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financing, eligibility, and benefits) through the use of Section 1115 demonstration waivers. The Trump administration has aimed to reshape the Medicaid program (e.g. The Trump administration’s Section 1115 waiver policy has emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing. Although each administration has some discretion over which waivers to approve and encourage, that discretion is not unlimited. Under different administrations in the past, waivers have been used to expand coverage, modify delivery systems, and restructure financing and other program elements. Beginning in the 1990s, there was an increase in waiver activity, and waivers became broader in scope. Section 1115 waivers generally reflect priorities identified by the states and the federal Centers for Medicare and Medicaid Services (CMS), as well as changing priorities from one presidential administration to another. In March 2020, the Trump administration released guidance for states to obtain emergency COVID-19 waivers in response to the pandemic. States can also use waivers to respond to emergencies.
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Section 1115 waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute and can provide states considerable flexibility in how they operate their programs. As the Trump administration reaches the end of its first term, this issue brief considers the landscape of approved and pending Section 1115 Medicaid demonstration waivers under this administration and how the November 2020 presidential election may impact this landscape.