Medicaid 1115 Waiver Watch: Round-up of Key Themes at the End of the Biden Administration

Section 1115 Medicaid demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, so long as the approach is likely to “promote the objectives of the Medicaid program.” Waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another. Section 1115 waivers generally are approved for an initial five-year period and can be renewed, typically for three-to-five-year periods. The Biden administration encouraged states to propose waivers that expand coverage, reduce health disparities, advance whole-person care, and improve access to behavioral health care. Some waiver initiatives, including using Medicaid to assist with reentry from incarceration, have been pursued by both Republican and Democratic governors. This waiver watch recaps key Biden administration 1115 waiver priorities and initiatives, and highlights states that received approval in each area. For the latest on Medicaid waiver activity (pending applications and approvals), visit KFF’s 1115 tracker.

Looking ahead, the new Trump administration’s waiver priorities will likely differ significantly from those of the Biden administration. However, it is unclear how the Trump administration will treat certain waivers promoted and approved by the Biden administration. The Trump administration could choose not to approve waivers that remain pending or come up for renewal (as many existing waivers are due to expire during the Trump administration) or rescind existing waiver guidance. Additionally, outlined in waiver approval terms and conditions, CMS reserves the right to withdraw 1115 waiver or expenditure authorities at any time (including those already in operation under an active/approved waiver). Although this authority has been infrequently used in the past, the Biden administration withdrew Medicaid work requirement waivers in all states that had approvals, concluding that the provisions do not promote the objectives of the Medicaid program. States can appeal withdrawal decisions to the HHS Department Appeals Board and/or challenge recissions in court.

Health-Related Social Needs

The Biden administration approved 18 waivers authorizing evidence-based housing and nutrition services for specific high-need populations under a new “health-related social needs” (HRSN) 1115 framework. The Centers for Medicare and Medicaid Services (CMS) defines health-related social needs as an individual’s unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health (SDOH). In 2022, CMS announced a Section 1115 demonstration waiver opportunity to expand the tools available to states to address enrollee health-related social needs (building on guidance released at the end of the first Trump administration in 2021). In 2023, CMS issued a detailed Medicaid and CHIP HRSN framework accompanied by an Informational Bulletin, which was updated in 2024. Approvals under the HRSN framework include coverage of rent/temporary housing and utilities for up to 6 months and meal support up to three meals per day (for up to 6 months), departing from longstanding prohibitions on payment of “room and board” in Medicaid. North Carolina’s “Healthy Opportunities” pilots was originally approved during the first Trump administration (allowing the state to provide certain non-medical services targeting SDOH in limited regions of the state) but was recently renewed under the Biden administration’s HRSN framework (extending the scope of services and geographic reach). Some 1115 SDOH-related requests for housing and/or nutrition services remain pending with CMS, including Connecticut, DC, Maine, Nevada, and Rhode Island. Many HRSN waivers will face renewal during the Trump administration, with Colorado’s waiver set to expire at the end of 2025 and others (e.g., California, New York) due for renewal starting in late 2026/early 2027.

Medicaid Pre-release Coverage for Individuals Who Are Incarcerated

The Biden administration approved 19 state waivers to facilitate reentry for individuals who are incarcerated. In April 2023, CMS released guidance encouraging states to apply for a new Section 1115 demonstration opportunity to test transition-related strategies to support community reentry for people who are incarcerated—as directed by the 2018 SUPPORT Act (which was signed into law during the first Trump administration). This demonstration allows states a partial waiver of the inmate exclusion policy, which prohibits Medicaid from paying for services provided during incarceration (except for inpatient services). Reentry services aim to improve care transitions and increase continuity of health coverage, reduce disruptions in care, improve health outcomes, and reduce recidivism rates. At a minimum, states must provide case management, medication-assisted treatment for all types of substance use disorders (with accompanying counseling), and a 30-day supply of prescription medications at the time of release. Nine states (including DC) have waivers to provide reentry services pending with CMS.

Multi-year Continuous Eligibility for Children

The Biden administration approved 9 waivers that allow states to provide multi-year continuous eligibility for children (e.g., from birth to age six). The Consolidated Appropriations Act, 2023 required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. States may request Section 1115 waiver authority to provide continuous eligibility for children for longer than 12 months. Continuous eligibility has been shown to reduce Medicaid disenrollment and “churn” rates (rates of individuals temporarily losing Medicaid coverage and then re-enrolling within a short period of time). When individuals churn on and off coverage, the gaps in coverage may limit access to care or lead to delays in getting needed care, which can be especially problematic for young children who receive frequent screenings and check-ups. Most states with waivers are approved to provide continuous coverage for young children from birth to age six; some states are also approved to provide 24 months of continuous eligibility for children ages six to 19. While no additional multi-year continuous eligibility waivers for children are pending with CMS, some may remain under consideration at the state-level.