In the ever-changing landscape of healthcare delivery, waivers offer an opportunity for states to expand programs and services beyond traditional Medicaid service confines, allowing greater flexibility and innovation in care delivery and payment models. Health plans can benefit, too, by contracting with states to increase enrollment and a share of federal and state healthcare dollars.
Health plans seeking to increase enrollment will find the best bet in the 28 states that are participating in Medicaid expansion. The expansion, mandated by the Affordable Care Act (ACA), extended Medicaid coverage to all non-elderly adults with incomes at or below 138% of the federal poverty level (FPL), and opened the doors to Medicaid for millions of uninsured adults who were previously excluded.
The ACA is funding 100% of expansion costs until 2016, after which funds will decline to 90% through 2020. The traditional Medicaid model is a 50/50 split of costs between states and the federal government. The mandate was deemed optional for states by a Supreme Court ruling in 2012, but the ACA also called for other non-optional Medicaid revisions such as a simplified enrollment process, new funding opportunities, and payment reform initiatives.
Related: The Medicaid expansion divide
States can use a variety of waivers to offer specialized benefits packages, restrict beneficiaries to specific provider networks, or expand Medicaid coverage to those who are outside the traditional parameters. Medicaid waiver programs were created by the enactment of the Omnibus Budget Reconciliation Act of 1981 to offer states greater flexibility and the ability to test new delivery models.