If you receive both Medicare and Medicaid — a situation that applies to roughly 12 million Americans known as dual-eligible beneficiaries — you may have heard the term "Section 1115 waiver" mentioned by a caseworker, a doctor's office, or a state agency letter. Most people set that phrase aside because it sounds like bureaucratic noise. It isn't. These waivers are the legal mechanism states use to change how Medicaid works within their borders, and those changes can affect everything from whether you qualify for home-based care to whether your state covers dental services or postpartum support. Understanding what these waivers are, how they work, and what the current landscape looks like is not just policy trivia — it is practical knowledge that can protect your coverage.
A Section 1115 Medicaid demonstration waiver is, at its core, a permission slip. Federal Medicaid law sets a baseline for what states must cover and who must be eligible. But states can apply to the U.S. Department of Health and Human Services for a waiver of those federal requirements if they want to try something different — a new delivery model, an expanded eligibility group, a new benefit category, or in some cases, a restriction that federal law would not otherwise allow. The HHS Secretary must determine that the proposed approach is likely to "promote the objectives of the Medicaid program" before approving it. That standard has been interpreted differently by different administrations, which is why the waiver landscape shifts noticeably every four to eight years.
As of October 2026, nearly every state in the country has at least one active Section 1115 waiver, and many states have multiple waivers running simultaneously. According to KFF analysis of state Section 1115 Medicaid waivers posted to Medicaid.gov, these waivers span three broad categories: eligibility changes (who can enroll), benefit changes (what is covered), and social determinants of health and delivery system reforms (how care is organized and paid for). Each of those categories can have real consequences for seniors and people with disabilities who depend on Medicaid to fill the gaps that Medicare leaves behind.
For dual-eligible beneficiaries specifically, the eligibility provisions in these waivers matter most. Some states have used 1115 waivers to expand Medicaid to populations not traditionally covered — including people with behavioral health needs, individuals with physical disabilities who need home and community-based services, justice-involved individuals approaching release from incarceration, and postpartum individuals who would otherwise lose coverage shortly after giving birth. If you have a family member who might qualify for Medicaid under one of these expanded categories, your state's active waivers are worth reviewing. Conversely, some waivers include eligibility restrictions — such as work requirements or more frequent eligibility redeterminations — that could cause someone to lose coverage if they are not paying close attention to renewal notices.
The political dimension of these waivers is something beneficiaries need to understand plainly. Waiver priorities change with presidential administrations. Under the Biden administration, for example, the Centers for Medicare and Medicaid Services (CMS) developed a standardized application and special terms and conditions specifically designed to speed up approval of pre-release Medicaid waivers — programs that allow incarcerated individuals to begin receiving Medicaid benefits before they are released, so there is no gap in coverage. As of October 2026, no pre-release waivers have been approved under the second Trump administration, and the policy direction for those waivers remains uncertain. This is not a partisan observation — it is a practical one. If you or someone you care for was counting on a benefit that was approved under a prior administration, it is worth confirming with your state Medicaid office whether that benefit remains in effect.
Data Snapshot: According to CMS.gov data, as of 2024 there were approximately 12.4 million full-benefit dual-eligible beneficiaries enrolled in both Medicare and Medicaid nationwide. These individuals are among the most medically complex and financially vulnerable in the entire healthcare system — many rely on Medicaid not just for supplemental coverage of Medicare cost-sharing, but for long-term services and supports like personal care attendants, adult day programs, and nursing facility care that Medicare does not cover at all. Any state waiver that touches home and community-based services (HCBS) eligibility or benefit design has a direct line to the daily lives of this population.
Benefit-related waivers are the second major category to watch. States have used 1115 authority to add services that standard Medicaid does not require — things like housing support, nutrition assistance, employment services, and expanded mental health and substance use treatment. Some states have used waivers to cover dental care for adults, which is not a federal Medicaid requirement and is also not covered by traditional Medicare. If you are on Medicaid and have been receiving a benefit like transportation assistance or home-delivered meals through a waiver program, you should know that those benefits exist because of a specific waiver approval — and they can be modified or discontinued if the waiver is not renewed or if its terms change. Always ask your caseworker which of your benefits are waiver-based versus standard Medicaid entitlements.
The third category — social determinants of health and delivery system reforms — is the most abstract but increasingly important. States are using waivers to test new payment models, integrate physical and behavioral health care, and address upstream factors like housing instability and food insecurity that drive expensive emergency care. For a senior living alone with multiple chronic conditions, a waiver that funds a care coordinator or a community health worker could be the difference between staying at home and ending up in a nursing facility. These programs are often piloted in specific counties or regions before being expanded statewide, so availability varies significantly even within a single state.
If you want to know what waivers are active or pending in your state, the most reliable starting point is Medicaid.gov, which maintains a full list of approved and pending waivers. KFF also maintains a detailed tracker — updated regularly — that breaks down waiver provisions by state and topic, including whether a waiver expands or restricts eligibility, what benefits it adds or removes, and whether it is currently approved or still pending federal review. These are not light reading, but the tracker includes plain-language summaries that make it accessible. Your State Health Insurance Assistance Program (SHIP) counselor — available free of charge in every state — can also help you understand how active waivers in your state affect your specific situation. To find your local SHIP counselor, call 1-800-MEDICARE or visit medicare.gov/find-a-medicare-plan.
For Medicare Advantage beneficiaries who also have Medicaid, the intersection of these two programs is handled through a specific plan type called a Dual Eligible Special Needs Plan, or D-SNP. In 2025, there were more than 800 D-SNP plans available nationally, according to CMS.gov data, and these plans are specifically designed to coordinate Medicare and Medicaid benefits in a single plan. However, D-SNPs operate within the rules set by both federal Medicare law and your state's Medicaid program — including any active 1115 waivers. If your state's Medicaid waiver changes what behavioral health services are covered, for example, that change flows through to what your D-SNP can offer. This is why it is not enough to simply pick a D-SNP during the Annual Enrollment Period (October 15 through December 7) and assume your coverage is stable year to year. You need to review your plan's Annual Notice of Change each fall and confirm that the Medicaid-funded benefits you rely on are still in place.
One practical step that many beneficiaries overlook: if you receive a letter from your state Medicaid agency about a waiver renewal, a public comment period, or a change in program terms, do not discard it. These letters are your early warning system. States are required to hold public comment periods before submitting major waiver applications to CMS, and beneficiaries have the legal right to submit comments. If a proposed waiver would restrict your eligibility or eliminate a benefit you depend on, your comment — and the comments of others in similar situations — can influence whether and how the waiver is approved. Advocacy organizations like AARP and state-based disability rights groups often organize comment campaigns around high-stakes waiver applications and can help you understand what is at stake and how to respond.
Finally, it is worth understanding that the waiver tracker maintained by KFF and the official list on Medicaid.gov represent a snapshot in time. Waivers are living documents — they are approved for fixed periods (typically five years), subject to renewal, and can be amended during their active period. A waiver that was approved last year may be under amendment review today. The pace of change has accelerated in recent years as administrations have moved quickly to reshape Medicaid policy through the waiver process rather than waiting for congressional action. For dual-eligible beneficiaries, staying informed is not optional — it is a form of self-protection. Check your state Medicaid agency's website at least once a year, keep your contact information current with your caseworker, and respond promptly to any renewal or redetermination notices you receive in the mail.