Kentucky Making Changes to Medicaid and Cabinet for Health and Family Services Making Changes to Medicaid and the Waiver Work in Your Business Stephen P. Miller Commissioner Department for Medicaid Services 2017 Brain Injury Summit March 3, 2017

Kentucky Medicaid at a Glance Approximately 1,393,000 Members including 435,700 children Over 76,000 Children in KCHIP 1,242,700 members in Managed Care (90%) 5 Medicaid Managed Care Organizations 440,300 covered under Medicaid Expansion (ACA) 802,400 covered under Traditional (Non-ACA) 40,700 enrolled providers

Kentucky Challenges 20% Poverty 47th in Median Household Income 85% of National Average Less than 60% of eligible population is in workforce 45th in Nation 46th in Adults over 25 with High School Diploma

Kentucky Medicaid Challenges Rich benefit program covering 18% of population prior to Expansion 33% obese 1st in Cancer Deaths 2nd Highest smoking rate Cardiovascular Disease Diabetes CDC identified 220 counties in U.S. as “at risk” for HIV and Hepatitis C 54 Counties located in Kentucky 5 Kentuckians die daily from overdose

Medicaid Enrollment Growth Enrollment has grown approximately 66% since Expansion was implemented in January 2014 National Medicaid Enrollment growth 2013-2016 - 28.9% (Source: CMS.Gov National Health Expenditure Projections 2012-22) Eligibility is December 2013 was 829,141 Eligibility in May 2016 was 1,377,024 Total increase is 547,883 (or 66.08% increase)

The Commonwealth of Kentucky Report on 2014 Medicaid Expansion February 2015 Kentucky Cost of Medicaid Expansion 100% Federal Match in CY 2014 through CY 2016 95% Federal Match in CY 2017 94% Federal Match in CY 2018 $247M 93% Federal Match in CY 2019 90% Federal Match in CY 2020 $510M

State Fiscal Years 2017 & 2018 $585M Revenue Growth Forecast $587M Increase Medicaid Funding $2M Shortfall

1115 Waiver Kentucky HEALTH Goals Helping to Engage and Achieve Long Term Health Improve participants’ health and help them be responsible for their health Encourage individuals to become active participants and consumers of healthcare who are prepared to use commercial health insurance Empower people to seek employment & transition to commercial health insurance coverage Implement delivery system reforms to improve quality and outcomes Ensure fiscal sustainability

Kentucky HEALTH Goals Medicaid benefits equivalent to the Kentucky State Employees’ Health Plan Target Eligibility Groups: All Able-Bodied Adults Eligible for Medicaid Expansion Population (Income <138% FPL) Other Non-Disabled Medicaid Eligible Adults Low-Income Children (to promote family coverage) Two Paths to Kentucky HEALTH Coverage Employer Premium Assistance Program Option Consumer Driven Health Plan Option

1915(c): Home and Community-Based Services Overview The 1915(c) Home and Community Based Services (HCBS) waivers are one of many options available to states to allow the provision of long-term care services in home and community-based settings under the Medicaid program.   KY HCBS Waivers Acquired Brain Injury (ABI) Adults with an acquired brain injury who meet nursing facility level of care Michelle P. (MPW) Individuals with intellectual or developmental disabilities and meet ICF / IID level of care Acquired Brain Injury-Long Term Care (ABI-LTC) Adults with an acquired brain injury who meet nursing facility level of care and need long term supports Model II (MIIW) Individuals who are ventilator-dependent and meet nursing facility level of care Home and Community Based (HCB) Individuals who are elderly or disabled who meet nursing facility level of care Supports for Community Living (SCL) Individuals with intellectual or developmental disabilities who meet ICF / IID level of care

Acquired Brain Injury Overview The Acquired Brain Injury (ABI) waiver program provides intensive services and support to adults with acquired brain injuries working to re-enter community life. Services are provided exclusively in community settings. Services Case management Counseling and training Speech and language services Personal care Structured day program Companion services Specialized medical equipment and supplies Community residential services Respite care Environmental modifications Supported employment Behavior programming Occupational therapy Eligibility To qualify for services, an individual must: Have an acquired brain injury Be age 18 or over Meet nursing facility level of care requirements Be expected to benefit from waiver services Be financially eligible for Medicaid services

Acquired Brain Injury – Long Term Care Overview The ABI Long Term Care (LTC) waiver program provides an alternative to institutional care for individuals that have reached a plateau in their rehabilitation level and require maintenance services to avoid institutionalization and to live safely in the community. Services Case Management Counseling Nursing Supports Community Living Supports Group Counseling Family Training Respite Care Specialized Medical Equipment and Supplies Physical Therapy Adult Day Health Care Assessment and Reassessment Adult Day Training Supported Employment Environmental Modifications Occupational Therapy Supervised Residential Care Behavior Programming Speech Therapy Eligibility To qualify for services, an individual must: Be age 18 or over Meet nursing facility level of care Have a primary diagnosis of an acquired brain injury which necessitates supervision, rehabilitative services, and long term supports Be Medicaid eligible

Status of Waivers and Slots

2016-2018 Biennium Budget Additional Slots Supports for Community Living 41 Slots in FY 16-17 130 Slots in FY 17-18 Acquired Brain Injury 8 Slots in FY 16-17 8 Slots in FY 17-18 Michelle P 83 Slots in FY 16-17 166 Slots in FY 17-18 SCL will have 240 slots after approval of the pending waiver renewal which were approved in a previous budget.

Waiver Redesign

Waiver Redesign Goals of Redesign access to high quality services Engage stakeholders in an assessment and redesign of the six home and community based waivers. Goals of Redesign access to high quality services collaboration among stakeholders clear and consistent communication increased consistency across waivers and across the state streamlined and simplified processes and documentation programs that are aligned with the HCBS rules and financially sustainable a seamless, flexible system that serves individuals across the lifespan Redesign Process Convened HCBS Waiver Redesign Stakeholder Advisory Group - December 2016 Included over 60 representatives: self-advocates, family members, consumer advocacy groups, provider associations and state waiver staff Three meetings: December 7, December 14 and January 11

Waiver Redesign Next Steps Operationalize certain system efficiencies that have been identified Documentation Training Assistance Exceptional Support Process Engage consultant with expertise in HCBS waivers to assess Medicaid’s organizational structure, business processes and recommend improvements Designate a project manager to facilitate future stakeholder engagement and development of a redesign plan Incorporate stakeholder input into sample models Submit to CMS for review and approval

HCBS Federal Final Rule Review

HCBS Federal Final Rules Overview The Centers for Medicare & Medicaid Services (CMS) implemented new regulations for Medicaid’s 1915(c) Home and Community-Based Services (HCBS) waivers on March 17, 2014. Key elements of the rule include: PERSON-CENTERED SERVICE PLAN PROVIDER SETTINGS PERSON-CENTERED PLANNING PROCESS CONFLICT-FREE CASE MANAGEMENT Providers of HCBS for the individual must not provide case management or develop the person-centered service plan, unless the provider is the only willing and qualified provider in the geographic area (30 miles) Reflect the needs identified through an assessment, as well as the individual's strengths, preferences, identified goals, and desired outcomes Individual leads the process to the maximum extent possible and is provided information and support to make informed choices regarding his/her services, as well as providers The setting is integrated in and supports full access of individuals receiving HCBS to the greater community, giving the individual initiative and independence in making life choices 2016-2017 First round provider setting requirements and all other HCBS Final Rules components effective in Kentucky HCBS regulations Jan 1, 2019 Second round provider setting requirements will be effective and implemented in Kentucky HCBS regulations

HCBS Final Rule Implementation – Status Update Kentucky has continued its efforts in implementing the HCBS Final Rules. Our priority for the next few months will be continuing to assess provider compliance with the new requirements. Key Accomplishments Statewide Transition Plan (STP) Received initial approval of the STP on 6/2/16, making Kentucky the second state to receive initial approval Updated the STP with the Commonwealth’s progress on assessing providers and identifying settings for heightened scrutiny; submitted the revised STP to CMS on 2/1/17 Heightened Scrutiny for Settings Presumed Not to be Home and Community-Based Completed site visits to over 350 settings subject to heightened scrutiny and identified 23 settings for the first round heightened scrutiny submission Developed 10 page summaries for each setting in the first round submission that describes its home and community-based characteristics Reviewed summaries with a stakeholder group composed of self-advocates, families, advocates, and providers Upcoming Activities Heightened Scrutiny Submission Collect and summarize all public comments received (public comment period ends 3/18/17) Update setting evidence summaries with public comments and submit to CMS (anticipated 4/1/17)