This report summarizes SHADAC's analysis of how four states implemented Section 1115 Medicaid expansion wiavers. These states--Arkansas, Indiana, Iowa, and Michigan--are among eight that have expanded their Medicaid programs through Section 1115 of the Social Security Act rather than through the expansion option available under the Affordable Care Act (ACA).

SHADAC's analysis was commissioned by the Medicaid and CHIP Payment and Access Commission (MACPAC) and sought to understan how Arkansas, Indiana, Iowa, and Michigan approached the implementation of key provisions of their Section 1115 Medicaid expansion waivers:

• Exchange plan premium assistance (Arkansas & Iowa)
• Enrollee contribution requirements (Iowa & Michigan)
• Health savings accounts (Arkansas & Indiana)
• Healthy behavior incentives (Indiana, Iowa, & Michigan)
• Graduated copayments for emergency department use (Indiana)

SHADAC researchers conducted interviews with 33 individuals representing current and former state agency staff and health insurance carriers in the four study states to identify the steps that states took to operationalize their programs. The report provides background information on the waiver program elements implemented in each of the four study states, summarizes the key pieces of administrative capacity that states put into place to implement their waivers, and details the specific program challenges they faced.

Access the report.