Call to Order and Roll Call
Thefirst meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, June 18, 2014, at 10:00 a.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 10:08 a.m., and the secretary called the roll.
Members:Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Julian M. Carroll, Perry B. Clark, Jimmy Higdon, and Reginald Thomas; Representatives Bob M. DeWeese, Mary Lou Marzian, Darryl T. Owens, Ruth Ann Palumbo, Russell Webber, Susan Westrom, and Addia Wuchner.
Guests: Representative Jimmie Lee; Beth Jurek, Executive Director, Office of Policy and Budget, Cabinet for Health and Family Services; Mary Begley, Commissioner, Allen Brenzel, Medical Director, and Natalie Kelley, Director, Division for Behavioral Health, Department for Behavioral Health, Developmental, and Intellectual Disabilities, Cabinet for Health and Family Services; Lisa Lee, Deputy Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; Oliver Olson, Registered Nurse Practitioner; Eric Crawford, Mason County Resident; Jaime Montalvo, President and Tori Burgin, KY4MM; Eric T. Clark, Kentucky Association for Health Care Facilities; Kimberlee Richardson, Coventry; David Beyer, Executive Director, Kentucky Board of Dentistry; Sarah S. Nicolson, Kentucky Hospital Association; and Patti Parsons, mother of an autistic child.
IMPACT Plus Program Changes
Mary Begley, Commissioner, Dr. Allen Brenzel, Medical Director, and Natalie Kelly, Director of the Division of Behavioral Health, Department for Behavioral Health, Developmental, and Intellectual Disabilities, and Lisa Lee, Deputy Commissioner of the Department for Medicaid Services, Cabinet for Health and Family Services, testified that IMPACT Plus was designed to serve children with high intensity behavioral health needs who were in or at a risk of out-of-home placement. Children were required to meet program eligibility criteria established in 907 KAR 3:030. Under the Title V Agreement, the Department for Behavioral Health, Developmental, and Intellectual Disabilities (DBHDID) has had the primary responsibility for payment to subcontractors, developing policy, managing subcontractor network through enrollment and termination, credentialing individual providers, enforcement through onsite monitoring of billing documentation and the clinical records of each agency, and collecting quality improvement and outcome data. The DBHDID’s current role is duplicative of the managed care organizations (MCOs), creates inefficiency in program administration and service delivery, and increases costs.
On January 1, 2014, the Center for Medicare and Medicaid Services (CMS) authorized a State Plan Amendment for Kentucky. Key services that were once unique to the IMPACT Plus program and the new substance abuse treatment benefit are now included in Kentucky’s Medicaid State Plan. IMPACT Plus services will no longer require prior authorization unless required by the MCOs. The MCOs do not require prior-authorization on all behavioral health services. Providers will receive payment from the MCOs directly. The provider network is open to providers other than the Community Mental Health Centers (CMHCs) for behavioral health services. Kentucky is ready to fully transition the administration of IMPACT Plus services from DBHDID to the MCOs.
The transition will begin July 1, 2014 when no new children will be enrolled into the Title V IMPACT Plus program. Beginning July 1, 2014, newly eligible children may receive services under traditional Medicaid. Services will be billed directly by the contracted MCO provider to the MCO. DBHDID will continue as the administrator of the IMPACT Plus program for eligible children enrolled through June 30, 2014 and will continue to credential individual service providers from the 49 DBHDID subcontracted agencies. Subcontractors will continue to deliver services to children under 21 who were determined eligible for the Title V IMPACT Plus program through June 30, 2014 and billing for those children will still require the pass through between DBHDID, the MCO, and the IMPACT Plus subcontractor until October 1, 2014. Beginning October 1, 2014, all behavioral health services for all children who are in need of intensive, community-based behavioral health services, will be authorized through the traditional Medicaid benefit by the MCO.
IMPACT Plus services will be available to all Medicaid-eligible children rather than only those who meet the regulated eligibility criteria of the IMPACT Plus program. Providers will be able to negotiate their own rates and have more freedom of choice in their participation with MCO selection. Clients will have a broader panel of providers from which to choose. DBHDID is maintaining an updated database which will track all subcontractors and individual professionals who are providing IMPACT Plus services as they enroll with Medicaid and are contracted with each MCO. Training sessions and a Frequently Asked Questions document regarding obtaining Medicaid numbers, expanded services, and information about MCOs are available to providers.
In response to questions by Senator Denton, Commissioner Begley stated that if there is no adequate network by July 1, 2014, children can receive needed services; however, the MCOs say they will be ready by that date. Nine of the 49 active IMPACT Plus subcontractors have obtained a multi-specialty provider group number. Ms. Lee stated that the multi-specialty provider group number is a Medicaid number created to allow providers within a group to participate in the program and bill under the same number so each individual provider in the group would not have to enroll and bill as an independent provider. Ms. Kelley stated that since January 1, 2014, 670 independent providers have enrolled and obtained a Medicaid number. Some MCOs will allow providers to contract on a case-by-case basis until the provider becomes credentialed. Commissioner Begley stated that the July 1, 2014 date was established to keep the process moving forward so that all Medicaid-eligible children can receive services and more providers could provide the services. The implementation date can always be moved if the MCOs are not ready.
In response to questions by Representative Westrom, Ms. Lee stated that all providers can negotiate rates with the MCOs that include flexibility for children with more complex needs than the standard rate would allow. Dr. Brenzel stated that the cabinet enforces the contractual requirement for MCOs to maintain an adequate network that helps providers in negotiations. Since November 2011, MCOs have determined who is eligible for IMPACT Plus services required by regulation. MCOs can and will offer services to children who may not meet regulatory eligibility requirements for IMPACT Plus. MCOs are incentivized to provide and authorize services.
In response to a question by Senator Higdon, Commissioner Begley stated that the DMS will now keep the $400,000 currently given to BHDID to monitor the IMPACT Plus program. Payment for behavioral health services is already included in the contract with each of the MCOs.
In response to questions by Senator Buford, Commissioner Begley stated that no additional money will be given to the MCOs for providing the new services. Ms. Lee stated that flexibility to provide behavioral health services was built into the contracts negotiated between the provider and the MCO. Additional funds were appropriated to provide substance abuse treatment because these services were not part of the data book when the MCOs bid on contracts with the cabinet. When services are denied, the family has to go through a denial process. The first step when a child is denied services is a peer-to-peer review from the physician and a provider of similar background at the MCO. After appeal rights from the MCO have been exhausted, then an appeal can filed with the state.
In response to questions by Representative Burch, Commissioner Begley stated that there are currently 3,500 children who receive IMPACT Plus services. There are 49 agencies that have 1,100 individual providers. Ms. Lee stated the cabinet will monitor the appeals claims process and results to see which MCOs have denied more children services, watch claims utilization outliers, and identify areas of concern by the DMS Division of Quality Management who is responsible for reviewing all claims and reports from MCOs. Senator Denton stated that the MCOs will conduct their own audits and quality controls.
In response to questions by Representative Wuchner, Dr. Brenzel stated that Medicaid-eligible children are already enrolled with the MCO, therefore, there will be no changes in formularies and will not require any disruption of services. Commissioner Begley stated that geographical data on all providers is on the DHDID web site. DHDID is working on a web site that lists the location of providers by county. Some providers still do not have contracts with the MCOs.
In response to questions by Representative Owens, Ms. Kelley stated that the number of IMPACT Plus children is higher in June because one MCO did not submit accurate data in May. Dr. Brenzel stated that the cabinet anticipates a significant increase in number of children who will have access to the services that were previously only accessible through the IMPACT Plus Program. The number of children receiving IMPACT Plus services will be difficult to track because the children will only be receiving the appropriate behavioral health services as a part of the full array of behavioral health benefits. Commissioner Begley stated that some providers have obtained a Medicaid number but are waiting on approval from the MCOs to provide services.
In response to a question by Representative Marzian, Commissioner Begley stated that all CMHCs will be able to provide services under the new program. The CMHCs can expand and contract for services they were unable to in the past because they are now a part of the Medicaid program. This is a continued expansion of the behavioral health network and behavioral health services. Ms. Lee stated that she would follow-up to see why Anthem requires providers to be Medicare eligible to participate in the new behavioral health network.
Bart Baldwin stated that the DMS is working hard to expedite the process to get a Medicaid number to providers as soon as possible in order to get credentialed by and negotiate a contract with the MCOs. One concern is what happens after July 1, 2014 if a provider has not completed the MCO credentialing process. Sometimes there are multiple individual providers within a provider group, and each of them has to have a Medicaid number and be credentialed.
In response to a question by Representative Westrom, Mr. Baldwin stated that once a provider has a Medicaid number, the standard timeline to go through the MCO credentialing process is 30 to 90 days.
Cabinet for Health and Family Services Budget Overview
Beth Jurek, Executive Director, Office of Policy and Budget, stated that final FY 2014 financial information will be available in mid-July. All agencies are ending the year as expected and as budgeted for FY 2014. Once the fiscal year is closed out, the cabinet will be able to project the budget for FY 2015. The cabinet had a five percent general fund reduction. The difference between the Governor’s recommendation and the enacted budget is $17.7 million less. Across the cabinet, program agencies and their community partners are transitioning from an environment where many persons are uninsured to an environment where most are either Medicaid eligible because of the expansion or they are able to obtain affordable health insurance. The cabinet will begin to pay for services that were not previously covered by Medicaid or health insurance. The Department for Community Based Services did not receive additional funds to serve the 300 new children in out-of-home care. DCBS is trying to develop more community-based services so children can remain at home or go home sooner from an out-of-home placement. The adult abuse registry, juvenile justice, and cybersecurity requirements enacted during the 2014 General Assembly will significantly impact the cabinet’s budget.
In response to questions by Representative Burch, Ms. Jurek stated that information on the amount of funds Kentucky will receive from the tobacco company settlement could be obtained from the state budget office, which has been working with the Attorney General on negotiations with tobacco companies. She did not know when the funds would appear in the general fund. Between August 1, 2014 and September 1, 2014, the cabinet will be able to fund childcare assistance up to 125 percent of the federal poverty level (FPL) and 150 percent in 2016 with funds provided by the General Assembly in the FY 2014-2016 budget.
In response to questions by Senator Denton, Ms. Jurek stated that the $35 million Medicaid administration budget baseline has remained the same or slightly less than FY 2013. Since 2012, the number of Medicaid administration employees has remained between 170 and 180. Kentucky has one of the smallest Medicaid administration staff nationwide. The cap on employees in the Office of Health Benefit Exchange (OHBE) is 30, but OHBE is not presently fully staffed. The OHBE used temporary staff in the start-up of the exchange, because they did not know how many employees would be needed on a full-time basis.
Consideration of Referred Administrative Regulations
The following administrative regulations were available for consideration and placed on the agenda having been referred to the Committee on June 6, 2014, pursuant to KRS 13A.290(6): 201 KAR 8:016 – establishes fees for the issuance, renewal, and reinstatement of registrations of dental laboratories with the Kentucky Board of Dentistry; 201 KAR 8:532 – establishes requirements and procedures for licensure of dentists; 201 KAR 8:562 – establishes requirements and procedures for the licensure of dental hygienists; 908 KAR 2:240 & E – establishes the minimum eligibility and training requirements for a Kentucky youth peer support specialist; and 908 KAR 2:250 & E – establishes the eligibility criteria and training requirements for community support associates employed by an entity which provides comprehensive community support services. A motion to adopt a technical amendment to 201 KAR 8:016 from the Kentucky Board of Dentistry was made by Senator Clark, seconded by Senator Denton, and adopted by voice vote. David Beyer, Executive Director of the Kentucky Board of Dentistry was present to explain the amendment. A motion to adopt the administrative regulations as amended was made by Senator Clark, seconded by Representative Palumbo, and adopted by voice vote.
Oliver Olson, Kentucky Registered Nurse Practitioner, stated that there should not be a prohibition on the use of medicinal marijuana. Marijuana has been used for medicinal purposes since 1830 and is one of the most studied drugs. Access to marijuana is a national issue not just a state issue.
Eric Crawford, Mason County resident, stated that individuals with medical conditions have to worry about their health every day. He does not care about recreational uses of marijuana but wants to talk about medical cannabis and the immediate need for the laws of Kentucky to change to allow truly sick and disabled people to legally use medical marijuana as an option to treat illnesses. There are a lot of people whose body or mind do not handle narcotics very well. A huge problem for most individuals is that they have to travel far distances to see a doctor. One of his doctors recommended the use of medicinal marijuana to lower the pressure in his eyes. Medical marijuana helps control his glaucoma. He and other people need medical cannabis for relief of pain and a better quality of life. A May 2013 Fox News poll found that approximately 85 percent of Americans think that marijuana should be allowed to be used for medical purposes if prescribed by a doctor. One-third of Americans live in a state where patients can use cannabis with a doctor’s advice. He asked that legislators legalize the use of medical cannabis so that individuals do not have to leave Kentucky to have better health and quality of life.
Senator Clark stated that there is no reason why Kentucky cannot be compassionate enough to allow its people access to something that is effectual with many modalities. The time to do something is now and it should be done quickly.
Senator Thomas stated that during the 2014 Regular Session, Senate Bill 124 was enacted that would allow the use of cannabis oil. The committee needs some results about the use of cannabidiol from the University of Louisville and the University of Kentucky in order to make an informed decision.
Representative Burch and Senator Denton agreed that it was known that there would be obstacles with the use of cannabidiol, but there has to be a starting place. Representative Burch stated that approximately 87 percent of the people in his district support the legalization of medicinal marijuana. If there are no marijuana plants available, the universities cannot conduct the needed research.
Senator Denton stated that the University of Louisville is aggressively trying to implement the enacted legislation. Approval from the federal government to grow hemp plants could be a huge economic advantage for Kentucky.
Jaime Montalvo, President of KY4MM, stated that it is illegal to bring marijuana cross the state line. The growth of marijuana plants could bring revenue to the Commonwealth. The laws need to be changed so it is not illegal for a person to obtain medicinal marijuana for relief from health issues. Approximately 150,000 Kentuckians could benefit from pain relief if medicinal marijuana is legalized.
Representative Burch stated that it takes time for change, but the legalization of medical marijuana will happen eventually.
Tori Burgin stated that the diagnosis of her husband’s esophageal cancer affected the lives of everyone in the family. He was diagnosed on December 2, admitted to the hospital on December 5, and suffered toxic shock to his body on December 11. The medications alone prescribed each month costs $10,000. When injected, cannabis oil or medical marijuana in highly concentrated forms has been shown to kill cancer. The federal government has known since 1972 that cannabidiol can heal cancer. She is willing to go to jail to obtain marijuana if it will relieve her husband’s pain.
In response to a question by Senator Higdon, Mr. Crawford stated that he uses a vaporized form of marijuana to help his symptoms. Mr. Montalvo stated that each state will have to deal with the issue of impaired driving, but currently there is no set standard to check the levels of cannabis in a person’s body. Someone can test positive 30 days after smoking marijuana.
Senator Denton and Representative Burch stated that the committee needs as much scientific data available in order to make an informed decision. There are challenges with the federal law, and Kentucky does not typically violate federal law.
There being no further business, the meeting was adjourned at 12:30 p.m.