DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland  21244-1850 
CMCS Informational Bulletin 
DATE:  August 16, 2018 
FROM:  Timothy B. Hill 
Acting Director  
SUBJECT:   Update on State Plan Amendment and Section 1915 Waiver Process 
Improvements 
On March 14th, 2017, the Department of Health and Human Services (HHS) and Centers for 
Medicare & Medicaid Services (CMS) issued a letter to Governors highlighting key areas for 
improved collaboration with states and more effective Medicaid program management.  In the 
letter, CMS committed to engaging with states to make state plan amendment (SPA) and waiver 
reviews and approvals more transparent, efficient, and less burdensome.  CMS is committed to 
fulfilling our statutory obligations to review SPA and section 1915(b) and 1915(c) waiver 
submissions for consistency with the requirements of the Social Security Act and any applicable 
agency regulations as efficiently as possible.  This is the second Informational Bulletin CMS has 
issued related to SPA and 1915 waiver process improvements.  This Bulletin provides an update 
on CMS collaboration with states since release of the first Bulletin, outlines the initial strategies 
CMS adopted to implement more efficient SPA and 1915 waiver review and adjudication 
processes, and highlights additional long term process improvements CMS has implemented.  
CMS is also announcing new procedures, effective October 1, 2018, to prevent formation of a 
backlog of pending amendments in instances where CMS has not received a state response to a 
formal request for additional information within 90 days of issuance.  This issue is addressed on 
page five of this Bulletin.  CMS addressed changes to Section 1115 demonstration review and 
approvals in separate guidance. 
Progress on SPA and 1915 Waiver Processing Times 
A key goal of this initiative was to develop a process improvement strategy that enhanced the 
efficiency of the SPA and 1915 waiver review process, reducing the administrative burden for 
states and, ultimately, reducing processing times.  We collaborated closely with states and the 
National Association of Medicaid Directors (NAMD) to identify the issues that impact SPA and 
1915 waiver processing and jointly developed a number of process improvement strategies, the 
first of which was implemented in the fourth quarter of 2017.  The concerted effort by both states 
and CMS on process improvement and the implementation of the new strategies are beginning to 
result in more efficient and timely processing of SPA and 1915 waiver actions:  
 Between calendar year 2017 and the first quarter of 2018, there was a 24 percent decrease
in the median approval time for Medicaid SPAs.
 Eighty-four percent of Medicaid SPAs were approved within the first 90 day review
period in the first quarter of 2018, a 21 percent increase over calendar year 2017. CMCS Informational Bulletin  Page 2 
 
  Between calendar year 2017 and the first quarter of 2018, median approval times for 
1915(b) waivers decreased by 7 percent, 1915(c) renewal approval times decreased by 54 
percent, and 1915(c) amendment approval times decreased by 48 percent.  
 
Additional information on processing times is contained in Appendix 1.  
 
Developing and Implementing a Process Improvement Strategy 
 
In order to develop a process improvement strategy that would have an impact and achieve 
measurable improvements in SPA and 1915 waiver processing times, CMS undertook a number 
of activities to better understand current processes, identify issues, and develop improvement 
strategies.  Staff examined available SPA and 1915 waiver processing data for 2016 and 2017 
and conducted an analysis of a sample of SPAs and waivers to better understand the factors 
impacting processing time.  CMS also conducted an intensive review of the current SPA and 
1915 waiver standard operating procedures to identify areas for increased consistency and 
enhanced efficiency. 
 
Soliciting state input was also essential to this process.  State feedback was received through a 
variety of mechanisms to ensure that any process improvement activities were comprehensive 
and responsive to state needs.  To facilitate collaboration, a federal-state workgroup was formed 
with representatives from more than a dozen states.  In-person working sessions were held at the 
National Association of Medicaid Directors conferences in June and November of 2017, and the 
group met monthly through March of 2018 to ensure that states were able to respond to proposals 
developed by CMS and offer additional approaches and ideas.  CMS also worked with 
representatives from states and several National Associations to hold similar conversations 
specific to enhancing the efficiency of the section 1915(c) waiver process. 
  
On November 6th, 2017, CMS released an Informational Bulletin outlining the initial actions 
taken to bring efficiency and consistency to the SPA and 1915 waiver review processes.  The 
Bulletin highlighted four process improvements: 1) implementation of a call with states within 
15 days of receipt of each new SPA or 1915 waiver submission to review the states intent for 
the submission and any critical timelines to help expedite the review process; 2) launch of a SPA 
and 1915 Waiver Processing page on Medicaid.gov with a compilation of tools available to 
states to facilitate the development of complete SPA and 1915 waiver submissions; 3) 
implementation of a strategy to reduce a significant backlog of SPAs and 1915 waivers that are 
pending due to a formal Request for Additional Information (RAI) from CMS to the state to 
which the state has not responded; and 4) expansion of the use of MACPro, a web-based system 
for SPA processing, to include Medicaid Modified Adjusted Gross Income (MAGI)-based 
eligibility and administration SPAs.  The expansion included state plan provisions related to 
MAGI-based eligibility, enrollment processes (application and renewal), single state agency, 
citizenship/immigration, and presumptive eligibility. 
 
The initial process improvement strategies implemented by CMS have been well received  for 
example, anecdotal evidence from states and CMS staff indicates that the 15 day call is having 
the intended effect and enhancing the efficiency of the review process by reducing the need for 
CMS to issue informal sets of questions to states related to SPA and 1915 waiver actions.  
Together, the combined focus on SPA and 1915 waiver processing and implementation of these  CMCS Informational Bulletin  Page 3 
 
strategies is beginning to prove successful, with a 14 percent decrease in overall processing time 
in the first quarter after implementation of improvement strategies and a 20 percent increase in 
SPAs approved on the first clock over the baseline period. 
  
Long-Term Process Improvements 
 
To further our improvement efforts, CMS engaged in a longer term effort to review current 
business processes and identify areas for streamlining.  This Bulletin highlights two long-term 
process improvements CMS is adopting as a result of these business process reviews.  In 
addition, CMS continues to expedite and leverage the MACPro systems build, which will further 
streamline SPA reviews and provide a more collaborative, consistent and transparent review 
process for states. 
  
Updates to the CMS SPA and 1915 Waiver Processing Standard Operating Procedures: 
  
As previously discussed, in October of 2017, CMS implemented a permanent change to CMS 
Standard Operating Procedures (SOP) for SPA and 1915 waiver reviews with the 
implementation of a CMS-state call within 15 days of a SPA or 1915 waiver submission.  The 
purpose of this discussion is to expedite the SPA or 1915 waiver review by allowing states to 
explain the intent of the submission and allow CMS to communicate any incomplete information 
or identify any initial known policy issues. 
 
CMS has continued to develop and implement additional changes to the SPA and 1915 waiver 
review SOP.  On June 1, 2018, CMS established a new triaging protocol that will determine the 
path that SPAs and 1915 waivers will follow from submission to adjudication.  The protocol 
includes three potential paths that a SPA or 1915 waiver can follow  expedited, escalation, and 
standard review paths.  A process flow depicting the three pathways is included in Appendix 3. 
 
Expedited Review Path:  
CMS is piloting a new expedited review path whereby a cohort of SPAs and 1915 waivers will 
be adjudicated through a streamlined review process.  These SPAs and 1915 waiver actions will 
be processed independently by CMS Regional Offices with the goal of adjudicating the SPAs 
and waivers significantly faster than the standard review path.  Upon receipt, CMS will quickly 
assess whether new SPA and 1915 waiver submissions meet the criteria for expedited review or 
one of the other paths.  To be eligible for expedited review, a SPA or 1915 waiver action must 1) 
be one of the SPA or waiver types identified in Appendix 2; and 2) be deemed complete, with all 
necessary information to process the action provided, including acceptable Upper Payment 
Limits, cost reports and funding questions, completed 179 forms, public notice information, and 
tribal consultation documentation, as applicable.  These SPAs and waivers should have all 
information readily available at the time of the review and are technical changes that require 
minimal interaction between the state and CMS.  At any given time during the review process, if 
CMS or the state discover unexpected issues or that the information provided is incomplete, 
approval of the SPA or waiver may be delayed.  As CMS assesses the effectiveness of the 
streamlined review process during the pilot period, the criteria for expedited reviews may be 
updated and the actions eligible for expedited review in Appendix 2 may be modified. 
    CMCS Informational Bulletin  Page 4 
 
Escalation Review Path:  
This new review path identifies an escalation strategy for SPAs and 1915 waivers that have legal 
or policy issues or may be at risk for disapproval.  The escalation path will engage CMS and 
state leadership during the first 90 day review period to collaborate and ideally resolve major 
issues quickly.  Today, leadership involvement often does not occur until the second 90 day 
review period.  The goal of earlier leadership engagement on challenging SPAs and 1915 
waivers is to minimize the need for formal Requests for Additional Information, which 
frequently result in these actions spending prolonged periods of time in pending status, and 
disapprovals.  We anticipate that these changes will result in faster processing times, increase the 
frequency of resolution during the first 90 day review period, and reduce administrative burden 
for both states and CMS. 
  
Following the 15 day call, CMS staff will assess all SPA and 1915 actions for major policy 
issues that pose a high likelihood of disapproval, and the escalation pathway will initially be 
limited to these actions.  This will allow CMS leadership to engage state leadership early, with 
the goal of preventing disapproval of the action.  If, at any point later in the review process, a 
SPA or 1915 waiver action is determined to meet the criteria below, it will be elevated to the 
escalation review path and CMS leadership will engage with the state.  An action could be 
escalated if (1) a significant policy issue arises that could result in a disapproval, (2) there is a 
lack of agreement on a policy between the state and CMS that cannot be resolved at the staff 
level, or (3) the state does not provide timely responses to informal RAI questions or other 
requested information needed to adjudicate the action.  For example, if CMS and state staff are 
collaborating to complete a technical change and CMS staff receive new information indicating 
that the SPA or 1915 waiver has a significant policy issue that has a high likelihood of 
disapproval, this action would be escalated to leadership. 
  
Standard Review Path:  
Any SPA or 1915 waiver that is not identified as being eligible for the expedited or escalation 
paths will follow the current standard/routine SPA and 1915 waiver review process.  The 
majority of SPAs and waivers will continue to be on the standard review path with the goal of 
adjudication within the first 90 days.  
 
Reduction of the Pending SPA and 1915 Waiver Backlog: 
  
A key driver of processing time is the length of time SPAs and waivers spend on hold, awaiting a 
response to a formal RAI issued from CMS to the state.  In July 2017, there was a backlog of 365 
SPAs and 1915 waivers pending on RAI, often for extended periods of time.  This can delay both 
the approval of new SPA submissions that modify the same pages and a states ability to draw 
down funds, as states are unable to claim federal financial participation (FFP) for pending SPAs. 
  
In the fall of 2017, CMS implemented a strategy to reduce the backlog of pending SPAs and 
1915 waivers on RAI, beginning with the 150 oldest actions.  All states received a 
comprehensive list of their SPAs and waivers on RAI, and CMS partnered with states to provide 
technical assistance on the identified SPAs and 1915 waivers to move them towards resolution.  
CMS appreciates the partnership of states in this effort and together, we have achieved a 61 
percent reduction of the total 365 backlogged pending SPAs and 1915 waivers.  We continue to 
collaborate closely with states to resolve the remaining backlog of RAIs, but expect states to  CMCS Informational Bulletin  Page 5 
 
commit to resolving outstanding issues quickly.  For RAIs issued prior to October 1, 2018, we 
are encouraging states to respond as quickly as possible to the formal RAI request.  States that 
are not working with CMS on these actions run the risk of disapproval. 
  
CMS is also implementing new procedures to prevent a future backlog of amendments on RAI.  
For RAIs issued on or after October 1, 2018, if a response to a formal request for additional 
information from CMS is not received from the state within 90 days of issuance, CMS will 
initiate disapproval of the SPA or waiver action.  CMS will only initiate disapproval when the 
state does not provide CMS with information sufficient to continue advancement of the SPA or 
waiver action.  We intend to resolve these actions in a manner that is both timely and satisfactory 
to states and CMS. Special consideration will be given to waiver renewals in order to avoid a 
disruption in services to beneficiaries. 
 
Section 1915 Waiver Process Improvements 
 
CMS formed a workgroup to focus specifically on additional strategies to increase the efficiency 
of processing 1915(c) Home and Community Based Waiver actions (new waivers, amendments 
and renewals).  The group was comprised of representatives from NAMD, the National 
Association of State Directors of Developmental Disabilities Services (NASDDDS), the National 
Association of States United for Aging and Disabilities (NASUAD), the National Association of 
State Mental Health Program Directors (NASMHPD), the National Association of State Head 
Injury Administrators (NASHIA), and the American Public Human Services Association 
(APHSA), Louisiana, Minnesota, Pennsylvania, Wyoming, Nebraska, Texas, Florida, Michigan, 
and Wisconsin. 
 
Based on their feedback and suggestions, CMS has instituted the following process 
improvements: 
  Updates to the Waiver Review Tool: CMS has updated the 1915(c) Waiver Review Tool 
used by CMS analysts to review waiver submissions.  It has been modified to focus only 
on regulatory citations in an effort to reduce the number of questions posed to States in 
Formal Requests for Additional Information (RAIs).  The updated Tool was recently 
posted in the Waiver Application and Accompanying Materials on the Waiver 
Management System.  
  1915(c) Frequently Asked Questions: 1915(c) waiver actions are submitted by states to 
CMS electronically through the Waiver Management System (WMS).  Several states 
raised similar questions and concerns about the system, as well as the automated 
submission and review process.  Based on that feedback, CMS has developed a 
Frequently Asked Questions (FAQ) document to address common questions and 
concerns regarding the automated 1915(c) process.  It is now posted on the Medicaid.gov 
page for 1915 Waiver Processing Tools for States. 
  Template Language for Transition Plans: The requirement to submit a Waiver Specific 
Transition Plan in each 1915(c) Amendment or Renewal has been a difficult and time 
consuming process for States.  CMS has developed the following language for states to 
use in Attachment 2 of the waiver application in order to fulfill the requirement: 
The state assures that this waiver amendment or renewal will be subject to any 
provisions or requirements included in the state's most recent and/or approved home 
and community-based settings Statewide Transition Plan. The state will implement any  CMCS Informational Bulletin  Page 6 
 
required changes by the end of the transition period as outlined in the home and 
community-based settings Statewide Transition Plan.  
 
Conclusion 
The SPA and 1915 waiver review and approval processes represent a substantial workload for 
both states and CMS.  CMS looks forward to continued collaboration with states to ensure these 
improvement strategies are implemented in an efficient and streamlined manner.  If you have any 
questions or need additional information, please contact Anne Marie Costello at 
AnneMarie.Costello@cms.hhs.gov or Verlon Johnson at Verlon.Johnson@cms.hhs.gov. 
    CMCS Informational Bulletin  Page 7 
 
Appendix 1: Medicaid SPA and 1915 Waiver Adjudication Processing Times 
 
Table 1 shows the percentage of Medicaid SPAs that were approved within the first 90 day 
review period.  Tables 2 - 5 show the median processing time for Medicaid SPAs and 1915(b) 
and (c) waiver actions approved in calendar years 2016 and 2017, the final quarter of 2017 and 
2018, including the median number of days that SPAs spent on the clock under review with 
CMS and off the clock pending additional information from the state. 
  
Table 1. Percentage of Medicaid SPAs Approved Within the First 90 Day Review Period 
 
Time Period  % Approved in First 90 Days 
Calendar Year 2016  64 
Calendar Year 2017  63 
First Quarter 2018  84 
 
 
Table 2. Medicaid SPA Processing Times 
 
Median number 
Median number 
Median number  of days pending 
Number of SPAs  of days between 
Time Period  of days under  additional 
Approved  SPA submission 
CMS review  information 
and approval 
from the state1 
Calendar Year 
839  82  80  90 
2016 
Calendar Year 
950  83  81  2492 
2017 
First Quarter 
195  102  89  205 
2017 
Second Quarter 
261  85  81  157 
2017 
Third Quarter 
215  82  77  3092 
2017 
Fourth Quarter 
279  73  73  2972 
2017 
First Quarter 
192  63  63  90 
2018 
1 The denominator for the median number of days pending additional information from the state includes only SPAs 
approved during the specified time period for which CMS had issued a written request for additional information to 
the state. 
2 In late 2017, CMS partnered with states to reduce a backlog of SPAs pending additional information from states. 
The increase in the median number of days SPAs spent in pending status is a reflection of adjudication of SPAs that 
had remained in pending status for several years.   CMCS Informational Bulletin  Page 8 
 
Table 3. 1915(b) Waiver Processing  New Waiver Requests, Renewals and Amendments 
Median number  Median number of 
Number of  Median number 
of days between  days pending 
Time Period  Actions  of days under 
submission and  additional information 
Approved  CMS review 
approval  from the state1 
Calendar Year 
30  79  79  38 
2016 
Calendar Year 
45  81  81  83 
2017 
First Quarter 
9  99  85  17 
2017 
Second 
14  81  81  76 
Quarter 2017 
Third Quarter 
10  67  37  N/A 
2017 
Fourth 
12  71  71  255 
Quarter 2017 
First Quarter 
4  75  75  N/A2 
2018 
1 The denominator for the median number of days pending additional information from the state includes only 1915 
waivers where CMS issued a written request for additional information (RAI) to the state.  
2 There were no 1915(b) waivers approved in Q1 of 2018 where CMS issued a formal RAI. 
 
Table 4. 1915(c) Waiver Amendments 
Median number 
Median number 
Number of  Median number  of days pending 
of days between 
Time Period  Actions  of days under  additional 
submission and 
Approved  CMS review  information 
approval 
from the state1 
Calendar Year 
150  78  78  53 
2016 
Calendar Year 
195  69  69  105 
2017 
First Quarter 
36  56  56  54 
2017 
Second Quarter 
47  86  86  156 
2017 
Third Quarter 
51  70  70  218 
2017 
Fourth Quarter 
61  44  44  16 
2017 
First Quarter 
33  36  36  18 
2018 
1 The denominator for the median number of days pending additional information from the state includes only 1915 
waivers where CMS issued a written request for additional information (RAI) to the state.  CMCS Informational Bulletin  Page 9 
 
Table 5. 1915(c) Waiver Renewals  
 
Median number 
Median number 
Number of  Median number  of days pending 
of days between 
Time Period  Actions  of days under  additional 
submission and 
Approved  CMS review  information 
approval 
from the state1 
Calendar Year 
43  135  100  215 
2016 
Calendar Year 
81  181  113  62 
2017 
First Quarter 
15  205  108  120 
2017 
Second Quarter 
27  161  88  422 
2017 
Third Quarter 
19  154  89  608 
2017 
Fourth Quarter 
20  138  87  60 
2017 
First Quarter 
5  84  76  8 
2018 
 
1 The denominator for the median number of days pending additional information from the state includes only 1915 
waivers where CMS issued a written request for additional information (RAI) to the state. 
    CMCS Informational Bulletin  Page 10 
 
  
Appendix 2: Actions Eligible for Expedited Review 
 
The initial SPA and 1915 waiver types included in CMS expedited review path pilot are listed 
below.  As CMS assesses the effectiveness of the streamlined review process, the criteria for 
expedited reviews may be updated. 
  
1932(a) Managed Care SPAs 
  1932(a) actions that are only making technical changes, such as: 
  Regulatory citation modifications 
  Selective contracting arrangement description 
Coverage SPAs 
  Inpatient hospital SPA with no hard limits 
 
Payment SPAs  
  Nominal rate increases (up to 4% annually) with no evident Upper Payment Limit issues 
  Nominal rate reductions (less than 4% of overall spending) within a service category with 
no access to care concerns captured during public notice process  
  Updates to effective dates  
  Routine fee schedule changes 
  Alignment with Medicare fee schedule  
  Standard trend adjustments (Cost Of Living Adjustments (COLA), Consumer Price Index 
(CPI), etc.) 
  Technical changes such as minor language changes and Healthcare Common Procedure 
Coding System (HCPCS)/CPT (Current Procedural Terminology) codes 
 
1915(b) Waivers 
  Waivers that are only making technical changes, such as: 
  State contact name, phone number and email address 
  Name of state contracted managed care plan(s) 
  Type of optional External Quality Review Organization activities performed 
  Waivers that change the names of the managed care plans based on a re-procurement 
  Waivers that do not include (b)(3) services and are only making changes to cost-
effectiveness on a retroactive basis, after comparing to the actuals on the CMS-64 
 
1915(c) Waivers and 1915(i) SPAs 
  A waiver amendment (no new waivers or renewals) that: 
  Does not contain a change to the waiver specific transition plan, AND 
  Does not include a substantive change because it only makes one or more of the 
following changes: 
  Increases in Factor C (number of waiver participants) 
  Nominal rate increases (up to 10% annually) with no change in rate 
methodology  CMCS Informational Bulletin  Page 11 
 
  Updates to effective dates for amendments submitted within the first year 
of the approved waiver effective date  
  Routine fee schedule changes 
  Alignment with Medicare fee schedule changes 
  Standard trend adjustments consistent with approved rate methodology 
(COLA, CPI, etc.) 
  Technical changes such as change in waiver name, links or references 
within the waiver, minor language changes, and the like. 
 
 
    CMCS Informational Bulletin  Page 12 
 
Appendix 3: Triaging Protocol Process Flow 
 
This process flow outlines the three review pathways a SPA or 1915 waiver could follow under 
CMS triaging protocol: standard, escalated, or expedited review pathways.