If your family's home care, respite hours, or day supports arrive through Medicaid, there is a piece of paper somewhere in your state capital with an expiration date on it. Most families never see it. On July 7, CMS made that paper harder to renew.

In an informational bulletin, CMS rescinded the 2015 guidance that let states use a "fast track" review when they wanted to extend an existing Section 1115 demonstration without changing much about it. Under the old path, a state submitting a straightforward extension could expect a federal answer in a little over three months. With that guidance withdrawn, every 1115 extension now goes through the standard review process, which takes longer and looks harder at the details.

Why CMS Made the Change

The 2025 reconciliation law, Public Law 119-21, added budget neutrality as a statutory requirement for Section 1115 demonstrations. Starting January 1, 2027, CMS cannot approve, renew, or amend a demonstration unless the agency's Chief Actuary certifies that the project costs the federal government no more than it would have spent without it. That certification applies to every state, the District of Columbia, and the territories.

CMS said the expedited path could not coexist with that requirement. A three-month review does not leave room for an actuarial certification of a program that may cover a million people. So the agency withdrew the 2015 guidance and its application templates, and told states to plan for full reviews and longer timelines.

Who This Touches

Here is the part that matters for sorting out whether this is your problem. Most families receiving home and community based services get them through a Section 1915(c) waiver, and 1915(c) waivers are not affected by this bulletin at all. If your child is on a state DD waiver or a children's HCBS waiver, nothing in this announcement changes your renewal.

Seven states are different. Arizona, Delaware, Hawaii, Rhode Island, Tennessee, Vermont, and Washington deliver at least some home and community based services through Section 1115 authority rather than 1915(c). Arizona runs its entire Medicaid program that way, including ALTCS and the services that reach 58,000 families through the state's DDD program. Arizona's demonstration expires September 30, 2027. Rhode Island folded its former 1915(c) waivers into a single comprehensive demonstration in 2025. Tennessee's CHOICES and ECF CHOICES programs carry the same 1115 dependency.

For families in those seven states, a slower renewal arriving in the same window as a new budget neutrality test is worth understanding now rather than in a year.

What Families Can Do

Start by finding out which authority pays for your services. Your case manager or support coordinator can tell you whether your program runs under a 1915(c) waiver or an 1115 demonstration, and CMS publishes the answer for every state on its demonstration and waiver list at medicaid.gov. If the answer is 1115, ask when the current approval expires. States are required to submit a renewal request a year before that date, which means the paperwork moves long before the deadline shows up in the news.

Then get on the record. Extension applications require a public notice and comment period of at least 30 days at the state level, followed by a federal comment period once the application reaches CMS. Those windows are the formal place where a parent's description of what 40 hours of weekly respite makes possible becomes part of the file a reviewer reads. Arizona has already begun hosting listening sessions ahead of its renewal. Families who commented on the state directed payments proposal earlier this summer already know the rhythm of it.

Document what you receive while you still have it. Budget neutrality certification puts pressure on the optional pieces of a demonstration, and the pieces states describe as optional are frequently the ones families describe as the reason they can keep working, keep their child at home, and stay off a waiting list. Service authorization letters, assessment scores, and denial notices from the past two years all carry weight in a renewal comment.

An expiration date is not a shutoff date. When Colorado's demonstration ran up against its deadline this March, CMS granted a 90 day extension to keep authorities in place while review continued. Services in these states are not scheduled to stop. What changed on July 7 is how much scrutiny stands between a state's request and a federal yes, and how much time families have to put their own evidence in front of the people writing that answer.