Medicaid 1115 Waivers: Tracking SDOH, Pre-Release Coverage & Continuous Eligibility Changes

The landscape of Medicaid waivers is shifting, with the Trump administration signaling a move away from some of the priorities established under the Biden administration. Recent actions include rescinding guidance related to health-related social needs (HRSN) and phasing out funding for programs designed to address social determinants of health. These changes impact states with existing waivers and those considering new applications, particularly in areas like housing, nutrition, and continuous eligibility for children.

Social Determinants of Health: A Changing Approach

For years, Medicaid waivers have served as a tool for states to innovate and address the complex needs of their Medicaid populations. The Biden administration actively encouraged states to propose waivers that expanded coverage and tackled health-related social needs – the conditions in which people are born, grow, live, work and age. These include factors like housing instability, food insecurity, transportation access, and exposure to violence. In 2022, the Centers for Medicare & Medicaid Services (CMS) even announced a demonstration waiver opportunity specifically to expand tools for states to address these “HRSN,” building on earlier guidance issued in 2021. A detailed framework accompanied this initiative in 2023, further clarifying how states could incorporate HRSN into their waiver proposals.

Though, in March 2025, the Trump administration rescinded this Biden-era HRSN guidance. While CMS stated this doesn’t invalidate existing approvals for states already implementing HRSN-focused waivers, future requests will be evaluated on a case-by-case basis. This signals a potential slowdown in the approval of new waivers centered on addressing social determinants of health. The administration is likewise phasing out federal funding for “Designated State Health Programs” (DSHP) within waivers, further limiting the financial resources available for these types of initiatives.

Currently, several states have waivers approved under the Biden administration’s HRSN framework. KFF’s Medicaid Waiver Tracker provides a comprehensive overview of approved and pending waivers, including those specifically related to social determinants of health. It’s important to note that some states were already pursuing SDOH-related waivers prior to the HRSN framework, and those continue to be tracked separately.

Expanding Coverage for Individuals Re-entering Society

Another area of change involves waivers aimed at improving healthcare access for individuals transitioning out of incarceration. In April 2023, the Biden administration encouraged states to apply for waivers that would allow for pre-release coverage for incarcerated individuals, partially waiving the traditional rule prohibiting Medicaid payments for services provided during incarceration (except for inpatient care). This initiative aimed to improve care transitions, reduce disruptions in coverage, and ultimately lower recidivism rates. Nineteen states received approval for waivers to facilitate this pre-release coverage, demonstrating bipartisan support for addressing the healthcare needs of this population. KFF’s Medicaid Waiver Tracker provides detailed information on these waivers.

Continuous Eligibility for Children: A Shift in Policy

The Consolidated Appropriations Act of 2023 mandated that all states implement 12-month continuous eligibility for children, beginning January 1, 2024. This provision aimed to reduce disruptions in coverage and improve health outcomes for children. The Biden administration had previously approved waivers allowing nine states to extend continuous eligibility for children beyond the standard 12 months. However, in July 2025, the Trump administration announced it would not approve new waivers for continuous eligibility, nor would it extend existing ones for either children or adults. This represents a significant shift in policy, potentially leading to increased churn – the cycle of losing and regaining Medicaid coverage – for vulnerable populations. KFF’s Medicaid Waiver Tracker offers further details on these waivers.

Section 1115 waivers are inherently dynamic, reflecting the evolving priorities of both states and the federal government. The recent actions taken by the Trump administration signal a clear departure from the Biden administration’s emphasis on addressing social determinants of health and expanding coverage. States will need to adapt to these changes as they navigate the Medicaid waiver process going forward.

Looking Ahead: Waiver Reviews and Potential Adjustments

The coming months will be crucial for states with existing waivers. While the rescission of HRSN guidance doesn’t immediately invalidate approved waivers, states will need to carefully consider how the new federal stance might impact their ability to renew or modify those waivers when they come up for review (typically every three to five years). The phasing out of DSHP funding will also require states to reassess their financial strategies for supporting social determinants of health initiatives. It’s likely we’ll see a period of increased scrutiny and potentially more limited flexibility in the waiver approval process. The Centers for Medicare & Medicaid Services (CMS) will be closely watching how states respond to these changes, and further guidance may be issued as the situation evolves.