Waivers 1115 (Medicaid, old), 1115A (Medicare, 2010 ACA), 1332 (State Exchanges "Obamacare" 2010 ACA).

 The health plan waivers under Sections 1115, 1115A, and 1332 of the Social Security Act (SSA) and Affordable Care Act (ACA) serve distinct purposes and apply to different areas of healthcare policy. Here’s a breakdown:

---

1. Section 1115 Waivers (Medicaid Demonstration Waivers)

• Purpose:
  Section 1115 waivers allow states to test innovative approaches to delivering Medicaid services while waiving certain federal requirements. These waivers are intended to demonstrate or pilot programs that improve care, increase efficiency, and/or reduce costs.

• Authority:
  Established under Title XI of the SSA and predates the ACA.

• Key Features:

  • Focus on Medicaid and CHIP (Children's Health Insurance Program).
  • States may waive requirements like mandatory benefits, eligibility limits, or cost-sharing rules.
  • Common examples include expanding Medicaid eligibility, restructuring payment systems, or introducing new delivery models like managed care.
  • Requires budget neutrality (federal costs cannot exceed what they would be under standard Medicaid rules).

• Examples:

  • Work requirements for Medicaid beneficiaries (though these have faced legal challenges).
  • Expansion of home and community-based services.

---

2. Section 1115A Waivers (Medicare and CMMI Demonstrations)

• Purpose:
  Section 1115A, created under the Affordable Care Act (ACA) in 2010, authorizes the Center for Medicare and Medicaid Innovation (CMMI) to test innovative payment and delivery models in Medicare, Medicaid, and CHIP to improve quality and reduce costs.

• Authority:
  Part of the ACA; applies to both Medicare and Medicaid programs.

• Key Features:

  • Broader than Section 1115 in scope, as it covers both Medicare and Medicaid.
  • Does not require states to apply directly; CMMI often develops models in partnership with providers and payers.
  • Examples of CMMI-led programs include Accountable Care Organizations (ACOs), Bundled Payments for Care Improvement (BPCI), and Medicare Direct Contracting models.
  • Does not require budget neutrality in the same way Section 1115 does but must demonstrate value.

• Examples:

  • Medicare Shared Savings Program.
  • Comprehensive Primary Care Plus (CPC+).

---

3. Section 1332 Waivers (State Innovation Waivers)

• Purpose:
  Section 1332 waivers allow states to waive specific requirements of the Affordable Care Act (ACA) to pursue innovative strategies for providing affordable health insurance while maintaining coverage standards.

• Authority:
  Part of the ACA (Section 1332), these waivers target the private insurance market (individual and small-group plans).

• Key Features:

  • Waivers apply to ACA requirements like the individual mandate, essential health benefits, or marketplace structure.
  • States must ensure that their innovation plans are budget neutral, provide coverage that is as comprehensive and affordable as under the ACA, and cover at least as many people.
  • Typically used to stabilize insurance markets, lower premiums, or implement reinsurance programs.

• Examples:

  • Alaska's reinsurance program, which helped reduce individual market premiums by covering high-cost claims.
  • Colorado's public option for health insurance.

---

Summary of Differences

Feature	Section 1115 (Medicaid)	Section 1115A (Medicare & Medicaid)	Section 1332 (ACA)
Focus	Medicaid and CHIP only	Medicare, Medicaid, and CHIP	Private insurance (ACA markets)
Authority	Social Security Act (historic)	ACA (2010)	ACA (2010)
Purpose	Test Medicaid flexibility	Test innovative payment/delivery models	Innovate ACA insurance structure
Requirements Waived	Medicaid-specific rules	Medicare/Medicaid delivery/payment rules	ACA insurance requirements
Examples	Medicaid managed care, eligibility expansions	ACOs, Bundled Payments, CPC+	Reinsurance programs, public options
Budget Neutrality	Required	Not explicitly required	Required

---

#####

####

###

Here is an example of a 1332 state exchange plan waiver for Nevada released by Biden on 1/10/2025.

Overview: Nevada's Section 1332 State Innovation Waiver under the ACA, approved for 2026–2030, aims to improve affordability and coverage in the individual health insurance market by implementing:

1. Battle Born State Plans (BBSPs): State-contracted qualified health plans.
2. Market Stabilization Program: Includes a reinsurance program, premium relief subsidies, and quality/provider retention incentives.

Key Highlights:

• Waivers Granted: The ACA’s single risk pool requirement is waived to allow plan-level rating variation and reinsurance payments to reduce premiums.
• Premium Reduction Targets: BBSPs aim to reduce premiums by 3% in 2026 and up to 15% by 2029, with reinsurance and subsidies reducing net premiums further.
• Statutory Guardrails Met:
  • Affordability: Lower average premiums compared to the baseline.
  • Coverage: Slight enrollment increases (600–2,000 individuals annually).
  • Deficit Neutrality: Expected $322M in federal savings over five years, used as pass-through funding to support programs.
• Public Engagement: Extensive state and federal comment periods showed general support, with adjustments made in response to concerns (e.g., phased premium reductions, subsidy refinements).

Programs Included:

• Reinsurance Program: Stabilizes the market and lowers premiums.
• Premium Relief Program: Subsidies for enrollees at risk of premium increases.
• Practice in Nevada Program: Incentivizes healthcare providers to remain in the state.
• Quality Incentive Payment Program: Rewards providers and plans meeting care standards.

Implementation & Monitoring:

• Nevada must submit quarterly/annual reports on enrollment, premium impacts, subsidy use, and progress toward premium reduction targets.
• If BBSP enrollment is below 35%, additional premium relief will be triggered.
• Pass-through funding (from federal savings) is used exclusively for waiver implementation.

Next Steps: The state must accept the terms by February 8, 2025, and comply with reporting and oversight requirements to ensure the waiver meets goals.

Let me know if you'd like details on any specific program or provision!