What’s the timeline for HHSC’s 1115 waiver extension request submission?

Two weeks after the end of the state public comment period for Texas’s Medicaid 1115 waiver extension application — the previous version of which was rescinded by the Centers for Medicare and Medicaid Services (CMS) in April — the Texas Health and Human Services Commission (HHSC) is preparing to send the request to the federal government.


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Supporters of Medicaid expansion have viewed the rescission of Texas’s previous waiver as an opportunity to expand Medicaid. Accordingly, public comments largely consisted of calls to include the expansion of Medicaid eligibility to 138% of the federal poverty level.

Joan Alker, executive director of Georgetown University’s Center for Children and Families, has considerable experience with the state waiver application process. She gave State of Reform and overview of what the next couple of months could look like for Texas’s 1115 waiver.

HHSC is required to include a summary of the comments received during this period in its application to CMS, along with explanations of how the state is responding to these requests. For instance, if HHSC disagrees with a certain request, it needs to explain why.

Once the federal government receives Texas’s application, it will evaluate it and certify whether it’s complete or not within 15 days. Alker said it’s fairly rare for state waivers to be deemed incomplete.

After this, the federal government will hold a second, 30-day public comment period to get additional stakeholder input. 

Unlike HHSC, CMS isn’t required to disclose how they’re responding to the comments they received. 

“Typically, in state comment periods, most of the people making comments are in the state … At the federal level, there are a lot of comments that will come in from national stakeholders and public policy analysts like us, [and] different national groups representing patients [and] providers…”

She noted that stakeholders who submitted comments during the state’s comment period and didn’t have their comments incorporated are likely to voice their concerns again to the federal government.

“The state folks often comment again to the federal government, and they’ll say slightly different things because the state has already responded — or not — to their comments. So now it’s a different actor, it’s the federal government who has to approve or disapprove the state’s request. So the commenters will be saying, ‘Here’s what we think Secretary Becerra should do.’”

When asked whether she thinks President Biden’s CMS will give more consideration to public comments than HHSC, Alker said:

“This is sort of the central issue in what’s going to happen to the waiver overall, because the waiver is a lot of money, and the Trump administration…pushed this out right before they left because they violated the transparency rules by not taking public comment at the federal level. 

The Biden administration is clearly going to be taking another look at this, and where they end up is an open question. The state and the feds have to come to an agreement on this.”