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State Plan Amendment vs Medicaid 1115 Waiver Process and Timelines



As more states consider expanding Medicaid, it is important for legislators and policy-makers to understand that adding expansion features which require federal approval—like a work requirement —will delay people from receiving health coverage, and the state’s receipt of any enhanced federal matching funds.

Requiring waiver approval by the Centers for Medicare & Medicaid Services (CMS) before implementing Medicaid expansion will add significant delays. Table 1 shows the steps required to approve a Medicaid expansion through an 1115 waiver versus a straight state plan amendment (SPA). An 1115 waiver is required to include a work requirement or enrollee reporting requirements, among other elements, whereas a SPA is the mechanism for how states expand Medicaid if the program changes do not require federal approval.

This fact sheet provides advocates and policymakers a step-by-step overview comparing the approval process and timeline to get a SPA vs. Medicaid 1115 Waiver approved.

It is part of the Medicaid Expansion Leadership Team’s Medicaid Expansion Toolkit.