State Innovation Waivers:
January 29, 2021
Frequently Asked Questions
Ryan J. Rosso
State Innovation Waivers: Frequently Asked Questions
Updated May 5, 2026
(R44760)
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Summary
Section 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148Section 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148
, as , as
Analyst in Health Care
amended) provides states with the option to waive specified requirements of the ACA. amended) provides states with the option to waive specified requirements of the ACA.
Financing
In the absence of these requirements, a state is to implement its own plan to provide In the absence of these requirements, a state is to implement its own plan to provide
health insurance coverage to state residents that meets the ACAhealth insurance coverage to state residents that meets the ACA
’'s terms.s terms.
Under a state innovation waiver, a state can apply to waive ACAUnder a state innovation waiver, a state can apply to waive ACA
requirements related to requirements related to
qualified health plans, health insurance exchanges, premium tax credits, cost-sharing subsidies, the individual qualified health plans, health insurance exchanges, premium tax credits, cost-sharing subsidies, the individual
mandate, and the employer mandate. The state can apply to waive any or mandate, and the employer mandate. The state can apply to waive any or
al all of these requirements, in part or in of these requirements, in part or in
their entirety.their entirety.
To obtain approval for a waiver application, a state must show that the plan it To obtain approval for a waiver application, a state must show that the plan it
wil will implement in the absence of the implement in the absence of the
waived provision(s) meets certain requirements. waived provision(s) meets certain requirements.
Under current guidance, theThe state state
’'s plan must ensure that s plan must ensure that
a comparable number ofas many state residents have health insurance coverage under the plan as would have had coverage state residents have health insurance coverage under the plan as would have had coverage
absent the waiver. It also must provide a comparable number of residents with the opportunity to purchase coverage that isabsent the waiver, and the coverage must be as affordable and comprehensive as as affordable and comprehensive as
it would have been would have been
available absent the waiver. However, applications do not need to demonstrate that the comparable number of residents would be enrolled in the affordable and comprehensive coverage, as would have been required under previous guidance. Final y, the state’s
absent the waiver. Additionally, the state's plan cannot increase the federal deficit.plan cannot increase the federal deficit.
The Secretary of the Department of Health and Human Services (HHS) and the Secretary of the Treasury share The Secretary of the Department of Health and Human Services (HHS) and the Secretary of the Treasury share
responsibility for reviewing state innovation waiver applications and deciding whether to approve applications. responsibility for reviewing state innovation waiver applications and deciding whether to approve applications.
State innovation waivers cannot extend longer than five years, unless a state requests continuation and the State innovation waivers cannot extend longer than five years, unless a state requests continuation and the
appropriate Secretary does not deny such request. The earliest a state innovation waiver could appropriate Secretary does not deny such request. The earliest a state innovation waiver could
have gone into
take effect was January 1, 2017.effect was January 1, 2017.
In October 2018, the Centers for Medicare & Medicaid Services (CMS) released updated guidance regarding the
state innovation waiver process that superseded previously issued CMS guidance from December 2015. In general, the updated guidance attempts to make it easier for a state plan to be approved. The updated guidance applies to al waiver applications that had not been approved prior to the date of the guidance’s release. Waivers
approved under the previously issued guidance did not require reconsideration.
As of the date of this report, As of the date of this report,
1621 states—Alaska, Colorado, Delaware, Georgia, states—Alaska, Colorado, Delaware, Georgia,
Hawai Hawaii, Idaho, Maine, Maryland, , Maine, Maryland,
Minnesota, Montana, Minnesota, Montana,
Nevada, New Hampshire, New Jersey, New Hampshire, New Jersey,
New York, North Dakota, Oregon, Pennsylvania, Rhode Island, North Dakota, Oregon, Pennsylvania, Rhode Island,
Virginia, Washington, and and
Wisconsin—have approved state innovation waivers. Wisconsin—have approved state innovation waivers.
Eight of these waivers were considered and approved under the initial state innovation waiver guidance, and eight were considered and approved under the current state
innovation waiver guidance. Fifteen of the 16 approved waivers implement(However, New York requested, and was approved, to terminate its approved waiver effective July 1, 2026). The most common feature of approved state innovation waivers are reinsurance programs, as 18 of the 21 approved waivers include a variant of a statewide individual a variant of a statewide individual
market reinsurance program.
Idaho, Massachuset s, Ohio, and Vermont have submitted applications and received notification that their applications were incomplete. It does not appear that any of these states has modified its application in response to the notification (as of the date of this report). If these states take action, any further review of their waiver application would be under the updated state innovation waiver guidance. Three states—California, Iowa, and
Oklahoma—submitted waiver applications and have since withdrawn their applications.
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Contents
Which ACA Provisions May a State Waive Under a State Innovation Waiver? .......................... 1
Which Federal Agencies Have the Authority to Grant a Waiver?............................................. 2
What Are the Minimum Requirements for a Successful Application? ...................................... 2
May a State Modify Its Use of the Federal y Facilitated Health Insurance Exchange
Platform Under a State Innovation Waiver? ...................................................................... 6
Are There Any Limitations on the Scope of State Innovation Waivers? .................................... 6
What Is the Application Process for a State Innovation Waiver? ............................................. 7
Is Any Federal Funding Available Under a State Innovation Waiver?....................................... 8
How Long Can a State Innovation Waiver Be in Effect?........................................................ 8
May States Submit State Innovation Waiver Applications in Coordination with Other
Federal Waiver Applications? ......................................................................................... 8
How Many States Have Applied for State Innovation Waivers? .............................................. 9
Tables
Table 1. Requirements for a Successful State Innovation Waiver Application............................ 3
Table 2. States That Have Applied for State Innovation Waivers ........................................... 10
Contacts
Author Information ....................................................................................................... 23
Congressional Research Service
State Innovation Waivers: Frequently Asked Questions
ection 1332 of the Patient Protection and Affordable Care Act (ACA; market reinsurance program. These reinsurance programs typically offset a portion of the insurer's high-cost claims for certain individual market enrollees, reducing the insurer's overall risk and contributing to lower premiums in the individual market.
Idaho, Massachusetts, Ohio, and Vermont have submitted applications and received notification that their applications were incomplete. In October 2025, Idaho indicated that it is seeking to amend its approved waiver to incorporate a plan similar to the one discussed in its incomplete application. It does not appear that Massachusetts, Ohio, or Vermont has modified their incomplete applications in response to the notification (as of the date of this report). Three states—California, Iowa, and Oklahoma—submitted waiver applications and have since withdrawn their applications.
Section 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as P.L. 111-148, as
amended) amended)
al owsallows states to apply for waivers of specified provisions of the ACA. Under a states to apply for waivers of specified provisions of the ACA. Under a
S state innovation waiver, a state is expected to implement a plan (in place of the waived state innovation waiver, a state is expected to implement a plan (in place of the waived
provisions) that meets certain minimum requirements. The Centers for Medicare & Medicaid Services’ (CMS’s) initial interpretation of these requirements was published in guidance released in 2015 but has since been superseded, as with other aspects of the waiver process, in updated
guidance released by the agency on October 24, 2018.1 Many aspects of the 2018 guidance were
codified in a final rule issued on January 19, 2021.2
Under current guidance, the state’s plan must ensure that a comparable number of state residents have health insurance coverage under the plan as would have had coverage absent the waiver. It also must provide a comparable number of residents with the opportunity to purchase coverage that is as affordable and comprehensive as would have been available absent the waiver. However, applications do not need to demonstrate that the comparable number of residents would be enrolled in the affordable and comprehensive coverage, as would have been required under
previous guidance. Final y, the state’provisions) that meets certain minimum requirements. The state's plan must provide coverage to as many state residents as would be covered absent the waiver, that coverage must be as affordable and comprehensive as it would be absent the waiver, and the state's plan cannot increase the federal deficit.s plan cannot increase the federal deficit.
This report answers frequently asked questions about how states can use and apply for state This report answers frequently asked questions about how states can use and apply for state
innovation waivers. It also addresses changes to the Section 1332 waiver process, as made by the
2018 CMS guidance. Final y, itinnovation waivers and summarizes states summarizes states
’' submitted waiver applications. submitted waiver applications.
Which ACA Provisions May a State Waive Under a
State Innovation Waiver?
A state may apply to waive A state may apply to waive
any or all of the ACA of the ACA
provisions listed belowprovisions listed below
for plan years
beginning on or after January 1, 2017.3
.1 Part I of Subtitle DSubtitle D of the ACA: Part I of Subtitle D comprises Sections 1301- Part I of Subtitle D comprises Sections 1301-
1304. In general, the provisions in Part I relate to the establishment of qualified 1304. In general, the provisions in Part I relate to the establishment of qualified
health plans (QHPs).health plans (QHPs).
4
2
Part II of Subtitle DSubtitle D of the ACA: Part II of Subtitle D comprises Sections 1311- Part II of Subtitle D comprises Sections 1311-
1313, which largely include provisions related to the establishment of health 1313, which largely include provisions related to the establishment of health
insurance exchanges and related activities.
1 T he requirements are not specified in regulations. Department of the T reasury, Department of Health and Human Services (HHS), “Waivers for State Innovation,” 80 Federal Register 78131, December 16, 2015. Department of the T reasury, HHS, “State Relief and Empowerment Waivers,” 83 Federal Register 53575, October 24, 2018 (Hereinafter “State Relief and Empowerment Waivers guidance”). 2 “Patient Protection and Affordable Care Act; HHS Notice of Benefit and P ayment Parameters for 2022; Updates to State Innovation Waiver (Section 1332 Waiver) Implementing Regulations,” 86 Federal Register 6138, January 19, 2021. However, this rule did not take effect before the presidential transition. As a result, it may be re viewed by the Biden Administration in accordance with a memorandum issued by Ronald A. Klain, Assistant to the President and
Chief of Staff. Office of Management and Budget, “Memorandum for the Heads of Executive Departments and Agencies,” 86 Federal Register 7424, January 28, 2021. 3 42 U.S.C. §18052(a)(2). 4 A qualified health plan (QHP) is a plan that meets certain requirements and is certified to be sold through a health insurance exchange (in the non-group or small-group market). Although QHPs are cert ified to be sold through exchanges, they also can be sold in the non -group or small-group market outside of exchanges. For more information, see CRS Report R44065, Overview of Health Insurance Exchanges.
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State Innovation Waivers: Frequently Asked Questions
insurance exchanges and related activities.
Section 1402 of the ACA: This section includes the provision of cost-sharing This section includes the provision of cost-sharing
reductions to eligiblereductions to eligible
individuals who purchase individual market coverage individuals who purchase individual market coverage
through a health insurance exchange.through a health insurance exchange.
5
3
Section 36B of the Internal Revenue Code (IRC): This section includes the This section includes the
provision of premium tax credits to eligible individualsprovision of premium tax credits to eligible individuals
who purchase individual who purchase individual
market coverage through a health insurance exchange.market coverage through a health insurance exchange.
Section 4980H of the IRC: This section includes the shared responsibility This section includes the shared responsibility
requirement for large employers (often requirement for large employers (often
cal edcalled the the
employer mandate).).
6
4
Section 5000A of the IRC: This section includes the requirement for individuals This section includes the requirement for individuals
to maintain health insurance coverage (often to maintain health insurance coverage (often
cal edcalled the the
individual mandate).).
7
5Each part noted above is comprised of many provisions, which makes the scope of the provisions Each part noted above is comprised of many provisions, which makes the scope of the provisions
that can be waived under a state innovation waiver quite broad. For example, Part I of Subtitle D that can be waived under a state innovation waiver quite broad. For example, Part I of Subtitle D
of the ACAof the ACA
includes provisions that outline requirements for health plans to be certified as QHPs. includes provisions that outline requirements for health plans to be certified as QHPs.
It defines the essential health benefits (EHB) package that each QHP must offer, places It defines the essential health benefits (EHB) package that each QHP must offer, places
limitations on the enrollee cost sharing that QHPs may impose, and requires that QHPs provide limitations on the enrollee cost sharing that QHPs may impose, and requires that QHPs provide
coverage meeting a minimum level of actuarial value.coverage meeting a minimum level of actuarial value.
8 Additional y, 6 Additionally, Part I of Subtitle D Part I of Subtitle D
establishes requirements for catastrophic health plans and determines eligibilityestablishes requirements for catastrophic health plans and determines eligibility
for such plans.for such plans.
Which Federal Agencies Have the Authority to
Grant a Waiver?
The Secretary of the Department of Health and Human Services (HHS) The Secretary of the Department of Health and Human Services (HHS)
ishas authority to review and grant to review and grant
waiver requests for provisions not included in the IRC; the Secretary of the Treasury waiver requests for provisions not included in the IRC; the Secretary of the Treasury
ishas authority to review to review
and grant requests to waive provisions in the IRC (the availabilityand grant requests to waive provisions in the IRC (the availability
of premium tax credits and the of premium tax credits and the
application of the employer and individualapplication of the employer and individual
mandates).mandates).
9 7
What Are the Minimum Requirements for a
Successful Application?
The Secretary of HHS or the Treasury is to assess a waiver application to determine whether the The Secretary of HHS or the Treasury is to assess a waiver application to determine whether the
state’state's plan meets the requirements related to coverage, affordability, comprehensiveness, and s plan meets the requirements related to coverage, affordability, comprehensiveness, and
5 For more information about the current status of the cost-sharing reductions, see archived CRS Insight IN10786, Paym ents for Affordable Care Act (ACA) Cost-Sharing Reductions.
6 For more information about the employer mandate, see CRS Report R45455, The Affordable Care Act’s (ACA’s)
Em ployer Shared Responsibility Provisions (ESRP).
7 For more information about the individual mandate, see CRS Report R44438, The Individual Mandate for Health
Insurance Coverage: In Brief. T he 2017 tax revision, P.L. 115-97, effectively eliminated the individual mandate penalty beginning in 2019. However, the 2017 tax revision did not make any other substantive changes to the statutory language establishing the mandate and its associated penalty.
8 Note that essential health benefit (EHB) and related cost-sharing and actuarial value requirements apply to all non-grandfathered plans in the individual and small group markets, including QHPs. For more information about the essential health benefits package, see CRS Report R44163, The Patient Protection and Affordable Care Act’s Essential
Health Benefits (EHB).
9 42 U.S.C. §18052(a)(6).
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federal-deficit neutrality outlined in statute and further described in guidance.10 These requirements are described in Table 1. federal-deficit neutrality.8
The interpretation of these four statutory requirements has been expressed in regulations and guidance by different Administrations and changed over time. The current interpretation of these requirements was established by the Biden Administration in 2021 and seeks "to strengthen the ACA and increase enrollment in comprehensive, affordable health coverage among the remaining underinsured and uninsured."9 This interpretation is described in Table 1. It replaced a previous interpretation that was initially outlined by the first Trump Administration in 2018 and sought to "promote private market competition and increase consumer choice."10
The Secretary or Secretaries (as appropriate) may grant a The Secretary or Secretaries (as appropriate) may grant a
request for a state innovation waiver if a staterequest for a state innovation waiver if a state
’'s application meets the requirements.
s application meets the requirements. In making this determination, the Secretaries wil “consider favorably” any waiver that incorporates some or al of the following principles: provide increased access to affordable private market coverage, encourage sustainable spending growth, foster state innovation, support and empower those in
need, and promote consumer-driven health care.11
In guidance, HHS and the Treasury note that their assessment of a stateHHS and the Treasury note that their assessment of a state
’'s waiver application s waiver application
considers changes to the stateconsiders changes to the state
’'s health care system that are contingent only upon approval of the s health care system that are contingent only upon approval of the
waiver.waiver.
1211 Their assessment does not consider policy changes that are dependent on further state Their assessment does not consider policy changes that are dependent on further state
action or other federal determinations. For example, the Secretaryaction or other federal determinations. For example, the Secretary
’'s or Secretariess or Secretaries
’' (as (as
appropriate) assessment of a state innovation waiver application would not consider changes to appropriate) assessment of a state innovation waiver application would not consider changes to
Medicaid or the state ChildrenMedicaid or the state Children
’'s Health Insurance Program (CHIP) that require approval outside s Health Insurance Program (CHIP) that require approval outside
of the state innovation waiver process, and of the state innovation waiver process, and
savings accrued as a result of changes to Medicaid or
CHIPresulting costs or savings attributable to Medicaid or CHIP changes outside of the state innovation waiver process would not be considered when determining whether the state innovation waiver meets the would not be considered when determining whether the state innovation waiver meets the
deficit-neutrality requirement. HHS and the Treasury indicate that this is the case regardless of deficit-neutrality requirement. HHS and the Treasury indicate that this is the case regardless of
whether a statewhether a state
’'s application for a state innovation waiver is submitted alone or in coordination s application for a state innovation waiver is submitted alone or in coordination
with another waiver application. (For more information about the coordinated waiver process, see with another waiver application. (For more information about the coordinated waiver process, see
"“May States Submit State Innovation Waiver Applications in Coordination with Other Federal
Waiver Applications?”) ")
Table 1. Requirements for a Successful State Innovation Waiver Application
(as described in statute(as described in statute
and guidance)
Statute
Current Guidancea
Previous Guidance , regulations, and other guidance)
|
Statute
|
Current Interpretation
|
Coverage: The state: The state
’s
At least a comparable number of
At least as many individuals who are
plan must provide
individuals who are forecasted to have
forecasted to have minimum essential
coverage to at least a
health care coverage absent a waiver must
coverage (MEC) absent a waiver must
comparable number of
have health care coverage under the
have MEC under the waiver.c This
individuals as the
waiver.b This requirement general y must
requirement general y must be forecast to
provisions of Title I of
be forecast to be met for each year the
be met for each year the waiver is in
the Patient Protection
waiver is in effect, but a waiver may be
effect.
and Affordable Care
approved if a temporary reduction in
In considering whether this requirement
Act (ACA; P.L. 111-
coverage would produce longer-term
is met, the plan’s impact on al state
148, as amended)
increases in coverage.
residents, regardless of coverage type, wil
would provide.
In considering whether this requirement
be considered and the plan’'s plan must provide coverage to at least a comparable number of individuals as the provisions of Title I of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) would provide.
At least as many individuals who are forecasted to have minimum essential coverage (MEC) absent a waiver must have MEC under the waiver.a This requirement generally must be forecast to be met for each year the waiver is in effect.
In considering whether this requirement is met, the plan's impact on all state residents, regardless of coverage type, will be considered and the plan's effects on different groups of individuals in the state, particularly those considered vulnerable or underserved, will be assessed.b A state plan that satisfied this requirement s effects on
is met, the plan’s impact on al state
different groups of individuals in the state,
residents, regardless of coverage type, wil
particularly those considered vulnerable,
be considered. Whether the plan
wil be assessed.d A state plan that
sufficiently prevents gaps in or
satisfied this requirement in the aggregate
discontinuations of coverage also wil be
but reduced coverage for vulnerable
considered.
populations would notin the aggregate but reduced coverage for vulnerable or underserved populations would be highly unlikely to be approved. be approved.
Whether the plan sufficiently prevents Whether the plan sufficiently prevents
gaps in or discontinuations of coverage gaps in or discontinuations of coverage
also also
wil will be considered.
Affordability: The state's plan must provide coverage and cost-sharing protections that are at least as affordable as the provisions of Title I of the ACA.
|
Individuals' health care coverage under the waiver must be as affordable as coverage would be absent the waiver.
Affordability is generally measured by comparing the sum of an individual's premium contributions and cost-sharing responsibilities for a health plan to the individual's income. be considered.
10 42 U.S.C. §18052(b)(1) and State Relief and Empowerment Waivers guidance. 11 State Relief and Empowerment Waivers guidance. 12 State Relief and Empowerment Waivers guidance.
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Statute
Current Guidancea
Previous Guidance
Affordability: The
Individuals must be provided with the
Individuals’ health care coverage under
state’s plan must
opportunity to purchase coverage that is
the waiver must be as affordable as
provide coverage and
at least as affordable and comprehensive
coverage would be absent the waiver.
cost-sharing
as coverage available absent the waiver.e
Affordability is general y measured by
protections that are at
Applications do not need to demonstrate
comparing the sum of an individual’s
least as affordable as
that the affordable and comprehensive
premium contributions and cost-sharing
the provisions of Title I
coverage wil actual y be received by a
responsibilities for a health plan to the
of the ACA.
comparable number of state residents.
individual’s income. Spending on health
Affordability is general y measured by
Spending on health care servicescare services
that are not covered by a health plan may be considered if the services are affected by the state'that are not covered by a
comparing the sum of an individual’s
health plan may be considered if the
premium contributions and cost-sharing
services are affected by the state’s plan.
responsibilities for a health plan or direct
This requirement general y must be
payments for health care to the
s plan. This requirement generally must be forecast to be met for each year the forecast to be met for each year the
individual’s income.
waiver is in effect.waiver is in effect.
In considering whether this requirement
In considering whether this requirement In considering whether this requirement
is met, the planis met, the plan
’'s impact on all state residents, regardless of coverage type, will be considered, and the plan's impact on al state
is met, the plan’s impact on al state
residents, regardless of coverage type,
residents, regardless of coverage type, wil
and the plan’s effects on al groups of
be considered, and the plan’s effects on
individuals in the state, including low-
different groups of individuals in the state,
income residents and those with high
particularly those considered vulnerable,
expected health care costs, wil be
wil be assessed.d A state plan that
considered. In assessing the plan, access
satisfied this requirement s effects on different groups of individuals in the state, particularly those with large health care spending burdens and those considered vulnerable or underserved, will be assessed.b A state plan that satisfied this requirement in the aggregate but increases the number of individuals with large health care spending burdens would not be approved. A state plan that satisfied this requirement in the aggregate but reduced affordability for vulnerable or underserved populations would be highly unlikely to be approved. In addition, a state plan that increasesin the aggregate
to affordable coverage wil be considered
but reduced affordability for vulnerable
according to the number of individuals for
populations would not be approved. In
whom available coverage has become
assessing the plan, the affordability of
more affordable and the magnitude of
coverage on average wil be considered,
such changes.
and how the plan affects the number of the number of
individuals who have large heath care spending burdens relative to their incomes wil be examined.
Comprehensiveness:
Individuals must be provided with the
Individuals’ health care coverage under
The state’s plan must
opportunity to purchase coverage that is
the waiver must be at least as
provide coverage that
at least as affordable and comprehensive
comprehensive overal as their coverage
is at least as
as coverage available absent the waiver.e
would be absent the waiver.
comprehensive as the
Applications do not need to demonstrate
Comprehensiveness is measured by
essential health benefits
that the affordable and comprehensive
comparing coverage under the plan to
(EHB),f as certified by
coverage wil actual y be received by a
coverage under the state’s EHB
the Office of the
comparable number of state residents.
benchmark plan or coverage under the
Actuary of the Centers
Comprehensiveness is measured by
state’s Medicaid program individuals with coverage that does not have specified cost-sharing-related protections would also not be approved.
Comprehensiveness: The state's plan must provide coverage that is at least as comprehensive as the essential health benefits (EHB),c as certified by the Office of the Actuary of the Centers for Medicare & Medicaid Services (CMS).
Individuals' health care coverage under the waiver must be at least as comprehensive overall as their coverage would be absent the waiver.
Comprehensiveness is measured by comparing coverage under the plan to coverage under the state's EHB benchmark plan (including with respect to each individual EHB category) or coverage under the state's Medicaid program and/or the State Children's Health Insurance Programs (CHIP), as appropriate.c This requirement generally must be forecast to be met for each year the waiver is in effect.
In considering whether this requirement is met, the proposal's impact on all state residents, regardless of coverage type, will be considered, and/or the State
for Medicare &
comparing coverage under the plan to
Children’s Health Insurance Programs
Medicaid Services
coverage under the state’s EHB
(CHIP), as appropriate. This requirement
(CMS).
benchmark plan, any other state’s
general y must be forecast to be met for
benchmark plan chosen by the state, or
each year the waiver is in effect.
any benchmark plan chosen by the state
In considering whether this requirement
that could potential y become its EHB
is met, the proposal’s impact on al state
benchmark plan.
residents, regardless of coverage type, wil
In considering whether this requirement
be considered, and the effects of the
is met, the proposal’s impact on al state
proposal on different groups of individuals
residents, regardless of coverage type, wil
in the state, particularly those considered
be considered.
vulnerable, wil be assessed.d and the effects of the proposal on different groups of individuals in the state, particularly those considered vulnerable or underserved, will be assessed.b A state plan A state plan
that satisfied this requirement in the that satisfied this requirement in the
aggregate but reduced comprehensiveness aggregate but reduced comprehensiveness
for vulnerable populations would not be approved.
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Statute
Current Guidancea
Previous Guidance
Deficit Neutral: The
Projected federal spending net of federal
for vulnerable and underserved populations would be highly unlikely to be approved.
Deficit Neutral: The state's plan must not increase the federal deficit.
|
Projected federal spending net of federal revenues must be equal to or lower than it would be absent the waiver. The state's Projected federal spending net of federal
state’s plan must not
revenues must be equal to or lower than
revenues must be equal to or lower than
increase the federal
it would be absent the waiver. The state’s
it would be absent the waiver. The state’s
deficit.
plan must not increase the federal deficit
plan must not increase the federal deficit
over the period of the waiver or in total
over the period of the waiver or in total
over the 10-year budget plan submitted
over the 10-year budget plan submitted
by the state as part of its application.g
by the state as part of its application.g
Source: Congressional Research Service’s compilation and summary of statute (42 U.S.C. plan must not increase the federal deficit over the period of the waiver or in total over the 10-year budget plan submitted by the state as part of its application.d
Source: Congressional Research Service's compilation and summary of statute (42 U.S.C. §18052(b)(1)) and regulations (45 C.F.R. §155.1308(f)(3)(iv), and 86 Federal Register 53466, September 27, 2021).
Notes: §18052(b)(1)) and guidance (80 Federal Register 78131, December 16, 2015, and 83 Federal Register 53575, October 24, 2018). The requirements are not covered in regulations. Notes: Previous guidance applies to al waivers approved prior to October 24, 2018. The Secretary of the The Secretary of the
Department of Health and Human ServicesDepartment of Health and Human Services
(HHS) is to review(HHS) is to review
requests to waive provisions not included in the requests to waive provisions not included in the
Internal Revenue Code (IRC); the SecretaryInternal Revenue Code (IRC); the Secretary
of the Treasury is to reviewof the Treasury is to review
requests to waive requests to waive
p rovisions provisions in the IRC in the IRC
(the availability of premium(the availability of premium
tax credits and the application of the employertax credits and the application of the employer
and individual mandates).
a. MEC isand individual mandates). a. Many aspects of the current guidance were codified in a final rule issued on January 19, 2021. This rule did
not take effect before the presidential transition. As a result, it may be reviewed by the Biden Administration in accordance with a memorandum issued by Ronald A. Klain, Assistant to the President and Chief of Staff. See “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2022; Updates to State Innovation Waiver (Section 1332 Waiver) Implementing Regulations,” 86 Federal Register 6138, January 19, 2021 and Office of Management and Budget, “Memorandum for the Heads of Executive Departments and Agencies,” 86 Federal Register 7424, January 28, 2021.
b. Health care coverage includes al types of coverage that would qualify as MEC or would be included in the
definition of the term health insurance coverage in regulations. MEC, as defined in the tax code (26 U.S.C. defined in the tax code (26 U.S.C.
§5000A(f))§5000A(f))
, and includes most types of comprehensive includes most types of comprehensive
coverage,coverage,
including public coverage,including public coverage,
such as coverage such as coverage
under programs sponsored by the federal government (e.g.,under programs sponsored by the federal government (e.g.,
Medicaid, Medicare),Medicaid, Medicare),
as wel as well as private as private
insurance (e.g.,insurance (e.g.,
employer-sponsoredemployer-sponsored
insurance, non-group coverage).
b. Vulnerable and underserved individuals include "low-income individuals, older adults, those with serious health issues or who have a greater risk of developing serious health issues, and people of color and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality" (86 Federal Register 53412, September 27, 2021, p. 53465).
c. Under the ACA, certain health plans must cover the EHB. The ACA does not explicitly define the EHB; rather, it lists 10 broad categories from which benefits and services must be included and requires the Secretary of HHS to further define the EHB. For information about the 10 categories as well as how the insurance, non-group coverage). Health insurance coverage, as defined in regulations (45 C.F.R. §144.103), includes group health insurance coverage (e.g., employer-sponsored insurance, association health plans), individual health insurance coverage, and short-term, limited-duration insurance.
c. MEC is defined in the tax code (26 U.S.C. §5000A(f)) and includes most types of comprehensive coverage,
including public coverage, such as coverage under programs sponsored by the federal government (e.g., Medicaid, Medicare), as wel as private insurance (e.g., employer-sponsored insurance, non-group coverage).
d. Vulnerable individuals include “low-income individuals, elderly individuals, and those with serious health
issues or who have a greater risk of developing serious health issues” (80 Federal Register 78131, December 16, 2015, p. 78132).
e. The affordability and comprehensiveness guardrails are considered in conjunction and not in isolation (i.e., a
state plan must make coverage that is both comprehensive and affordable available to a comparable number of individuals).
f.
Under the ACA, certain health plans must cover the EHB. The ACA does not explicitly define th e EHB; rather, it lists 10 broad categories from which benefits and services must be included and requires the Secretary of HHS to further define the EHB. For information about the 10 categories as wel as how the EHB are currently defined, see the Center for Consumer Information and Insurance Oversight (CCIIO) EHB are currently defined, see the Center for Consumer Information and Insurance Oversight (CCIIO)
webpage, webpage,
“"Information on Essential Health Benefits (EHB) Benchmark Plans,Information on Essential Health Benefits (EHB) Benchmark Plans,
”" at https://www.cms.gov/ at https://www.cms.gov/
cci omarketplace/resources/data/essential-health-benefits.
d. /resources/data-resources/ehb.
g. The state innovation waivers cannot extend longer than five years unless a state requests continuation and The state innovation waivers cannot extend longer than five years unless a state requests continuation and
such request is not denied by the appropriate Secretary.such request is not denied by the appropriate Secretary.
Statute requiresStatute requires
that an application for a waiver that an application for a waiver
include a 10-year budget plan that is budget neutral for the federal government (42 U.S.C. include a 10-year budget plan that is budget neutral for the federal government (42 U.S.C.
§18052(a)(1)(B)(§18052(a)(1)(B)(
i ii)). This determination takes into account costs associated with changes to federal )). This determination takes into account costs associated with changes to federal
administrative processes.
Congressional Research Service
5
State Innovation Waivers: Frequently Asked Questions
administrative processes.
May a State Modify Its Use of the Federally
Facilitated Health Insurance Exchange Platform
Under a State Innovation Waiver?
HHS administers HHS administers
al federal yall federally facilitated exchanges (FFEs), and it operates the same information facilitated exchanges (FFEs), and it operates the same information
technology platform (Healthcare.gov) in each state that has an FFE. Some states administer their technology platform (Healthcare.gov) in each state that has an FFE. Some states administer their
own state-based exchanges, except they also use the federal information technology platform own state-based exchanges, except they also use the federal information technology platform
(SBE-FP).(SBE-FP).
13
Initial y, 12
Initially, it was not possible for states that use the federal technology platform to make eligibility it was not possible for states that use the federal technology platform to make eligibility
and enrollment changes related to that platform.and enrollment changes related to that platform.
14 However Since then, HHS and the Treasury have indicated that technical enhancements made it feasible for the Centers for Medicare & Medicaid Services (CMS) to support certain state-specific variations.13, HHS and the Treasury indicated in
the updated guidance released in October 2018 that technical enhancements made it feasible for CMS to support certain variations. For example, waivers that would require a state to create its own website to replace the consumer-facing aspects of HealthCare.gov can incorporate CMS’s enrollment functionalities (e.g., account creation, application, enrollment and coverage maintenance experience for consumers). States are asked to work with HHS early in the waiver
States are asked to work with HHS early in the waiver application process to determine whether application process to determine whether
specific modificationsproposed operational modifications or technical changes can be accommodated. can be accommodated.
States are responsible for funding States are responsible for funding
al all FFE platform modifications and associated operational FFE platform modifications and associated operational
support. Any changes to CMS administrative processes are taken into account when determining support. Any changes to CMS administrative processes are taken into account when determining
whether a waiver application satisfies the deficit neutrality requirement; however, waiver costs whether a waiver application satisfies the deficit neutrality requirement; however, waiver costs
for technical and specialized services that CMS for technical and specialized services that CMS
typical ytypically provides to states (and states cover the provides to states (and states cover the
cost of) would not be included in such determinations.cost of) would not be included in such determinations.
15 14
Are There Any Limitations on the Scope of State
Innovation Waivers?
In guidance issued in October 2018,
HHS and the Treasury described some federal operational HHS and the Treasury described some federal operational
considerations that may limit the scope of the waivers.considerations that may limit the scope of the waivers.
16 Specifical y15 Specifically, the Internal Revenue , the Internal Revenue
Service (IRS) Service (IRS)
general ygenerally is not able to accommodate any state-specific changes to is not able to accommodate any state-specific changes to
federal tax rules.tax rules.
HHS and the Treasury have indicated that states considering a state innovation wavier that would modify premium tax credit eligibility or amounts could consider waiving the provision entirely and creating a state-level subsidy program.16
However, the IRS may be able to accommodate However, the IRS may be able to accommodate
smal small changes to the administration of federal tax changes to the administration of federal tax
provisions, in particular when such changes overlap with the IRSprovisions, in particular when such changes overlap with the IRS
’'s current capabilities.s current capabilities.
17 For 17 As an example, waivers that would require the IRS to expand premium tax credit eligibilityexample, waivers that would require the IRS to expand premium tax credit eligibility
to individuals to
individuals with household income under 100% of the federal poverty levelwith household income under 100% of the federal poverty level
(FPL) may be feasible, may be feasible,
because it incorporates a similar special rule that the IRS currently administers.18
13 For more information about exchange types, see CRS Report R44065, Overview of Health Insurance Exchanges. 14 State Relief and Empowerment Waivers guidance. 15 Specifically, the Centers for Medicare & Medicaid Services (CMS) services covered under the Intergovernmental Cooperation Act (ICA) are not considered for deficit neutrality purposes. 16 State Relief and Empowerment Waivers guidance. 17 States are responsible for funding all changes to IRS administrative processes associated with waiver implementation. T hese costs are incorporated into the assessment of whether a waiver application satisfies the deficit neutrality requirement.
18 For more information about how household income is calculated to determine premium tax credit eligibility, see CRS Report R43861, The Use of Modified Adjusted Gross Incom e (MAGI) in Federal Health Program s.
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State Innovation Waivers: Frequently Asked Questions
because it incorporates a similar special rule that the IRS currently administers.18 Another example of an approved waiver that included changes to federal tax rules is New York's waiver that removed premium tax credit eligibility for individuals under age 65 with income at or below 250% of FPL and replaced those subsidies with Essential Plan Expansion coverage under the waiver.19
What Is the Application Process for a State
Innovation Waiver?
A state seeking a state innovation waiver must enact a law that A state seeking a state innovation waiver must enact a law that
al owsallows the state to carry out the the state to carry out the
actions under the waiver prior to submitting an application for a waiver.actions under the waiver prior to submitting an application for a waiver.
1920 In certain In certain
circumstances, a state can be considered to have enacted such a law by coupling a state law that circumstances, a state can be considered to have enacted such a law by coupling a state law that
enforces ACA provisions and/or the state plan with administrative or executive actions.enforces ACA provisions and/or the state plan with administrative or executive actions.
20 21
Prior to Prior to
submitting an application, a state submitting an application, a state
generally must provide a public notice and comment period and conduct must provide a public notice and comment period and conduct
public hearings regarding the statepublic hearings regarding the state
’'s application.s application.
2122 Upon conclusion of these activities, a state Upon conclusion of these activities, a state
may submit its application to the Secretary of HHSmay submit its application to the Secretary of HHS
. , which should be sufficiently in advance of the implementation date to allow for federal public notice and comment, federal review, and state implementation of the waiver should it be approved.
The Secretary of HHS is to transmit any The Secretary of HHS is to transmit any
application seeking to waive requirements in the IRC to the Secretary of the Treasury for review.application seeking to waive requirements in the IRC to the Secretary of the Treasury for review.
The Secretary or Secretaries (as appropriate) are to review a stateThe Secretary or Secretaries (as appropriate) are to review a state
’'s application to determine s application to determine
whether it is complete. A statewhether it is complete. A state
’'s application is not considered complete unless it includes the s application is not considered complete unless it includes the
materials identified in regulations.materials identified in regulations.
2223 The materials include, but are not limited to, information The materials include, but are not limited to, information
about the enacted state legislation about the enacted state legislation
al owingallowing the state to carry out the actions under the waiver, a the state to carry out the actions under the waiver, a
description of the plan or program the state expects to implement in place of the waived description of the plan or program the state expects to implement in place of the waived
provisions, and analyses showing that the stateprovisions, and analyses showing that the state
’'s plan or program meets the requirements for s plan or program meets the requirements for
granting a waiver. If a stategranting a waiver. If a state
’'s application is not complete, the state is to be notified about the s application is not complete, the state is to be notified about the
missing elements and given an opportunity to submit them. Once the Secretary or Secretaries (as missing elements and given an opportunity to submit them. Once the Secretary or Secretaries (as
appropriate) make a preliminary determination that a stateappropriate) make a preliminary determination that a state
’'s application is complete, the entire s application is complete, the entire
application is to be made availableapplication is to be made available
to the public for review and comment.to the public for review and comment.
23
24
The final decision of the Secretary or Secretaries on a stateThe final decision of the Secretary or Secretaries on a state
’'s application must be issued no later s application must be issued no later
than 180 days after the determination that the Secretary of HHS received a complete application than 180 days after the determination that the Secretary of HHS received a complete application
from a state.24
19 42 U.S.C. §18052(b)(2). 20 State Relief and Empowerment Waivers guidance. 21 T he public notice and comment period is to be “sufficient to ensure a meaningful level of public input for the application for a section 1332 waiver.” In general, the comment period cannot be less than 30 days. However, in light of the Coronavirus Disease 2019 (COVID-19) pandemic, HHS and the T reasury provided states submitting a waiver application during the COVID-19 public health emergency period with the ability to request m odification of the public notice and comment procedures and requirements (e.g., the requirement that states conduct in -person public hearings). T he Secretaries may grant such requests if a delay of the proposed waiver would undermine the waiver request and if the state satisfies certain requirements. 45 C.F.R. §§ 155.1312 and 155.1318. HHS, Department of the T reasury, and Department of Labor, “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” 85 Federal Register 71142, November 2, 2020. 22 45 C.F.R. §155.1308(f). 23 T he public notice and comment period is to be “sufficient to ensure a meaningful level of public input and does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act, or requirements that are unreasonable to unnecessarily burdensome with respect to state compliance.” 45 C.F.R. §155.1316(b).
24 42 U.S.C. §18052(d)(1) and 45 C.F.R. §155.1316(c).
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link to page 5 link to page 5 State Innovation Waivers: Frequently Asked Questions
Is Any Federal Funding Available Under a State
Innovation Waiver?
It is possible for a state to receive federal funding under an approved waiver. A state’s receipt of a state innovation waiver could result in the residents of the state not receiving the “premium tax
credits, cost-sharing reductions, or smal business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible.”25 If this occurs, the state is to receive the aggregate amount of subsidies that would have been available to the state’s residents had the state not received a state innovation waiver—this is referred to as pass-through funding. The amount of pass-through funding is to be determined
annual y by the appropriate Secretary and may be updated at any time to account for changes in state or federal law. The state is to use the pass-through funding for purposes of implementing the
plan or program established under the waiver.26
How Long Can a State Innovation Waiver Be
in Effect?
State innovation waivers cannot extend longer than five years, unless a state requests continuation and the appropriate Secretary does not deny such request.27 Requests for continuation are to be deemed granted unless, within 90 days of submission, the appropriate Secretary either denies the
request or informs the state that additional information is needed for the Secretary to consider
such request. from a state.25
Is Any Federal Funding Available Under a State Innovation Waiver?
It is possible for a state to receive federal funding under an approved waiver. A state's receipt of a state innovation waiver could result in the residents of the state not receiving the "premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible."26 If this occurs, the state is to receive the aggregate amount of subsidies that would have been available to the state's residents had the state not received a state innovation waiver—this is referred to as pass-through funding. The amount of pass-through funding is to be determined annually by the appropriate Secretary and may be updated at any time to account for changes in state or federal law. The state is to use the pass-through funding for purposes of implementing the plan or program established under the waiver.27
How Long Can a State Innovation Waiver Be in Effect?
State innovation waivers are approved for a period of up to five years. States may request to extend approved waivers for additional periods of up to five years.28
A state wanting to extend a waiver for up to five additional years must notify HHS and the Treasury of its intent at least one year prior to the end of the approved waiver. Once notified, the HHS and the Treasury would communicate the information that must be included in the waiver extension request. A state must solicit public feedback and then can submit a waiver extension request.
Once the Secretary or Secretaries (as appropriate) make a preliminary determination that a state's waiver extension request is complete, the waiver extension request is to be made available to the public for review and comment.
Waiver extension requests are to be deemed granted unless, within 90 days of the determination that the Secretary of HHS received a complete request from a state, the appropriate Secretary either denies the request or informs the state that additional information or actions are needed for the Secretary to consider such request. If additional information or responses are needed, any further review would take at most 90 days from the date the additional information or responses are provided.
May States Modify an Approved State Innovation Waiver?
A state with an approved waiver is allowed to apply to the Secretaries to make a change to the plan or program established under the waiver.29
A state wanting to amend an approved waiver is encouraged to notify HHS and the Treasury of its intent at least 15 months prior to the implementation date of the proposed waiver amendment. Once notified, HHS and the Treasury would communicate the information that must be included in the waiver amendment request, which is similar to the information provided with a new waiver application. HHS and the Treasury also would communicate whether the waiver amendment request would be subject to additional or different requirements. A state generally must solicit public feedback before submitting an amendment request.
Once the Secretary or Secretaries (as appropriate) make a preliminary determination that a state's application is complete, the waiver amendment request is to be made available to the public for federal review and comment.
The Secretary or Secretaries would evaluate the original waiver and the waiver amendment together to determine if the "combined" waiver satisfies the minimum requirements for a successful waiver.
The final decision of the Secretary or Secretaries on a state's waiver amendment request must be issued no later than 180 days after the determination that the Secretary of HHS received a complete waiver amendment request. Any subsequent pass-through funding would incorporate the changes made by the waiver amendment.
May States Submit State Innovation Waiver
Applications in Coordination with Other Federal
Waiver Applications?
The Secretaries were required to develop a process for coordinating applications for state The Secretaries were required to develop a process for coordinating applications for state
innovation waivers and applications for other existing waivers under federal law relating to the innovation waivers and applications for other existing waivers under federal law relating to the
provision of health care, including waivers availableprovision of health care, including waivers available
under Medicare, Medicaid, and CHIP.under Medicare, Medicaid, and CHIP.
Under the coordinated process, a state Under the coordinated process, a state
must be able tomay submit a single application for a state submit a single application for a state
innovation waiver and any other applicable waivers availableinnovation waiver and any other applicable waivers available
under federal law.under federal law.
2830 The single The single
application must comply with the procedures described for state innovation waiver applications application must comply with the procedures described for state innovation waiver applications
and the procedures in any other applicable federal law under which the state seeks a waiver.and the procedures in any other applicable federal law under which the state seeks a waiver.
29
31
However, each waiver is evaluated independently. As discussed in the answer to the question As discussed in the answer to the question
"“What Are the Minimum Requirements for a
Successful Application?,”," HHS and the Treasury HHS and the Treasury
have indicated that an application forassess a state a state
innovation waiver innovation waiver
wil be assessedbased on its own terms and that assessment of the state innovation on its own terms and that assessment of the state innovation
25 42 U.S.C. §18052(a)(3). 26 42 U.S.C. §18052(a)(3). 27 42 U.S.C. §18052(e). 28 42 U.S.C. §18052(a)(5). 29 45 C.F.R. §155.1302(a).
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link to page 13 link to page 13 State Innovation Waivers: Frequently Asked Questions
waiver wil waiver will not consider the impact of changes that require separate federal approvalnot consider the impact of changes that require separate federal approval
(e.g., a Medicaid waiver). This is the . This is the
case even if the state submits a single application for multiple waivers.case even if the state submits a single application for multiple waivers.
How Many States Have Applied for State
Innovation Waivers?
As of the date of this report, As of the date of this report,
2327 states have submitted applications for state innovation waivers states have submitted applications for state innovation waivers
—Alaska, California, .32 HHS and the Treasury have approved 21 applications from Alaska, Colorado, Delaware, Georgia, Colorado, Delaware, Georgia,
Hawai Hawaii, Idaho, , Idaho,
Iowa, Maine, Maryland, Maine, Maryland,
Massachusetts, Minnesota, MontanaMinnesota, Montana, Nevada, New Hampshire, New Jersey, , New Hampshire, New Jersey,
North Dakota, Ohio, OklahomaNew York, North Dakota, Oregon, Pennsylvania, Rhode Island, , Oregon, Pennsylvania, Rhode Island,
VermontVirginia, Washington, and Wisconsin, though New York requested, and was approved, to terminate its waiver effective July 1, 2026.33
The most common feature of approved state innovation waivers are reinsurance programs, as 18 of the 21 approved waivers include a variant of a statewide individual market reinsurance program.34 These reinsurance programs typically offset a portion of the insurer's high-cost claims for certain individual market enrollees, reducing the insurer's overall risk and contributing to lower premiums in the individual market.
Idaho, Massachusetts, and Wisconsin.30 HHS and the Treasury have approved 16 applications, from Alaska, Colorado, Delaware, Georgia, Hawai ,
Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Wisconsin.
Eight of these waivers were considered and approved under the initial state innovation waiver
guidance, and eight were considered and approved under the current state innovation waiver guidance. Fifteen of the 16 approved waivers implement a variant of a statewide individual
market reinsurance program.31
Idaho, Massachuset s, Ohio, and Vermont received notification from HHS and the Treasury that , Ohio, and Vermont received notification from HHS and the Treasury that
their applications were incompletetheir applications were incomplete
, and it does not appear that any of these states has modified its application in response to the notification. If one of these four states does take action, any review of its waiver application would be under the updated state innovation waiver guidance (even if
such state initial y submitted its waiver under the initial guidance). . In October 2025, Idaho indicated that it is seeking to amend its approved waiver to incorporate a plan similar to the one discussed in its incomplete application.35 It does not appear that Massachusetts, Ohio, or Vermont has modified their incomplete applications in response to the notification.
California, Iowa, and Oklahoma have withdrawn their applications.California, Iowa, and Oklahoma have withdrawn their applications.
32 See36
See Table 2 for more details.
30 For information about each state’s application, see CMS, Center for Consumer Information and Insurance Oversight (CCIIO), “Section 1332: State Innovation Waivers,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html.
31 CMS issued a data brief that compares various aspects of the state-based reinsurance programs implemented through the Section 1332 waiver process. See CMS, CCIIO, State Relief and Em powerm ent Waivers: State-based Reinsurance
Program s, June 2020, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/1332-Data-Brief-June2020.pdf. As described in Table 2, Georgia’s waiver included two parts: a reinsurance program and the Georgia Access Model. For more information on reinsurance, see CRS In Focus IF10707, Reinsurance in
Health Insurance. 32 T o read the withdrawal letters, see CMS, CCIIO, “Section 1332: State Innovation Waivers,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html.
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link to page 25 link to page 25
Table 2. States That Have Applied for State Innovation Waivers
(as of January 29, 2021)
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Approved Waivers
Alaska
Jan. 3, 2017
Approved—
Alaska established a state-based reinsurance program, the Alaska Reinsurance Program (ARP), The Centers for
CY2018-
July 17, 2017
for more details.
Table 2. States That Have Applied for State Innovation Waivers
(as of March 20, 2026)
Application Information
|
Waiver Information
|
State
|
Submitted
|
Status
|
Overview
|
Pass-Through Fundinga
Effective Period
|
|
Approved Waivers
|
Alaska
Initial Waiver:—Jan. 3, 2017
Waiver Extension—Mar. 17, 2022
Initial Waiver Approved—July 17, 2017
Waiver Extension Approved—July 13, 2022
Alaska established a state-based, conditions-based reinsurance program, the Alaska Reinsurance Program (ARP), to help health insurance issuers offering plans in the individual market offset the to help health insurance issuers offering plans in the individual market offset the
entire cost of covering enrolleescost of
Medicare & Medicaid CY2022
covering enrol ees with 1 or more of with 1 or more of
3334 specified high-cost conditions. specified high-cost conditions.
Services (CMS)b
Under the approved waiver, the Patient Protection and Affordable Care Act (ACA; P.L. 111-
Under the approved waiver, the Patient Protection and Affordable Care Act (ACA; P.L. 111-
indicated Alaska
148148) provision requiring issuers to consider ) provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the in individual plans offered by the
would receive $58.5
issuer to be members of a single risk pool is issuer to be members of a single risk pool is
waived,b waived,c to the extent the provision prohibits to the extent the provision prohibits
mil ion for CY2018,
issuers from including expected reinsurance payments from the ARP when establishing issuers from including expected reinsurance payments from the ARP when establishing
$68.7 mil ion for
market-wide index rates.
CY2019, and $76.7
mil ion for CY2020.
market-wide index rates.
The expected effect of The expected effect of
al owingallowing issuers to consider the ARP payments when setting market- issuers to consider the ARP payments when setting market-
wide rates is to reduce premiums in the individual market, and the expected effect of the wide rates is to reduce premiums in the individual market, and the expected effect of the
reduced premiums is reduced federal spending on premium tax credits for residents of Alaska. reduced premiums is reduced federal spending on premium tax credits for residents of Alaska.
The state is to receive the resulting reductions in federal spending as pass-through funding. The state is to receive the resulting reductions in federal spending as pass-through funding.
Under the waiver, Alaska is to use the pass-through funding to support ARP and Under the waiver, Alaska is to use the pass-through funding to support ARP and
corresponding payments to issuerscorresponding payments to issuers
beginning in calendar year (CY) 2018 and continuing
through CY2022. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Alaska.residents of Alaska.
CRS-10
link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Colorado
May 20, 2019 Approved—
Colorado established a state-based reinsurance program. From CY2020 through CY2021, the CMS indicated
CY2020-
July 31, 2019
program is reimbursing issuers sel ing coverage in the state’
Alaska's waiver extension did not include any substantial changes to the approved waiver.
CY2018: $58.5 million
CY2019, $68.7 million
CY2020: $76.7 million
CY2021: $122.3 million
CY2022: $119.4 million
CY2023: $129.1 million
CY2024: $110.1 million
CY2025: $118.4 million
|
CY2018- CY2027
|
Colorado
Initial Waiver—May 20, 2019
Waiver Extension—Apr. 30, 2021
Waiver Amendment—Nov. 30, 2021
Initial Waiver Approved—July 31, 2019
Waiver Extension Approved—Aug. 13, 2021
Waiver Amendment Approved—June 23, 2022
Colorado's approved waiver currently consists of a state-based, claims cost-based reinsurance program, a state-based public option health insurance program, and a state-based subsidy program for certain enrollee populations. The reinsurance component of the waiver has been effective since CY2020, while the public option and subsidy components were added with a waiver amendment and have been effective since CY2023.
Initial Waiver: Colorado established a state-based, claims cost-based reinsurance program. The program reimburses issuers selling coverage in the state's individual market for a percentage of enrollees's individual market for a
Colorado would
CY2021
percentage of enrol ees’ claims between an attachment point and a cap. The reimbursement claims between an attachment point and a cap. The reimbursement
receive $169.4
percentage varies across geographic rating areas in the state.percentage varies across geographic rating areas in the state.
mil ion for CY2020.
Colorado’
Colorado's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider Colorado issuers to consider Colorado
reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Colorado for residents of Colorado
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Colorado is to use the pass-federal spending as pass-through funding. Under the waiver, Colorado is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
beginning in CY2020 and continuing through CY2021.c The approved waiver does not modify the eligibility criteria for .d
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Colorado.
Colorado's waiver extension did not include any substantial changes to the approved waiver.
Waiver Amendment: Colorado established the Colorado Option, which is a state-based public option health insurance program that is offered on Colorado's health insurance exchange and outside of the exchange. Under the Colorado Option program, issuers in the individual and small group markets are required to offer Colorado Option plans that must meet specified premium reduction targets (and satisfy other requirements). Issuers must offer Colorado Option plans in 2023 with premiums that are 5% lower than the lowest-premium plan offered by the issuer in that county in 2021, adjusted for inflation (CPI-U, Medical Component). In 2024, Colorado Option plans must have a premium that is 10% lower than the 2021 rate, as adjusted for inflation. In 2025, Colorado Option plans must have a premium that is 15% lower than the 2021 rate, as adjusted for inflation. For 2026 and later years, Colorado Option plan premiums may only increase to account for inflation. Colorado expects premium reductions to come from "lower provider rates, reductions in profits, and reduced utilization through effective care management."e
Colorado's approved waiver amendment waives the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to be members of a single risk pool and the ACA provision requiring issues to consider all enrollees in the small group market offer by the issuer to be members of a single risk pool.f This allows issuers to attribute health care savings (e.g., resulting from lower provider rates) only to Colorado Option plan premiums instead of spreading such savings across the issuer's Colorado Option and non-Colorado Option individual and small group market plans. Waiving this requirement also allows issuers to adjust premiums to satisfy the premium reduction targets for Colorado Option plans. The projected decrease in individual market premiums is expected to decrease federal spending on premium tax credits for residents of Colorado. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Colorado is to use the pass-through funding to support a state-based subsidy program. The state-based subsidy provides increased cost-sharing subsidies for premium tax credit eligible individuals from 150%-200% of the federal poverty level starting in 2022. The state-based subsidy also provides premium assistance and cost-sharing subsidies to individuals ineligible for federal premium assistance (e.g., due to immigration status, lack of documentation, or the "family glitch") up to a certain income threshold starting in 2023. Other state-based subsidy program eligibility criteria apply, and the income thresholds may vary depending on funding availability.
The approved waiver amendment does not modify the eligibility criteria for federal premium tax credits for residents of Colorado.
Colorado's waiver amendment also included an extension of the approved reinsurance-aspect of the waiver from CY2026 through CY2027. It did not change other aspects of the reinsurance component of the waiver.
CY2020: $169.4 million
CY2021: $182.7 million
CY2022: $196.7 million
CY2023: $245.0 million
CY2024: $361.7 million
CY2025: $339.1 million
Initial Waiver—CY2020-CY2022
Amended Waiver—CY2023-CY2027
|
Delaware
Initial Waiver—July 10, 2019
Waiver Extension—April 2, 2024, updated May 21, 2024
Initial Waiver Approved—Aug. 20, 2019
Waiver Extension Approved—July 31, 2024
premium tax credits for
residents of Colorado.
Delaware
July 10, 2019
Approved—
Delaware established a state-basedDelaware established a state-based
, claims cost-based reinsurance program, the Delaware Health Insurance reinsurance program, the Delaware Health Insurance
CMS indicated
CY2020-
Aug. 20, 2019
Individual Market Stabilization Reinsurance Program, which reimburses issuers Individual Market Stabilization Reinsurance Program, which reimburses issuers
sel ing coverage Delaware would
CY2024
selling coverage in the statein the state
’'s individual market for a percentage of s individual market for a percentage of
enrol ees’enrollees' claims between an attachment claims between an attachment
receive $21.7 mil ion
point and a cap.point and a cap.
for CY2020.
Delaware’
Delaware's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider Delaware issuers to consider Delaware
reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Delaware for residents of Delaware
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Delaware is to use the pass-federal spending as pass-through funding. Under the waiver, Delaware is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
beginning in CY2020 and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Delaware.residents of Delaware.
CRS-11
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Georgia
December
Approved—
Georgia’s approved waiver has two parts: a reinsurance program scheduled to begin in
Georgia estimated it
CY2022-
23, 2019,
Nov. 1, 2020
CY2022 and the Georgia Access Model, which is to begin in CY2023.
would receive $306
CY2026
application
With respect to first part of the waiver, Georgia established a state-based reinsurance
mil ion for CY2022
was updated
program. Starting in 2022, the program is to reimburse issuers sel ing coverage in the state’s
and $1.6 bil ion over
on July 31,
individual market for a percentage of enrol ees’ claims between an attachment point and a cap. the period CY2022-
2020, and
The reimbursement percentage is to vary across geographic rating areas in the state.
CY2026.
modified on
Oct. 9, 2020.
Georgia’
Delaware's waiver extension did not include any substantial changes to the approved waiver.
CY2020: $21.7 million
CY2021: $38.9 million
CY2022: $35.0 million
CY2023: $46.7 million
CY2024: $64.7 million
CY2025: $49.3 million
|
CY2020-CY2029
|
Georgia
December 23, 2019, modified July 31, 2020, and updated Oct. 9, 2020
|
Approved—Nov. 1, 2020
Partial Suspension—Apr. 29, 2022
Georgia's approved waiver has two parts: a state-based, claims cost-based reinsurance program and the Georgia Access Model. The second part of the waiver, the Georgia Access Model, was suspended prior to implementation and is pending Georgia satisfying certain requirements.
With respect to first part of the waiver, Georgia established a state-based, claims cost-based reinsurance program. Starting in 2022, the program is to reimburse issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap. The reimbursement percentage is to vary across geographic rating areas in the state.
Georgia's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider Georgia issuers to consider Georgia
’s
's reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Georgia for residents of Georgia
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Georgia is to use the pass-federal spending as pass-through funding. Under the waiver, Georgia is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Georgia.
beginning in CY2022 and continuing through CY2026. With respect to the With respect to the
secondsuspended part of the waiver, Georgia part of the waiver, Georgia
is shiftingplanned to shift its individual market its individual market
exchange enrol mentexchange enrollment to the Georgia Access Model beginning in CY2023. Under the Georgia to the Georgia Access Model beginning in CY2023. Under the Georgia
Access Model, residents would no longer Access Model, residents would no longer
behave been able to able to
enrol enroll in individual market coverage in individual market coverage
through the through the
federal yfederally facilitated exchange and would facilitated exchange and would
have instead only instead only
bebeen able to utilize commercial able to utilize commercial
market web brokers or buy directly from issuers. Residents market web brokers or buy directly from issuers. Residents
are stil still would have had to be eligible for premium to be eligible for premium
tax credits while tax credits while
enrol ingenrolling in coverage through the Georgia Access Model. in coverage through the Georgia Access Model.
Under Under
the approvedthis part of the waiver, ACA requirements relating to the state establishment of health waiver, ACA requirements relating to the state establishment of health
insurance exchanges insurance exchanges
arewould have been waived to the extent they are inconsistent with the Georgia Access waived to the extent they are inconsistent with the Georgia Access
Model.d Model.g As a result, Georgia As a result, Georgia
iswould have been able to implement the Georgia Access Model.
CY2022: $255.2 million
CY2023: $526.5 million
CY2024: $756.7 million
CY2025: $1,015.8 million
|
CY2022-CY2026
|
Hawaii
Initial Waiver—Aug. 10, 2016
Waiver Extension—Aug. 13, 2021
Initial Waiver Approved—Dec. 30, 2016
Waiver Extension Approved—Dec. 10, 2021
Under the approved waiver, multiple ACA provisions relating to the establishment and operation of a Small Business Health Options Program (SHOP) exchange, as they pertain to small employers and SHOP exchanges, are waived.h As a result, Hawaii is no longer required to operate SHOP exchanges for small employers. The amount that small employers in Hawaii would have received in small business tax credits for coverage purchased through a SHOP exchange is provided to the state in pass-through funding to support a program that assists small employers with the cost of health insurance coverage.
Hawaii's waiver extension did not include any substantial changes to the approved waiver.
CY2017: $428,864
CY2018: $933,130
CY2019: $287,409
CY2020: $120,361
CY2021: $60,865
CY2022: $29,503
CY2023: $51,033
CY2024: $45,269
CY2025: $45,372i
CY2017- CY2026
|
Idaho
May 5, 2022
|
Approved—Aug. 16, 2022
|
Idaho established a state-based, conditions-based reinsurance program, the Idaho Individual High Risk Reinsurance Pool, to help health insurance issuers offering plans in the individual market offset the cost of covering a percentage of claims for enrollees with specified high-cost conditions between an attachment point and a cap.
Idaho's waiver is similar to other reinsurance-type waivers in that the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to be members of a single risk pool is waived,c to the extent the provision prohibits issuers from including expected reinsurance payments when establishing market-wide index rates. The expected effect is that individual market premiums will decrease and federal spending on premium tax credits for residents of Idaho will decrease. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Idaho is to use the pass-through funding to support the reinsurance program and corresponding payments to issuers.
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Idaho.
CY2023: $51.5 million
CY2024: $97.9 million
CY2025: $148.7 million
|
CY2023-CY2027
|
Maine
Initial Waiver—May 9, 2018
Waiver Amendment—Feb. 10, 2022, addended Mar. 23, 2022
Initial Waiver Approved—July 30, 2018
Waiver Amendment—July 15, 2022
Initial Waiver: Maine established a state-based reinsurance program administered by the Maine Guaranteed Access Reinsurance Association (MGARA). From CY2019-CY2021, the program operated as a conditions-based reinsurance program, which helped health insurance issuers offering plans in the individual market offset the cost of a percentage of claims for enrollees with one or more of eight specified high-cost conditions between an attachment point and a cap. Under this structure, health insurance issuers offering plans in the individual market also had able to implement the Georgia Access Model. Georgia
anticipates web brokers wil be incentivized to bring in new consumers, and, when combined with other outreach and support, there wil be increased enrol ment in the individual market.
Georgia anticipates the net effect of these new enrol ees wil be an increase in the amount of
premium tax credits received by residents. Georgia requested to reduce the pass-through
funding that would be provided in accordance with the reinsurance program aspect of the waiver to account for these costs. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Georgia.
CRS-12
link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Hawai
Aug. 10,
Approved—
Under the approved waiver, multiple ACA provisions relating to the establishment and
CMS indicated
CY2017-
2016
Dec. 30, 2016 operation of a Smal Business Health Options Program (SHOP) exchange, as they pertain to
Hawai would
CY2021
smal employers and SHOP exchanges, are waived.e As a result, Hawai is no longer required
receive $428,864 for
to operate SHOP exchanges for smal employers. The amount that smal employers in Hawai
CY2017, $933,130
would have received in smal business tax credits for coverage purchased through a SHOP
for CY2018,
exchange is provided to the state in pass-through funding to support a program that assists
$287,409 for
smal employers with the cost of health insurance coverage.
CY2019, and
$120,361 for CY2020. CMS
estimated the state
would receive $64,544 in CY2021.f
Maine
May 9, 2018
Approved—
Maine established a hybrid state-based reinsurance/invisible high-risk pool program
CMS indicated Maine CY2019-
July 30, 2018
administered by the Maine Guaranteed Access Reinsurance Association (MGARA), which
would receive $62.3
CY2023
helps health insurance issuers offering plans in the individual market offset the cost of covering mil ion for CY2019 enrol ees with one or more of eight specified high-cost conditions. Under the waiver, health
and $26.3 mil ion for
insurance issuers offering plans in the individual market also have the discretion to include
CY2020.
additional enrol ees the discretion to include additional enrollees in the program if such determinations are made during the first 60 days of in the program if such determinations are made during the first 60 days of
an enrol ee’s plan year. Maine’an enrollee's plan year. Since CY2022, the reinsurance program has operated as a claims cost-based reinsurance program. Under the claims cost-based version of the reinsurance program, issuers selling coverage in the state's individual market are reimbursed for a percentage of enrollees' claims between an attachment point and a cap irrespective of the health condition of the enrollee.
Maine's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider MGARA issuers to consider MGARA
payments when setting market-wide index rates. The expected effect is that individual market payments when setting market-wide index rates. The expected effect is that individual market
premiums wil premiums will decrease and federal spending on premium tax credits for residents of Maine decrease and federal spending on premium tax credits for residents of Maine
wil will decrease. The state is to receive the resulting reductions in federal spending as pass-decrease. The state is to receive the resulting reductions in federal spending as pass-
through funding. Under the approved waiver, Maine is to use the pass-through funding to through funding. Under the approved waiver, Maine is to use the pass-through funding to
support MGARA and corresponding payments to issuerssupport MGARA and corresponding payments to issuers
beginning in CY2019 and continuing
through CY2023. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Maine.
CRS-13
link to page 25 link to page 25 link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Maryland
May 31, 2018 Approved—
Maryland established a state-based reinsurance program administered by the Maryland Health
CMS indicated
CY2019-
Aug. 22, 2018
Benefit Exchange, which reimburses issuers sel ing coverage in the state’s individual market for Maryland would
CY2023h
a percentage of enrol ees’ claims between an attachment point and a cap.
receive $373.4
Maryland’residents of Maine.
Waiver Amendment: Maine extended its state-based, claims cost-based reinsurance program to also apply to the small-group market by combining the individual and small-group markets into a single risk pool and extending the reinsurance program to the combined risk pool. Maine also allowed for quarterly rating adjustments for non-calendar year small group plans that are now part of the combined risk pool.
Maine's approved waiver amendment waives the ACA provisions requiring issuers to consider all enrollees in plans offered by the issuer to be members of a single risk pool,j which allows issuers to consider MGARA payments when setting market-wide index rates for the combined risk pool. It also waives the provision that prohibits quarterly rating adjustments for non-calendar year small group plans when there is a merged risk pool.k The expected effect is that individual market premiums will decrease and federal spending on premium tax credits for residents of Maine will decrease. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the approved waiver, Maine is to use the pass-through funding to support MGARA and corresponding payments to issuers.
The approved waiver amendment does not modify the eligibility criteria for premium tax credits for residents of Maine.
Maine's waiver amendment also included an extension of the approved reinsurance-aspect of the waiver from CY2026 through CY2027.
CY2019: $62.3 million
CY2020: $26.3 million
CY2021: $39.3 million
CY2022: $45.8 million
CY2023: $61.4 million
CY2024: $45.7 million
CY2025: $43.4 million
|
Initial Waiver—CY2019-CY2022
Waiver Amendment—CY2023-CY2027
|
Maryland
Initial Waiver—May 31, 2018, addended Aug. 4, 2018
Waiver Extension—Mar. 30, 2023
Waiver Amendment—July 15, 2024
Initial Request to Suspend Waiver Amendment—Oct. 20, 2025, updated Nov. 6, 2025
Initial Waiver Approved—Aug. 22, 2018
Waiver Extension Approved—June 28, 2023
Waiver Amendment Approved—Jan. 15, 2025
Waiver Amendment Suspension Approved—Dec. 29, 2025
Initial Waiver: Maryland established a state-based, claims cost-based reinsurance program administered by the Maryland Health Benefit Exchange, which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
Maryland's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
mil ion for CY2019
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
and $447.3 mil ion
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider the state issuers to consider the state
’s
for CY2020.
's reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Maryland for residents of Maryland
wil will decrease. The state requested to receive a portion of the decrease. The state requested to receive a portion of the
resulting reductions in federal spending as pass-through funding. Under the waiver, Maryland resulting reductions in federal spending as pass-through funding. Under the waiver, Maryland
is to use the pass-through funding to support the reinsurance program and corresponding is to use the pass-through funding to support the reinsurance program and corresponding
payments to issuers beginning in CY2019 and continuing through CY2021, unless additional payments to issuers beginning in CY2019 and continuing through CY2021, unless additional
funds become funds become
available.h
The approved waiver available.
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Maryland.
Maryland's waiver extension did not include any substantial changes to the approved waiver.
Waiver Amendment: Maryland created the Qualified Resident Enrollment Program, which allows all qualified Maryland residents to enroll in health insurance through an exchange, regardless of immigration status.
Maryland's approved waiver amendment waives the ACA provision that prohibits individuals who are not United States citizens, United States nationals or aliens lawfully present in the United States from being able to enroll in health insurance coverage through an exchange, which would allow such individuals to enroll in exchange coverage.l The expected effect is that there will be a negligible impact on premiums. Maryland did not request pass-through funding under the waiver amendment (unless it is subsequently determined that pass-through funding is warranted).
The approved waiver amendment does not modify the eligibility criteria for premium tax credits for residents of Maryland, as such the newly-eligible individuals still would not be eligible for the premium tax credit.
Maryland's waiver amendment did not change the reinsurance component of the waiver.
The Qualified Resident Enrollment Program portion of the amended waiver was suspended until CY2028, pending Departmental approval to continue the program. Maryland requested this suspension in order to first address substantial information technology system changes resulting from changes in federal law (P.L. 119-21) and regulations (Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability; 90 Federal Register 27074).
CY2019: $373.4 million
CY2020: $447.3 million
CY2021: $474.5 million
CY2022: $344.1 million
CY2023: $473.0 million
CY2024: $526.7 million
CY2025: $577.8 million
|
Initial Waiver—CY2019-CY2028
Waiver Amendment (incl. suspension)—
CY2028, pending Departmental approval to continue the programm
Minnesota
Initial Waiver—May 30, 2017
Waiver Extension—Dec. 22, 2021, revised May 12, 2022
Initial Waiver Approved—Oct. 19, 2017
Waiver Extension Approved—July 13, 2022
does not modify the eligibility criteria for premium tax credits for
residents of Maryland.
Minnesota
May 30, 2017 Approvedi—
Minnesota established a state-basedMinnesota established a state-based
, claims cost-based reinsurance program, the Minnesota Premium Security reinsurance program, the Minnesota Premium Security
CMS indicated
CY2018-
Sept. 22, 2017 Plan (MSPS), which reimburses issuers Plan (MSPS), which reimburses issuers
sel ingselling coverage in the state coverage in the state
’'s individual market for a s individual market for a
Minnesota would
CY2022
percentage of enrol ees’percentage of enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
receive $130.7
Minnesota’
Minnesota's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
mil ion for CY2018,
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
$84.8 mil ion for
be members of a single risk pool is be members of a single risk pool is
waived,b which al ows issuers to consider MSPS payments
CY2019, and $86.1
waived,c which allows issuers to consider MSPS payments when setting market-wide index rates. The expected effect is that individual market premiumswhen setting market-wide index rates. The expected effect is that individual market premiums
mil ion for CY2020.
wil will decrease and federal spending on premium tax credits for residents of Minnesota decrease and federal spending on premium tax credits for residents of Minnesota
wil
will decrease. The state is to receive the resulting reductions in federal spending as pass-through decrease. The state is to receive the resulting reductions in federal spending as pass-through
funding.funding.
n Under the waiver, Minnesota is to use the pass-through funding to support MSPS and Under the waiver, Minnesota is to use the pass-through funding to support MSPS and
corresponding payments to issuerscorresponding payments to issuers
beginning in CY2018 and continuing through CY2022. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Minnesota.residents of Minnesota.
CRS-14
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Montana
June 19, 2019 Approved—
Montana established a state-based
Minnesota's waiver extension did not include any substantial changes to the approved waiver.
CY2018: $130.7 million
CY2019: $84.8 million
CY2020: $86.1 million
CY2021: $142.7 million
CY2022: $91.1 million
CY2023: $119.5 million
CY2024: $129.9 million
CY2025: $179.3 million
|
CY2018-CY2027
|
Montana
Initial Waiver—June 19, 2019
Waiver Extension—May 17, 2024
Initial Waiver Approved—Aug. 16, 2019
Waiver Extension Approved—Sep. 17, 2024
Montana established a state-based, claims cost-based reinsurance program, the Montana Reinsurance Program, reinsurance program, the Montana Reinsurance Program,
CMS indicated
CY2020-
Aug. 16, 2019
which reimburses issuers which reimburses issuers
sel ingselling coverage in the state coverage in the state
’'s individual market for a percentage of s individual market for a percentage of
Montana would
CY2024
enrol ees’enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
receive $22.5 mil ion
Montana’
Montana's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
for CY2020.
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider Montana issuers to consider Montana
reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Montana for residents of Montana
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Montana is to use the pass-federal spending as pass-through funding. Under the waiver, Montana is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
beginning in CY2020 and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Montana.
New
Apr. 23,
Approved—
New Hampshire established a state-based reinsurance program, which reimburses issuers
New Hampshire
CY2021-
Hampshire
2020
Aug. 5, 2020
sel ing coverage in the state’s individual market for a percentage of enrol ees’ claims between
estimated it would
CY2025
an attachment point and a cap.
receive $32.9 mil ion
New Hampshire’residents of Montana.
Montana's waiver extension did not include any substantial changes to the approved waiver.
CY2020: $22.5 million
CY2021: $30.8 million
CY2022: $29.7 million
CY2023: $28.4 million
CY2024: $35.8 million
CY2025: $51.8 million
|
CY2020-CY2029
|
Nevada
Dec. 29, 2023, addended Aug. 23, 2024 and Jan. 1, 2025
|
Jan. 10, 2025
|
Nevada's approved waiver consists of a state-based public option health insurance program, and a Market Stabilization Program. The Market Stabilization Program includes a state-based, claims cost-based reinsurance program, premium assistance for certain populations, a "quality incentive payment program," and a "provider retention program."
Nevada established Battle Born State Plans (BBSP), which are state-based public option health insurance plans that are offered on Nevada's health insurance exchange. Under the public option health insurance program, issuers offering a bid to participate in Nevada's Medicaid Managed Care program also must submit a good faith bid to offer at least one bronze, one silver, and one gold BBSP, and one non-BBSP silver plan in each rating area through the exchange. BBSP plans must meet specified premium reduction targets (and satisfy other requirements).
Issuers must offer BBSP plans in 2026 with premiums that are 3% lower than the 2024 second-lowest cost silver plan, adjusted for inflation, utilization, and morbidity. In 2027 and 2028, Nevada will negotiate premium reduction amounts with the intention of ensuring that issuers, in 2029, achieve a 15% reduction in premiums relative to the 2024 second-lowest cost silver plan, adjusted for inflation, utilization, and morbidity. For 2030, issuers must maintain the 15% premium reduction. These reductions are expected to be derived from lower provider rates, administrative efficiencies, and the implementation of reinsurance.
The Market Stabilization Program includes a state-based, claims cost-based reinsurance program, which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
Under the approved waiver, the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to be members of a single risk pool is waived,c which allows issuers to adjust premiums to satisfy the premium reduction targets for BBSPs and allows issuers to consider reinsurance program payments when setting market-wide index rates. The projected decrease in individual market premiums is expected to decrease federal spending on premium tax credits for residents of Nevada. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Nevada is to use the pass-through funding to support the reinsurance program, and provide premium assistance to individuals renewing a policy whose net premium is higher under the waiver program than it would have been without the waiver (due to the effect of BBSPs on premium tax credit amounts). If additional pass-through funding is available, Nevada is to use the funds to support a quality incentive payment program that pays BBSP issuers for achieving state-defined quality goals, and a provider retention program that acts as a loan repayment program to providers committing to live and work in Nevada for four years.
The approved waiver amendment does not modify the eligibility criteria for federal premium tax credits for residents of Nevada.
CY2026-CY2030
|
New Hampshire
Initial Waiver—Apr. 23, 2020
Waiver Extension—Aug. 21, 2024
Initial Waiver Approved—Aug. 5, 2020
Waiver Extension Approved—Nov. 19, 2024
New Hampshire established a state-based, claims cost-based reinsurance program, which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
New Hampshire's approved waiver is similar to other reinsurance-type waivers in that the s approved waiver is similar to other reinsurance-type waivers in that the
for CY2021 and
ACA provision requiring issuers to consider ACA provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the in individual plans offered by the
$180.9 mil ion over
issuer to be members of a single risk pool is issuer to be members of a single risk pool is
waived,b which al ows issuers to consider
the period CY2021-
waived,c which allows issuers to consider reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
CY2025.
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of New Hampshire for residents of New Hampshire
wil will decrease. The state is to receive the resulting reductions decrease. The state is to receive the resulting reductions
in federal spending as pass-through funding. Under the waiver, New Hampshire is to use the in federal spending as pass-through funding. Under the waiver, New Hampshire is to use the
pass-through funding to support the reinsurance program and corresponding payments to pass-through funding to support the reinsurance program and corresponding payments to
issuers beginning in CY2021 and continuing through CY2025. issuers.
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of New Hampshire.residents of New Hampshire.
CRS-15
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
New Jersey
July 2, 2018
Approved—
New Jersey established a state-based reinsurance program, the
New Hampshire's waiver extension did not include any substantial changes to the approved waiver.
CY2021: $31.5 million
CY2022: $26.6 million
CY2023: $32.0 million
CY2024: $28.0 million
CY2025: $34.1 million
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CY2021-CY2030
|
New Jersey
Initial Waiver—July 2, 2018
Waiver Extension—July 6, 2023, amended July 11, 2023
Initial Waiver Approved—Aug. 16, 2018
Waiver Extension Approved—Aug. 15, 2023
New Jersey established a state-based, claims cost-based reinsurance program, the New Jersey Health Insurance Premium Health Insurance Premium
CMS indicated New
CY2019-
Aug. 16, 2018
Security Plan, which reimburses issuers Security Plan, which reimburses issuers
sel ingselling coverage in the state coverage in the state
’'s individual market for a s individual market for a
Jersey would receive
CY2023
percentage of enrol ees’percentage of enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
$180.2 mil ion for
New JerseyNew Jersey
’'s approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
CY2019 and $190.0
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
mil ion for CY2020.
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider the state issuers to consider the state
’s
's reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of New Jersey for residents of New Jersey
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, New Jersey is to use the pass-federal spending as pass-through funding. Under the waiver, New Jersey is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
beginning in CY2019 and continuing through CY2023. The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of New Jersey.
North Dakota May 10, 2019 Approved—
North Dakota established a state-based reinsurance program, the Reinsurance Association of
CMS indicated
CY2020-
July 31, 2019
North Dakota (RAND), which reimburses issuers sel ing coverage in the state’s individual
North Dakota would CY2024
market for a percentage of enrol ees’ claims between an attachment point and a cap.
receive $21.5 mil ion
North Dakota’s approved waiver is similar to other reinsurance-type waivers in that the ACA for CY2020.
provision requiring issuers to consider al enrol eesresidents of New Jersey.
New Jersey's waiver extension did not include any substantial changes to the approved waiver.
CY2019: $180.2 million
CY2020: $190.0 million
CY2021: $282.1 million
CY2022: $323.0 million
CY2023: $375.3 million
CY2024: $608.9 million
CY2025: $554.8 million
|
CY2019-CY2028
|
New York
|
Initial Waiver—May 12, 2023, addended Aug. 23, 2023, Nov. 14, 2023, and Dec. 18, 2023
Waiver Amendment—June 28, 2024
Waiver Extension—Dec. 9, 2024, updated Dec. 11, 2024
Termination Request—Oct. 20, 2025
Initial Waiver Approved—Mar. 1, 2024
Waiver Amendment Approved—Sep. 25, 2024
Waiver Extension Approved—Jan. 15, 2025
Termination Request Approved—Mar. 20, 2026
Initial Waiver: New York's approved waiver shifts its Essential Plan program from operating under Basic Health Program (BHP) authority to operating under Section 1332 waiver authority, which allows New York to generally mirror the program as it operated under BHP authority but expand Essential Plan program eligibility to certain populations. As operated under Section 1332 waiver authority, CMS refers to the program as the Essential Plan Expansion. New York suspended its BHP for the duration of the waiver.
As a BHP, the Essential Plan provided coverage to premium tax credit-eligible individuals aged 19-64 with estimated incomes above the Medicaid ceiling and up to 200% of FPL, but eligibility expands under the Essential Plan Expansion to also include premium tax credit-eligible individuals aged 19-64 with estimated incomes between 200% and 250% of FPL, and Deferred Action for Childhood Arrivals (DACA) recipients aged 19-64 with estimated incomes up to 250% of FPL. In addition, Essential Plan Expansion enrollees that became pregnant and eligible for Medicaid are given the choice to maintain Essential Plan coverage through the postpartum period, as opposed to transitioning to Medicaid.
New York's approved waiver also includes an Insurer Reimbursement Implementation Plan (IRIP). Under the IRIP, New York provides payments to issuers in lieu of approving increased individual market premiums that were expected to result from the removal of premium tax credit-eligible individuals with estimated incomes between 200% and 250% of FPL from the individual market.
Under the approved waiver, multiple ACA provisions are waived. The ACA provisions pertaining to premium tax credit eligibility and cost-sharing reduction eligibility are waived for individuals under age 65 who are determined by the exchange to have estimated household income at or below 250% of FPL (with some exceptions). As a result of this waiver, these individuals no longer are eligible for premium tax credit amounts or cost-sharing reductions, but instead receive their coverage through the Essential Plan Expansion. The expected effect is that federal spending on premium tax credits for residents of New York would decrease. These amounts are combined with savings attributable to the suspension of the BHP, and New York receives the total reductions in federal spending as pass-through funding. In addition, the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to be members of a single risk pool is waived,c which allows issuers to determine market-wide index rates as if those with estimated household income between 200% and 250% of FPL still were included in the single risk pool. The expected effect is that individual market premiums would not increase as a result of excluding those with estimated household income between 200% and 250% of FPL from the single risk pool due to their enrollment in the Essential Plan Expansion. New York uses the pass-through funding to implement the Essential Plan Expansion and IRIP.
Waiver Amendment: New York's waiver amendment expands the uses of federal pass-through funding to allow the state to use the funding on three new cost-sharing reduction programs for exchange enrollees. The first program expands the cost-sharing reductions available to those with incomes between 100% and 250% of FPL to apply to individuals with incomes between 100% and 400% of FPL. The second program reduces cost-sharing to $0 for non-hospital-based diabetes-related services, supplies, and prescription drugs. The third program reduces cost-sharing to $0 for outpatient covered services, supplies, and prescription drugs during pregnancy and postpartum. New York uses pass-through funding to provide payments to issuers offsetting the costs to provide these cost-sharing reduction programs. New York's waiver amendment did not request to waive additional ACA requirements.
New York's waiver extension did not include any substantial changes to the approved waiver
New York requested termination of its approved waiver and reactivation of its BHP by July 1, 2026 due to changes in premium tax credit eligibility included in the budget reconciliation law sometimes referred to as the One Big Beautiful Bill Act (P.L. 119-21). The termination was approved and the reactivation will go into effect July 1.
CY2024: $10.0 billion
CY2025: $15.9 billion
CY2026 (Interim):o $2 billion
Initial Waiver—Apr. 1, 2024-Dec. 31, 2024
Waiver Amendment—CY2025-July 1, 2026
|
North Dakota
Initial Waiver—May 10, 2019
Waiver Extension—Aug. 30, 2024, updated Oct. 2, 2024
Initial Waiver Approved—July 31, 2019
Waiver Extension Approved—Nov. 7, 2024
North Dakota established a state-based, claims cost-based reinsurance program, the Reinsurance Association of North Dakota (RAND), which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
North Dakota's approved waiver is similar to other reinsurance-type waivers in that the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider RAND payments issuers to consider RAND payments
when setting market-wide index rates. The expected effect is that individual market premiums when setting market-wide index rates. The expected effect is that individual market premiums
wil will decrease and federal spending on premium tax credits for residents of North Dakota decrease and federal spending on premium tax credits for residents of North Dakota
wil
will decrease. The state is to receive the resulting reductions in federal spending as pass-through decrease. The state is to receive the resulting reductions in federal spending as pass-through
funding. Under the waiver, North Dakota is to use the pass-through funding to support funding. Under the waiver, North Dakota is to use the pass-through funding to support
RAND and corresponding payments to issuersRAND and corresponding payments to issuers
beginning in CY2020 and continuing through
CY2024. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of North Dakota.residents of North Dakota.
CRS-16
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Oregon
Aug. 31,
Approved—
Oregon established a state-based
North Dakota's waiver extension did not include any substantial changes to the approved waiver.
CY2020: $21.5 million
CY2021: $20.5 million
CY2022: $19.0 million
CY2023: $14.5 million
CY2024: $20.8 million
CY2025: $38.1 million
|
CY2020-CY2029
|
Oregon
Initial Waiver—Aug. 31, 2017
Waiver Extension—Mar. 31, 2022, addended Apr. 22, 2022
Initial Waiver Approved—Oct. 18, 2017
Waiver Extension Approved—July 13, 2022
Oregon established a state-based, claims cost-based reinsurance program, the Oregon Reinsurance Program reinsurance program, the Oregon Reinsurance Program
CMS indicated that
CY2018-
2017
Oct. 18, 2017
(ORP), which reimburses issuers (ORP), which reimburses issuers
sel ingselling coverage in the state coverage in the state
’'s individual market for a s individual market for a
Oregon would
CY2022
percentage of enrol ees’percentage of enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
receive $54.5 mil ion
Oregon’Oregon's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
for CY2018, $41.8
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
mil ion for CY2019,
be members of a single risk pool is be members of a single risk pool is
waived,b which al ows issuers to consider ORP payments
and $54.4 mil ion for
waived,c which allows issuers to consider ORP payments when setting market-wide index rates. The expected effect is that individual market premiumswhen setting market-wide index rates. The expected effect is that individual market premiums
CY2020. wil will decrease and federal spending on premium tax credits for residents of Oregon decrease and federal spending on premium tax credits for residents of Oregon
wil
will decrease. The state is to receive the resulting reductions in federal spending as pass-through decrease. The state is to receive the resulting reductions in federal spending as pass-through
funding. Under the waiver, Oregon is to use the pass-through funding to support ORP and funding. Under the waiver, Oregon is to use the pass-through funding to support ORP and
corresponding payments to issuerscorresponding payments to issuers
beginning in CY2018 and continuing through CY2022. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Oregon.
Pennsylvania
Feb. 11, 2020 Approved—
Pennsylvania established a state-based reinsurance program, which reimburses issuers sel ing
Pennsylvania
CY2021-
July 24, 2020
coverage in the state’s individual market for a percentage of enrol ees’residents of Oregon.
Oregon's waiver extension did not include any substantial changes to the approved waiver.
CY2018: $54.5 million
CY2019: $41.8 million
CY2020: $54.4 million
CY2021: $73.7 million
CY2022: $71.3 million
CY2023: $77.1 million
CY2024: $68.3 million
CY2025: $86.0 million
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CY2018-CY2027
|
Pennsylvania
Initial Waiver—Feb. 11, 2020
Waiver Extension—Dec. 30, 2024
Initial Waiver Approved—July 24, 2020
Waiver Extension Approved—Apr. 24, 2025
Pennsylvania established a state-based, claims cost-based reinsurance program, which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
Pennsylvania' claims between an
estimated it would
CY2025
attachment point and a cap.
receive $95.1 mil ion
Pennsylvania’s approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
for CY2021 and
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
$547.5 mil ion over
be members of a single risk pool is be members of a single risk pool is
waived,b which al ows issuers to consider reinsurance
the period CY2021-
waived,c which allows issuers to consider reinsurance program payments when setting market-wide index rates. The expected effect is that program payments when setting market-wide index rates. The expected effect is that
CY2025.
individual market premiums individual market premiums
wil will decrease and federal spending on premium tax credits for decrease and federal spending on premium tax credits for
residents of Pennsylvania residents of Pennsylvania
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Pennsylvania is to use the pass-federal spending as pass-through funding. Under the waiver, Pennsylvania is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
beginning in CY2021 and continuing through CY2025. The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Pennsylvania.residents of Pennsylvania.
CRS-17
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Rhode Island
July 8, 2019
Approved—
Rhode Island established a state-based
Pennsylvania's waiver extension did not include any substantial changes to the approved waiver.
CY2021: $120.2 million
CY2022: $124.2 million
CY2023: $115.4 million
CY2024: $121.1 million
CY2025: $165.3 million
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CY2021-CY2030
|
Rhode Island
Initial Waiver—July 8, 2019
Waiver Extension—July 8, 2024
Initial Waiver Approved—Aug. 26, 2019
Waiver Extension Approved—Oct. 28, 2024
Rhode Island established a state-based, claims cost-based reinsurance program, the Rhode Island Reinsurance reinsurance program, the Rhode Island Reinsurance
CMS indicated
CY2020-
Aug. 26, 2019
Program, which reimburses issuers Program, which reimburses issuers
sel ingselling coverage in the state coverage in the state
’'s individual market for a s individual market for a
Rhode Island would
CY2024
percentage of enrol ees’percentage of enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
receive $5.2 mil ion
Rhode IslandRhode Island
’'s approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
for CY2020.
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
be members of a single risk pool is be members of a single risk pool is
waived,b which al owswaived,c which allows issuers to consider Rhode Island issuers to consider Rhode Island
reinsurance program payments when setting market-wide index rates. The expected effect is reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums that individual market premiums
wil will decrease and federal spending on premium tax credits decrease and federal spending on premium tax credits
for residents of Rhode Island for residents of Rhode Island
wil will decrease. The state is to receive the resulting reductions in decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Rhode Island is to use the pass-federal spending as pass-through funding. Under the waiver, Rhode Island is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuersthrough funding to support the reinsurance program and corresponding payments to issuers
.
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Rhode Island.
Rhode Island's waiver extension did not include any substantial changes to the approved waiver.
CY2020: $5.2 million
CY2021: $12.4 million
CY2022: $9.7 million
CY2023: $10.8 million
CY2024: $9.6 million
CY2025: $12.2 million
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CY2020-CY2029
|
Virginia
Dec. 30, 2021
|
May 18, 2022
|
Virginia established a state-based, claims cost-based reinsurance program, which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
Virginia's approved waiver is similar to other reinsurance-type waivers in that the ACA provision requiring issuers to consider all enrollees in individual plans offered by the issuer to be members of a single risk pool is waived,c which allows issuers to consider reinsurance program payments when setting market-wide index rates. The expected effect is that individual market premiums will decrease and federal spending on premium tax credits for residents of Virginia will decrease. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Virginia is to use the pass-through funding to support the reinsurance program and corresponding payments to issuers.
The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Virginia.
CY2023: $331.9 million
CY2024: $481.9 million
CY2025: $450.3 million
|
CY2023-CY2027
|
Washington
May 13, 2022, updated June 8, 2022, and Aug. 3, 2022
|
Dec. 9, 2022
|
Washington's approved waiver allows all qualified residents to enroll in health insurance through an exchange, regardless of immigration status, thereby expanding the number of individuals eligible under the state's Cascade Care Savings program.
The Cascade Care Savings program is a state-based premium subsidy program for individuals with incomes up to 250% of FPL who purchase silver or gold Cascade Care plans and meet other eligibility criteria.p Cascade Care Savings program premium subsidies are a maximum monthly amount that are determined annually depending on available funding. Subsidies are available to eligible individuals who are also eligible for the premium tax credit, and eligible individuals who are not eligible for the premium tax credit, including due to immigration status. For those eligible for the premium tax credit, this subsidy amount is in addition to any premium tax credit amounts (although it cannot be greater than the net premium for the lowest-cost silver Cascade Care plan, after accounting for the premium tax credit).
Under the approved waiver, the ACA provision that prohibits individuals who are not United States citizens, United States nationals or aliens lawfully present in the United States from being able to enroll in health insurance coverage through an exchange is waived, which would allow such individuals to enroll in exchange coverage.l Per the waiver application, the expected effect is that individual market premiums will decrease as a result these individuals enrolling in coverage, including with support from the state-based subsidy, however, the Departments did not project an increase or decrease in individual market premiums upon waiver approval. To the extent that there are future decreases in individual market premiums, the state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Washington is to use the pass-through funding, if applicable, to support the Cascade Care Savings program.
The approved waiver amendment does not modify the eligibility criteria for premium tax credits for residents of Washington, as such the newly-eligible individuals still would not be eligible for the premium tax credit.
Upon approval, the Departments indicated that the waiver was not projected to result in PTC savings, and no pass-through funding has since been posted.
|
CY2024-CY2028
|
Wisconsin
Initial Waiver—Apr. 18, 2018
Waiver Extension—Aug. 5, 2022
Initial Waiver Approved—July 29, 2018
Waiver Extension Approved—Dec. 1, 2022
Wisconsin established a state-based, claims cost-based reinsurance program, the Wisconsin Healthcare Stability Plan (WIHSP), which reimburses issuers selling coverage in the state'
beginning in CY2020 and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Rhode Island.
Wisconsin
Apr. 18,
Approved—
Wisconsin established a state-based reinsurance program, the Wisconsin Healthcare Stability
CMS indicated
CY2019-
2018
July 29, 2018
Plan (WIHSP), which reimburses issuers sel ing coverage in the state’s individual market for a
Wisconsin would
CY2023
percentage of enrol ees’s individual market for a percentage of enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
receive $127.7
Wisconsin’Wisconsin's approved waiver is similar to other reinsurance-type waivers in that the ACA s approved waiver is similar to other reinsurance-type waivers in that the ACA
mil ion for CY2019
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
and $142.0 mil ion
be members of a single risk pool is be members of a single risk pool is
waived,b which al ows issuers to consider WIHSP
for CY2020.
waived,c which allows issuers to consider WIHSP payments when setting market-wide index rates. The expected effect is that individual market payments when setting market-wide index rates. The expected effect is that individual market
premiums premiums
wil will decrease and federal spending on premium tax credits for residents of decrease and federal spending on premium tax credits for residents of
Wisconsin wil Wisconsin will decrease. The state is to receive the resulting reductions in federal spending as decrease. The state is to receive the resulting reductions in federal spending as
pass-through funding. Wisconsin is to use the pass-through funding to support WIHSP and pass-through funding. Wisconsin is to use the pass-through funding to support WIHSP and
corresponding payments to issuerscorresponding payments to issuers
beginning in CY2019 and continuing through CY2023. .
The approved waiver does not modify the eligibility criteria for premium tax credits for The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Wisconsin.residents of Wisconsin.
CRS-18
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Pending Applications
Idaho
July 15, 2019
Received
Wisconsin's waiver extension did not include any substantial changes to the approved waiver.
CY2019: $127.7 million
CY2020: $142.0 million
CY2021: $229.2 million
CY2022: $181.9 million
CY2023: $213.5 million
CY2024: $195.6 million
CY2025: $223.3 million
|
CY2019-CY2028
|
|
Pending Applications
|
Idaho
|
July 15, 2019
|
Received notification of incomplete application—Aug. 29, 2019
|
Idaho is seeking to waive the requirements that prevent individuals purchasing health Idaho is seeking to waive the requirements that prevent individuals purchasing health
Idaho is not
N.A.
notification of
insurance through an exchange from being eligible to claim premium tax credits and cost insurance through an exchange from being eligible to claim premium tax credits and cost
requesting pass-
incomplete
sharing reductions if they are eligible for other types of qualifying coverage (e.g., Medicaidsharing reductions if they are eligible for other types of qualifying coverage (e.g., Medicaid
).j
through funding.
application—
).q
At the time the application was submitted, Idaho residents with incomes between 100% and At the time the application was submitted, Idaho residents with incomes between 100% and
Aug. 29, 2019
138% of the federal poverty level (FPL)138% of FPL who purchased health insurance through the individual who purchased health insurance through the individual
exchange were eligible for premium tax credits and cost-sharing reductions (assuming other exchange were eligible for premium tax credits and cost-sharing reductions (assuming other
eligibility criteria also were met). However, Idaho was in the process of expanding Medicaid eligibility criteria also were met). However, Idaho was in the process of expanding Medicaid
eligibility to individuals with incomes between 100% and 138% of eligibility to individuals with incomes between 100% and 138% of
the FPL, which was assumed FPL, which was assumed
by Idaho to be effective beginning CY2020. Once the Medicaid expansion went into effect, by Idaho to be effective beginning CY2020. Once the Medicaid expansion went into effect,
those who were newly eligible for Medicaid would no longer be eligible for premium tax those who were newly eligible for Medicaid would no longer be eligible for premium tax
credits and cost-sharing reductions through the exchange. credits and cost-sharing reductions through the exchange.
By waiving the specified provisions, Idaho indicates that individuals with incomes between By waiving the specified provisions, Idaho indicates that individuals with incomes between
100% and 138% of 100% and 138% of
the FPL would be able to choose between subsidized exchange coverage FPL would be able to choose between subsidized exchange coverage
and Medicaid.
Massachusetts Sept. 8, 2017 Received
and Medicaid.
Idaho is not requesting pass-through funding.
|
N.A.
|
Massachusetts
|
Sept. 8, 2017
|
Received notification of incomplete application—Oct. 23, 2017
|
Massachusetts is seeking to create a Premium Stabilization Fund (PSF), which would be used Massachusetts is seeking to create a Premium Stabilization Fund (PSF), which would be used
Massachusetts
N.A.
notification of
to reimburse issuers amounts equal to what would have been provided by cost-sharing to reimburse issuers amounts equal to what would have been provided by cost-sharing
estimated it would
incomplete
reduction payments. At the time the application was submitted, cost-sharing reduction reduction payments. At the time the application was submitted, cost-sharing reduction
receive between
application—
payments were payments were
stil still being made to insurers; however, there was uncertainty as to whether thebeing made to insurers; however, there was uncertainty as to whether the
$143 and $146
Oct. 23, 2017
current administration would continue to make payments moving forward. Massachusetts current administration would continue to make payments moving forward. Massachusetts
mil ion for CY2018.
sought to use the waiver process to avoid the need for a rate revision in the event that cost-sought to use the waiver process to avoid the need for a rate revision in the event that cost-
sharing reduction payments stopped. sharing reduction payments stopped.
Under the proposed waiver, the ACA provision that provides for cost-sharing subsidy Under the proposed waiver, the ACA provision that provides for cost-sharing subsidy
payments to issuers from HHS would be payments to issuers from HHS would be
waived,k waived,r which Massachusetts indicates would which Massachusetts indicates would
al ow
allow the state to substitute these payments with the state to substitute these payments with
al ocationsallocations from the PSF. The expected effect is from the PSF. The expected effect is
that individual market premiums would decrease and federal spending on premium tax credits that individual market premiums would decrease and federal spending on premium tax credits
for residents of Massachusetts also would decrease. The state would receive the resulting for residents of Massachusetts also would decrease. The state would receive the resulting
reductions in federal spending as pass-through funding. reductions in federal spending as pass-through funding.
Under the proposed waiver, Massachusetts would use the pass-through funding for PSF Under the proposed waiver, Massachusetts would use the pass-through funding for PSF
payments to issuers for an initial period of one year, beginning in CY2018, and the state would payments to issuers for an initial period of one year, beginning in CY2018, and the state would
request the opportunity to renew the waiver through CY2022.request the opportunity to renew the waiver through CY2022.
CRS-19
link to page 25 link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Ohio
Mar. 30,
Received
Massachusetts estimated it would receive between $143 and $146 million for CY2018.
N.A.
|
Ohio
|
Mar. 30, 2018
|
Received notification of incomplete application—May 17, 2018
|
Ohio is seeking to waive the requirement that individuals must maintain minimum essential Ohio is seeking to waive the requirement that individuals must maintain minimum essential
Ohio is not
N.A.
2018
notification of
coverage, as established under the ACAcoverage, as established under the ACA
’'s individual mandate s individual mandate
provision.lprovision.s Under the proposed Under the proposed
requesting pass-
incomplete
waiver, the requirement would be waived beginning in waiver, the requirement would be waived beginning in
CY2019.m
through funding.
application—
May 17, 2018
Vermont
Apr. 25,
Received
CY2019.t
Ohio is not requesting pass-through funding.
|
N.A.
|
Vermont
|
Apr. 25, 2016
|
Received notification of incomplete application—June 9, 2016
|
Vermont is seeking an exemption from the requirement that a state must establish a SHOP Vermont is seeking an exemption from the requirement that a state must establish a SHOP
Vermont is not
N.A.
2016
notification of
exchange for smal exchange for small employers.employers.
requesting pass-
incomplete
Under the proposed waiver, Vermont seeks to waive multiple ACA provisions relating to the Under the proposed waiver, Vermont seeks to waive multiple ACA provisions relating to the
through funding.
application—
establishment and operation of a SHOP establishment and operation of a SHOP
exchange.n exchange.u As a result, Vermont indicates that As a result, Vermont indicates that
June 9, 2016
employers in the employers in the
smal small-group market would purchase qualified health plans directly from an -group market would purchase qualified health plans directly from an
issuer.
Withdrawn Applications
California
Dec. 19,
Withdrawn—
California sought to provide undocumented immigrants with the ability to purchase
California did not
N.A.
2016
Jan. 18, 2017
issuer.
Vermont is not requesting pass-through funding.
|
N.A.
|
|
Withdrawn Applications
|
California
|
Dec. 19, 2016
|
Withdrawn—Jan. 18, 2017
|
California sought to provide undocumented immigrants with the ability to purchase unsubsidized insurance through its exchange.unsubsidized insurance through its exchange.
request pass-through
Under this waiver, the ACA provision that prohibits the marketing of nonqualified health plansUnder this waiver, the ACA provision that prohibits the marketing of nonqualified health plans
funding. (QHPs) on the exchanges would have been (QHPs) on the exchanges would have been
waived,o waived,v which California indicates would have which California indicates would have
al owed “allowed "California Qualified Health Plans (CQHP)California Qualified Health Plans (CQHP)
”" to be offered through its exchange. to be offered through its exchange.
CQHPs would have differed from QHPs only in that undocumented individuals could CQHPs would have differed from QHPs only in that undocumented individuals could
purchase CQHPs and purchase CQHPs and
enrol mentenrollment in CQHPs would disqualify individuals from receiving in CQHPs would disqualify individuals from receiving
premium tax credits and cost-sharing subsidies.premium tax credits and cost-sharing subsidies.
CRS-20
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Iowa
Aug. 21,
Withdrawn—
Iowa sought to al ow
California did not request pass-through funding.
|
N.A.
|
Iowa
|
Aug. 21, 2017
|
Withdrawn—Oct. 23, 2017
|
Iowa sought to allow issuers in its individual market to offer one standard health plan, to issuers in its individual market to offer one standard health plan, to
Iowa estimated it
N.A.
2017
Oct. 23, 2017
provide age- and income-based premium tax credits to individuals purchasing the standard provide age- and income-based premium tax credits to individuals purchasing the standard
would have received
plans, and to support a state-based reinsurance program.plans, and to support a state-based reinsurance program.
$422 mil ion for
Under this waiver, Iowa sought to waive the Under this waiver, Iowa sought to waive the
fol owing ACA provisions.p
CY2018.
following ACA provisions.w Iowa applied to waive the provisions establishing premium tax credits and cost-sharing Iowa applied to waive the provisions establishing premium tax credits and cost-sharing
reductions. Iowa indicates that it would have received the resulting reductions in federal reductions. Iowa indicates that it would have received the resulting reductions in federal
spending as pass-through funding and would have spending as pass-through funding and would have
al ocatedallocated this funding to its age- and this funding to its age- and
income-based premium tax credit and its reinsurance program.income-based premium tax credit and its reinsurance program.
Iowa applied to waive the provision that defines the coverage levels based on actuarial Iowa applied to waive the provision that defines the coverage levels based on actuarial
value. Iowa indicates waiving the provision would authorize issuers to offer one standard value. Iowa indicates waiving the provision would authorize issuers to offer one standard
plan to consumers. The standard plan would be similar in actuarial value to a silver-tier plan to consumers. The standard plan would be similar in actuarial value to a silver-tier
plan and would be purchased directly from an issuer.plan and would be purchased directly from an issuer.
Final y
Finally, Iowa applied to waive the provision that provides the Secretary with 180 days to , Iowa applied to waive the provision that provides the Secretary with 180 days to
review al review all state innovation waiver requests. Iowa indicates that waiving the provision state innovation waiver requests. Iowa indicates that waiving the provision
would have would have
al owedallowed for expedited review of its waiver application. for expedited review of its waiver application.
The Iowa waiver would have begun in CY2018 and would have The Iowa waiver would have begun in CY2018 and would have
al owedallowed Iowa to request Iowa to request
renewal of the program for CY2019 if necessary.renewal of the program for CY2019 if necessary.
Oklahoma
Aug. 16,
Withdrawn—
Oklahoma established a state-based reinsurance program, the Oklahoma Individual Health
Oklahoma estimated
N.A.
2017
Sept. 29, 2017
Iowa estimated it would have received $422 million for CY2018.
|
N.A.
|
Oklahoma
|
Aug. 16, 2017
|
Withdrawn—Sept. 29, 2017
|
Oklahoma established a state-based reinsurance program, the Oklahoma Individual Health Insurance Market Stabilization Program (OMSP), though the operation of the program was Insurance Market Stabilization Program (OMSP), though the operation of the program was
it would have
conditional upon receiving federal funds to implement and sustain the OMSP. Had the waiver conditional upon receiving federal funds to implement and sustain the OMSP. Had the waiver
received $309
been approved, the OMSP would have reimbursed issuers been approved, the OMSP would have reimbursed issuers
sel ingselling coverage in the state coverage in the state
’s
mil ion for CY2018
's individual market for a percentage of individual market for a percentage of
enrol ees’enrollees' claims between an attachment point and a cap. claims between an attachment point and a cap.
and $1,395 mil ion
OklahomaOklahoma
’'s withdrawn waiver was similar to other reinsurance-type waivers in that the ACA s withdrawn waiver was similar to other reinsurance-type waivers in that the ACA
over the period
provision requiring issuers to consider provision requiring issuers to consider
al enrol eesall enrollees in individual plans offered by the issuer to in individual plans offered by the issuer to
CY2018-CY2022.
be members of a single risk pool would have been be members of a single risk pool would have been
waived,b waived,c which would have which would have
al owedallowed issuers issuers
to consider OMSP payments when setting market-wide index rates. The expected effect was to consider OMSP payments when setting market-wide index rates. The expected effect was
that individual market premiums would have decreased and federal spending on premium tax that individual market premiums would have decreased and federal spending on premium tax
credits for residents of Oklahoma also would have decreased. The state would have received credits for residents of Oklahoma also would have decreased. The state would have received
the resulting reductions in federal spending as pass-through funding. Under the waiver, the resulting reductions in federal spending as pass-through funding. Under the waiver,
Oklahoma would have used the pass-through funding for OMSP payments to issuers beginning Oklahoma would have used the pass-through funding for OMSP payments to issuers beginning
in CY2018. in CY2018.
Oklahoma estimated it would have received $309 million for CY2018 and $1,395 million over the period CY2018-CY2022.
|
N.A.
|
Source: Various documents available on the CMS website,Various documents available on the CMS website,
“ "Section 1332: State Innovation Waivers,Section 1332: State Innovation Waivers,
” " at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-
Innovation-Waivers/Section_1332_State_Innovation_Waivers-.htmlInnovation-Waivers/Section_1332_State_Innovation_Waivers-.html
, , viewed January 25, 2021.viewed January 25, 2021.
CRS-21
Notes: Estimated pass-through funding describes either the amount of pass-through funding that a state estimates Estimated pass-through funding describes either the amount of pass-through funding that a state estimates
it wil receive it will receive in its waiver application or, when in its waiver application or, when
available, the amount of pass-through funding CMS estimatesavailable, the amount of pass-through funding CMS estimates
it wil it will provide to the state as determinedprovide to the state as determined
annual y annually by the Secretary of the Department of by the Secretary of the Department of
Healt hHealth and Human and Human
Services Services and/or the Secretaryand/or the Secretary
of the Department of the Treasury (as appropriate). For moreof the Department of the Treasury (as appropriate). For more
information on reinsurance,information on reinsurance,
see CRS In Focus IF10707, see CRS In Focus IF10707,
Reinsurance in Health
Insurance..
a.
a. As indicated by CMS. At the timeAt the time
of this reportof this report
’s 's publication, CMS has not communicated the publication, CMS has not communicated the
total amount of pass-through funding for approved waivers in amount of pass-through funding for approved waivers in
CY2021. b. Specifical y, ACA §1312(c)(1). c. CY2026. New York was provided interim pass-through funding of $2 billion for CY2026 with a final CY2026 pass-through funding amount to be determined after the date of publication of this report.
b. For CY2018-CY2019, the Alaska Reinsurance Program (ARP) offset the entire cost of covering enrollees with 1 or more of 33 specified high-cost conditions, with severe COVID-19 cases being added as a condition starting in CY2020.
c. Specifically, ACA §1312(c)(1).
d. Although waivers can be approved for a period of up to five years, the Although waivers can be approved for a period of up to five years, the
initial Colorado application requested, and was approved for,Colorado application requested, and was approved for,
an effective periodan effective period
from CY2020 through CY2021.
e. Colorado Division of Insurance, Colorado Section 1332 Innovation Waiver Amendment Request Colorado Option, November 20, 2021, https://drive.google.com/file/d/1SUy-iNz3i7IIRTPTqy2OJgNYH1oyN5mX/view.
f. Specifically, ACA §1312(c)(1) and (c)(2).
g. Specifically, from CY2020
through CY2021.
d. Specifical y, ACA §1311(b), (c), (d), (e), and (i) onlyACA §1311(b), (c), (d), (e), and (i) only
to the extent that it is inconsistent with the Georgiato the extent that it is inconsistent with the Georgia
Access Model.Access Model.
e. Specifical y, the fol owing ACA §§:
h. Specifically, the following ACA §§: 1301(a)(1)(C)(1301(a)(1)(C)(
i ii); 1301(a)(2); 1304(b)(4)(D)(i) and (); 1301(a)(2); 1304(b)(4)(D)(i) and (
i ii); 1311(b)(1)(B); 1312(a)(2); 1312(f)(2)(A); and 1321(c)(1). ); 1311(b)(1)(B); 1312(a)(2); 1312(f)(2)(A); and 1321(c)(1).
f.
i. The final amounts of pass-through funding received by The final amounts of pass-through funding received by
Hawai Hawaii account for budget sequestration.
j. Specifically, ACA §1312(c)(1), (2), and (3).
k. Specifically, ACA §1312(c)(3).
l. Specifically, ACA §1312(f)(3).
m. Maryland's waiver amendment was initially approved with an effective date of January 1, 2026, but the effective date of the waiver amendment was subsequently postponed until January 1, 2028. Maryland indicated that it may be able to implement the waiver amendment earlier than 2028 if time and resources allow.
n. In addition to what is described in the table about Minnesota's approved waiver, Minnesota's waiver application and waiver extension application also requested that the state receive, in pass-account for budget sequestration. The final amount of pass-through funding to be received by Hawai in 2021 is subject to a final administrative determination by the Department of the Treasury.
g. The final amount of pass-through funding to be received by Hawai in 2021 is subject to a final administrative determination by the Department of the Treasury. h. Although Maryland’s waiver application anticipated having enough funds to operate the Maryland State Reinsurance Program from CY2019 through CY2021, the
application requested, and was approved for, an effective period from CY2019 through CY2023.
i.
In addition to what is described in the table about Minnesota’s approved waiver, Minnesota’s waiver application also requested that the state receive, in pass-through funding, the amount that the federal government would save in payments to Minnesotathrough funding, the amount that the federal government would save in payments to Minnesota
’'s Basic Health Program s Basic Health Program
because of premium (BHP) because of premium reductions due to reductions due to
MSPS. This request was not granted under the approved waiverMSPS. This request was not granted under the approved waiver
. For details, see Letter from Mark Dayton, Governor of Minnesota, et al. and waiver extension due to pass-through funding being limited to savings based on "premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible." (42 U.S.C. §18052(a)(3)). Subsequent BHP rulemaking addressed this issue by incorporating the effects of an approved Section 1332 waiver into the BHP payment methodology to counteract BHP funding reductions resulting from an approved Section 1332 waiver. For details, see Letter from Mark Dayton, Governor of Minnesota to Thomas Price, to Thomas Price,
Secretary of the U.S.Secretary of the U.S.
Department of Health and Human Services,Department of Health and Human Services,
September September 19, 2017, http://mn.gov/gov-stat/pdf/19, 2017, http://mn.gov/gov-stat/pdf/
2017_09_19_Governor_Dayton_Letter_to_Secretary_Price_1332_Waiver.pdf2017_09_19_Governor_Dayton_Letter_to_Secretary_Price_1332_Waiver.pdf
, , and Letter from Mark Dayton, Governorand Letter from Mark Dayton, Governor
of Minnesota,of Minnesota,
to Seema Verma, to Seema Verma,
Administrator Administrator of the Centers for Medicare & Medicaid Services,of the Centers for Medicare & Medicaid Services,
October 16, 2017, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/October 16, 2017, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/
Downloads/Approval-Letter-MN.pdfDownloads/Approval-Letter-MN.pdf
.
j.
Idaho applied to waive ACA §1402 and 26 U.S.C. §36B(c)(2)(B), the latter of which was added to the Internal Revenue Code by ACA §1401.
k. Massachusetts applied to waive ACA §1402(c)(3)(A). l.
Ohio applied to waive 26 U.S.C. §5000A(a), which was added to the Internal Revenue Code by ACA §1501.
m. Ohio’s House Bil 49 requires Ohio’s department of insurance to submit a 1332 waiver application that includes a request to waive the ACA’s , Letter from Grace Arnold, Minnesota Department of Commerce Commissioner (Temporary), and Jodi Harpstead, Minnesota Department of Human Services Commissioner, to Elizabeth Richter, Centers for Medicare and Medicaid Services Acting Administrator, February 5, 2021, https://www.cms.gov/cciio/programs-and-initiatives/state-innovation-waivers/downloads/1332-mn-bhp-request-response-letter.pdf, and Centers for Medicare & Medicaid Services, "Basic Health Program; Federal Funding Methodology for Program Year 2023 and Changes to the Basic Health Program Payment Notice Process," 87 Federal Register 77722, December 20, 2022.
o. New York's pass-through funding is made available to the state in two portions, with the interim funding representing the first portion.
p. Cascade Care Plans have a standard benefit design, and include Cascade Plans and Cascade Select Plans. Cascade Select Plans are Washington's public option plans and satisfy additional requirements. American Indian and Alaska Natives do not need to purchase Cascade Care silver or gold plans for premium subsidy eligibility purposes and instead may purchase any qualified health plan.
q. Idaho applied to waive ACA §1402 and 26 U.S.C. §36B(c)(2)(B), the latter of which was added to the Internal Revenue Code by ACA §1401.
r. Massachusetts applied to waive ACA §1402(c)(3)(A).
s. Ohio applied to waive 26 U.S.C. §5000A(a), which was added to the Internal Revenue Code by ACA §1501.
t. Ohio's House Bill 49 requires Ohio's department of insurance to submit a 1332 waiver application that includes a request to waive the ACA's individual and employer individual and
employer mandates. In its waiver application, Ohio acknowledgesmandates. In its waiver application, Ohio acknowledges
that the 2017 tax revisionthat the 2017 tax revision
( (P.L. 115-97) effectively eliminatesP.L. 115-97) effectively eliminates
the penalty associated with the the penalty associated with the
individual mandate beginning in CY2019 but points out that the law does not eliminateindividual mandate beginning in CY2019 but points out that the law does not eliminate
the individual mandate. As such, Ohiothe individual mandate. As such, Ohio
’s 's 1332 waiver application requests to 1332 waiver application requests to
waive the individual mandate (however, the application does not include a request to waive the employerwaive the individual mandate (however, the application does not include a request to waive the employer
mandate).mandate).
n.
u. Vermont applied to waive the Vermont applied to waive the
fol owingfollowing ACA §§: ACA §§:
1311(b)(1)(B); 1311(c)(3); 1311(c)(4); 1311(c)(5); 1311(d)(1); 1311(d)(2); 1311(d)(4)(A); 1311(d)(4)(B); 1311(b)(1)(B); 1311(c)(3); 1311(c)(4); 1311(c)(5); 1311(d)(1); 1311(d)(2); 1311(d)(4)(A); 1311(d)(4)(B);
1311(d)(4)(C); 1311(d)(4)(D); 1311(d)(4)(E); 1311(d)(4)(G); 1311(k); 1312(a)(2); 1312(f)(2)(A)1311(d)(4)(C); 1311(d)(4)(D); 1311(d)(4)(E); 1311(d)(4)(G); 1311(k); 1312(a)(2); 1312(f)(2)(A)
. .
o. v. California applied to waive ACA §1311(d)(2)(B)(i). California applied to waive ACA §1311(d)(2)(B)(i).
p.
w. Iowa applied to waive ACA §§1402; 1401(a); 1302(d); and 1332(d).Iowa applied to waive ACA §§1402; 1401(a); 1302(d); and 1332(d).
CRS-22
State Innovation Waivers: Frequently Asked Questions
Author Information
Ryan J. Rosso
Analyst in Health Care Financing
Acknowledgments
Earlier versions of this report were authored by Annie Mach, former CRS Specialist in Health Care Financing.
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material.
Congressional Research Service
R44760 · VERSION 20 · UPDATED
23
Earlier versions of this report were authored by Annie Mach, former CRS Specialist in Health Care Financing.
Footnotes
| 1.
|
42 U.S.C. §18052(a)(2).
|
| 2.
|
A qualified health plan (QHP) is a plan that meets certain requirements and is certified to be sold through a health insurance exchange (in the non-group or small-group market). Although QHPs are certified to be sold through exchanges, they also can be sold in the non-group or small-group market outside of exchanges. For more information, see CRS Report R44065, Health Insurance Exchanges and Qualified Health Plans: Overview and Policy Updates.
|
| 3.
|
For more information about the current status of the cost-sharing reductions, see archived CRS Insight IN10786, Payments for Affordable Care Act (ACA) Cost-Sharing Reductions.
|
| 4.
|
For more information about the employer mandate, see CRS Report R45455, The Affordable Care Act's (ACA's) Employer Shared Responsibility Provisions (ESRP).
|
| 5.
|
For more information about the individual mandate, see CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief. The 2017 tax revision, P.L. 115-97, effectively eliminated the individual mandate penalty beginning in 2019. However, the 2017 tax revision did not make any other substantive changes to the statutory language establishing the mandate and its associated penalty.
|
| 6.
|
Note that essential health benefit (EHB) and related cost-sharing and actuarial value requirements apply to all non-grandfathered plans in the individual and small group markets, including QHPs. For more information about the essential health benefits package, see CRS Report R44163, The Patient Protection and Affordable Care Act's Essential Health Benefits (EHB).
|
| 7.
|
42 U.S.C. §18052(a)(6).
|
| 8.
|
42 U.S.C. §18052(b)(1) and 45 C.F.R. §155.1308(f)(3)(iv).
|
| 9.
|
Department of the Treasury and Department of Health and Human Services (HHS), "Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond," 86 Federal Register 53412, September 21, 2021. Hereinafter, Section 1332 2021 Rule.
|
| 10.
|
Section 1332 2021 Rule.
|
| 11.
|
Section 1332 2021 Rule.
|
| 12.
|
For more information about exchange types, see CRS Report R44065, Health Insurance Exchanges and Qualified Health Plans: Overview and Policy Updates.
|
| 13.
|
Department of the Treasury, HHS, "Waivers for State Innovation," 80 Federal Register 78131, December 16, 2015. Department of the Treasury, HHS, "State Relief and Empowerment Waivers," 83 Federal Register 53575, October 24, 2018.
|
| 14.
|
Specifically, the Centers for Medicare & Medicaid Services (CMS) services covered under the Intergovernmental Cooperation Act (ICA) are not considered for deficit neutrality purposes.
|
| 15.
|
Section 1332 2021 Rule.
|
| 16.
|
Section 1332 2021 Rule.
|
| 17.
|
States are responsible for funding all changes to IRS administrative processes associated with waiver implementation. These costs are incorporated into the assessment of whether a waiver application satisfies the deficit neutrality requirement.
|
| 18.
|
For more information about how household income is calculated to determine premium tax credit eligibility, see CRS Report R43861, The Use of Modified Adjusted Gross Income (MAGI) in Federal Health Programs.
|
19.
|
For a description of New York's waiver, see Table 2.
| 20.
|
42 U.S.C. §18052(b)(2).
|
| 21.
|
45 C.F.R. §155.1308(f)(3)(i).
|
| 22.
|
The Secretaries of HHS and Treasury may modify state and federal public notice and comment requirements during unforeseen and urgent situations (e.g., natural disasters, public health emergencies) where a delay would threaten access to health insurance, access to health care, or human life. 45 C.F.R. §155.1318.
|
| 23.
|
45 C.F.R. §155.1308(f).
|
| 24.
|
See footnote 22.
|
| 25.
|
42 U.S.C. §18052(d)(1) and 45 C.F.R. §155.1316(c).
|
| 26.
|
42 U.S.C. §18052(a)(3).
|
| 27.
|
42 U.S.C. §18052(a)(3).
|
| 28.
|
42 U.S.C. §18052(e). Section 1332 2021 Rule, 86 Federal Register 53412, September 21, 2021, pp. 53486-53488.
|
| 29.
|
This includes situations where a state was seeking changes that were not allowed under the terms and conditions that the state agreed to with the Departments when the waiver was approved, and situations where a waiver would affect any of the waiver requirements related to coverage, affordability, comprehensiveness, and federal-deficit neutrality. 45 C.F.R. §155.1330. Section 1332 2021 Rule.
|
| 30.
|
42 U.S.C. §18052(a)(5).
|
| 31.
|
45 C.F.R. §155.1302(a).
|
| 32.
|
For information about each state's application, see CMS, Center for Consumer Information and Insurance Oversight (CCIIO), "Section 1332: State Innovation Waivers," at https://www.cms.gov/marketplace/states/section-1332-state-innovation-waivers.
|
| 33.
|
New York State Department of Health, Submission to the Centers for Medicare and Medicaid Services (CMS): New York State's Request to Terminate the Section 1332 State Innovation Waiver and Return to the Basic Health Program, October 20, 2025, https://info.nystateofhealth.ny.gov/sites/default/files/1332%20Termination%20Notice%2010-20-25.pdf.
|
34.
|
Waivers with reinsurance programs may also have other features, as described in Table 2. CMS has issued data briefs that compare various aspects of the state-based reinsurance programs implemented through the Section 1332 waiver process. See CMS, CCIIO, Data Brief on State Innovation Waivers: Section 1332 Waivers, April 2024, https://www.cms.gov/files/document/cciio-data-brief-042024-508-final.pdf. For more information on reinsurance, see CRS In Focus IF10707, Reinsurance in Health Insurance.
| 35.
|
Letter from Dean L. Cameron, Idaho Department of Insurance Director, to Robert F. Kennedy Jr., Secretary of Health and Human Services, and Scott Bessent, Secretary of the Treasury, October 1, 2025, https://www.cms.gov/cciio/programs-and-initiatives/state-innovation-waivers/downloads/1332-id-loi-amendment-and-response-letter.pdf.
|
| 36.
|
To read the withdrawal letters, see CMS, CCIIO, "Section 1332: State Innovation Waivers," at https://www.cms.gov/marketplace/states/section-1332-state-innovation-waivers.
|