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CMS Increases Monitoring and Evaluation Requirements for Section 1115(a) Medicaid Demonstrations

This week, our In Focus reviews the implications of the new federal guidance for state waivers with community engagement, premiums, non-eligibility periods, and other personal responsibility provisions.


On March 14, 2019, the Centers for Medicare & Medicaid Services (CMS) issued several new guidance documents that significantly increase the level of monitoring and evaluation required for Section 1115(a) Medicaid Demonstrations. These new requirements apply to community engagement, premiums, and other waiver provisions that impact eligibility and enrollment, and affect states currently with such waivers as well as any states proposing these ideas.  Changes in reporting, data collection, and waiver monitoring processes will be necessary, and soon—as the materials details compliance dates for these significant new requirements.

These guidance materials fall into five broad categories:

  1. Implementation Plan Template: A 27-page document issued for states to describe their approach for implementing community engagement policies.
  2. Monitoring Report Template: A 28-page outline for quarterly and annual monitoring reports that are required by Section 1115(a) Medicaid Demonstration Special Terms and Conditions (STCs).
  3. Monitoring Metrics: An extensive list of quantitative metrics on which states will be required to report to CMS monthly, as well as within the aforementioned quarterly and annual monitoring reports. The metrics are divided into six separate modules:
    • Module 1 (45 metrics): “Overview of eligibility and coverage metrics standard across any demonstration with premiums, Marketplace-focused premium assistance, health behavior incentives, community engagement, or retroactive eligibility waiver policies”
    • Module 2 (21 metrics): “Additional metrics relevant for states that require premiums or other monthly payments”
    • Module 3 (3 metrics): “Additional metrics relevant for states with Marketplace-focused premium assistance programs”
    • Module 4 (7 metrics): “Additional metrics relevant for states with programs that incentivize particular health behaviors”
    • Module 5 (46 metrics): “Metrics relevant for states with community engagement requirements”
    • Module 6 (3 metrics): “Monitoring metrics for states with retroactive eligibility waivers”
  1. Evaluation Design Master Narrative: A blueprint for states to use in submitting their Evaluation Design to CMS. This document includes the preferred methodologies, target and comparison groups, and analytic approaches.
  2. Evaluation Design Appendices: In addition to the Evaluation Design Master Narrative, CMS has issued five separate appendices which outline the recommended approaches for assessing the impact of the following five Demonstration policies:
    1. Community Engagement
    2. Non-eligibility Periods
    3. Premium/Account Payments
    4. Retroactive Coverage
    5. Demonstration Sustainability

Implications for States

The release of these guidance documents is likely to have significant implications for states’ evaluation and monitoring activities, and in some instances, may require a significant investment of resources. This new requirement applies to states currently operating these waivers as well as all upcoming waiver applicants. The communications from CMS suggest that adherence to the letter of the guidance is compulsory rather than optional. For example, CMS indicated that states with approved Section 1115(a) Medicaid Demonstrations that contain one or more of the provisions covered by the guidance documents will be required to submit both an Implementation Plan Template and Monitoring Report Template at a date to be determined in consultation with CMS, while future Demonstrations will have the due dates for these documents outlined within the STCs (as demonstrated by Ohio’s Demonstration).[1] Therefore, states with current personal responsibility waivers should begin preparing to submit both documents, while states that are considering personal responsibility waivers (or that have waivers pending with CMS) should be prepared to submit these documents during the first several months after waiver approval. Additionally, CMS has indicated that states without approved Evaluation Designs will be expected to adhere to the Evaluation Design Master Narrative and the associated Evaluation Design Appendices in their evaluation plan submissions.

System changes may also be required to comply with these new requirements. This may require significant operational changes and/or capacity enhancements to ensure compliance. For example, in order to track and report on the 125 metrics contained in the Monitoring Report Template, states may need to increase capacity to handle this process internally, delegate the responsibility to the STC-required independent third-party evaluator, or some combination of both of these. Similarly, states may need to adopt system changes to capture information which may have not been monitored previously, such as the number of beneficiaries who lost Medicaid and transitioned to a qualified health plan offered in the Marketplace. Although states may have reported this type information during annual or summative evaluation reports previously, the current guidance calls for each of these metrics—and over 100 others—to be measured monthly, and reported at a level of granularity and specificity outside of current experience.

Next Steps

This recent guidance from CMS fundamentally changes the monitoring and evaluation requirements for Section 1115(a) Medicaid Demonstrations. States will need to increase the level of effort and rigor within their evaluation plans and will also need to incorporate ongoing standardized monitoring of a large number of metrics related to their demonstrations.

HMA’s Medicaid Market Solutions division has conducted an extensive review of each of the guidance documents and is prepared to assist states and stakeholders in navigating the new requirements.


[1] Within the STCs for Ohio’s Group VIII Work Requirement and Community Engagement Section 1115 Demonstration, it states, “The state must submit a Community Engagement Implementation Plan to CMS no later than 90 calendar days after approval of the demonstration” (page 33), and “The state must submit to CMS a Monitoring Protocol no later than 150 calendar days after approval of the demonstration.”