DEPARTMENT OF HEALTH AND 
HUMAN SERVICES Centers for Medicare 
& Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
DATE:   July 24, 2015 
 
FROM:  Vikki Wachino 
    Director 
 
SUBJECT:  Implementation of a Fast Track Federal Review Process for Section 1115 
Medicaid and CHIP Demonstration Extensions 
 
The Centers for Medicare & Medicaid Services (CMS) is establishing a new fast track process 
for reviewing proposals from states to extend established Medicaid and Childrens Health 
Insurance Program (CHIP) section 1115 demonstrations that reauthorize longstanding policies 
with proven program outcomes.  This process is designed to facilitate faster review of and 
federal decisions regarding state requests to extend established 1115 demonstrations, reducing 
administrative burden on states and the federal government.   
 
This approach streamlines the extension process for those states with established demonstrations 
that are working successfully and who are not proposing to make major or complex policy 
changes to the demonstration.  Timeframes for these reviews will be comparable to those CMS 
uses to make decisions on Medicaid section 1915 waivers or state plan amendments.  This new 
approach provides for a more efficient federal review process, as well as a more effective 
assessment of demonstrations progress in promoting high quality, accessible, and affordable 
health care coverage to beneficiaries.        
 
The Social Security Act establishes three pathways through which states can propose to extend 
1115 demonstrations:  1115(a), 1115(e) and 1115(f).  This Informational Bulletin describes a 
streamlined approach for 1115(a) extensions and simplifications to the other two pathways.      
 
Which State Demonstration Programs Qualify for the Fast Track Review Process? 
 
The fast track extension process is available for states that meet the following four criteria:  
1)  have established demonstration programs, meaning that they have had at least one full 
extension cycle without substantial program changes;  
2)  have demonstrations in compliance with reporting deliverables and that have positive 
monitoring and evaluation results that indicate that the objectives of the demonstration 
and of the Medicaid/CHIP program have been achieved;  
3)  are not proposing major or complex changes (as discussed further below); and  
4)  use the streamlined extension application templates. 
  Page 2  CMCS Informational Bulletin 
What is the Fast Track Review Process? 
 
Section 1115(a) extensions 
Section 1115(a) extensions are available to states with targeted or comprehensive 
demonstrations, and at the states discretion, include requests to make program changes. With the 
new fast track process states would submit a state attestation, a streamlined extension template 
(that includes the information required for an extension application to be considered complete) 
and, if the state chooses, a redline version of the approved Special Terms and Conditions (STCs) 
to outline how the STCs would have to change to effectuate the requested program changes.  
CMS will review monitoring and evaluation information to assess progress with meeting 
Medicaid/CHIP program objectives and any specific program components the state has proposed 
to change as identified in the extension template.   
 
CMS will offer states eligible for an 1115(a) fast track review a 5-year extension period.  
Currently, a minority of demonstrations, such as those that include dual eligible beneficiaries, are 
extended for more than three years at a time.  There are no statutory timeframes for which CMS 
is required to render a decision on 1115(a) extensions; however, under this initiative, we are 
aligning the review timeframes with those CMS uses to make decisions on Medicaid Section 
1915 waivers or State plan amendments.   
 
CMS successfully piloted this fast track process with the extension of a section 1115(a) 
demonstration in Colorado.  The demonstration has been operating since 2002 and 
maintains federal funding for uninsured pregnant women with family incomes from 141 
percent to 195 percent of the federal poverty level.  Colorado submitted an extension 
application with no changes requested and showed positive outcomes in meeting the 
objectives of the demonstration.  CMS review focused on whether the demonstration had 
been operating successfully and that the demonstration would meet its future goals.  CMS 
approved the demonstration extension for a 5-year period on July 24, 2015; completing 
federal review in 98 days.    
   
 
 
Complex Policy Areas  
 
There are certain policy areas that are inherently complex to review, and demonstration programs 
that involve these complex policy areas will not be eligible for the fast track process.  Below, 
we identify an initial list of current demonstration policies considered to be complex policy areas 
not subject to fast track review.    
 
Demonstration policies that CMS considers to be complex policy areas not eligible for the fast 
track review process to date are as follows: 
  
  Medicaid Expansion Programs tied to enhanced Federal Medical Assistance 
o
Percentage (FMAP);  Page 3  CMCS Informational Bulletin 
  Delivery system reform, financing, and payments arrangements that cannot be 
o
authorized under state plan authority, including delivery system reform incentive 
pools;  
  Designated State Health Programs; 
o
  Demonstrations with dual eligible Medicare and Medicaid populations; 
o
  Establishing Home and Community-Based Services (HCBS), including those 
o
discussed in the 2014 HCBS final rule;  
  Enrollment caps and eligibility limitations; and 
o
  Uncompensated care pools. 
o
 
CMS maintains the right to determine that a policy area, not previously identified as a complex 
policy area, will be considered as such and therefore not subject to fast track review.  In these 
instances, CMS will issue an Informational Bulletin update to identify the new list of policy 
areas excluded from fast track review because of particular complexity or whose impact has not 
yet been evaluated to determine whether they meet the objectives of the Medicaid program, 
which is the statutory standard for 1115 approvals.      
 
Section 1115(e) extensions 
Section 1115(e) extensions are available to states with comprehensive demonstrations proposing 
no program changes.  By statute, CMS can only consider an extension period of up to three 
years.  With the new fast track process states would submit a state attestation and an abbreviated 
set of supporting documents required for an extension application to be considered complete.  
CMS is statutorily required to render a decision within six months of a states submission; 
however, under this initiative, we are aligning the review timeframes with those CMS uses to 
make decisions on Medicaid Section 1915 waivers or State plan amendments.   
 
Section 1115(f) extensions 
States with extensions authorized under 1115(e) authority are eligible for three year extensions 
under 1115(f) authority.  States can propose changes under this extension pathway.  The 1115(f) 
pathway already outlines an expedited 120-day review process; however, very few states 
currently utilize this option.  We believe that the new fast track process requiring submission of a 
state attestation and the streamlined extension template if changes are being requested will assist 
states with providing the information needed to meet the short target dates outlined in statute, 
thereby expanding the availability of this option for states.   
 
Fast Track Application Process  
 
As mentioned above, CMS has created a streamlined extension application for each 1115 
extension option for states that want to be considered for the fast track process.  The streamlined 
extension application comprises a state certification statement that identifies an abbreviated set 
of supporting documents to accompany the certification that are required for an extension 
application to be considered complete.  There is also an extension template for the state to 
outline any proposed program changes.  The streamlined application templates can be found on 
Medicaid.gov at http://www.medicaid.gov/medicaid-chip-program-information/by-
topics/waivers/1115/application.html.   
  Page 4  CMCS Informational Bulletin 
CMS will notify the state of whether its extension request meets the criteria for expedited review 
within 15 days of receiving it, as part of our assessment of application completeness.  We also 
reserve discretion to determine that a states extension application no longer qualifies for fast 
track review, if during the course of the federal review through work with the state or through 
public comment, we identify significant program concerns.  Examples of such concerns are 
compliance or program integrity issues, or programmatic issues identified through public 
comment.  We will promptly notify the state of our determination of whether we are 
reconsidering its extension request through the full 1115(a) process or fast track review.  States 
will have an opportunity to modify their extension request in order to proceed with the fast track 
review process based on CMS feedback. 
 
Improving 1115 Demonstration Monitoring 
 
CMS fast track review will coincide with a stronger and streamlined monitoring process for all 
state demonstrations.   This will require renewed collaboration between CMS and states.  To this 
end, CMS is revising some monitoring requirements for section 1115 demonstrations.  The goal 
of this effort is to improve federal capacity to use consistent data to measure the impact that 
individual 1115 demonstrations have on Medicaid and CHIP beneficiaries and the health system.  
We intend to rely on state data reported through existing Medicaid and CHIP data systems, such 
as the Transformed Medicaid Statistical Information System (T-MSIS), and are reviewing the 
data states are beginning to provide through T-MSIS to revise 1115 monitoring requirements to 
ensure that states do not provide duplicative information.  We are also reviewing monitoring 
terms and conditions for 1115 demonstrations to revise and strengthen monitoring requirements 
to focus on core performance-related data.  This approach to monitoring will also facilitate a 
more efficient federal review of established demonstrations eligible for fast track extension.  We 
will reach out to states to discuss potential changes to the monitoring requirements in their 
demonstration terms and conditions.  We invite states to propose monitoring requirement 
changes to their CMS 1115 project officers.  CMS is also developing an automated data 
collection and reporting tool that will make the submission of 1115 deliverables, such as 
quarterly reports, more structured and administratively simple. 
 
State Demonstrations Group 
 
CMCS has changed its organizational structure and is increasing staffing to support its work on 
section 1115 demonstrations and their growing role in delivering care to Medicaid and CHIP 
beneficiaries.  This new group, which was created July 2015, has responsibility for reviewing 
and making recommendations on 1115 demonstration applications, amendments, and extensions, 
as well as for monitoring, oversight and evaluation of approved demonstrations.  Eliot Fishman 
[Eliot.Fishman@cms.hhs.gov] is the State Demonstrations Groups (SDG) Director and Julia 
Hinckley [Julia.Hinckley@cms.hhs.gov] is its Deputy Director.  SDG staff will assess state, 
federal, and stakeholder experience with the fast track review process and use that assessment to 
inform broader improvements to the 1115 demonstration approval and amendment process.  
CMCS invites suggestions on these reforms at 1115DemoRequests@cms.hhs.gov. 
 
 
  Page 5  CMCS Informational Bulletin 
Next Steps 
 
CMS will reach out to states 18 months prior to the expiration of their current demonstration 
with a fast track extension packet to assist the state in considering use of the new fast track 
process.   
 
If you have questions about this bulletin, please contact Angela Garner, State Demonstrations 
Group, at Angela.Garner@cms.hhs.gov.