If you receive both Medicare and Medicaid — or if you're a low-income Medicare beneficiary who relies on Medicaid to help pay your premiums and cost-sharing — then a relatively obscure federal policy tool called the Section 1115 waiver may be shaping your healthcare in ways you've never been told about. As of September 30, 2026, nearly every state in the country has at least one active Section 1115 Medicaid demonstration waiver, and some states are running multiple waivers simultaneously. Understanding what these waivers are, what they can change, and how to find out what your state is doing is genuinely important for any senior who depends on Medicaid for any part of their coverage.
Section 1115 of the Social Security Act gives the Secretary of Health and Human Services the authority to approve state experiments that depart from standard Medicaid rules — as long as the experiment is likely to promote the objectives of the Medicaid program. In plain language, that means a state can apply to the federal government for permission to do things differently: cover people who wouldn't normally qualify, restrict benefits that are usually required, test new ways of delivering care, or address social factors like housing instability and food insecurity that affect health outcomes. These waivers are called "demonstrations" because they're technically experiments, but in practice many have been renewed for decades and function as permanent features of a state's Medicaid program.
For Medicare beneficiaries, the most direct connection to Section 1115 waivers runs through the roughly 12.5 million Americans who are "dual eligible" — enrolled in both Medicare and Medicaid at the same time. According to CMS.gov data, dual-eligible individuals represent about 20% of Medicare enrollment but account for a disproportionately large share of total Medicare and Medicaid spending combined. These are typically seniors and people with disabilities who have low enough incomes and assets to qualify for Medicaid on top of their Medicare coverage. For this group, what a state does with its Medicaid waivers can determine whether they receive home-based care instead of nursing home placement, whether behavioral health services are covered, and whether they qualify for expanded benefits through a Dual Special Needs Plan (D-SNP) offered through Medicare Advantage.
Section 1115 waivers fall into several broad categories that matter differently depending on your situation. Eligibility waivers can expand who qualifies for Medicaid — for example, extending postpartum coverage from 60 days to 12 months, or covering people leaving incarceration in the period just before their release. They can also restrict eligibility in ways that may affect current beneficiaries, such as adding work or community engagement requirements. Benefit waivers can add services not normally covered under federal Medicaid rules — things like respite care for family caregivers, supported housing services, or expanded dental and vision coverage. Delivery system reform waivers restructure how care is organized and paid for, often moving toward managed care arrangements or value-based payment models. And a growing category of waivers addresses social determinants of health (SDOH), allowing states to use Medicaid dollars for services like medically tailored meals, transportation to medical appointments, or short-term housing assistance.
According to KFF analysis of state Section 1115 Medicaid waivers posted to Medicaid.gov as of September 30, 2026, the landscape of approved and pending waivers spans all of these categories, with significant variation by state. Some states have pursued aggressive expansions — adding home and community-based services (HCBS) waivers that allow seniors to receive care at home rather than in a nursing facility, which is both less expensive and strongly preferred by most older adults. Other states have pursued restrictions, including work requirements for certain Medicaid populations, though the legal and administrative durability of work requirements has been contested across multiple presidential administrations. The current status of any specific provision in your state depends on whether it has been approved by CMS, is pending review, or has been withdrawn or denied.
For Medicare Advantage enrollees specifically, Section 1115 waivers interact with the D-SNP structure in important ways. D-SNPs are Medicare Advantage plans specifically designed for dual-eligible beneficiaries, and they are required to coordinate with state Medicaid programs. In 2026, CMS has continued pushing for tighter integration between D-SNPs and state Medicaid managed care, a policy direction called "integrated care." States that have active 1115 waivers covering their dual-eligible populations may have negotiated specific benefit packages, cost-sharing rules, or care coordination requirements that affect which D-SNPs operate in the state and what those plans must cover. If you're a dual-eligible beneficiary shopping for a Medicare Advantage plan during the Annual Enrollment Period (October 15 through December 7), the D-SNP options available to you in your county are directly shaped by your state's Medicaid waiver landscape.
Data Snapshot: According to CMS.gov data for 2026, there are more than 800 Medicare Advantage plan options nationally that carry a Special Needs Plan (SNP) designation, with D-SNPs representing the largest share of that category. CMS star ratings data shows that D-SNPs as a group have faced quality measurement challenges, with a meaningful portion of plans rated below 4 stars — a threshold that affects plan bonuses and, indirectly, the richness of supplemental benefits plans can afford to offer enrollees. In states with robust 1115 waiver-based Medicaid managed care programs, D-SNP integration requirements tend to be more stringent, which can mean better care coordination but also a more limited number of plan choices.
One of the most consequential categories of Section 1115 waivers for older adults is the Home and Community-Based Services (HCBS) waiver, sometimes called a 1915(c) waiver, though states also pursue HCBS expansions through 1115 demonstrations. These waivers fund services that allow seniors with functional limitations to remain in their homes and communities rather than entering nursing facilities. Services covered can include personal care aides, adult day programs, home-delivered meals, home modifications like grab bars and ramps, and caregiver support. Waiting lists for HCBS waivers have historically been a serious problem in many states — some seniors wait years for a slot to open. States with approved 1115 waivers that expand HCBS capacity or eliminate waiting lists are offering a meaningfully different level of support than states that have not pursued such expansions.
Behavioral health is another area where 1115 waivers have become increasingly important for older adults. Depression, anxiety, and substance use disorders are underdiagnosed and undertreated in the senior population, and standard Medicaid coverage has historically had gaps in mental health and substance use treatment. Several states have used 1115 waivers to expand behavioral health benefits, integrate mental health care into primary care settings, or fund community-based crisis services. For a dual-eligible senior whose Medicare covers some mental health services but whose Medicaid fills in cost-sharing gaps, the scope of a state's behavioral health waiver can determine whether they can actually afford to access care.
If you want to find out exactly what waivers your state has approved or pending, the most direct path is Medicaid.gov's state waiver list, which is publicly searchable by state and waiver type. Your state Medicaid agency — usually called the Department of Health, Department of Social Services, or a similar name depending on your state — also publishes information about active waivers and any public comment periods for new waiver applications. Federal rules require states to hold public comment periods before submitting major waiver applications to CMS, which means beneficiaries technically have an opportunity to weigh in before a waiver is approved. In practice, these comment periods are not widely publicized, but advocacy organizations like your State Health Insurance Assistance Program (SHIP) counselor can alert you to pending changes that might affect your coverage.
Work requirements are worth addressing directly because they have generated significant controversy and confusion. Under the current administration as of 2026, some states have received approval or are pursuing approval for community engagement requirements that condition Medicaid eligibility on documented work, volunteering, job training, or similar activities. These requirements, where approved and implemented, generally apply to working-age adults rather than seniors or people with disabilities — but the exemption categories matter enormously. If you are a Medicare beneficiary who is also on Medicaid and you are under 65 or have a disability, you should verify with your state Medicaid agency whether any community engagement requirement applies to your eligibility category. Misunderstanding an exemption and failing to report correctly has caused coverage losses for people who were actually exempt.
For beneficiaries in states that have not expanded Medicaid under the Affordable Care Act — as of 2026, a shrinking but still significant group of states — Section 1115 waivers have sometimes been used as an alternative path to covering low-income adults who fall in the coverage gap. These partial-expansion or alternative-expansion waivers may come with conditions not present in standard ACA expansion, such as premiums, cost-sharing requirements, or time limits on coverage. If you live in a non-expansion state and you're trying to understand your Medicaid eligibility, the standard income thresholds and rules you read about nationally may not apply to your state — your state's specific waiver terms govern.
The practical bottom line for Medicare beneficiaries is this: Medicaid is not a single national program with uniform rules. It is 50 different state programs operating within a federal framework, and Section 1115 waivers are the primary mechanism through which states customize their programs most dramatically. If you are dual eligible, if you rely on Medicaid for long-term care, if you receive home-based services funded by Medicaid, or if you're enrolled in a D-SNP, the specific waivers your state has in place are directly relevant to your coverage. Calling your State Health Insurance Assistance Program (SHIP) — reachable through 1-800-MEDICARE — is a free, unbiased way to get help understanding how your state's Medicaid program works and how it interacts with your Medicare coverage. SHIP counselors are trained specifically to help beneficiaries navigate the Medicare-Medicaid intersection, and their services cost nothing.