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Centers for Medicare & Medicaid Services
Office of Information Services
Information Services Design & Development Group
7500 Security Blvd
Baltimore, MD 21244-1850
Section 1115 Demonstration Program
Template
1
Section 1115 Demonstration
Template for New Demonstrations
Instructions: This template is meant to assist states that are developing an application for a new
section 1115 demonstration project; submission of the information provided in this template or
the attachments does not guarantee approval of a state’s demonstration request.
CMS will work
with states to identify any additional information necessary to consider demonstration requests.
Use of this guide/format is not required; it is a tool that states can use at their option.
It was
designed to help states ensure the application contains the required elements as provided for
under 42 CFR
431.412, as well as promote an efficient review process. It can also be used by
states as a template for their application; states can add narrative responses to the information
requested in the sections below that are applicable to the state’s particular application, and
complete the charts and check boxes provided.
We will continue to improve this guide based on
input from states and expect to have an online section 1115 demonstration application available
for use in the future.
Please submit applications electronically to 1115DemoRequests@cms.hhs.gov and mail hard
copies to:
Ms. Victoria Wachino
Centers for Medicare & Medicaid Services
Children and Adults Health Programs Group
Mail Stop: S2-01-16
7500 Security Boulevard
Baltimore, MD 21244
Section I - Program Description
This section should contain information describing the goals and objectives of the
Demonstration, as well as the hypotheses that the Demonstration will test. In accordance with 42
CFR 431.412(a)(i), (v) and (vii), the information identified in this section must be included in a
state’s application in order to be determined complete. Specifically, this section should:
1) Provide a summary of the proposed Demonstration program, and how it will further the
objectives of title XIX and/or title XXI of the Social Security Act (the Act).
(This
summary will also be posted on Medicaid.gov after the application is submitted. If
additional space is needed, please supplement your answer with a Word attachment);
2) Include the rationale for the Demonstration (if additional space is needed, please
supplement your answer with a Word attachment);
3) Describe the hypotheses that will be tested/evaluated during the Demonstration’s
approval period and the plan by which the State will use to test them (if additional space
is needed, please supplement your answer with a Word attachment);
4) Describe where the Demonstration will operate, i.e., statewide, or in specific regions
within the State. If the Demonstration will not operate statewide, please indicate the
2
geographic areas/regions of the State where the Demonstration will operate (if additional
space is needed, please supplement your answer with a Word attachment);
5) Include the proposed timeframe for the Demonstration(if additional space is needed,
please supplement your answer with a Word attachment); and
6) Describe whether the Demonstration will affect and/or modify other components of the
State’s current Medicaid and CHIP programs outside of eligibility, benefits, cost sharing
or delivery systems (if additional space is needed, please supplement your answer with a
Word attachment).
Section II – Demonstration Eligibility
This section should include information on the populations that will participate in the
Demonstration, including income level. In accordance with 42 CFR 431.412(a)(ii), the
information identified in this section must be included in a state’s application in order to be
determined complete. Specifically, this section should:
1) Include a chart identifying any populations whose eligibility will be affected by the
Demonstration (an example is provided below; note that populations whose eligibility is
not proposed to be changed by the Demonstration do not need to be included).
Please
refer to Medicaid Eligibility Groups: http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Waivers/1115/Downloads/List-of-Eligibility-Groups.pdf when
describing Medicaid State plan populations, and for an
3
expansion eligibility group, please provide the state name for the groups that is sufficiently
descriptive
to explain the groups to the
public.
Example Eligibility Chart
Eligibility Group Name
Social Security Act and CFR Citations
Income Level
Transitional Medical Assistance
408(a)(11)(A)
1931(c)(2)
1925
1902(a)(52)
0 – 100% of the
FPL
Families who would qualify for
cash assistance if the State had
expanded its cash assistance
program as allowed under
federal law (Parent/Caretaker
Relatives)
1902(a)(10)(A)(ii)(III)
42 CFR 435.223
1905(a)
100 – 200% of
the FPL
Adults without dependent
children not otherwise eligible
under the State plan
N/A
0-200% of the
FPL
Eligibility Chart
Mandatory State Plan Groups
Eligibility Group Name
Social Security Act and CFR Citations
Income Level
Optional State Plan Groups
Eligibility Group Name
Social Security Act and CFR Citations
Income Level
Expansion Populations
Eligibility Group Name
N/A
Income Level
2) Describe the standards and methodologies the state will use to determine eligibility for
any populations whose eligibility is changed under the Demonstration, to the extent those
standards or methodologies differ from the State plan (if additional space is needed,
please supplement your answer with a Word attachment);
4
3) Specify any enrollment limits that apply for expansion populations under the
Demonstration (if additional space is needed, please supplement your answer with a
Word attachment);
4) Provide the projected number of individuals who would be eligible for the
Demonstration, and indicate if the projections are based on current state programs (i.e.,
Medicaid State plan, or populations covered using other waiver authority, such as
1915(c)). If applicable, please specify the size of the populations currently served in
those programs (if additional space is needed, please supplement your answer with a
Word attachment);
5) To the extent that long term services and supports are furnished (either in institutions or
the community), describe how the Demonstration will address post-eligibility treatment
of income, if applicable. In addition, indicate whether the Demonstration will utilize
spousal impoverishment rules under section 1924, or will utilize regular post-eligibility
rules under 42 CFR 435.726 (SSI State and section 1634) or under 42 CFR 435.735
(209b State) (if additional space is needed, please supplement your answer with a Word
attachment);
6) Describe any changes in eligibility procedures the state will use for populations under the
Demonstration, including any eligibility simplifications that require 1115 authority (such
as continuous eligibility or express lane eligibility for adults or express lane eligibility for
children after 2013) (if additional space is needed, please supplement your answer with a
Word attachment); and
7) If applicable, describe any eligibility changes that the state is seeking to undertake for the
purposes of transitioning Medicaid or CHIP eligibility standards to the methodologies or
standards applicable in 2014 (such as financial methodologies for determining eligibility
based on modified adjusted gross income), or in light of other changes in 2014 (if
additional space is needed, please supplement your answer with a Word attachment).
Section III – Demonstration Benefits and Cost Sharing Requirements
This section should include information on the benefits provided under the Demonstration as
well as any cost sharing requirements. In accordance with 42 CFR 431.412(a)(ii), the
information identified in this section must be included in a state’s application in order to be
determined complete. Specifically, this section should:
1) Indicate whether the benefits provided under the Demonstration differ from those
provided under the Medicaid and/or CHIP State plan:
Yes No (if no, please skip questions 3 – 7)
2) Indicate whether the cost sharing requirements under the Demonstration differ from those
provided under the Medicaid and/or CHIP State plan:
Yes No (if no, please skip questions 8 - 11)
3) If changes are proposed, or if different benefit packages will apply to different eligibility
groups affected by the Demonstration, please include a chart specifying the benefit
package that each eligibility group will receive under the Demonstration (an example is
provided):
Example Benefit Package Chart
Eligibility Group
Benefit Package
Transitional Medical Assistance
Full State Plan
Optional State plan parent/caretaker relatives
Benchmark Equivalent Benefit Package
Expansion Adults
Demonstration-only Benefit Package
Benefit Package Chart
Eligibility Group
Benefit Package
4) If electing benchmark-equivalent coverage for a population, please indicate which
standard is being used:
Federal Employees Health Benefit Package
State Employee Coverage
Commercial Health Maintenance Organization
Secretary Approved
**Please note that, in accordance with section 1937(a)(2)(B) of the Act, the following populations
are exempt from benchmark equivalent benefit packages: mandatory pregnant women, blind or
disabled individuals, dual eligibles, terminally ill hospice patients, individuals eligible on basis
of
institutionalization,
medically frail and special medical needs individuals, beneficiaries qualifying for
long-
term care services, children in foster care or receiving adoption assistance, mandatory section 1931
parents, and women in the breast or cervical cancer program. Also, please note that children must be
provided full EPSDT benefits in benchmark coverage.
5) In addition to the Benefit Specifications and Qualifications form:
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/Downloads/Interim1115-Benefit-Specifications-and-Provider-
Qualifications.pdf, please complete the following chart if the Demonstration will
provide benefits that differ from the Medicaid or CHIP State plan, (an example is
provided).
Example Benefit
Chart
Benefit
Description of Amount, Duration and Scope
Reference
Inpatient
Hospital
Services
No limitations – coverage is based on State plan
Mandatory
1905(a)(1)
Podiatrist
Services
Limited to 12 visits per year
Optional
1905(a)(6)
Benefit
Chart
Benefit
Description of Amount, Duration and Scope
Reference
Benefits Not
Provided
Benefit
Description of Amount, Duration and Scope
Reference
Please refer to List of Medicaid and CHIP Benefits:
http://www.medicaid.gov/Medicaid- CHIP-Program-Information/By-
Topics/Waivers/1115/Downloads/List-of-Medicaid-and-CHIP-Benefits.pdf, when
completing this chart.
6) Indicate whether Long Term Services and Supports will be provided.
Yes (if yes, please check the services that are being offered) No
In addition, please complete the: http://medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Waivers/1115/Downloads/List-of-LTSS-Benefits.pdf, and
the: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/Downloads/Long-Term-Services-Benefit-Specifications-and-
Provider-Qualifications.pdf.
Homemaker
Case Management
Adult Day Health Services
Habilitation – Supported Employment
Habilitation – Day Habilitation
Habilitation – Other Habilitative
Respite
Psychosocial Rehabilitation
Environmental Modifications
(Home Accessibility Adaptations)
Non-Medical Transportation
Home Delivered Meals Personal
Emergency Response
Community Transition Services
Day Supports (non-habilitative)
Supported Living Arrangements
Assisted Living
Home Health Aide
Personal Care Services
Habilitation – Residential Habilitation
Habilitation – Pre-Vocational
Habilitation – Education (non-IDEA
Services)
Day Treatment (mental health service)
Clinic Services
Vehicle Modifications
Special Medical Equipment (minor
assistive devices)
Assistive Technology
Nursing Services
Adult Foster Care
Supported Employment
Private Duty Nursing
Adult Companion Services
Supports for Consumer Direction/Participant Directed Goods and Services
Other (please describe)
7) Indicate whether premium assistance for employer sponsored coverage will be available
through the Demonstration.
Yes (if yes, please address the questions below)
No (if no, please skip this question)
a) Describe whether the state currently operates a premium assistance program and
under which authority, and whether the state is modifying its existing program or
creating a new program (if additional space is needed, please supplement your
answer with a Word attachment);
b) Include the minimum employer contribution amount (if additional space is
needed, please supplement your answer with a Word attachment);
c) Describe whether the Demonstration will provide wrap-around benefits and cost-
sharing (if additional space is needed, please supplement your answer with a
Word attachment); and
d) Indicate how the cost-effectiveness test will be met (if additional space is needed,
please supplement your answer with a Word attachment).
8) If different from the State plan, provide the premium amounts by eligibility group and
income level (if additional space is needed, please supplement your answer with a Word
attachment).
9) Include a table if the Demonstration will require copayments, coinsurance and/or
deductibles that differ from the Medicaid State plan (an example is provided):
Example Copayment Chart
Eligibility Group
Benefit
Copayment Amount
Childless Adults
Podiatrist
Services
$3 per visit
Copayment Chart
Eligibility Group
Benefit
Copayment Amount
If the state is proposing to impose cost sharing in the nature of deductions, copayments or
similar charges beyond what is permitted under the law, the state should also address in
its application, in accordance with section 1916(f) of the Act, that its waiver request:
a) will test a unique and previously untested use of copayments;
b) is limited to a period of not more than two years;
c) will provide benefits to recipients of medical assistance which can reasonably be
expected to be equivalent to the risks to the recipients;
d) is based on a reasonable hypothesis which the demonstration is designed to test in
a methodologically sound manner, including the use of control groups of similar
recipients of medical assistance in the area; and
e) is voluntary, or makes provision for assumption of liability for preventable
damage to the health of recipients of medical assistance resulting from
involuntary participation.
Please refer to Information on Cost Sharing http://www.medicaid.gov/Medicaid-CHIP-
Program-Information/By-Topics/Waivers/1115/Downloads/Interim1115-Information-on-
Cost-Sharing-Requirements.pdf requirements for further information on statutory
exemptions and limitations applicable to certain populations and services.
10) Indicate if there are any exemptions from the proposed cost sharing (if additional space
is needed, please supplement your answer with a Word attachment).
Section IV – Delivery System and Payment Rates for Services
This section should include information on the means by which benefits will be provided to
Demonstration participants. In accordance with 42 CFR 431.412(a)(ii), a description of the
proposed healthcare delivery system must be included in a state’s application in order to be
determined complete. Specifically, this section should:
1) Indicate whether the delivery system used to provide benefits to Demonstration
participants will differ from the Medicaid and/or CHIP State plan:
Yes
No (if no, please skip questions 2 – 7 and the applicable payment rate questions)
2) Describe the delivery system reforms that will occur as a result of the Demonstration, and
if applicable, how they will support the broader goals for improving quality and value in
the health care system. Specifically, include information on the proposed
Demonstration’s expected impact on quality, access, cost of care and potential to improve
the health status of the populations covered by the Demonstration. Also include
information on which populations and geographic areas will be affected by the reforms
(if additional space is needed, please supplement your answer with a Word attachment);
3) Indicate the delivery system that will be used in the Demonstration by checking one or
more of the following boxes:
Managed care
Managed Care Organization (MCO),
Prepaid Inpatient Health Plans (PIHP)
Prepaid Ambulatory Health Plans (PAHP)
Fee-for-service (including Integrated Care Models)
Primary Care Case Management (PCCM)
Health Homes
Other (please describe)
4) If multiple delivery systems will be used, please include a table that depicts the delivery
system that will be utilized in the Demonstration for each eligibility group that
participates in the Demonstration (an example is provided). Please also include the
appropriate authority if the Demonstration will use a delivery system (or is currently
seeking one) that is currently authorized under the State plan, section 1915(a) option,
section 1915(b) or section 1932 option:
Example Delivery System Chart
Eligibility Group
Delivery System
Authority
Transitional Medical Assistance
Fee-for-service
State plan
Optional State plan
parent/caretaker relatives
Managed Care – MCO
Section 1915(b) waiver
Childless Adults
Managed Care – MCO
1115
Delivery System Chart
Eligibility Group
Delivery System
Authority
5) If the Demonstration will utilize a managed care delivery system:
a) Indicate whether enrollment be voluntary or mandatory. If mandatory, is the state
proposing to exempt and/or exclude populations (if additional space is needed,
please supplement your answer with a Word attachment)?
b) Indicate whether managed care will be statewide, or will operate in specific areas
of the state (if additional space is needed, please supplement your answer with a
Word attachment);
c) Indicate whether there will be a phased-in rollout of managed care (if managed
care is not currently in operation or in specific geographic areas of the state. If
additional space is needed, please supplement your answer with a Word
attachment);
d) Describe how will the state assure choice of MCOs, access to care and provider
network adequacy (if additional space is needed, please supplement your answer
with a Word attachment); and
e) Describe how the managed care providers will be selected/procured (if additional
space is needed, please supplement your answer with a Word attachment).
6) Indicate whether any services will not be included under the proposed delivery system
and the rationale for the exclusion (if additional space is needed, please supplement your
answer with a Word attachment);
7) If the Demonstration will provide personal care and/or long term services and supports,
please indicate whether self-direction opportunities are available under the
Demonstration. If yes, please describe the opportunities that will be available, and also
provide additional information with respect to the person-centered services in the
Demonstration and any financial management services that will be provided under the
Demonstration (if additional space is needed, please supplement your answer with a
Word attachment).
Yes No
8) If fee-for-service payment will be made for any services, specify any deviation from State
plan provider payment rates. If the services are not otherwise covered under the State
plan, please specify the rate methodology (if additional space is needed, please
supplement your answer with a Word attachment);
9) If payment is being made through managed care entities on a capitated basis, specify the
methodology for setting capitation rates, and any deviations from the payment and
contracting requirements under 42 CFR Part 438 (if additional space is needed, please
supplement your answer with a Word attachment); and
10) If quality-based supplemental payments are being made to any providers or class of
providers, please describe the methodologies, including the quality markers that will be
measured and the data that will be collected (if additional space is needed, please
supplement your answer with a Word attachment).
13
Section V – Implementation of Demonstration
This section should include the anticipated implementation date, as well as the approach that the
State will use to implement the Demonstration. Specifically, this section should:
1) Describe the implementation schedule. If implementation is a phase-in approach, please
specify the phases, including starting and completion dates by major
component/milestone (if additional space is needed, please supplement your answer with
a Word attachment);
2) Describe how potential Demonstration participants will be notified/enrolled into the
Demonstration (if additional space is needed, please supplement your answer with a
Word attachment); and
3) If applicable, describe how the state will contract with managed care organizations to
provide Demonstration benefits, including whether the state needs to conduct a
procurement action (if additional space is needed, please supplement your answer with a
Word attachment).
14
Section VI – Demonstration Financing and Budget Neutrality
This section should include a narrative of how the Demonstration will be financed as well as the
expenditure data that accompanies this application. The State must include 5 years of historical
data, as well as projections on member month enrollment. In accordance with 42 CFR
431.412(a)(iii) and (iv), historical and projected expenditures as well as projected enrollment for
the proposed demonstration project must be included in a state’s application in order to be
determined complete. The additional information requested will be needed before the application
can be acted upon.
Please complete the Demonstration financing and budget neutrality forms, respectively, and
include with the narrative discussion. The Financing Form: http://www.medicaid.gov/Medicaid-
CHIP-Program-Information/By-Topics/Waivers/1115/Downloads/Interim1115-Demo-
Financing-Form.pdf includes a set of standard financing questions typically raised in new
section 1115 demonstrations; not all will be applicable to every demonstration application. The
Budget Neutrality form and spreadsheet: http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Waivers/1115/Downloads/Interim1115-Budget-Neutrality-Form.pdf
includes a set of questions with respect to historical expenditure data as well as projected
Demonstration expenditures.
Section VII – List of Proposed Waivers and Expenditure Authorities
This section should include a preliminary list of waivers and expenditures authorities related to
title XIX and XXI authority that the State believes it will need to operate its Demonstration. In
15
accordance with 42 CFR 431.412(a)(vi), this section must be included in a state’s application in
order to be determined complete. Specifically, this section should:
1) Provide a list of proposed waivers and expenditure authorities; and
2) Describe why the state is requesting the waiver or expenditure authority, and how it will
be used.
Please refer to the list of title XIX and XXI waivers and expenditure authorities:
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/
1115 /Downloads/List-of-Waivers-and-Expenditure-Authorities.pdf that the state can reference to
help complete this section. CMS will work with the State during the review process to determine
the appropriate waivers and expenditures needed to ensure proper administration of the
Demonstration.
Section VIII – Public Notice
This section should include information on how the state solicited public comment during the
development of the application in accordance with the requirements under 42 CFR 431.408. For
specific information regarding the provision of state public notice and comment process, please
click on the following link to view the section 1115 Transparency final rule and corresponding
16
State Health Official Letter: http://medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/Section-1115-Demonstrations.html
Please include the following elements as provided for in 42 CFR 431.408 when developing this
section:
1) Start and end dates of the state’s public comment period (if additional space is needed,
please supplement your answer with a Word attachment);
2) Certification that the state provided public notice of the application, along with a link to
the state’s web site and a notice in the state’s Administrative Record or newspaper of
widest circulation 30 days prior to submitting the application to CMS (if additional space
is needed, please supplement your answer with a Word attachment);
3) Certification that the state convened at least 2 public hearings, of which one hearing
included teleconferencing and/or web capability, 20 days prior to submitting the
application to CMS, including dates and a brief description of the hearings conducted (if
additional space is needed, please supplement your answer with a Word attachment);
4) Certification that the state used an electronic mailing list or similar mechanism to notify
the public. (If not an electronic mailing list, please describe the mechanism that was used.
If additional space is needed, please supplement your answer with a Word attachment);
5) Comments received by the state during the 30-day public notice period (if additional
space is needed, please supplement your answer with a Word attachment);
6) Summary of the state’s responses to submitted comments, and whether or how the state
incorporated them into the final application (if additional space is needed, please
supplement your answer with a Word attachment); and
7) Certification that the state conducted tribal consultation in accordance with the
consultation process outlined in the state’s approved Medicaid State plan, or at least 60
days prior to submitting this Demonstration application if the Demonstration has or
would have a direct effect on Indians, tribes, on Indian health programs, or on urban
Indian health organizations, including dates and method of consultation (if additional
space is needed, please supplement your answer with a Word attachment).
If this application is an emergency application in which a public health emergency or a natural
disaster has been declared, the State may be exempt from public comment and tribal consultation
requirements as outlined in 42 CFR 431.416(g). If this situation is applicable, please explain the
basis for the proposed emergency classification and public comment/tribal consultation
exemption (if additional space is needed, please supplement your answer with a Word
attachment).
17
Section IX – Demonstration Administration
Please provide the contact information for the state’s point of contact for the Demonstration
application.
Name and Title:
Telephone Number:
Email Address:
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