Deciphering State Medicaid Programs

January 08, 2019
Rachel Gershon
Rachel Gershon, JD, MPH
Senior Associate, Health Law & Policy

State Medicaid programs vary substantially from one another.  For members, researchers, policymakers, and advocates trying to decipher a state’s Medicaid program, this variation can be a source of frustration, because the details of this variation can be hard to locate. 

Medicaid is a public health insurance program for low-income Americans administered by states.  When running their Medicaid programs, states must follow federal Medicaid law and other requirements.  Federal Medicaid law is quite detailed and prescriptive, but also offers states paths toward greater flexibility.

There is a set of documents that can be helpful in finding the details of a state’s Medicaid program, because they describe how a state takes advantage of options for flexibility.  This blog post briefly describes these documents and where to find them.  

Medicaid State Plans

A Medicaid State Plan sets forth how a state Medicaid agency will operate its Medicaid program in accordance with federal law. Typically about a thousand pages long, the Medicaid state plan includes information about who is eligible for Medicaid, what services are available, and how Medicaid providers get paid. Within federal Medicaid law, there are various “state plan options,” for example, the option to provide dental services or the option to offer care through Health Homes. Medicaid state plans contain information about whether a state has selected a state plan option or not.

Medicaid state plans are available online for the following states and territories:  Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Florida, Georgia, Guam, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee, Texas, Vermont, Washington State, West Virginia, Wisconsin, and Wyoming.  State plans posted online are not always up to date; make sure to check the effective date and look for state plan amendments posted after that date (see the next section). 

Medicaid State Plan Amendments

When a state wants to change its Medicaid state plan, it submits a state plan amendment to the federal government.  These state plan amendments can be used to update Medicaid state plans, described above. The Secretary of the United States Department of Health and Human Services, or HHS, must approve the amendment before it can take effect.  Recently approved state plan amendments are available here.

Waiver documents

Sometimes, a state wants to make changes to its Medicaid program that are not available through a state plan option.  In those cases, a state may submit a waiver application to be approved at the discretion of the HHS Secretary and in accordance with specific programmatic and financial requirements.

  • Section 1115 waivers offer broad waiver and expenditure authorities to states.  Changes approved under Section 1115 waivers can affect eligibility, services, and service delivery.  For example, one of Oregon’s 1115 waivers moves care delivery to Coordinated Care Organizations (CCOs). Pending and approved 1115 Demonstration documents are available here.
  • Section 1915(c) waivers offer states an opportunity to provide long-term services and supports in the community, rather than in an institution like a nursing home.  Approved 1915(c) applications set out the parameters of the 1915(c) program, and are available here.
  • Section 1915(b) waivers offer states an opportunity to waive various parts of federal Medicaid law related to delivery systems. Approved 1915(b) applications set forth parameters associated with 1915(b) waivers, and are available here.

Flexibility available through the Center for Medicare and Medicaid Innovation

The Center for Medicare and Medicaid Innovation (CMMI) has the authority to grant state Medicaid agencies additional flexibility (technically available through Section 1115A of the Social Security Act). 

  • Duals Demonstration projects are projects that offer states an opportunity to align member experiences for individuals who receive both Medicaid and Medicare.  Duals Demonstration materials are available here
  • Other CMMI projects offer states additional ways to modify their Medicaid programs.  Information is available here

Conclusion

State Medicaid programs vary from state to state.  These documents and links can help interested parties navigate these variations.  This blog post focused solely on the documents that memorialize agreements between a state and the federal government regarding areas of state flexibility and variation.  For a broad understanding of how Medicaid functions and the requirements a state must follow, these documents should be read within the context of federal and state statutes, regulations, guidance materials, administrative decisions, court cases, and procurement materials.