Appendix E. Characteristics of Statutory Authorities: Medicaid Managed Care

 

Sec. 1932(a) State Plan

Sec. 1915(b) Waivers

Sec. 1915(b)(c) Combo Waivers

Sec. 1115 Demo/Waivers

General Authority

Exempts states from these statutory requirements:

*        Statewideness

*        Comparability

*        Freedom of choice

Waives state plan requirements for:

*        Statewideness

*        Comparability

*        Freedom of choice

Allows state to provide “other” services” and limits number/types of providers

Same as Sec. 1915(b), but permits reimbursement for non-Medicaid services necessary to allow people to live in home and community settings

Supports all of the waivers permitted under Sec. 1915(b) & (c) plus the waiver of other Sec. 1902 requirements. Also permits federal matching for non-Medicaid funded services

Approval Period

Indefinite

Initial 3-year period + indefinite 5-year renewals

Same as Sec. 1915(b)

Initial 5-year period, subject to renewal

Mandatory Enrollment Target Populations

All state plan populations except children with special needs, American Indians, and Medicare beneficiaries

All state plan populations

All state plan populations

All state plan populations plus designated groups not otherwise eligible for Medicaid benefits

Application Requirements

Completion of state plan amendment preprint

Completion of CMS application template

Same as Sec. 1915(b)

Submit proposal describing key program features

Fed. Budget Requirements

No budget/cost analysis required

Demonstrate cost-effectiveness

Same as Sec. 1915(b)

Demonstrate budget neutrality

CMS Review Timeframe

Approval within 90 days unless disapproved or CMS requests additional info. Request must be approved or disapproved by CMS within 90 days of receipt of additional info.

Same as Sec. 1932(a) state plan amendments

Same as Sec. 1932(a) state plan amendments

No required timeframe for CMS review or approval

Renewal Period

No renewal required

After 3 years for initial waiver requests and after 5 years for all subsequent requests

Same as Sec. 1915(b) waiver requests

Customarily up to 3 years, but CMS may approve a 5-year period if dual eligibles are being enrolled

Program Documentation

Contained within CMS state plan preprint

Contained within CMS application template

Contained within CMS application template

Special terms and conditions negotiated between CMS and the state

Monitoring/
Evaluation

CMS monitors implementation of the State Plan Amendment to ensure that requirements are met. State required to conduct separate evaluations of managed care entities

CMS monitors implementation of waiver to ensure that requirements are met. State required to conduct separate evaluations of managed care entities

Same as for Sec. 1915(b) waivers

CMS monitors implementation of the waiver to ensure that requirements are met. Periodic external evaluations also required

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