Section 1115 waiver
A section 1115 waiver (formally a section 1115 demonstration) is a state project that the Secretary of Health and Human Services approves because it is likely to promote the objectives of Medicaid or CHIP. Under section 1115 of the Social Security Act, the Secretary can waive some federal Medicaid requirements and can let costs that wouldn’t otherwise qualify count as Medicaid spending, so they get federal matching funds. Federal rules for applying, public notice and evaluation are in 42 CFR 431 Subpart G.
Why it matters
A demonstration must be budget neutral, meaning federal Medicaid spending can’t be higher than it would have been without it. It is generally approved for 5 years at first and can be extended (Medicaid.gov).
A state can deliver home care through an 1115 demonstration, including managed LTSS, where health plans pay for long-term care (Medicaid.gov). If your state does, the demonstration’s special terms and conditions set who qualifies and which services are covered. When a plan pays, you contract with and bill the plan.
Personal care delivered under section 1115 is still subject to EVV, according to CMS’s EVV guidance.
Example: a state might use one 1115 demonstration to enroll older adults and people with disabilities into health plans that cover both medical care and in-home personal care.
Related: what a Medicaid waiver is and who pays whom, 1915(c) waiver, HCBS.