Medicaid 1115 Waivers: Compliance, Modernization & RHTP Alignment
By Engineering Solutions, Inc.
At a Glance
- 1115 waivers allow Medicaid demonstration projects outside standard rules.
- States use waivers to test delivery reform, VBC, SUD services, and rural innovation.
- CMS requires budget neutrality and rigorous evaluation.
- ESI ties waiver design to FHIR modernization and RHTP compliance.
Why 1115 Waivers Matter for RHTP
Section 1115 waivers give states flexibility to transform Medicaid, but every approval hinges on alignment with CMS objectives. For rural health, waivers are a critical lever to sustain RHTP activities beyond the initial funding window. By embedding waiver authority into RHTP strategies, states can extend innovations and secure long-term reimbursement streams.
Common Waiver Priorities
- Delivery & Payment Reform: Integrate physical, behavioral, and social services.
- Value-Based Care: Launch shared savings, global budgets, or APM pilots.
- SUD & Behavioral Health: Expand treatment access, especially in rural areas.
- Coverage Experiments: Extend eligibility, maternal health, or continuous coverage.
ESI’s Compliance & Modernization Framework
Engineering Solutions, Inc. ensures waiver submissions meet CMS’s strict compliance and budget neutrality tests. Our framework ties policy goals to technical infrastructure:
- FHIR-based APIs for patient access, payer-to-payer, and prior authorization.
- MES modular upgrades aligned with MITA standards.
- Equity dashboards using FHIR bulk data for rural, tribal, and maternal health.
- ROI models linking waiver innovations to budget neutrality (e.g., ER diversion savings).
Lessons Learned
CMS evaluations show mixed results when states neglect compliance or data strategy. Successful waivers pair clear policy design with early data pipelines, independent evaluation, and credible baselines. ESI brings experience from Oregon’s $350M Medicaid modernization to ensure states avoid pitfalls and win approvals.
Aligning Waivers with RHTP
States preparing RHTP plans should assess how 1115 waivers can serve as long-term anchors. By pairing waiver authority with RHTP-funded pilots—such as FHIR data hubs, rural workforce programs, and solvency pilots—states create a bridge from short-term funding to durable transformation.
Next Steps
States should launch waiver concept development alongside RHTP planning, ensuring policy design, technical architecture, and evaluation are ready for CMS review. ESI stands ready to guide both tracks.
