1. 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

2. 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

3. 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

4. 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

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

6. 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 $247M
93% Federal Match in CY 2019
90% Federal Match in CY $510M

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Status of Waivers and Slots

14. 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.

15. Waiver Redesign

16. 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

17. 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

18. HCBS Federal Final Rule Review

19. 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, 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
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

20. 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)