This is a very important provision that can give states more flexibility to do things differently than the way they are specifically addressed in the legislation. With a waiver, if states can demonstrate the ability achieve an objective in a different way, the waiver is approved. For example, in the case of tax credits only being available through the exchange, if a state could demonstrate the ability to administer the tax credits both through the exchange and outside the exchange, it could be approved.
This is a huge tool for health care reform. Insurance plans could accomplish the goal of reform without the federal gov.