Medicaid: Active State Plan Amendments and Waivers
What to know
State Plan Amendments (SPAs) and waivers are two key Medicaid policy tools. Using SPAs and waivers, Wisconsin Medicaid describes who is eligible for Medicaid, what services Medicaid will cover, and how Medicaid will pay for covered services. The federal government must approve all SPAs and waivers.
The Wisconsin Department of Health Services (DHS) works closely with the federal Centers for Medicare & Medicaid Services (CMS) to run Medicaid. Two important Medicaid policy tools are state plan amendments (SPAs) and waivers.
About SPAs
Each state has a Medicaid State Plan. The State Plan describes how Medicaid works in that state, including:
- Who is eligible.
- What services are covered, and any limitations.
- How Medicaid pays for services.
To change how Medicaid works, DHS must update the Wisconsin Medicaid State Plan using an amendment (SPA). CMS must approve all SPAs. When CMS reviews SPAs, they make sure that DHS is following all of the federal regulations. After the SPA is approved, DHS can update the State Plan and make the requested change.
SPA tracker
This table describes recently-submitted SPAs. Each SPA is tracked by its name and identification number, along with a brief summary, the date it takes effect, and the status of CMS’ review. Some SPAs are noticed in the administrative register for public awareness and comments—links to those public notices are in the first column.
For additional information, including the full text of approved SPAs, you can visit the CMS Medicaid SPAs webpage and search for Wisconsin SPAs.
| Number and Name | Summary | Effective Date | Status |
|---|---|---|---|
| 25-0015: Single Case Agreements | When there is no Medicaid rate for a service that is needed for lifesaving care, DHS negotiates special rates with hospitals. This SPA clarifies which hospitals are eligible, and the timing for negotiating single case agreements. | July 1, 2025 | CMS review |
| 25-0016: Hospital Access Payments | DHS collects a fee from Wisconsin hospitals and uses these funds to make "Access Payments" to hospitals for services to Medicaid patients, which support member access. This SPA will exempt long-term acute care hospitals from these fees and payments, and note increases to the fees and payments. | July 1, 2025 | Approved by CMS |
| 25-0017: Nursing Home Annual Rate Update | DHS is making regular yearly updates to nursing home rates. The SPA will also clarify the independent audit requirement policy for nursing homes. | July 1, 2025 | CMS review |
| 25-0018: Coverage of Services within Provider Scope of Practice | Wisconsin 2017 Act 119 broadens the scope of who may prescribe or order some Medicaid services. This change allows members to see more provider types for some types of care, and Medicaid will pay for these services. | December 1, 2025 | Approved by CMS |
| 25-0019: Graduate Medical Education Add-on—Clean Up | DHS provides supplemental payments to hospitals to support graduate medical education. This SPA clarifies that these payments are not limited to the specialty programs currently listed. | July 1, 2025 | Withdrawn |
| 25-0020: Required Clinic Services Template Update | Covered clinic services are now described in a new CMS template. DHS put existing information about Medicaid-covered clinic services into this template. This SPA did not change any existing policies. | July 1, 2025 | Approved by CMS |
| 25-0021: Advisory Committee on Immunization Practices (ACIP) Vaccine Coverage | The change allows Medicaid to cover vaccines recommended by additional governing bodies that offer clinical expertise on vaccines, in addition to ACIP. | July 1, 2025 | Approved by CMS |
| 25-0022: Recovery Audit Contractor Exception | CMS requires states to contract with a recovery audit contractor (RAC) to identify underpayments and overpayments of Medicaid claims. Wisconsin's exception was approved to continue. | November 1, 2025 | Approved by CMS |
| 25-0023: Chiropractic Coverage Expansion | If approved, this expansion would allow Medicaid to reimburse for all services that are within the scope of practice for chiropractors under state law, as required by the Wisconsin 2025-2027 Biennial Budget. | January 1, 2026 | CMS review |
| 25-0024: Care4Kids Update | The Care4Kids pages of the State Plan are now updated to reflect existing changes to the Medicaid State Plan. New populations are also now eligible for Care4Kids and retroactive coverage for care coordination is now available in some cases. | January 1, 2026 | Approved by CMS |
| 25-0025: Mandatory Medication Assisted Treatment (MAT) Template Update | MAT benefits are now described using a new CMS-required template. | October 1, 2025 | Approved by CMS |
| 26-0001: Annual Cost of Living Adjustment (COLA) Update | Annual adjustments were made to the home maintenance allowance and income standards for members of Elderly, Blind, or Disabled (EBD) Medicaid based on COLA. | January 1, 2026 | Approved by CMS |
| 26-0002: Interoperability Rule Updates | The Medicaid State Plan was updated to reflect prior authorization requirement updates as a result of the 2024 Interoperability and Prior Authorization Rules. The SPA removed the definition of spell of illness language from therapies pages impacting physical therapy, occupational therapy, and speech-language pathology. | January 1, 2026 | Approved by CMS |
| 26-0003: Inpatient Rate Increases | Some rates were adjusted to reflect anticipated reductions in outlier payments for critical access and acute care hospitals. This SPA also increased the behavioral health policy adjuster. | January 1, 2026 | Approved by CMS |
| 26-0004: Outpatient Dental Add-on | The per-visit add-on for outpatient deep sedation for dental services was updated to meet budgetary target estimates. | January 1, 2026 | Approved by CMS |
| 26-0005: Private Duty Nursing Rate Increase | This SPA increases private duty nursing rates as directed in the 2025-2027 biennial budget. | January 1, 2026 | CMS review |
| 26-0006: Personal Care Rate Increase | This SPA increases personal care rates as directed in the 2025-2027 biennial budget. | January 1, 2026 | CMS review |
| 26-0007: Home Health Rate Increase | This SPA increases home health rates as directed in the 2025-2027 biennial budget. | January 1, 2026 | CMS review |
| 26-0008: Obstetrics Rate Increase | This SPA increases rates for obstetrics services as directed in the 2025-2027 biennial budget. | January 1, 2026 | CMS review |
| 26-0009: School-Based Services (SBS) | This SPA is to comply with May 2023 CMS guidance. Specifically, the SPA will change how Wisconsin Medicaid:
| July 1, 2026 | CMS review |
| 26-0010: COLA Update #2 | This is a continuation of SPA 26-0001, making additional updates based on federal changes. Wisconsin Medicaid updated the Medicaid State Plan to reflect the annual COLA to the SSI benefit amount. | May 1, 2026 | Approved by CMS |
| 26-0011: Prenatal Care Coordination | This SPA aligns the Prenatal Care Coordination benefit with recent admin rule changes (provider qualifications and documentation requirements). | June 1, 2026 | CMS review |
| 26-0012: Peer Recovery Services (PRS) | This SPA adds new PRS services and a peer recovery coach provider type. | April 1, 2026 | CMS review |
| 26-0013: DSH Elimination | Absolute latest submission is June 30 (assuming Access payment approval) | June 16, 2026 | CMS review |
| 26-0014: 12-Month Postpartum Eligibility | This SPA extends postpartum coverage from 60 days to 12 months. | June 1, 2026 | CMS review |
About waivers
In some cases, DHS wants to make changes that are not normally allowed by CMS. We can’t make these changes in the State Plan. Instead, DHS asks for a waiver from CMS. CMS can make an exception to (or waive) some federal requirements.
Wisconsin Medicaid uses two of the most common types of waivers: 1115 waivers and 1915 waivers.
1115 waivers can test new ways of running Medicaid without following some federal requirements. States use 1115 waivers to:
- Cover populations who are not usually eligible for Medicaid.
- Provide services that Medicaid usually cannot cover.
- Charge members premiums or copayments.
- Pay providers in new ways.
There are a few types of 1915 waivers. They can waive very specific requirements. They allow states to:
- Require members to use a provider network called a managed care organization (MCO).
- Provide home and community-based services to some groups of members.
Waiver tracker
Know what waivers there are and what their status is.
BadgerCare
Summary
The BadgerCare 1115 waiver adds Medicaid coverage for:
- Adults without children who have low incomes.
- Former foster care youth from another state.
- Residential substance use disorder treatment for adults in institutions for mental disease (IMD).
Members enroll in a managed care organization.
The BadgerCare waiver allows the Medicaid to charge an $8 copayment when members visit the emergency room when their care needs aren’t an emergency.
Population(s) covered
- Adults with incomes up to 100% federal poverty level (FPL) who do not have children
- Former foster care youth up to age 26 from out of state
Effective dates
October 29, 2024–December 31, 2029
Ongoing activities
DHS submitted two required reports to CMS:
- BadgerCare evaluation for the 2018-2024 waiver period: CMS provided minor questions and feedback. DHS shared answers. We received approval December 9.
- Proposed approach to evaluate BadgerCare in the current waiver period from 2024–2029: CMS provided minor questions and feedback. DHS provided responses. We are waiting for approval, which may happen in early 2026.
More information
BadgerCare serious mental illness (SMI) or serious emotional disturbance (SED) Amendment
Summary
This addition to the BadgerCare waiver would add coverage for inpatient stays in an IMD for adults age 21-64 who have SMI or SED.
Population(s) covered
Adults with SMI or SED, age 21-64
Effective dates
Pending
Ongoing activities
DHS submitted to CMS in December 2024. Approval may happen in 2026.
More information
Serious Mental Illness and Serious Emotional Disturbance Waiver
SeniorCare
Summary
The SeniorCare 1115 waiver adds Medicaid coverage for:
- Prescription drugs
- Medication Therapy Management for members with high risk for medical complications due to their medications
Members are older adults who aren’t eligible for Wisconsin Medicaid because their annual income is too high.
Population(s) covered
Adults age 65 and older with income up to 200% FPL
Effective dates
April 12, 2019–December 31, 2028
Ongoing activities
DHS submitted an annual evaluation report in March 2025. This was approved in November 2025.
More information
Family Care and Family Care Partnership
Summary
The Family Care and Family Care Partnership 1915 waiver adds Medicaid coverage for long term care services. Members use home and community-based services (HCBS) and would otherwise require enough care that they would live in a nursing home. Covered services include day care, care management, transportation, and daily living.
Members work with a managed care organization to plan, find, manage, and pay for the services they need.
Population(s) covered
- Adults age 65 and older
- Adults age 18-64 with disabilities who need a nursing home level of care
- Adults age 18 and older with intellectual and/or development disabilities
Effective dates
January 1, 2025–December 31, 2029
Ongoing activities
Renewed January 2025.
DHS submitted updated budget information to CMS in October 2025.
More information
IRIS (Include, Respect, I Self-Direct)
Summary
The IRIS 1915 waiver adds Medicaid coverage for long term care services. Members use HCBS and would otherwise require enough care that they would live in a nursing home. Covered services include: live-in caregivers, nursing, assistive equipment and devices, transportation, and counseling.
IRIS members work with a partner agency to manage their care. They create their own care plan, choose services and providers, and pay for their care within an approved budget.
Population(s) covered
- Adults 65 and older
- Adults ages 18-64 with disabilities who need a nursing home level of care
- Adults age 18 and older with intellectual and/or development disabilities
Effective dates
January 1, 2026–December 31, 2030
Ongoing activities
In September 2025, DHS submitted a request to CMS to extend the IRIS waiver. This extension was approved December 2, 2025.
More information
Children’s Long-Term Support (CLTS)
Summary
The CLTS 1915 waiver adds Medicaid coverage for long term care services. The CLTS Program covers HCBS for kids with disabilities (and their families). Without HCBS, members would otherwise require enough care that they would live in an institution.
County agencies work with members and families to determine kids’ needs and coordinate services. Covered services include: support services, teaching and skills development, service coordination, assistive equipment, and housing supports.
Population(s) covered
Kids up to age 21 who have:
- An intellectual disability
- A physical disability
- Been diagnosed with severe emotional disturbance
Effective dates
January 1, 2022–December 31, 2026
Ongoing activities
CMS approved small, technical changes in early 2025.
In July 2026, DHS submitted a request to CMS to extend the CLTS waiver.
More information
Questions and answers
State and federal governments work together to run Medicaid. Medicaid programs must follow strict rules and laws. Many of these regulations are described in the Social Security Act, which created Medicaid and the requirements for how Medicaid must operate. Sometimes, these regulations mean Medicaid must cover some services and populations. Other times, these regulations limit what Medicaid can do.
While DHS and our state elected officials can make many decisions about Medicaid in Wisconsin, we also need approval from the federal government for many decisions. CMS gives us permission (also called “authority”). SPAs and waivers are two ways DHS gets authority from CMS to run our Medicaid programs.
Our Medicaid Advisory Committee helps us shape policy decisions for Medicaid. In addition to CMS and Wisconsin’s elected officials, DHS asks for feedback on SPAs and waivers from:
- Tribal health directors.
- The Medicaid Advisory Committee.
- The Medicaid Member Experience Council.
- The public.
This feedback and input helps make sure that Wisconsin Medicaid works well for the people who need it. DHS might get feedback about how SPAs or waivers:
- Change costs for providers.
- Impact different populations.
- Increase or decrease access to services.
- Create or worsen disparities.
DHS uses this feedback to make Medicaid policies better and more fair.
The SPA process looks like this:
- Wisconsin finds ways to improve how Medicaid works. DHS gets feedback about the changes needed to improve.
- DHS submits a SPA to CMS for review.
- If CMS approves the SPA, DHS updates the State Plan.
- DHS makes the changes. For example, providers can offer a new service or get paid a new rate.
The waiver process looks like this:
- Wisconsin finds ways to improve how Medicaid works.
- DHS gets input and feedback from the public.
- DHS submits the waiver to CMS.
- CMS reviews and asks DHS questions.
- If CMS approves, DHS makes the change.