivery system of some or all of the individuals eligible for Medicaid in a state by - mandatory enrollment of beneficiaries into managed care programs (although states have the option, through the Balanced Budget Act of 1997 to enroll certain beneficiaries into mandatory managed care via a State Plan Amendment), or
- creating a "carve out" delivery system for specialty care, such as behavioral health care.
Section 1915(b) waiver programs do not have to be operated statewide. They may not be used to expand eligibility to individuals not eligible under the approved Medicaid state plan. States also have the option to use savings achieved by using managed care to provide additional services to Medicaid beneficiaries not typically provided under the state plan. To implement these programs, the Secretary may waive certain Medicaid requirements (statewide, comparability of services, and freedom of choice of provider.) There are four types of authorities under Section 1915(b) that states may request: - (b)(1) mandates Medicaid Enrollment into managed care
- (b)(2) utilize a "central broker"
- (b)(3) uses cost savings to provide additional services
- (b)(4) limits number of providers for services
PROGRAM REQUIREMENTS: A Section 1915(b) waiver program cannot negatively impact beneficiary access, quality of care of services, and must be cost effective (cannot cost more than what the Medicaid program would have cost without the waiver). Section 1915(b) waivers do not carry the evaluation requirements necessary for Section 1115 waivers, but an independent assessment is due for the first two waiver periods. More information is available about this requirement in the Independent Assessment Guidelines, published by the Centers for Medicare & Medicaid Services (CMS) in 1998 that may be downloaded below. APPLICATION PROCESS The application must be submitted to CMS by the Single State Medicaid Agency for review. Upon receiving the application, CMS has 90 days to approve, disapprove, or request additional information on the proposal. If CMS does not act within 90 days, the application is deemed approved. Section 1915(b) waiver programs are approved for 2-year periods, and states may submit renewal applications to continue these programs ongoing. CMS developed a template waiver application that may be downloaded below under "Downloads." Use of this template is not required, but if used in conjunction with State Medicaid Manual instructions at section 2106-2112, could help CMS process the application in a timely manner. PRIMARY CARE CASE MANAGER (PCCM) WAIVERS: This ZIP file contains a Word document version of the application and spreadsheet for renewal applications.
Page Last Modified: 03/11/2008 4:22:57 PM
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