NGA Releases New Medicaid Toolkit

NYAPRS Note: The National Governors Association has just released step-by-step guide for states seeking to design and implement major changes to their Medicaid programs, such as by obtaining Section 1115 waivers. The guide is intended to "pull back the veil on the complex negotiations" between states and the feds, NGA's Frederick Isasi said. See the toolkit at

The Future of Medicaid Transformation: A Practical Guide for States

The toolkit is a guide for states seeking to design and implement statewide transformation of Medicaid programs, using the federal authorities of either State Plan Amendments or Section 1115 demonstrations (referred to as “Section 1115 waivers”). Specifically, the toolkit identifies the steps that will help states successfully engage with stakeholders and “get to yes” with the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS).1

The toolkit is not a comprehensive, exhaustive manual for every aspect of statewide health care transformation. Rather, it is intended to highlight the concepts and processes states should consider to create a more efficient path to approval for the states and CMS. The toolkit has been organized into two phases of statewide transformation: developing the building blocks for transformation and preparing, submitting and negotiating a proposal with CMS.

Within each phase, we highlight key elements critical to success. Note, however, that these phases are not linear and certain steps may need to occur concurrently. As a result, each state can adapt the process to meet its individual needs.

Implementation and evaluation are critical components to the successful transformation of a state Medicaid program, ensuring that the vision is successfully operationalized and that the state will be able to measure the impact of the reform on its Medicaid recipients and health care expenditures.

This toolkit does not focus on the implementation process, but states should consider planning for implementation and evaluation while they are negotiating with CMS for approval.

Although the toolkit addresses certain Medicaid requirements and policies, these requirements can change over time, and subsequent Administrations may interpret them differently. Accordingly, states should consult with their own legal counsel about federal and state requirements throughout their transformation efforts.

We also note that in 2017, the change in presidential Administration may affect states seeking to negotiate Medicaid transformation proposals with CMS and states will need to adjust their negotiations accordingly. The steps in this toolkit, however, address the fundamental building blocks for effectively designing and negotiating Medicaid transformation proposals and can be modified as needed to address new developments at the state or federal level.