Submit a Standard 1135 Medicaid Waiver/Flexibility Request

Summary

A Quick Reference Guide, Submit a Standard 1135 Medicaid Waiver/Flexibility Request, outlining six steps for completing an online form. It states that all questions are required unless noted, that the system times out after thirty (30) minutes of inactivity with a five (5) minute warning after twenty-five (25) minutes, and that Google Chrome or Mozilla Firefox are the recommended browsers. Step 1 is selecting I want to submit a waiver/flexibility request, Step 2 is selecting the Public Health Emergency that applies, with a note that the portal cannot be used for COVID-19 PHE related Medicaid 1135 waiver submissions, and Step 3 is completing contact information.

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“Submit a Standard 1135 Medicaid Waiver/Flexibility Request.” Original at www.cms.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/ppr-int-6e543c1705187830-1135-medicaid-waiver-pdf-6071c84a2c-b9d63389c9/, SHA-256 7c793dc93ad4e72e61f650a02fddc4c159a1c0a0d1630b1cefde4a13a77b4e9f.

Full text

QUICK REFERENCE GUIDE
Submit a Standard 1135 Medicaid Waiver/Flexibility Request
Please complete the form and answer all the questions in order.
Six (6) simple steps are outlined below including several optional questions. The form is more easily
processed if the optional questions are also completed. All questions are required, unless otherwise
noted. A submit button only appears after all the required questions are completed.
Important: Before you begin, please note the system times out after thirty (30) minutes of inactivity,
at which point your data will be lost. There is a five (5) minute warning after twenty-five (25) minutes.
have passed). if not submitted promptly.

Begin by using one of the two recommended browsers (Google Chrome or Mozilla Firefox) to navigate
to the web page at https://cmsqualitysupport.servicenowservices.com/cms_1135
Note: When working with this form, hover over the question mark (?) icon for additional information or review
the ghost text in the textbox for instructions. All fields are required unless otherwise noted.

Step 1: Select “I want to submit a waiver/flexibility request”.

Figure 1

Step 2: Select the Public Health Emergency (PHE) that applies. This field is
required.

Note: This portal cannot be utilized for COVID-19 PHE related Medicaid 1135 waiver submissions.

• Select from the choices in the dropdown box using the down arrow, OR
• Complete the name of the emergency in the search bar to locate it.

Figure 2
Step 3: Complete the Contact Information.
The following fields are all required fields, except the Phone number field. After the first submission, the First
name, Last name, and Organization name fields are automatically populated based on the email entered in
each subsequent submission.

• Enter an email address.
• Type to confirm the email address in the Confirm Email question.
• Enter the First name. The First name automatically populates in subsequent submissions.
• Enter the Last name. The Last name automatically populates in subsequent submissions.
• Enter the Phone number. This field is optional. If provided, phone number may be used if there is a
need for direct contact.

Figure 3

Note: After the first submission, the First name, Last name, and Organization name fields are automatically
populated based on the email entered in each subsequent submission.

Step 4: Complete the Organization Information.
• Enter the name of the organization making the request. The Organization Name automatically
populates in subsequent submissions, based on the email address entered. This should be the
name of the State Medicaid or CHIP Agency.
• Select the State, US Territory or Federal District covered by this request. Start typing, and a
dropdown box appears and selection may be made.
• If you accidentally enter an incorrect State/US Territory/Federal District, click on the “x” next to the
name to easily remove it.
Figure 4

• Select State Medicaid or CHIP Agency.

Figure 5

Select the type of waiver(s) you want to submit:
• Select “I want to submit a general waiver” if it applies to Medicare. Select the link provided for
instructions on completing the general waiver request form.
• Select “I want to submit a Medicaid/CHIP waiver” if the waiver applies to Medicaid only.
Select both checkboxes to submit one or more of each.

Figure 6
• Identify the Medicaid or CHIP State Contact Information (all fields are required, except where noted).
This is the contact information that will be used for official CMS communications. This is likely the State
Medicaid or CHIP Director’s contact information and will be used for official CMS communications.

o Enter the State Official title; for example, Director
o Enter the State Agency name
o Enter the State Official first name
o Enter the State Official last name
o Enter the State Official suffix, such as M.D., Ph.D., RN, etc. (Optional field)
o Enter the State Agency address
o Enter Address 2; for example, suite number (Optional field)
o Enter City
o Enter State/US Territory/Federal District
o Enter Zip code
o Enter State Agency email address
o Confirm State Agency email address; You must retype the email address
Figure 7
Step 5: Describe the request.
• For Waiver/Flexibility Request Type, you may either select from the choices in the dropdown box,
or you may type the name of the waiver/flexibility in the search bar. Please refer to Appendix A for a
list of Medicaid Waiver Types.
• Select “Click here if you do not see your Waiver Request Type” checkbox if you do not see the
needed Waiver Request Type in the dropdown list.
• Enter the desired Waiver Request type in the text box.
• The Description of Waiver Request field is pre-populated with a description based on the Waiver
Request Type selected. For certain waiver request types, you may also be prompted to add
additional information to your waiver request.
• If “Other” is selected, please provide a detailed summary of the request. Providing as much detail
as possible, including the relevant regulation, will help facilitate CMS review of the request.

Figure 8

Select the Add another waiver request link to add multiple requests in one submission.

• Complete Request #2 form and continue to add requests until complete.

Figure 9
Figure 10

Step 6: Submit the form.
• Click Submit when all required fields are complete.

Figure 11

A confirmation message appears including a Medicaid waiver case number. Please note the Case number
(CSXXXXXXX) in the event further follow-up is needed.
The system also automatically sends an email notification containing additional information. Note: If you do not
receive the email notification, check your spam folder.
Figure 12

If both a general waiver and a Medicaid/CHIP waiver request were submitted, please note there will be two
separate case numbers.

Figure 13

If you experience any technical issues, please contact:
CCSQ Service Center between 8 a.m. - 8 p.m. ET, Monday – Friday.
Phone: (866) 288-8912*
TRS: 711
Fax: (888) 329-7377
Email: qnetsupport@hcqis.org
Appendix A – List of Medicaid Waiver Types

1. Clinic Facility Requirement - Allow provision of clinic services in alternative settings
2. Clinic Facility Requirement - Allow provision of services via telehealth
3. Fee for Service and Eligibility Fair Hearings - Extend fair hearing request timelines
4. Fee for Service and Eligibility Fair Hearings - Extend timelines for reinstatement of benefits
5. Home Health State Plan Services Timeframe (Face-to-Face Encounters)
6. Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan Timelines -
Initial Evaluation of Need
7. Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan Timelines -
Reevaluation
8. Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan Timelines -
Review and Revision of Person-Centered Service Plan
9. Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered Service Plans -
Initial Evaluation of 1915(i) Eligibility
10. Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered Service Plans -
Initial Independent Assessment of Need
11. Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered Service Plans -
Reassessments of Need
12. Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered Service Plans -
Reevaluation of 1915(i) Eligibility
13. Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered Service Plans -
Review and Revision of the Person-Centered Service Plan
14. Long Term Services and Supports (LTSS) - 1915(j) State Plan Benefit - Annual Reviews
15. Long Term Services and Supports (LTSS) - 1915(j) State Plan Benefit - Initial Assessments
16. Long Term Services and Supports (LTSS) - 1915(j) State Plan Benefit - Use of Representatives
17. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Annual Reassessments
18. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Initial Assessments
19. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Level of Care Determinations
20. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Level of Care Redeterminations
21. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Person-Center Service Plan Reviews
22. Long Term Services and Supports (LTSS) - 1915(k) State Plan Benefit - Use of Representatives
23. Long Term Services and Supports (LTSS) - Conflict of Interest Requirements - 1915(c)
24. Long Term Services and Supports (LTSS) - Conflict of Interest Requirements - 1915(i)
25. Long Term Services and Supports (LTSS) - Conflict of Interest Requirements - 1915(k)
26. Long Term Services and Supports (LTSS) - Conflict of Interest Requirements - HCBS services in approved 1115
Demonstration
27. Long Term Services and Supports (LTSS) - HCBS Settings Requirements - 1915(c)
28. Long Term Services and Supports (LTSS) - HCBS Settings Requirements - 1915(i)
29. Long Term Services and Supports (LTSS) - HCBS Settings Requirements - 1915(k)
30. Long Term Services and Supports (LTSS) - HCBS Settings Requirements - HCBS services in approved 1115
Demonstration
31. Long Term Services and Supports (LTSS) - PASRR
32. Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider Signatures - 1915(c)
33. Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider Signatures - 1915(i)
34. Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider Signatures - 1915(k)
35. Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider Signatures - HCBS
services in approved 1115 Demonstration
36. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify adverse benefit appeals filing
timelines
37. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify authorization decision timelines
38. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify continuation of benefits
timelines
39. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify standard appeals timelines
40. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify state fair hearings timelines
41. Managed Care Appeals, Fair Hearings, and Continuation of Benefits - Modify timelines to resolve appeals
42. Physician Direction - Allow clinic services to be directed by other licensed professionals
43. Physician Direction - Allow inpatient psychiatric services for under 21 to be directed by other licensed
professionals
44. Private Duty Nursing - Modify practitioner requirements
45. Private Duty Nursing - Modify supervision requirements
46. Provider Enrollment - Allow out-of-state provider reimbursement
47. Provider Enrollment - Pause revalidation deadlines
48. Provider Enrollment - Waive application fees
49. Provider Enrollment - Waive criminal background checks
50. Provider Enrollment - Waive licensing requirements
51. Provider Enrollment - Waive site visits
52. Targeted Case Management Timeline – Monitoring and Follow-up Activities
53. Use of Legally Responsible Individuals to Render Personal Care Services

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