Medi-Cal Waivers and State Plan Amendments

Medi-Cal, California’s Medicaid program, provides health coverage for low-income Californians, including children and their parents, pregnant women, seniors, persons with disabilities, and nonelderly adults. Medi-Cal is operated by the California Department of Health Care Services (DHCS) in partnership with the state’s 58 counties

Medicaid was established in 1965, as part of the federal Social Security Act (SSA). Medicaid rules regarding who gets coverage and which benefits are included are determined by SSA requirements and implemented by the federal Centers for Medicare & Medicaid Services (CMS). Every state that participates in the Medicaid program must create a State Plan that describes the scope of its Medicaid program, and must seek federal approval for that plan. The State Plan serves as a contractual agreement between the state Medicaid agency and CMS.

Waivers and State Plan Amendments Defined

The law also permits CMS to waive certain aspects of the law to enable states to test different approaches to program eligibility, benefits, delivery systems, and financing. This is known as a waiver. Every state uses waivers for elements of their Medicaid programs, with some states operating multiple waivers simultaneously. The widespread use of waivers has contributed greatly to Medicaid program variation across states.

When a state wants to substantially change how it operates its Medicaid program, it must apply to change its State Plan by submitting a State Plan Amendment (SPA) to CMS for approval.

CHCF’s Medi-Cal Explained series includes three resources that outline waivers and SPAs:

  • Medicaid Waivers in California outlines Section 1115, 1915(b), and 1915(c) waivers.
  • California’s Medicaid State Plan Amendments provides an overview of how the SPA process works and explains the differences between waivers and SPAs.
  • Medicaid Waivers and State Plan Amendments Comparison Chart organizes the differences between these two instruments in an easy-to-read one-page document.

About the Authors

Medicaid Waivers in California was written by Julie Stone, an independent consultant, and Jennifer Ryan, executive vice president, Harbage Consulting, a Sacramento-based health care consulting firm.

The State Plan Amendments paper and comparison chart were written by three members of the Pacific Health Consulting Group, which specializes in providing health care and management consulting services to safety-net and public sector health organizations and foundations. Lisa Kodmur and Laura Hogan are senior health care consultants, and Bobbie Wunsch is founder and partner of the organization.