In the midst of the national push for Medicaid reform, one albatross is often cited by state policymakers for impeding their progress: the federal waiver process. The long and short of it is that it takes too long to get a waiver approved by the Centers for Medicare and Medicaid Services (CMS) if a state has an innovative idea to test. There are horror stories about waivers taking more than a year to be approved, even if they’ve been approved in the past and states are just looking to continue their programs. Six former governors (three Democrats and three Republicans) issued a report last year, bemoaning the problems with the waiver process and offering their recommendations for fixing it. CMS officials have acknowledged that it could be streamlined, though no specific improvements have been named or acted upon.

The Medicaid waiver conundrum most recently reappeared at the end of last year, as Kansas prepared to launch its new managed-care program on Jan. 1. A CMS waiver is required to move forward with those changes. But though Kansas first submitted its waiver application to Washington in April, the state had no assurances that its reforms, which would fundamentally remake the Medicaid program in the state, would be approved. Watchdogs like the Kansas Health Institute began to note the lack of action by the feds in early December, even as implementation of the program picked up. The process came down to the wire, but on Dec. 28, three days before KanCare was set to start, CMS granted its support and the program was able to commence on time. But KanCare was far from the last waiver application on the federal docket.

As 2013 begins, here are five major Medicaid reforms waiting for the all-clear from CMS. Information is drawn from the CMS Medicaid website, which provides all documents for pending waivers.

1. Moving California children to Medi-Cal

California’s Medicaid program is in a state of flux entering the new year—three waiver request are pending with CMS—but one would fundamentally restructure how the state’s youth receive health care services. The waiver would transfer administrative responsibility for kids in the Healthy Families Program, which covers more than 860,000 children for medical, dental and vision needs, from the Managed Risk Medical Insurance Board to the larger state Medicaid program, Medi-Cal.

As KPBS reported when Gov. Jerry Brown made the proposal in June, the move will simplify administration of the program and save the program up to $13 million in its first year, with more expected in later years. But the proposal has drawn the ire of some stakeholders, including the California Medical Association, which says the transition will disrupt care delivery for the affected children.

2. Extending family planning benefits

Since its inception, Medicaid has focused its attention on low-income families (as opposed to low-income adults, who are just now being brought into the fold by the Affordable Care Act’s Medicaid expansion). As an extension of that, young women have often been covered for family planning services under a Medicaid waiver. But on Dec. 31, four states’ waivers expired: Illinois, Mississippi, Pennsylvania and Texas.

The specifics of the programs vary-- Illinois covers women up to 200 percent of the federal poverty level, while the other three go to 185 percent -- but all have been in place for at least five years before expiring at the end of 2012. That means, technically, women in those states have lost coverage for such services as contraception, STD testing, Pap smears and counseling. However, there is usually some flexibility in expiration dates, according to state officials, so as long as CMS acts soon, those services should still be available.

3. Overhauling Minnesota's long-term care delivery

As Governing reported in its Generations series, many view Medicaid beneficiaries in need of long-term care as an opportunity for better efficiency and cost-savings. Minnesota has developed a program that would divide that population (made up of seniors and developmentally disabled) into different tiers based on their level of need. There would be those who require nursing home care, the most expensive kind, and then there would be those who could receive home and community-based services because their level of need isn’t as great.

Planning has been underway since 2009, and the state has consulted with various stakeholders in developing its plan. The goal would be to keep seniors in their homes and communities if possible, and by improving care in those settings, prevent the later need for institutionalization. That could mean allowing people to live in transitional settings, such as assisted living communities, or providing home health aides to keep them in the home. Minnesota estimated it would save $18 million in its first year, $44 million in the second year and $54 million in the third year if the reforms were approved.

4. Improving services for New York’s developmentally disabled

The developmentally disabled are sometimes an overlooked portion of Medicaid beneficiaries, but their high utilization means they cost a lot of money and their unique needs make them a unique subsection to serve. New York is aiming to address both of those concerns with a new demonstration project called People First. The program would place 100,000 developmentally disabled Medicaid enrollees into a managed-care program that would coordinate both their acute health care and long-term habilitative services into one delivery model. Covered services would be vast: from adult day care to psychotherapy to nutrition counseling. All care would be overseen by a single entity, so that the entirety of a patient’s experience is considered when delivering care. New York hopes to use savings from the program’s early years to invest in a quality assessment tool, a health risk screening pool and an electronic health information exchange to continue improving care for that population.

5. Testing the Medicaid expansion locally in Ohio

In Cuyahoga County, home to Cleveland and ravaged by the economic downturn, Ohio officials want to expand health-care services for the growing portion of uninsured childless adults. They’d do that by coordinating with MetroHealth, an academic health-care system in Cleveland that provides much of the health care for uninsured residents in the area, and expanding Medicaid benefits for people up to 133 percent of the federal poverty level—which happens to be the new threshold under the ACA. As many as 158,000 people could qualify, and about 20,000 will be initially enrolled to launch the project.

According to the state’s application, uninsured visits to MetroHealth increased by 40 percent in 2011. And even if they receive care, half of the prescriptions issued by the health system are never filled because their recipients can’t afford them. That led to the idea to incorporate that population into a waiver health plan with a set of comprehensive benefits. Prescription drugs, dental services, primary care and home health services would be among the benefits offered by the plan. MetroHealth provided nearly $130 million in uncompensated care in 2011, and about $30 million of that was reimbursed by the state. The hope, according to the state’s application, is that savings in the state reimbursements for uncompensated care could significantly offset any new spending by bringing that population into Medicaid. If the model proves successful, Ohio included plans to expand the program to other counties in the future.