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:   November 6, 2017 
    
FROM:   Brian Neale, Director  
Center for Medicaid and CHIP Services  
 
SUBJECT:   State Plan Amendment and 1915 Waiver Process Improvements to Improve  
    Transparency and Efficiency and Reduce Burden   
 
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.  The National 
Association of Medicaid Directors (NAMD) also shared a set of recommendations for advancing 
state flexibility with CMS and identified streamlining SPA and waiver reviews as a top priority.  
In response, CMS is developing a four-pronged approach to increase transparency, enhance 
efficiency, reduce burden and address a backlog of SPAs on hold due to a request for additional 
information (RAI) from CMS to the state to which the state has not responded.  This 
Informational Bulletin outlines the initial strategies CMS is adopting to implement more efficient 
SPA and section 1915(b) and 1915(c) waiver review processes.  CMS plans to address changes 
to section 1115 demonstration review and approvals in separate guidance.     
 
Background  
 
CMS is statutorily obligated to review Medicaid and Childrens Health Insurance Program 
(CHIP) SPAs and 1915 waiver submissions for consistency with the requirements of the Social 
Security Act and any applicable agency regulations.  CMS is committed to working with states to 
process Medicaid1 and CHIP2 SPAs and waivers as efficiently as possible, in accordance with 
the statute and regulations.  To inform the process improvement efforts, CMS analyzed various 
SPA and waiver processing metrics to establish baselines for measuring the success of future 
process improvements.  In 2016, CMS approved 839 Medicaid SPAs.  The majority, 64 percent, 
were approved within 90 days of submission.  
 
                                                 
1 42 CFR 430.16 requires CMS to approve, disapprove, or request additional information (RAI) on a Medicaid state plan 
amendment within 90 calendar days or the amendment is deemed approved. The 90-day time period (i.e., 1st clock) can be 
stopped only once by CMS through the written request for additional information. Upon receipt of the additional information, a 
second 90-day period (2nd clock) is initiated. 
2 42 CFR 457.160 requires CMS to approve, disapprove or send a written request for additional information; which stops the 90-
day review period, and resumes on the next calendar day after CMS receives all the requested information, within 90 calendar 
days after receipt of a CHIP SPA. CMS may send as many written requests for additional information as needed to obtain the 
complete information necessary to review the state plan or amendment; but has only one 90 calendar day review period.  CMCS Informational Bulletin  Page 2 
 
 
Table 1 shows the median processing time for SPAs approved in calendar year 2016, 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.  In the table below, the median number of 
days between SPA submission and approval includes time on the clock and time off the clock, 
while the median number of days under CMS review represents only time on the clock.  The 
median number of days pending additional information from the state represents time off the 
clock.  
 
Table 1. Medicaid SPA Approvals, Calendar Year 2016 
Number of  Median number of days  Median number of  Median number of days 
SPAs  between SPA submission  days under CMS  pending additional 
Approved  and approval  review  information from the state1 
839  82  80  90 
1 The denominator for the median number of days pending additional information from the state includes only SPAs 
where CMS issued a written request for additional information to the state.  
 
Table 2 shows the median processing times for 1915(b) and (c) waiver actions approved in 
calendar year 2016, including the number of days spent with CMS for review and the number of 
days spent in pending status, awaiting additional information from the state.  
 
Table 2. 1915 Waiver Processing Data, Calendar Year 2016 
Median number of  Median number of 
Median number 
Type of  Number of  days between  days pending 
of days under 
Waiver  Waiver Actions  submission and  additional information 
CMS review 
approval  from the state 
1915(b)  301  77  79  38 
1915(c) 
150   78   78  53 
Amendments 
1915(c) 
43   135  100  215 
Renewals 
1 Includes new 1915(b) waiver requests, amendments, & renewals. 
 
One of the key drivers of SPA processing time is the length of time SPAs spend in pending 
status, while CMS is awaiting a response to a written request for additional information (RAI) 
issued from CMS to the state.  There is currently a national backlog of over 350 SPAs and 1915 
waiver actions on RAI, where states have not responded to requests for additional information, 
often for extended lengths of time.  The average time that pending SPAs have been on RAI is 
two years, and there are SPAs that have been pending for nine years.  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.  
 
Developing a Solution 
 
To begin streamlining SPA and 1915 waiver processes, CMS undertook a number of activities to 
better understand current processes, identify issues, and develop improvement strategies.  Staff  CMCS Informational Bulletin  Page 3 
 
 
examined available SPA and waiver processing data for 2016 and conducted an analysis of a 
sample of SPAs to better understand the factors impacting processing time.  CMS also conducted 
an intensive review of the current SPA standard operating procedures to identify areas for 
increased consistency and enhanced efficiency.  Soliciting state input has also been essential to 
this process  in order to ensure that any process improvement activities are comprehensive and 
responsive to state needs, CMS has several mechanisms for obtaining state feedback.   
 
At the June NAMD meeting in Austin, Texas, CMS held a breakout session with states on SPA 
and section 1915 waiver processing.  As a result of the productive conversation during this 
session, a joint federal-state workgroup was formed to facilitate the continuing bilateral sharing 
of ideas and process improvements.  The federal-state workgroup began in early August, when 
workgroup members received a live demonstration of the new SPA functionality in the web-
based system, MACPro.  Workgroup members continue to meet regularly to ensure that states 
are able to respond to proposals that CMS is developing and offer additional novel approaches 
and ideas.  CMS is also working with representatives from states and several National 
Associations to begin a conversation specific to increasing the efficiency of the section 1915(c) 
waiver process.  Workgroup meetings will continue to be held with these stakeholders in order to 
share ideas and further refine the process.  Additional tools and/or a streamlined process will be 
shared when the workgroup completes this effort. 
 
The first actions CMS is taking to bring efficiency and consistency to the initial SPA review 
process are described below.  Successful implementation of these strategies will require 
commitment from both states and CMS. 
 
Short-Term SPA and 1915 Waiver Process Improvements  
 
  Early SPA and Waiver Review:  Effective October 1, 2017, CMS staff, including both 
central and regional office staff and relevant subject matter experts, began having calls 
with states within 15 days of receipt of each new SPA or section 1915 waiver submission.  
This introductory discussion allows states to review the intent of the submission and any 
critical timelines, which simplifies the initial CMS review, allows CMS to communicate 
any incomplete information, and allows for early identification of known major policy 
issues.  This call will help expedite the review process. 
 
  SPA and 1915 Waiver Toolkits:  CMS has compiled a package of tools available to states 
to help develop complete SPA and section 1915 waiver submissions, including preprints, 
templates, checklists and other guidance.  Submission of SPAs or section 1915 waiver 
actions without all of the necessary information hinders the review process, and use of 
these tools are one way to help reduce the number of incomplete submissions, which will 
often result in faster processing.  These tools are available on a new SPA and Section 
1915 Waiver Processing page on Medicaid.gov, available at:  
https://www.medicaid.gov/state-resource-center/spa-and-1915-waiver-
processing/index.html.  CMS intends to continue adding to the toolkits over time and will 
update Medicaid.gov with new tools as they become available. 
   CMCS Informational Bulletin  Page 4 
 
 
  Reduce the Pending SPA Backlog:  CMS developed a strategy to partner with states and 
reduce the backlog of pending SPAs.  In the coming months, all states will receive a 
comprehensive list of their SPAs on RAI, and CMS will work with states to resolve these 
amendments in batches, beginning with the 75 oldest SPAs.  CMS will collaborate with 
states to understand state priorities and provide technical assistance on the identified 
SPAs to move them towards resolution.      
    
In an effort to reduce the SPA backlog, if a response to a request for additional 
information is not received from the state within 90 days of issuance, CMS may exercise 
the authority to initiate disapproval of the SPA; however, CMS would only initiate this 
process when we cannot resolve our concerns with the state or the state continues to fail 
to respond to the pending request for additional information.  We intend to resolve these 
older amendments in a manner that is both timely and satisfactory to states and CMS and 
will continue to collaborate with states to gradually reduce the current backlog and 
implement new processes to prevent a future backlog of amendments on RAI. 
 
  Expand MACPro to Additional SPA Authorities:  MACPro is a web-based system for the 
submission, review, and disposition of SPAs.  Health Home SPAs were the first to be 
processed through MACPro.  In late August, CMS expanded the use of MACPro to 
include Medicaid Modified Adjusted Gross Income (MAGI)-based eligibility and 
administration SPAs.  CMS is currently charting which additional SPA authorities will be 
added to MACPro.  MACPro provides a number of benefits  simplified, structured SPA 
templates, automated workflows, and improved transparency, as states will be able to 
check the status of their submissions.  The use of MACPro will allow states and CMS to 
collaborate more efficiently and effectively to process SPAs.    
 
Addressing SPA Same Page Review  
 
Upon SPA submission, CMS has an obligation to review the proposed changes, as well as all 
other provisions contained on the submitted pages, for compliance with federal statute and 
regulations.  This review may identify state plan provisions not being modified that are contrary 
to federal statute, regulations, or established guidance.  In 2010, CMS consulted with states and 
implemented a process to ensure that issues identified in provisions not integral to the SPA can 
be resolved through a separate process and will not delay SPA adjudication.    
 
As stated in the 2010 guidance, when a non-compliant provision is identified in language that 
was not the direct subject of the SPA change, CMS will discuss the issue with the state during 
the early stages of the SPA review, and the state can choose to resolve the issue during the 
submitted SPA review or through a separate process.  If the state chooses a separate process, on 
or before the date of SPA adjudication, CMS will issue a companion letter describing the issues 
related to any non-compliant provisions not resolved during the SPA review.  CMS will work 
with the state to develop a plan and timeframe for resolving the issue and will typically delay 
initiating any formal compliance action when the state is demonstrating a good faith effort to 
comply.  Additional information on this process can be found at 
https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD10020.pdf. 
  CMCS Informational Bulletin  Page 5 
 
 
In a sample taken of SPAs approved in 2016, 75 percent of SPAs that triggered a same page 
review were approved within 90 days of submission.  As more SPAs are transitioned to the 
MACPro system, same page reviews will be eliminated, as MACPro enables states to submit 
smaller reviewable units that contain only the provisions being modified.  In the interim, we are 
committed to working with states to ensure that no SPA approvals are delayed as the result of a 
same page review issue.   
 
Next Steps for SPA and 1915 Waiver Process Improvements 
 
In addition to the initial strategies identified in this CIB, in the coming months, CMS is planning 
to implement additional short and long term strategies.  CMS is planning to develop additional 
tools for states, including standardized lists of review questions, as well as checklists for use 
during SPA and waiver development to ensure submissions are complete.  CMS is also engaging 
in a longer term effort to review current business processes, obtain input from the state partners 
on the federal-state workgroup, and identify areas for streamlining.  CMS is also continuing to 
expedite and leverage the MACPro systems build, which will streamline SPA reviews and 
provide a more collaborative, consistent and transparent review process for states.   
 
While the requirements for CHIP SPA reviews differ from that of Medicaid SPAs, CMS staff are 
committed to making improvements that enhance the efficiency of both processes.  The SPA and 
section 1915 waiver review and approval processes represent a substantial workload for both 
states and CMS, and we are vested in collaborating closely to identify strategies and 
commitments both partners can make to enhance efficiency and reduce collective burden.  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.