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Federal Register / Vol. 86, No. 124 / Thursday, July 1, 2021 / Proposed Rules extension process in the STCs for an approved waiver plan. These proposals are intended to align with the extension request process outlined in recent STCs for states with approved section 1332
waivers.155
The Departments propose to define a section 1332 waiver extension as an extension of an approved waiver under the existing waiver terms. As detailed further later in this section of this preamble, if a state wants to make changes to the existing terms of an approved section 1332 waiver, the proposed waiver amendment request framework outlined in this rulemaking would apply. The Departments propose that states with approved section 1332
waivers that want to pursue a waiver extension would be required to inform the Departments if the state will apply for extension of its waiver at least one year prior to the waivers end date. To request a section 1332 waiver extension, the Departments propose that the state must submit a letter of intent in an electronic format to the Departments to notify them in writing of its intent to request a waiver extension of its approved waiver plans. The Departments would then review the states letter of intent request. The Departments propose that, within approximately 30 days of the Departments receipt of the letter of intent, the Departments will respond to the state and confirm whether the extension request will be considered as an extension request or whether any changes requested result in the need for a waiver amendment request instead.
The Departments will also identify the information the state needs to submit in its section 1332 waiver extension request. The Departments also propose that section 1332 waiver extension requests must also be submitted in electronic format to the Departments, consistent with the format and manner requirements applicable to initial waiver applications under 31 CFR
33.108a and 45 CFR 155.1308a.
Furthermore, the Departments propose that the Departments may request an updated economic or actuarial analysis for the requested extension period in a section 1332
waiver extension request. Given that the Departments receive periodic reports from states with approved section 1332
waivers under 31 CFR 33.124 and 45
CFR 155.1324, in some circumstances the Departments may not need and therefore would not require full new 155 For example, see STC 10 in New Hampshires Approval Letter and STCs: https www.cms.gov/
CCIIO/Programs-and-Initiatives/State-InnovationWaivers/Downloads/1332-NH-Approval-STCs.pdf.

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analysis as required under 31 CFR
33.108f4 and 45 CFR 155.1308f4
for initial section 1332 waiver applications and instead may rely on the updated analyses provided as part of these periodic reports. In other instances, depending on the complexity of the section 1332 waiver and the extension request, the Departments may require additional data and information to be submitted to review the extension request.
The Departments propose to evaluate the states section 1332 waiver extension request and may approve the request if it meets the statutory guardrails as defined in section 1332
b1AD and meets other applicable requirements. The Departments propose that a state waiver extension request may be required to include the following information:
1 Updated economic or actuarial analyses for the requested extension period in a format and manner specified by the Departments;
2 Preliminary evaluation data and analysis from the existing section 1332
waiver program;
3 Evidence of sufficient authority under state laws in order to meet the ACA section 1332b2A requirement for purposes of pursuing the requested extension;
4 An explanation of the process followed by the state to ensure meaningful public input on the extension request at the state-level; and, 5 Other information as requested by the Departments that is necessary to reach a decision on the requested extension.
As noted above, the Departments would identify the specific information a state needs to include as part of its section 1332 waiver extension request in the response to the states letter of intent. Further, the Departments have proposed a requirement that the updated economic or actuarial analyses for the requested extension period would be in a format and manner specified by the Departments. The Departments will also rely on available data, such as the analyses provided as part of the periodic reports required under 31 CFR 33.124 and 45 CFR
155.1324, when evaluating a states waiver extension request if appropriate.
The Departments also propose that it would be permissible for a state to use its annual public forum required under 31 CFR 33.120c and 45 CFR
155.1320c for the dual purpose of soliciting public input on a proposed section 1332 waiver extension request and on the progress of its approved waiver plan. This policy proposal is in line with the flexibility the Departments
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permitted in the 2012 section 1332
regulations 156 to allow states to use Medicaid tribal consultation to also satisfy the requirements as set forth in 31 CFR 33.112a2 and 45 CFR
155.1312a2, that require a state with one or more federally-recognized tribes within its borders to conduct a separate process for meaningful consultation with such tribes as part of the state section 1332 waiver public notice and comment process. The Departments are of the view that allowing states to use the annual public forum for the dual purpose of soliciting public input on an extension request and on the progress of its approved section 1332 waiver would create a more efficient process for both the state and for the public to provide a meaningful level of input.
In this rule, the Departments are proposing a similar federal public notice and review process for a section 1332
waiver extension request as is outlined for new section 1332 waiver applications in 31 CFR 33.116 and 45
CFR 155.1316. The Departments propose that the Departments will review a states section 1332 waiver extension request and make a preliminary determination as to whether it is complete within approximately 30
days after it is submitted. In line with these requirements, the Departments propose that after determining that the section 1332 waiver extension request is complete, the waiver extension request would be made public through the CMS
website, and a 30-day federal public comment period would commence while the extension request is under review. The Departments will make available through the CMS website the information relating to how and where written comments may be submitted and the timeframe during which comments will be accepted.
Additionally, the Departments will make available public comments received on the section 1332 waiver amendment request during the Federal public notice and comment period. The determination that the section 1332
waiver extension request is complete would also mark the beginning of the 90-day clock outlined in section 1332e of the ACA for the Secretaries to deny or request more information regarding the continuation, or extension, of the states approved waiver plan. If, after the extension request has been determined complete, the Departments find that content is missing, additional information is required, or the state needs to respond to public comments received during the federal comment period, the Departments would notify 156 See
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77 FR at 11706.

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