What is a 1115 waiver?
An 1115 waiver, also called an 1115 demonstration, is used by a state that wants to make experimental or pilot demonstration changes to its Medicaid program.
Section 1115 of the Social Security Act gives the Secretary of HHS the authority to approve a state’s 1115 waiver/demonstration proposal as long as it’s determined that the state’s proposal will “assist in promoting the objectives” of the Medicaid program.
The Trump administration took a more relaxed approach in terms of what changes a state could make with an 1115 waiver, and notified governors in 2017 of their “intent to use existing Section 1115 demonstration authority to review and approve meritorious innovations that build on the human dignity that comes with training, employment, and independence.”
Medicaid work requirements
This ushered in an era of states submitting Medicaid work requirement (“community engagement”) proposals as 1115 demonstrations, several of which were approved by the Trump administration. Most of the approved Medicaid work requirements never took effect, as they were either overturned by judges or postponed by state officials.
By 2021, the Biden administration had withdrawn approval for all of the work requirement 1115 waivers that had been approved by the previous administration.
But Georgia implemented a Medicaid work requirement in mid-2023, using an 1115 waiver. The waiver proposal for the work requirement had been approved by the Trump administration and subsequently revoked by the Biden administration.
But Georgia successfully challenged this in court and was able to proceed with the work requirement for people newly eligible for Medicaid under the partial expansion of Medicaid that the state simultaneously implemented. Enrollment in the partially expanded Medicaid has been very low,1 due mostly to the work/work documentation requirement.
Georgia’s 1115 waiver demonstration is scheduled to end in September 2025, and CMS rejected the state’s initial request for a three-year extension.2
Although 1115 waiver proposals for work requirements often generate headlines, 1115 waivers have been around for decades and are used for a wide range of innovative changes to states’ Medicaid programs.
CMS has a webpage that shows a state-by-state list of approved, pending, and terminated 1115 waivers.
Footnotes
- Pathways Monitoring Reports, December 15, 2023. Georgia Department of Community Health. Accessed January 2024. ⤶
- Georgia Pathways to Coverage. Centers for Medicare and Medicaid Services. Accessed January 2024. ⤶
