1915(c) WAIVER REDESIGN 2019 Brain Injury Summit Commonwealth of Kentucky Department for Medicaid Services March 1, 2019

AGENDA Recap of 1915(c) Waiver Assessment Work Review of Stakeholder Engagement Understanding 1915(c) Waiver Applications vs. Kentucky administrative regulation Overview of Process to Develop Draft Amendments Next Steps and Closing Statement

Recap of 1915(c) waiver Assessment Work

RECAP OF 1915(c) ASSESSMENT WORK Spring 2017: The Cabinet partnered with Navigant to assess the 1915(c) waiver programs, with a charge to: 1. Evaluate the processes in place in the area of 1915(c) waivers and work to: Improve waiver services; Improve efficiency, including but not limited to, potential changes in internal structure and administration; and Improve cost effectiveness. 2. Provide support that includes the analysis, development, and implementation of the Department's fiscal processes, procedures and controls with focus on cost containment in the area of 1915(c) HCBS waivers. 

RECAP OF 1915(c) ASSESSMENT WORK (CONTINUED) The Department for Medicaid Services (the Department) has spent over a year considering how to improve the 1915(c) home and community based services (HCBS) waiver programs. Through careful and deliberate process the Department identified a series of opportunities to: Strengthen internal Department processes Improve administrative and oversight approaches Clarify and/or update policies that merit a change

Review of STAKEHOLDER ENGAGEMENT

1915(c) HCBS WAIVER REDESIGN STAKEHOLDER ENGAGEMENT ACTIVITIES AND COMMUNICATION TO DATE The Department began public outreach by hosting a public kickoff Established a dedicated email address for project, receiving over 300 emails to date Held stakeholder focus groups across the state which 480+ attended Received stakeholder comments regarding Navigant's preliminary report Conducted town halls to provide education on Navigant's recommendations and to receive public testimony regarding recommendations Released Navigant's Final Assessment Report Released a response to Final Assessment Report Established advisory panels representing a wide range of stakeholders Released Public Notice of Upcoming Formal Public Comment Period and accompanying educational documents Releasing draft waivers for public comment and provided educational opportunities for informed comments, after making revisions based on public comments from previous release Ongoing communication through in-person meetings, conferences, and email April 2017-January 2019

Informational Presentations As the Cabinet moves forward with addressing recommendations from the assessment report, the Cabinet will continue to engage with and seek stakeholder input to promote optimal success. Subpanels Public Comment Informational Presentations

Understanding 1915(c) Waiver Applications vs Understanding 1915(c) Waiver Applications vs. Kentucky administrative regulation (KaR)

DIFFERENCE IN 1915(c) WAIVER APPLICATION AND KENTUCKY ADMINISTRATIVE REGULATION Formal Agreement between state and CMS that provides partial federal funding Allows states to provide long term care services in the community Requires approval from CMS. Given based on federal requirements Summarizes state’s plan for providing services that demonstrates compliance with federal requirement Kentucky Administrative Regulations (KAR) Required for state specific approval of specific program KAR are required by Kentucky statute KAR does not require CMS approval KAR does not provide funding for services Standard KAR process requires a public comment period and public hearing, if applicable 1915(c) Application and KARs will not be submitted at the same time but must align and not conflict when completed.

OVERVIEW OF PROCESS TO DEVELOP DRAFT AMENDMENTS

WAIVER STANDARDIZATION PROCESS Submit final waiver amendment to CMS Update waivers based on public comments (if needed) Release of waivers for public comment Conduct informative public webinars on key policy changes Reviewed draft waivers with sister agencies and Cabinet leadership DMS compared current waivers and drafted revised waiver text c Stakeholder input was received and considered throughout this process c Stakeholders will continue to be involved and informed throughout the process

OVERVIEW OF PROCESS TO DEVELOP DRAFT AMENDMENTS In addition to stakeholder input, the Department is also reviewing the following sources: Existing 1915(c) waiver contents CMS 1915(c) Waiver Instructions, Technical Guidance and Review Criteria CMS federal rules, including the Federal Final Rule for 1915(c) Peer state policies Comparative research from other states Sister agencies input and feedback

OVERVIEW OF NATURE OF REVISIONS MADE Revisions focus on clarifying, updating, and enhancing policies to offer easier interpretation and improved compliance. Specifically, the policy changes: Standardize definitions that exist across waivers 1 Align and update the description process that exist across waivers 2 Clearly describe administrative processes and the responsible party for each step of the process 3 Streamline policies that influence individualized service planning to treat all waiver populations equitably 4 Confirm waiver language meets the intent of the sub-section, as per CMS 1915(c) Instructions, Technical Guide and Review Criteria 5

OVERVIEW OF NATURE OF REVISIONS MADE (CONTUNUED) When the rate methodology study is complete, there will be another series of changes via a second round of amendments, including submission of the rate-setting method developed. Some changes and improvements are not realistic for implementation until the pending rate methodology study is complete and HCBS reimbursement rates are confirmed The Department has several elements of redesign that require further review from stakeholders and the Department, therefore redesign needs to be done in phases. The purpose of making certain changes in the first round of changes is to begin making improvements to respond to stakeholder’s sense of urgency in stabilizing the HCBS waiver programs

1915(c) IMPLEMENTATION TIMELINE Changes will be sequenced so that the HCBS delivery system is not flooded with a large volume of changes at one time: The Department has heard that too many change happened too quickly and hindered the success of past waiver updates and has not allowed sufficient time to prepare for implementation. The Department also needs to build in sufficient time to offer training and education, necessary guidance, and technical assistance to all stakeholder types so the HCBS system is prepared to adapt to changes.

Next Steps & Closing statements

PUBLIC COMMENT PERIOD The formal public comment period for the proposed 1915(c) waiver revisions will be a full 30 day period that will begin with the release of the draft waivers. The 30-day public comment period is a mandated activity for states requesting Center’s for Medicare and Medicaid Services (CMS) approval for substantive changes made to any 1915(c) waiver. The Department is dedicated to recognizing and considering stakeholder input at any time. It is important to note that the Department is continuously accepting comments about the waiver redesign process. During the formal comment period, comments submitted during the formal 30 day period will be considered “official public comment”. These comments will be publicized and responded to through the public comment process with CMS. Once the public comment period has ended and the comments have been reviewed, the Department will host a webinar and Town Halls to share the results of the public comment period and the Department’s response to those comments. .

ROLE OF STAKEHOLDER INPUT DURING PUBLIC COMMENT Stakeholders are encouraged to review the contents of the waiver amendments and provide public comment. Public comment is a critical component for finalizing the waiver language. Stakeholder ideas and suggestions are welcome as is identifying concerns or elements of the proposed language that do not resonate. Although stakeholders serve as advisors to the process, the Cabinet and Department for Medicaid Services retain final decision-making authority.

CLOSING Submit questions and comments to the public inbox at: medicaidpubliccomment@ky.gov Thank you for your time and attention.