For Amber "Waives" of Grain: The Impact of Medicaid Managed Care Waiver Programs on Care Choices in Rural America

Research center:
Lead researcher:
Project funded:
September 2015
Project completed:
May 2018

The number of states using waivers to place Medicaid enrollees in managed care plans is increasing. Across the states, there are currently 121 Section 1115 and 1915(b) waivers in either pending or approved status; 42 approved and 21 pending Section 1115 waivers, and 58 Section 1915(b) waivers, all of which are approved. Federal regulations require that states must provide the choice of at least two managed care programs for all Medicaid enrollees unless an exception for rural residents is declared in the waiver. In that case, states may restrict choice to only one managed care program. At present, the number of states applying choice waivers to rural populations, as well as the perceived effects of provider restrictions when only one care plan is available in a county, are not known.

This project used a combination of systematic review of waiver content and structured interviews with key informants to assess the potential for rural disparities in access to care for Medicaid enrollees. All approved and pending waivers were analyzed and categorized. Interviews with knowledgeable state contacts, identified for each state by personnel at the local State Office of Rural Health, were used to understand the state decision-making process underlying the use/non-use of rural waivers and to ascertain local policy-makers assessment of the effects of the waivers on rural Medicaid populations.


  • Medicaid Managed Care and the Rural Exception: A Review of Issues and Perspectives From the Field
    Policy Brief
    Rural and Minority Health Research Center
    Date: 05/2018
    To examine the intersection of state Medicaid procedures with rural populations, we conducted a review of Medicaid waivers current as of September 2017. This was supplemented with calls to State Offices of Rural Health (SORHs), state Medicaid offices, and other relevant stakeholders in an attempt to understand the process of waiver development.