Table 5.A Overview of Authorities
Note: Links to relevant federal laws and regulations are available in the Resource Library in the menu above.
Authorities for Managed Care |
Authority | Description | Limitations |
| Section 1115 | Gives Secretary of HHS broad authority to approve demonstration programs that test innovative Medicaid policy. | Proposal must be truly innovative, not simply replicating an idea already demonstrated elsewhere. |
| Section 1915(a) | Statutory authority to enter into contracts with organizations to provide services already offered under the state plan. | Voluntary enrollment only; Existing services only; |
| Section 1915(b) | Waiver authority for mandatory enrollment in managed care. | With exceptions for rural areas, must offer at least 2 options. |
| Section 1932(a) | Statutory authority for mandatory enrollment in managed care. | Certain groups are exempted from mandatory enrollment; |
Authorities for Long Term Services and Supports |
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| Section 1915(c) | Waiver authority to offer HCBS services to beneficiaries who would otherwise meet institutional level of care. | Beneficiary must meet institutional level of care. |
| Section 1915(i) | Statutory authority to offer HCBS as a state plan service, whether or not a beneficiary meets institutional level of care. | State may not limit the number of eligible participants or have a waiting list. Service must be offered statewide. |
| Section 1915(j) | Statutory authority to offer self-directed personal assistance services option in a 1915(c) waiver program, or under state plan personal assistance services. | Not a service authorization per se, but rather a delivery option for services otherwise provided under the state plan. |
| Section 1915(k) | Statutory authority to offer attendant services and supports controlled by the beneficiary (Community First Choice Option). | State may not limit the number of eligible participants or have a waiting list. Service must be offered statewide. |
| Other State Plan | States must offer certain services (such as nursing home and home health) and may offer optional services (such as personal care and targeted case management). | State plan services must be offered to all eligible beneficiaries without waiting lists. Services must be offered statewide. |
Authorities for Medicare |
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| Section 1859 | Statutory authority for Medicare Advantage plans to create specialty plans targeted to special needs individuals, including Medicare-Medicaid beneficiaries. | Voluntary enrollment only; authority applies to Medicare Advantage plans (not to the State Medicaid agency); all Medicare Advantage rules must be met. |
| Sections 1894 and 1934 | Statutory authority to offer PACE, which combines Medicare and Medicaid services. | Voluntary enrollment only; PACE model only. |
| Section 402/222 | Statutory authority allows for experiments and demonstrations to test alternative methods of paying for Medicare services. | Limited to Medicare payment methods. |
| Section 1115A | Gives Center for Medicare and Medicaid Innovation broad authority to test innovative models that decrease costs and maintain or improve quality. | Proposed model must be innovative and fit within the statutory priorities of CMMI. |
(Click here for a pdf version of Table 5.A)
