Waiver Descriptions

​​​​​​​​​​​​​​​Cardinal Innovations provides access to Medicaid behavioral health and intellectual/developmental disabilities services through 1915(b) and 1915(c) waivers.  Sections 1915(b) and 1915(c) of the Social Security Act authorize the use of waivers to give states increased flexibility in operating their Medicaid programs.  States apply to the Centers for Medicare and Medicaid Services (CMS) for waiver approval through written applications that describe in detail how the waiver will operate.

The 1915(b) waiver is used to implement mandatory enrollment of Medicaid enrollees in managed care through entities such as prepaid health plans, health maintenance organizations (HMO) and primary care case management programs. The requirements of the Social Security Act pertaining to Medicaid that are typically waived to implement 1915(b) waivers are noted below.

  • Freedom of Choice – Medicaid beneficiaries may be required to receive services through specific types of managed care plans.  In addition, the number of plans may be limited through selective contracting, and the number of providers may be limited by the plans.
  • Statewideness – The waiver may be limited to specific geographic areas of the state. 
  • Comparability of Services – Additional benefits, such as care management and health education, which are not available to other Medicaid beneficiaries, may be provided.  In addition, any savings generated may be used to create and fund innovative and cost effective services, known as 1915(b)(3) services, for waiver participants. 

States that implement 1915(b) waivers comply with the federal regulations that govern managed care delivery systems regarding quality assurance and performance improvement; reasonable access to providers; grievance and appeal rights; and cost effectiveness. Cost effectiveness is achieved if the wa​iver does not increase Medicaid costs. Actual waiver expenditures are tracked and reported to CMS on a quarterly basis.

The 1915(c) waiver allows for the provision of long-term services and supports in an individual's home and community instead of an institution.  Nursing facilities, intermediate care facilities for individuals with intellectual disabilities (ICF/IID) and hospitals are considered institutions under this waiver authority. In order to qualify for the waiver, a Medicaid beneficiary must meet the institutional level of care requirements specified in the waiver and have a service plan that ensures the individual's health and safety. The requirements of the Social Security Act pertaining to Medicaid that may be waived through 1915(c) waivers are noted below.

  • Statewideness – The waiver may be limited to specific geographic areas of the state. 
  • Comparability of Services – An array of home- and community-based services geared toward the waiver target population is developed and available only to waiver participants. 
  • Income and Resources – Medicaid eligibility requirements for individuals living in the community may be waived and replaced with institutional budgeting, which is less restrictive.  A waiver participant's family members' income and resources are not considered when determining Medicaid eligibility.

 

Performance measurement and quality improvement strategies are required components of 1915(c) waivers.  Findings and remediation activities are reported to CMS on a regular basis.  1915(c) waivers must also be budget neutral. The average per capita cost of Medicaid-funded services for waiver participants cannot exceed the average per capita cost of Medicaid services if the individual was in an institution.

Concurrent operation of 1915(b)/(c) waivers provide for a managed care delivery system that covers both Medicaid state plan services and long-term services/supports created under the 1915(c) waiver. Cardinal Innovations and the state Medicaid agency worked together to develop and implement concurrent 1915(b)/(c) waivers for behavioral health and intellectual/developmental disabilities services in 2005. The waivers were implemented as a demonstration in Cardinal Innovations' original five counties. Significant savings and increased quality of care were achieved during the demonstration, and the waiver program has been expanded statewide as of 2013.  ​