Section 1332: State Innovation Waivers

Section 1332: State Innovation Waivers

Section 1332 of the Affordable Care Act (ACA) permits a state to apply for a State Innovation Waiver (also referred to as section 1332 waiver) to pursue innovative strategies for providing residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA.

Section 1332 waivers are subject to approval by the U.S. Department of Health and Human Services and the Department of the Treasury (the Departments). In order for a section 1332 waiver to be approved, the Departments must determine that the waiver will provide coverage that is at least as comprehensive as the coverage provided without the waiver; provide coverage and cost-sharing protections against excessive out-of-pocket spending that are at least as affordable as without the waiver; provide coverage to at least a comparable number of residents as without the waiver; and not increase the federal deficit.

State Innovation Waivers have been available since January 1, 2017, are approved for up to five-year periods, and can be extended.

Additional Resources:

Contact:

For additional information or to submit your application, contact the State Innovation Waiver team at  stateinnovationwaivers@cms.hhs.gov.

Pending Application(s):

Maryland:
On July 15, 2024, Maryland submitted a request to amend its State Innovation Waiver from January 1, 2026, through December 31, 2028. On August 22, 2024, the Departments deemed Maryland’s waiver application complete.  To view Maryland’s amendment application and public comments received on this application, please visit the Maryland waiver section of this webpage below.

Nevada:
The Departments held a public comment period on Nevada’s waiver application from February 12, 2024, through March 14, 2024. On March 21, 2024, Nevada requested that the Departments pause review of the waiver application. On August 23, 2024, Nevada submitted an updated waiver application and review of the waiver resumed. To view Nevada’s application and public comments on this application, please visit the Nevada waver section of this webpage below.

 

Regulations and Guidance

Fact Sheets, Data Briefs, and Evaluations

Frequently Asked Questions (FAQs)

Letters

  • March 13, 2017 (PDF) – Letter to States on 1332 State Innovation Waivers and high-risk pool/state-operated reinsurance programs
  • October 22, 2018 (PDF) – Letter to States on State Relief and Empowerment Waiver Guidance

Application Tools and Resources

Pass-through Funding Tools and Resources

About the 1332 State Innovation Waiver Application Process

States have the option to seek a State Innovation Waiver under Section 1332 of the Affordable Care Act to pursue innovative strategies to provide high quality, affordable health care coverage while retaining the statute’s basic protections. The U.S. Department of Health and Human Services (HHS) and the U.S. Department of the Treasury are responsible for reviewing waiver applications.

States may submit State Innovation Waiver applications to stateinnovationwaivers@cms.hhs.gov.

Public Input Process Prior to Submission of an Application

Prior to submitting a State Innovation Waiver application to HHS for review and consideration, a state must provide public notice and a comment period sufficient to ensure a meaningful level of public input on the application.  During the public comment period, the state must conduct public hearings regarding the state’s application.  In addition, a state with one or more federally recognized tribes within its borders must conduct a separate process for meaningful consultation with the tribes as part of the notice and comment process.

Application Requirements

The final regulations specify what information needs to be included in an application for a State Innovation Waiver.  Critical elements of that application include (but are not limited to):

  • The list of provisions the state seeks to waive, including the rationale for the specific requests;
  • Data, assumptions, targets, and other information sufficient to determine that the proposed waiver will provide coverage that is at least as comprehensive as would be provided absent the waiver, will provide coverage and cost sharing protections that keep care at least as affordable as would be provided absent the waiver, will provide coverage to at least a comparable number of residents as would be provided coverage absent the waiver, and will not increase the Federal deficit;
  • Actuarial analyses and actuarial certifications to support State estimates that the waiver will comply with the comprehensive coverage requirement, the affordability requirement, and the scope of coverage requirement;
  • A detailed 10-year budget plan that is deficit neutral to the Federal government;
  • A detailed analysis of the impact of the waiver on health insurance coverage in the state;
  • A description and copy of the enacted state legislation providing the state authority to implement the proposed waiver; and,
  • A detailed plan as to how the state will implement the waiver, including a timeline.

The regulations provide more detail about each of the application elements and should be consulted carefully as states develop applications.

HHS may also request, or a state may propose, additional information to aid in the review of the application.

Application Review Process

Upon receipt of a State Innovation Waiver application, HHS and the Department of the Treasury (the Departments) will work with the state on the review and approval process.  The Departments (in coordination with other agencies as applicable) will follow the process outlined below:

  1. The Departments will conduct a preliminary review within 45 days of submission to determine if the application is complete.  Written notice will be provided to the state that the preliminary determination has been made.  The written notice will either indicate that the application is complete or will identify elements missing from the application.
  2. The preliminary determination that the application was complete does not preclude a finding during the review process that a necessary element of the application is missing or insufficient.
  3. Following the preliminary determination that a state’s application is complete, the Departments will provide for a public notice and comment period.
  4. The final decision of the Secretaries of HHS and the Treasury will be issued no later than 180 days after the determination that an application is complete.

Section 1332 State Innovation Waiver Applications

Alaska

On July 17, 2017, the Departments, having completed a review of Alaska’s application, approved Alaska’s State Innovation Waiver under section 1332 of the ACA. On July 31, the state accepted the Specific Terms and Conditions (STCs). This approval is effective for January 1, 2018, through December 31, 2022.

On July 13, 2022, the Departments, having completed a review of Alaska's waiver extension application submitted on March 17, 2022, approved Alaska's waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Initial Waiver (2017)

Application:

Correspondence:

Waiver Extension Request (2022)

Application:

Correspondence:

Pass-through funding:

California

Application:

Correspondence:

Colorado

On July 31, 2019, the Departments, having completed a review of Colorado's application, approved Colorado's State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2020 through December 31, 2021

On August 13, 2021, the Departments, having completed a review of Colorado’s waiver extension application submitted on April 30, 2021, approved Colorado’s 5-year extension request under section 1332 of the ACA. This approval is effective for January 1, 2022 through December 31, 2026.

On June 22, 2022, the Departments, having completed a review of Colorado's waiver amendment application submitted on November 30, 2021, approved Colorado's waiver amendment request under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Initial Waiver (2019) 

Application:

Correspondence:

Waiver Extension Request (2021)

Application:

Correspondence:

Waiver Amendment Request (2021)

Application:

Correspondence:

Pass-through funding

Other Correspondence

Delaware

On August 20, 2019, the Departments, having completed a review of Delaware’s application, approved Delaware’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2020 through December 31, 2024.

On July 31, 2024, the Departments, having completed a review of Delaware's waiver extension application submitted on April 2, 2024, approved Delaware's waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2025, through December 31, 2029.

Initial Waiver (2020)

Application:

Correspondence:

Waiver Extension Request (2023)

Application:

Correspondence:

Pass-through funding

Other Correspondence

Georgia

On November 1, 2020, the Departments, having completed a review of Georgia’s application, approved Georgia’s State Innovation Waiver under section 1332 of the PPACA. This approval is effective for January 1, 2022 through December 31, 2026.

On April 29, 2022, the Departments sent a letter to Georgia informing the State that the Departments are suspending Part II of Georgia’s section 1332 waiver, the Georgia Access Model, that was initially approved on November 1, 2020, unless certain requirements are met. On July 27, 2022, Georgia submitted a written challenge to the Departments’ suspension determination. On August 9, 2022, the Departments sent  letter to Georgia informing the State that the Departments are suspending Part II of Georgia's section 1332 waiver, the Georgia Access Model, effective August 9, 2022. CMS will continue to operate the FFE in Georgia and Georgia consumers will retain access to HealthCare.gov for Plan Year (PY) 2023 to purchase qualified health plans in the individual market. Georgia may submit a corrective action plan to bring its waiver, with the Georgia Access Model, into compliance with the statutory coverage guardrail for the Departments' consideration to resume implementation for PYs 2024-2026. To view the letters, please see below under ‘Correspondence.’

Application:

Correspondence:

Pass-through funding:

Other Correspondence:

Hawaii

On December 30, 2016, the Departments, having completed a review of Hawaii's application, approved Hawaii's State Innovation Waiver under section 1332 of the ACA and the state accepted the Specific Terms and Conditions (STCs).  This approval is effective for January 1, 2017, through December 31, 2021. 

On December 10, 2021, the Departments, having completed a review of Hawaii’s waiver extension application submitted on August 12, 2021, approved Hawaii’s 5-year extension request under section 1332 of the ACA. This approval is effective for January 1, 2022 through December 31, 2026.

Initial Waiver (2016)

Application:

Correspondence:

Waiver Extension Request (2021)

Application: 

Correspondence:

Pass-through funding: 

Idaho

On July 15, 2019, Idaho submitted a State Innovation Waiver application.  The Departments determined that the application was not complete on August 29, 2019. 

On August 16, 2022, the Departments, having completed a review of Idaho’s waiver application submitted on May 5, 2022, approved Idaho’s waiver application under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Waiver (2019)

Application:

Correspondence:

Waiver (2022)

Application:

Correspondence:

 

Pass-through funding

Iowa

On August 21, 2017, Iowa submitted a State Innovation Waiver application.  The Departments deemed the application complete on September 19.  The Departments accepted public comments  on Iowa’s application from September 19, 2017 until October 19, 2017. Iowa withdrew the application on October 23, 2017.

Application:

Correspondence:

Maine

On July 30, 2018, the Departments, having completed a review of Maine’s application, approved Maine’s State Innovation Waiver under section 1332 of the ACA.  This approval is effective for January 1, 2019, through December 31, 2023.

On July 15, 2022, the Departments, having completed a review of Maine’s waiver amendment application submitted on February 10, 2022, with an addendum submitted on March 23, 2022, approved Maine’s waiver amendment request under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Initial Waiver (2018)

Application:

Correspondence:

Waiver Amendment Request (2022)

Application:

Correspondence:

Pass-through funding: 

Maryland

On August 22, 2018, the Departments, having completed a review of Maryland’s application, approved Maryland’s State Innovation Waiver under section 1332 of the ACA.  This approval is effective for January 1, 2019, through December 31, 2023.

On June 28, 2023, the Departments, having completed a review of Maryland's waiver extension application submitted on March 20, 2023, approved Maryland's State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2024 through December 31, 2028.

On July 15, 2024, Maryland submitted a request to amend its State Innovation Waiver from January 1, 2026, through December 31, 2028. 

Initial Waiver (2018)

Application:

Correspondence:

Waiver Extension Request (2023)

Application:

Correspondence:

Waiver Amendment Request (2024)

Application:

Correspondence:

Pass-through Funding:

Other Correspondence:

Massachusetts

On September 8, 2017, Massachusetts submitted a State Innovation Waiver application.  The Departments determined that the application was not complete on October 23, 2017.
 

Application:

Correspondence:

Minnesota

On September 22, 2017, the Departments, having completed a review of Minnesota’s application, approved Minnesota’s State Innovation Waiver under section 1332 of the PPACA.  On October 19, 2017, the Departments sent a revised approval, and on October 20, 2017, the state accepted the Specific Terms and Conditions (STCs).  This approval is effective for January 1, 2018, through December 31, 2022.

On December 22, 2021, Minnesota submitted a section 1332 waiver extension application to extend its currently approved waiver.  The Departments determined that the application was incomplete on January 27, 2022.

On July 13, 2022, the Departments, having completed a review of Minnesota's waiver extension application submitted on May 12, 2022, approved Minnesota's waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Initial Waiver (2017)

Application:

Correspondence:

Waiver Extension Request (2021/2022)

Application:

Correspondence:

Pass-through funding:

Other Correspondence

Montana

On August 16, 2019, the Departments, having completed a review of Montana’s application, approved Montana’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2020 through December 31, 2024.

On September 17, 2024,the Departments, having completed a review of Montana’s waiver extension application submitted on May 17, 2024, approved the extension of Montana’s State Innovation Waiver extension under section 1332 of the ACA. This approval is effective for January 1, 2025, through December 31, 2029. 

Initial Waiver (2019)

Application:

Correspondence:

Pass-through funding: 

Waiver Extension Request (2024)

Application:

Correspondence:

Nevada

On December 29, 2023, Nevada submitted a State Innovation Waiver application. On February 12, 2024, the Departments deemed Nevada’s waiver application as complete. Federal public comments were accepted from February 12, 2024, through March 14, 2024. On March 21, 2024, Nevada requested that the Departments pause review of the waiver application. On August 23, 2024, Nevada submitted an updated waiver application and review of the waiver resumed.

Application

Correspondence

 

New Hampshire

On August 5, 2020 the Departments, having completed a review of New Hampshire’s application, approved New Hampshire’s State Innovation Waiver under section 1332 of the PPACA. This approval is effective for January 1, 2021 through December 31, 2025.

On November 19, 2024, the Departments, having completed a review of New Hampshire’s waiver extension application submitted on August 21, 2024, approved New Hampshire’s waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2026, through December 31, 2030.

 

Initial Waiver (2020)


Application:

Correspondence

Waiver Extension Request (2023)

Application:

Correspondence:

Pass-through funding: 

Other Correspondence

New Jersey

On August 16, 2018, the Departments, having completed a review of New Jersey’s application, approved New Jersey’s State Innovation Waiver under section 1332 of the ACA.  This approval is effective for January 1, 2019, through December 31, 2023.

On August 15, 2023, the Departments, having completed a review of New Jersey's waiver extension application submitted on July 6, 2023, and addendum submitted on July 11, 2023, approved New Jersey's State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2024 through December 31, 2028.

Initial Waiver (2018)

Application:

Correspondence:

Pass-through funding: 

Waiver Extension Request (2023)
Application:

Correspondence:

New York

On  March 1, 2024, the Departments, having completed a review of New York’s application, approved New York’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for April 1, 2024, through December 31, 2028.

On September 25, 2024, the Departments, having completed a review of New York’s amendment application, approved the amendment to New York’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2025, through December 31, 2028.

Initial Waiver (2023)

Application:

Correspondence:

Other Correspondence:

Pass-through funding:

Waiver Amendment Request (2024)

Application:

Correspondence:

North Dakota

On July 31, 2019, the Departments, having completed a review of North Dakota’s application, approved North Dakota’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2020 through December 31, 2024.

On November 7, 2024, the Departments, having completed a review of North Dakota's waiver extension application submitted on August 30, 2024, approved North Dakota's waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2025, through December 31, 2029. 

 

Initial Waiver (2019)

Application:

Correspondence:

Waiver Extension Request (2024)

Application:

Correspondence:

Pass-through funding: 

Other Correspondence:

Ohio

On March 30, 2018, Ohio submitted a State Innovation Waiver application.  The Departments determined that the application was not complete on May 17, 2018.

Application:

Correspondence:

Oklahoma

On August 16, 2017, Oklahoma submitted a State Innovation Waiver application.  The Departments deemed the application complete on August 24.  The Departments accepted public comments on Oklahoma’s  application from August 24, 2017 until September 23, 2017. Oklahoma withdrew the application on September 29, 2017.

Application:

Correspondence:

Oregon

On October 18, 2017, the Departments, having completed a review of Oregon’s application, approved Oregon’s State Innovation Waiver under section 1332 of the PPACA.  On October 19, the state accepted the Specific Terms and Conditions (STCs).  This approval is effective for January 1, 2018, through December 31, 2022.

On July 13, 2022, the Departments, having completed a review of Oregon's waiver extension application submitted on March 31, 2022, approved Oregon's waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Initial Waiver (2017)

Application:

Correspondence:

Waiver Extension Request (2022)

Application:

Correspondence:

Pass-through funding: 

Pennsylvania

On July 24, 2020, the Departments, having completed a review of Pennsylvania’s application, approved Pennsylvania’s State Innovation Waiver under section 1332 of the PPACA. This approval is effective for January 1, 2021 through December 31, 2025.

Initial Waiver (2020)

Application:

Correspondence:

Pass-through funding: 

Waiver Extension Request (2023)

Correspondence:

Rhode Island

On August 26, 2019, the Departments, having completed a review of Rhode Island’s application, approved Rhode Island’s State Innovation Waiver under section 1332 of the PPACA. This approval is effective for January 1, 2020 through December 31, 2024.

On October 28, 2024, the Departments, having completed a review of Rhode Island’s waiver extension application submitted on July 8, 2024, approved Rhode Island’s waiver extension request under section 1332 of the ACA. This approval is effective for January 1, 2025, through December 31, 2029. 

Initial Waiver (2019)

Application:

Correspondence:

Waiver Extension Request (2023)

Application:

Correspondence:

Pass-through funding: 

Virginia

On May 18, 2022, the Departments, having completed a review of Virginia's application, approved Virginia's State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2023 through December 31, 2027.

Application:


Correspondence:

Other Correspondence

Pass-through Funding

Vermont

On April 25, 2016, Vermont submitted a State Innovation Waiver application.  The Departments determined that the application was not complete on June 9, 2016.

Application:

Correspondence:

 

Washington

On December 9, 2022, the Departments, having completed a review of Washington’s waiver application submitted on May 13, 2022, approved Washington’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2024, through December 31, 2028.

Waiver (2022)

Application:

Correspondence:

Wisconsin

On July 29, 2018, the Departments, having completed a review of Wisconsin’s application, approved Wisconsin’s State Innovation Waiver under section 1332 of the ACA and the state accepted the Specific Terms and Conditions (STCs).  This approval is effective for January 1, 2019, through December 31, 2023.

On December 1, 2022, the Departments, having completed a review of Wisconsin’s waiver extension application submitted on May 5, 2022, approved Wisconsin’s State Innovation Waiver under section 1332 of the ACA. This approval is effective for January 1, 2024, through December 31, 2028.

Initial Waiver (2018)

Application:

Correspondence:

Waiver Extension Request (2021)

Application:

Correspondence:

Pass-through funding: 

Frequently Asked Questions about the 1332 State Innovation Waivers

1. What is a State Innovation Waiver?

Under Section 1332 of the Affordable Care Act (ACA), a state can apply for a State Innovation Waiver, allowing states to implement innovative ways to provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.  If approved, these waivers can begin on or after January 1, 2017.

2. What can be waived pursuant to a State Innovation Waiver?

The Secretary of Health and Human Services and the Secretary of the Treasury are authorized to waive a number of provisions under their respective jurisdictions.  Specifically, the Secretaries are authorized to waive:

  • Part I of Subtitle D of Title I of the Affordable Care Act (relating to establishing qualified health plans (QHPs));
  • Part II of Subtitle D of Title I of the ACA (relating to consumer choices and insurance competition through health insurance marketplaces);
  • Sections 36B of the Internal Revenue Code and 1402 of the ACA (relating to premium tax credits and cost-sharing reductions for plans offered within the marketplaces);
  • Section 4980H of the Internal Revenue Code (relating to employer shared responsibility); and
  • Section 5000A of the Internal Revenue Code (relating to individual shared responsibility).

Section 1332 does not change existing waiver authority for provisions in other Federal health programs such as Medicaid or Medicare (including waiver authorities under section 3021 specific to the Center on Medicare and Medicaid Innovation or under section 1115 related to Medicaid and CHIP), although states may apply for such waivers as part of the coordinated application process to be developed by the Secretary.

3. How do states apply?

States should submit their completed application in an electronic format to the Secretary of Health and Human Services at stateinnovationwaivers@cms.hhs.gov.

4. Who can states contact if they are interested in submitting a waiver application and have questions?

States should contact stateinnovationwaivers@cms.hhs.gov.

5. Will states have to apply to each relevant agency separately when submitting a State Innovation Waiver?

No.  A state seeking a State Innovation Waiver should apply by submitting a completed application in electronic format to the Secretary of Health and Human Services at stateinnovationwaivers@cms.hhs.gov only.  Upon receipt, applications will be transmitted to the Secretary of the Treasury or other relevant agencies for review as appropriate.

6. When must states submit applications for approval? How long will the process take?

Prior to submitting an application, a state must provide a public notice and comment period sufficient to ensure a meaningful level of public input, including consultation with Federally-recognized Indian tribes within state borders.  During the public comment period, the state must conduct public hearings to obtain public input regarding the state’s application, and must also accept written comments.

The Secretary of Health and Human Services and the Secretary of the Treasury will review an application and make a preliminary determination of whether it is complete within 45 days after it is submitted to stateinnovationwaivers@cms.hhs.gov.

After determining that the application is complete, the application will be made public through the Department of Health and Human Services website, and a federal public comment period will commence while the application is under review.  A final decision regarding the waiver will be issued no later than 180 days after the preliminary determination of a complete application.

State Innovation Waivers will not be available with effective dates prior to January 1, 2017.

7. What guidance and regulations exist for State Innovation Waivers?

Regulations governing the application process for State Innovation Waivers can be found here or the Federal Register at 77 Fed. Reg. 11700 (Feb. 27, 2012).   Among other things, these regulations provide guidance on how to apply for a waiver and what an application from a state must contain, including actuarial and economic analyses.  The regulations detail public notice and comment requirements that a state must comply with before an application is submitted, including holding public hearings, in order to facilitate a meaningful level of public involvement, input, and transparency in the state application process.  They also describe the Federal public notice and comment process that will occur after a completed application has been received.  The regulations also describe the requirements for post-award reporting and the standards under which post-award monitoring will take place.

As additional questions and issues arise, the Departments of Health and Human Services and Treasury will issue further guidance.  

8. What do states have to include with their application?

The final regulations specify what information needs to be included in an application for a State Innovation Waiver.  Critical elements of that application include (but are not limited to):

  • The list of provisions the state seeks to waive, including the rationale for the specific requests;
  • Data, assumptions, targets, and other information sufficient to determine that the proposed waiver will provide coverage that is at least as comprehensive as would be provided absent the waiver, will provide coverage and cost sharing protections that keep care at least as affordable as would be provided absent the waiver, will provide coverage to at least a comparable number of residents as would be provided coverage absent the waiver, and will not increase the Federal deficit;
  • Actuarial analyses and actuarial certifications to support State estimates that the waiver will comply with the comprehensive coverage requirement, the affordability requirement, and the scope of coverage requirement;
  • A detailed 10-year budget plan that is deficit neutral to the Federal government;
  • A detailed analysis of the impact of the waiver on health insurance coverage in the state;
  • A description and copy of the enacted state legislation providing the state authority to implement the proposed waiver; and,
  • A detailed plan as to how the state will implement the waiver, including a timeline.

The regulations provide more detail about each of the application elements and should be consulted carefully as states develop applications.

 

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