[Federal Register Volume 80, Number 241 (Wednesday, December 16, 2015)]
[Rules and Regulations]
[Pages 78131-78135]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-31563]


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DEPARTMENT OF THE TREASURY

31 CFR Part 33

DEPARTMENT OF HEALTH AND HUMAN SERVICES

45 CFR Part 155

[CMS-9936-N]


Waivers for State Innovation

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS; Department 
of the Treasury.

ACTION: Guidance.

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SUMMARY: This guidance relates to Section 1332 of the Patient 
Protection and Affordable Care Act (ACA) and its implementing 
regulations. Section 1332 provides the Secretary of Health and Human 
Services and the Secretary of the Treasury with the discretion to 
approve a state's proposal to waive specific provisions of the ACA (a 
State Innovation Waiver), provided the proposal meets certain 
requirements. In particular, the Secretaries can only exercise their 
discretion to approve a waiver if they find that the waiver would 
provide coverage to a comparable number of residents of the state as 
would be provided coverage absent the waiver, would provide coverage 
that is at least as comprehensive and affordable as would be provided 
absent the waiver, and would not increase the Federal deficit. If the 
waiver is approved, the state may receive funding equal to the amount 
of forgone Federal financial assistance that would have been provided 
to its residents pursuant to specified ACA programs, known as pass-
through funding. State Innovation Waivers are available for effective 
dates beginning on or after January 1, 2017. They may be approved for 
periods up to 5 years and can be renewed. The Departments promulgated 
implementing regulations in 2012. This document provides additional 
information about the requirements that must be met, the Secretaries' 
application review procedures, the amount of pass-through funding, 
certain analytical requirements, and operational considerations.

DATES: Comment Date: Comments may be submitted at any time.

ADDRESSES: In commenting, please refer to file code CMS-9936-N. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
document to http://www.regulations.gov. Follow the ``Submit a comment'' 
instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-9936-N, P.O. Box 8016, 
Baltimore, MD 21244-8016.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-9936-N, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments ONLY to the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members. Comments erroneously mailed to 
the addresses indicated as appropriate for hand or courier delivery may 
be delayed.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Centers for Medicare & Medicaid 
Services: Tricia Beckmann, 301-492-4328, or Robert Yates, 301-492-5151.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received are available for viewing by the public, including any 
personally identifiable or confidential business information that is 
included in a comment. We post all comments received on the following 
Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received will also be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, at the headquarters of the Centers for 
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, 
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 
p.m. To schedule an appointment to view public comments, phone 1-800-
743-3951.

I. Statutory Requirements

    Under Section 1332 of the Affordable Care Act (ACA), the 
Secretaries of Health and Human Services (HHS) and the Treasury as 
appropriate may

[[Page 78132]]

exercise their discretion to approve a request for a State Innovation 
Waiver only if the Secretaries determine that the proposal meets the 
following four requirements: (1) The proposal will provide coverage to 
at least a comparable number of the state's residents as would be 
provided absent the waiver; (2) the proposal will provide coverage and 
cost-sharing protections against excessive out-of-pocket spending that 
are at least as affordable for the state's residents as would be 
provided absent the waiver; (3) the proposal will provide coverage that 
is at least as comprehensive for the state's residents as would be 
provided absent the waiver; and, (4) the proposal will not increase the 
Federal deficit. The Secretaries retain their discretionary authority 
under Section 1332 to deny waivers when appropriate given consideration 
of the application as whole, including the four requirements. As under 
similar waiver authorities, the Secretaries reserve the right to 
suspend or terminate a waiver, in whole or in part, any time before the 
date of expiration, if the Secretaries determine that the state 
materially failed to comply with the terms and conditions of the 
waiver, including any of the requirements discussed in this guidance.
    Final regulations at 31 CFR part 33 and 45 CFR part 155, subpart N 
require a state to provide actuarial analyses and actuarial 
certifications, economic analyses, data and assumptions, targets, an 
implementation timeline, and other necessary information to support the 
state's estimates that the proposed waiver will comply with these 
requirements.\1\
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    \1\ ``Application, Review, and Reporting Process for Waivers for 
State Innovation Final Rule.'' February 27, 2012. Available at: 
http://www.gpo.gov/fdsys/pkg/FR-2012-02-27/pdf/2012-4395.pdf.
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A. Coverage

    To meet the coverage requirement, a comparable number of state 
residents must be forecast to have coverage under the waiver as would 
have coverage absent the waiver.
    Coverage refers to minimum essential coverage (or, if the 
individual shared responsibility provision is waived under a State 
Innovation Waiver, to something that would qualify as minimum essential 
coverage but for the waiver). For this purpose, ``comparable'' means 
that the forecast of the number of covered individuals is no less than 
the forecast of the number of covered individuals absent the waiver. 
This condition generally must be forecast to be met in each year that 
the waiver would be in effect.
    The impact on all state residents is considered, regardless of the 
type of coverage they would have absent the waiver. (For example, while 
a State Innovation Waiver may not change the terms of a state's 
Medicaid coverage or change existing Medicaid demonstration authority, 
changes in Medicaid enrollment that result from a State Innovation 
Waiver, holding the state's Medicaid policies constant, are considered 
in evaluating the number of residents with coverage under a waiver.)
    Assessment of whether the proposal covers a comparable number of 
individuals also takes into account the effects across different groups 
of state residents, and, in particular, vulnerable residents, including 
low-income individuals, elderly individuals, and those with serious 
health issues or who have a greater risk of developing serious health 
issues. Reducing coverage for these types of vulnerable groups would 
cause a waiver application to fail this requirement, even if the waiver 
would provide coverage to a comparable number of residents overall. 
Finally, analysis under the coverage requirement takes into account 
whether the proposal sufficiently prevents gaps in or discontinuations 
of coverage.
    As provided in 31 CFR part 33 and 45 CFR part 155, subpart N, the 
waiver application must include analysis and supporting data that 
establishes that the waiver satisfies this requirement, including 
information on the number of individuals covered by income, health 
status, and age groups, under current law and under the waiver, 
including year-by-year estimates. The application should identify any 
types of individuals who are less likely to be covered under the waiver 
than under current law.
    The state should also provide a description of the model used to 
produce these estimates, including data sources and quality, key 
assumptions, and parameters. The state may be required to provide micro 
data and other information to inform the Secretaries' analysis.

B. Affordability

    To meet the affordability requirement, health care coverage under 
the waiver must be forecast to be as affordable overall for state 
residents as coverage absent the waiver.
    Affordability refers to state residents' ability to pay for health 
care and may generally be measured by comparing residents' net out-of-
pocket spending for health coverage and services to their incomes. Out-
of-pocket expenses include both premium contributions (or equivalent 
costs for enrolling in coverage), and any cost sharing, such as 
deductibles, co-pays, and co-insurance, associated with the coverage. 
Spending on health care services that are not covered by a plan may 
also be taken into account if they are affected by the waiver proposal. 
The impact on all state residents is considered, regardless of the type 
of coverage they would have absent the waiver. This condition generally 
must be forecast to be met in each year that the waiver would be in 
effect.
    Waivers are evaluated not only based on how they affect 
affordability on average, but also on how they affect the number of 
individuals with large health care spending burdens relative to their 
incomes. Increasing the number of state residents with large health 
care spending burdens would cause a waiver to fail the affordability 
requirement, even if the waiver would increase affordability for many 
other state residents. Assessment of whether the proposal meets the 
affordability requirement also takes into account the effects across 
different groups of state residents, and, in particular, vulnerable 
residents, including low-income individuals, elderly individuals, and 
those with serious health issues or who have a greater risk of 
developing serious health issues. Reducing affordability for these 
types of vulnerable groups would cause a waiver to fail this 
requirement, even if the waiver maintained affordability in the 
aggregate.
    In addition, a waiver would fail the affordability requirement if 
it would reduce the number of individuals with coverage that provides a 
minimal level of protection against excessive cost sharing. In 
particular, waivers that reduce the number of people with insurance 
coverage that provides both an actuarial value equal to or greater than 
60 percent and an out-of-pocket maximum that complies with section 
1302(c)(1) of the ACA, would fail this requirement. So too would 
waivers that reduce the number of people with coverage that meets the 
affordability requirements set forth in sections 1916 and 1916A of the 
Social Security Act, as codified in 42 CFR part 447, subpart A, while 
holding the state's Medicaid policies constant.
    As provided in 31 CFR part 33 and 45 CFR part 155, subpart N, the 
waiver application must include analysis and supporting data that 
establishes that the waiver satisfies this requirement. This includes 
information on estimated individual out-of-pocket costs by income, 
health status, and age groups, absent the waiver and with the waiver. 
The expected changes in premium contributions and other out-of-pocket

[[Page 78133]]

costs and the combined impact of changes in these components should be 
identified separately. The application should also describe any changes 
in employer contributions to health coverage or in wages expected under 
the waiver. The application should identify any types of individuals 
for whom affordability of coverage would be reduced by the waiver.
    The state should also provide a description of the model used to 
produce these estimates, including data sources and quality, key 
assumptions, and parameters. The state may be required to provide micro 
data and other information to inform the Secretaries' analysis.

C. Comprehensiveness

    To meet the comprehensiveness requirement, health care coverage 
under the waiver must be forecast to be at least as comprehensive 
overall for residents of the state as coverage absent the waiver.
    Comprehensiveness refers to the scope of benefits provided by the 
coverage as measured by the extent to which coverage meets the 
requirements for essential health benefits (EHBs) as defined in section 
1302(b) of the ACA, or, as appropriate, Medicaid and/or CHIP standards. 
The impact on all state residents is considered, regardless of the type 
of coverage they would have absent the waiver.
    Comprehensiveness is evaluated by comparing coverage under the 
waiver to the state's EHB benchmark, selected by the state (or if the 
state does not select a benchmark, the default base-benchmark plan) 
pursuant to 45 CFR 156.100, as well as to, in certain cases, the 
coverage provided under the state's Medicaid and/or CHIP programs. A 
waiver cannot satisfy the comprehensiveness requirement if the waiver 
decreases: (1) The number of residents with coverage that is at least 
as comprehensive as the benchmark in all ten EHB categories; (2) for 
any of the ten EHB categories, the number of residents with coverage 
that is at least as comprehensive as the benchmark in that category; or 
(3) the number of residents whose coverage includes the full set of 
services that would be covered under the state's Medicaid and/or CHIP 
programs, holding the state's Medicaid and CHIP policies constant. That 
is, the waiver must not decrease the number of individuals with 
coverage that satisfies EHB requirements, the number of individuals 
with coverage of any particular category of EHB, or the number of 
individuals with coverage that includes the services covered under the 
state's Medicaid and/or CHIP programs.
    Assessment of whether the proposal meets the comprehensiveness 
requirement also takes into account the effects across different groups 
of state residents, and, in particular, vulnerable residents, including 
low-income individuals, elderly individuals, and those with serious 
health issues or who have a greater risk of developing serious health 
issues. A waiver would fail the comprehensiveness requirement if it 
would reduce the comprehensiveness of coverage provided to these types 
of vulnerable groups, even if the waiver maintained comprehensiveness 
in the aggregate. This condition generally must be forecast to be met 
in each year that the waiver would be in effect.
    As provided in the final regulations at 31 CFR part 33 and 45 CFR 
part 155, subpart N, the waiver application must include analysis and 
supporting data that establishes that the waiver satisfies this 
requirement. This includes an explanation of how the benefits offered 
under the waiver differ from the benefits provided absent the waiver 
(if the benefits differ at all) and how the state determined the 
benefits to be as comprehensive.
    The state should also provide a description of the model used to 
produce these estimates, including data sources and quality, key 
assumptions, and parameters. The state may be required to provide micro 
data and other information to inform the Secretaries' analysis.

D. Deficit Neutrality

    Under the deficit neutrality requirement, the projected Federal 
spending net of Federal revenues under the State Innovation Waiver must 
be equal to or lower than projected Federal spending net of Federal 
revenues in the absence of the waiver.
    The estimated effect on Federal revenue includes all changes in 
income, payroll, or excise tax revenue, as well as any other forms of 
revenue (including user fees), that would result from the proposed 
waiver. Estimated effects would include, for example, changes in: The 
premium tax credit and health coverage tax credit, individual shared 
responsibility payments, employer shared responsibility payments, the 
excise tax on high-cost employer-sponsored plans, the credit for small 
businesses offering health insurance, and changes in income and payroll 
taxes resulting from changes in tax exclusions for employer-sponsored 
insurance and in deductions for medical expenses.
    The effect on Federal spending includes all changes in Exchange 
financial assistance and other direct spending, such as changes in 
Medicaid spending (while holding the state's Medicaid policies 
constant) that result from the changes made through the State 
Innovation Waiver. Projected Federal spending under the waiver proposal 
also includes all administrative costs to the Federal government, 
including any changes in Internal Revenue Service administrative costs, 
Federal Exchange administrative costs, or other administrative costs 
associated with the waiver.
    Waivers must not increase the Federal deficit over the period of 
the waiver (which may not exceed 5 years unless renewed) or in total 
over the ten-year budget plan submitted by the state as part of the 
State Innovation Waiver application. The ten-year budget plan must 
describe for both the period of the waiver and for the ten-year budget 
the projected Federal spending net of Federal revenues under the State 
Innovation Waiver and the projected Federal spending net of Federal 
revenues in the absence of the waiver.
    The ten-year budget plan should assume the waiver would continue 
permanently, but should not include Federal spending or savings 
attributable to any period outside of the ten-year budget window. A 
variety of factors, including the likelihood and accuracy of projected 
spending and revenue effects and the timing of these effects, are 
considered when evaluating the effect of the waiver on the Federal 
deficit. A waiver that increases the deficit in any given year is less 
likely to meet the deficit neutrality requirement.
    The state should also provide a description of the model used to 
produce these estimates, including data sources and quality, key 
assumptions, and parameters. The state may be required to provide micro 
data and other information to inform the Secretaries' analysis.
    As provided in 31 CFR part 33 and 45 CFR part 155, subpart N, a 
state must submit evidence to demonstrate deficit neutrality, including 
a description of the analysis used to produce its estimate of the 
impact of the waiver on the Federal deficit. The description must 
include detailed information about the model, data sources and quality, 
key assumptions, and parameters. The state may be required to provide 
micro data and other information to support actuarial and economic 
analyses, so that the Secretaries can independently verify that the 
waiver meets the deficit neutrality requirement.

[[Page 78134]]

II. Impact of Other Program Changes on Assessment of a Waiver Proposal

    The assessment of whether a State Innovation Waiver proposal 
satisfies the statutory criteria set forth in Section 1332 takes into 
consideration the impact of changes to ACA provisions made pursuant to 
the State Innovation Waiver. The assessment also considers related 
changes to the state's health care system that, under state law, are 
contingent only on the approval of the State Innovation Waiver. For 
example, the assessment would take into account the impact of a new 
state-run health benefits program that, under legislation enacted by 
the state, would be implemented if the State Innovation Waiver were 
approved.
    The assessment does not consider the impact of policy changes that 
are contingent on further state action, such as state legislation that 
is proposed but not yet enacted. It also does not include the impact of 
changes contingent on other Federal determinations, including approval 
of Federal waivers pursuant to statutory provisions other than Section 
1332. Therefore, the assessment would not take into account changes to 
Medicaid or CHIP that require separate Federal approval, such as 
changes in coverage or Federal Medicaid or CHIP spending that would 
result from a proposed Section 1115 demonstration, regardless of 
whether the Section 1115 demonstration proposal is submitted as part of 
a coordinated waiver application with a State Innovation Waiver. 
Savings accrued under either proposed or current Section 1115 Medicaid 
or CHIP demonstrations are not factored into the assessment of whether 
a proposed State Innovation Waiver meets the deficit neutrality 
requirement. The assessment also does not take into account any changes 
to the Medicaid or CHIP state plan that are subject to Federal 
approval.
    The assessment does take into account changes in Medicaid and/or 
CHIP coverage or in Federal spending on Medicaid and/or CHIP that would 
result directly from the proposed waiver of provisions pursuant to 
Section 1332, holding state Medicaid and CHIP policies constant.
    As the Departments receive and review waiver proposals, we will 
continue to examine the types of changes that will be considered in 
assessing State Innovation Waivers.
    Nothing in this guidance alters a state's authority to make changes 
to its Medicaid and CHIP policies consistent with applicable law. This 
guidance does not alter the Secretary of Health and Human Services' 
authority or CMS' policy regarding review and approval of Section 1115 
demonstrations, and states should continue to work with CMS' Center for 
Medicaid and CHIP Services on issues relating to Section 1115 
demonstrations. A state may submit a coordinated waiver application as 
provided in 31 CFR 33.102 and 45 CFR 155.1302; in such a case, each 
waiver will be evaluated independently according to applicable Federal 
laws.

III. Federal Pass-Through Funding

    The amount of Federal pass-through funding equals the Secretaries' 
annual estimate of the Federal cost (including outlays and forgone 
revenue) for Exchange financial assistance provided pursuant to the ACA 
that would be claimed by participants in the Exchange in the state in 
the calendar year in the absence of the waiver, but will not be claimed 
as a result of the waiver. The calculation of the amount of pass-
through funding does not account for any other changes in Federal 
spending or revenues as a result of the waiver, including Federal 
administrative expenses for making the payments (note, however that 
changes to Federal spending on administrative expenses is considered in 
determining whether a waiver proposal meets the deficit neutrality 
requirement). The estimates take into account experience in the 
relevant state and similar states. The amount is calculated annually.
    The waiver application must provide analysis and supporting data to 
inform the estimate of the pass-through funding amount. For states that 
do not utilize a Federally-facilitated or state Partnership Exchange 
this includes information about enrollment, premiums, and Exchange 
financial assistance in the state's Exchange by age, income, and type 
of policy, and other information as may be required by the Secretaries.
    For further information on the demographic and economic assumptions 
to be used in determining the pass-through amount, see Section IV 
below.

IV. Economic Assumptions and Methodological Guidelines

    The determination of whether a waiver meets the requirements under 
Section 1332 and the calculation of the pass-through funding amount are 
made using generally accepted actuarial and economic analytic methods 
such as micro-simulation. The analysis relies on assumptions and 
methodologies that are similar to those used to produce the baseline 
and policy projections included in the most recent President's Budget 
(or Mid-Session Review), but adapted as appropriate to reflect state-
specific conditions.
    The analysis is based on state-specific estimates of the current 
level and distribution of population by the relevant economic and 
demographic characteristics, including income and source of health 
coverage. It generally uses Federal estimates of population growth, 
economic growth as published in the Analytical Perspectives volume 
released as part of the President's Budget (https://www.whitehouse.gov/omb/budget/Analytical_Perspectives) and health care cost growth 
(https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index.html?redirect=/NationalHealthExpendData/.) to project the initial state variables 
through the ten-year Budget plan window. However, in limited 
circumstances where it is expected that a state will experience 
substantially different trends than the nation as a whole in the 
absence of a waiver, the Secretaries may determine that state-specific 
assumptions will be used.
    Estimates of the effect of the waiver assume, in accordance with 
standard estimating conventions, that macroeconomic variables like 
population, output, and labor supply are not affected by the waiver. 
However, estimates take into account, as appropriate, other changes in 
the behavior of individuals, employers, and other relevant entities 
induced by the waiver, including employer decisions regarding what 
coverage (and other compensation) they offer and individual decisions 
regarding whether to take up coverage. The same state-specific and 
Federal data, assumptions, and model are used to calculate 
comprehensiveness, affordability, and coverage, and relevant state 
components of Federal taxes and spending under the waiver and under 
current law.
    The analysis and information submitted by the state as part of the 
application must conform to these standards. The application must 
describe all modeling assumptions used, sources of state-specific data, 
and the rationale for any deviation from Federal forecasts. A state may 
be required to provide to the Secretaries copies of any data used for 
their waiver analyses that are not publicly available so that the 
Secretaries can independently verify the analysis produced by the 
state.

V. Operational Considerations

A. Federally-Facilitated Exchanges

    The Centers for Medicare & Medicaid Services (CMS) operates the 
Federally-

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facilitated Exchange (FFE) platform. Certain changes that affect FFE 
processes may make a waiver proposal not feasible to implement at this 
time. Until further guidance is issued, the Federal platform cannot 
accommodate different rules for different states. For example, waivers 
that would require changes to the calculation of Exchange financial 
assistance, non-standard enrollment period determinations, customized 
plan management review options, or changes to the design used to 
display plan options are generally not feasible at this time due to 
operational limitations. In addition, the Federal platform cannot 
accommodate changes to its plan management templates in the near term. 
States contemplating a waiver that requires such changes may consider 
establishing their own platform administered by the state.
    As noted in Section I.D. of this guidance, costs associated with 
changes to Federal administrative processes are taken into account in 
determining whether a waiver application satisfies the deficit 
neutrality requirement. Regulations at 31 CFR part 33 and 45 CFR part 
155, subpart N require that such costs be included in the 10-year 
budget plan submitted by the state.

B. Internal Revenue Service

    Certain changes that affect Internal Revenue Service (IRS) 
administrative processes may make a waiver proposal not feasible to 
implement. At this time, the IRS is not generally able to administer 
different sets of rules in different states. As a result, while a state 
may propose to entirely waive the application of one or more of the tax 
provisions listed in Section 1332 to taxpayers in the state, it is 
generally not feasible to design a waiver that would require the IRS to 
administer an alteration to these provisions for taxpayers in the 
state. For example, it is generally not feasible to have the IRS 
administer a different set of eligibility rules for the premium tax 
credit for residents of a particular state. States contemplating a 
waiver proposal that includes a modified version of a Federal tax 
provision may consider waiving the provision entirely and relying on a 
tax program administered by the state.
    In addition, a waiver proposal that completely waives one or more 
tax provisions in a state may create administrative costs for the IRS. 
As noted in Section I.D. above, costs associated with changes to 
Federal administrative processes are taken into account in determining 
whether a waiver application satisfies the deficit neutrality 
requirement. Regulations at 31 CFR part 33 and 45 CFR part 155, subpart 
N require that such costs be included in the 10-year budget plan 
submitted by the state.

VI. Public Input on Waiver Proposals

    Consistent with the statutory provisions of Section 1332, 
regulations at 31 CFR 33.112 and 45 CFR 155.1312 require states to 
provide a public notice and comment period for a waiver application 
sufficient to ensure a meaningful level of public input prior to 
submitting an application. As part of the public notice and comment 
period, a state with one or more Federally-recognized tribes must 
conduct a separate process for meaningful consultation with such 
tribes. Because State Innovation Waiver applications may vary 
significantly in their complexity and breadth, the regulations provide 
states with flexibility in determining the length of the comment period 
required to allow for meaningful and robust public engagement. The 
comment period must be sufficient to ensure a meaningful level of 
public input and in no case can be less than 30 days.
    Consistent with HHS regulations, waiver applications must be posted 
online in a manner that meets national standards to assure access to 
individuals with disabilities. Such standards are issued by the 
Architectural and Transportation Barriers Compliance Board, and are 
referred to as ``section 508'' standards. Alternatively, the World Wide 
Web Consortium's Web Content Accessibility Guidelines (WCAG) 2.0 Level 
AA standards would also be considered as acceptable national standard 
for Web site accessibility. For more information, see the WCAG Web site 
at http://www.w3.org/TR/WCAG20/.
    Section 1332 and its implementing regulations also require the 
Federal Government to provide a public notice and comment period, once 
the Secretaries receive an application. The period must be sufficient 
to ensure a meaningful level of public input and must not impose 
requirements that are in addition to, or duplicative of, requirements 
imposed under the Administrative Procedures Act, or requirements that 
are unreasonable or unnecessarily burdensome with respect to state 
compliance. As with the comment period described above, the length of 
the comment period should reflect the complexity of the proposal and in 
no case can be less than 30 days.

    Dated: December 8, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: December 11, 2015.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
    Approved: December 10, 2015.
Mark J. Mazur,
Assistant Secretary of the Treasury (Tax Policy).
[FR Doc. 2015-31563 Filed 12-11-15; 4:15 pm]
 BILLING CODE 4150-28-P