Interim Joint Committee on Health and Welfare and Family Services


Minutes of the<MeetNo1> Second Meeting

of the 2017 Interim


<MeetMDY1> July 17, 2017


Call to Order and Roll Call

The<MeetNo2> second meeting of the Interim Joint Committee on Health and Welfare and Family Services was held on<Day> Monday,<MeetMDY2> July 17, 2017, at<MeetTime> 10:00 a.m., in<Room> Room 129 of the Capitol Annex. Representative Addia Wuchner, Co-Chair, called the meeting to order at 10:07 a.m., and the secretary called the roll.


Present were:


Members:<Members> Senator Julie Raque Adams, Co-Chair; Representative Addia Wuchner, Co-Chair; Senators Ralph Alvarado, Tom Buford, Danny Carroll, David P. Givens, Denise Harper Angel, Alice Forgy Kerr, Stephen Meredith, and Max Wise; Representatives Danny Bentley, George Brown Jr, Joni L. Jenkins, Mary Lou Marzian, Kimberly Poore Moser, Melinda Gibbons Prunty, Steve Riley, and Russell Webber.


Guests: Melissa L. Currie, MD, FAAP, Medical Director and Chief, Kosair Charities Division of Pediatric Forensic Medicine, and Professor of Pediatrics, Department of Pediatrics, University of Louisville School of Medicine; Jill Seyfred, Executive Director, and Joel Griffin, Prevent Child Abuse Kentucky; Abby Carter Emanuelson, Associate Vice President for Advocacy and Activist Engagement, National Multiple Sclerosis Society; Keith Johnson, CPA, Robbins Enterprises; Wesley R. Butler, Attorney, Barnett Benvenuti & Butler PLLC; William C. Thornbury, Jr., MD, FAAFP, President, Kentucky Academy of Family Physicians, Kentucky Medical Association Board Member, and Chair of the Medicaid P&T Committee; Paula Schenk, MPH, RN, Executive Director, and Nathan Goldman, General Counsel, Kentucky Board of Nursing; Mark Milner R.N., BA, MHA, MBA, Chief Nursing Officer and Vice President of Medical Staff Services, Ephraim McDowell Regional Medical Center; Dr. Jessica Estes, President, Kentucky Coalition of Nurse Practitioners and Nurse Midwives; Mary Katherine DeLodder, The Kentucky Home Birth Coalition; Vickie Yates Brown Glisson, Secretary, Kristi Putnam, Project Manager, and Jill Hunter, Deputy Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; Scott Brinkman, Secretary of the Executive Cabinet; Adam Meier, Chief of Staff for Policy, Office of the Governor; Sarah S. Nicholson and Mike Rust, Kentucky Hospital Association; Liz Shepherd, Kentucky Justice Association; William Simpson, President, and Ben Donaldson, Director of Government Relations, DisposeRx; Jennie Varrousek, University of Louisville Pediatric Forensics; Steve Hart, Kentucky Board of Pharmacy; Cyndee Burton, Matthew 25 AIDS Services; Phyllis Sosa and Kristi Gentry, Department for Aging and Independent Living, Cabinet for Health and Family Services; Kim Hinkel, KIPDA, and Bob Silverthorn, Office of Inspector General, Cabinet for Health and Family Services.


LRC Staff: DeeAnn Wenk, Ben Payne, Sarah Kidder, Heather Scott, and Gina Rigsby.


Approval of the Minutes from the June 21, 2017 Meeting

            A motion to approve the minutes of the June 21, 2017 meet was made by Senator Adams, seconded by Senator Alvarado, and approved by voice vote.


Consideration of Referred Administrative Regulations

201 KAR 2:074 – establishes requirements for pharmacy services in hospitals or other organized health care facilities; 201 KAR 22:070 – establishes the requirements a foreign-educated physical therapist shall satisfy to become credentialed in the state of Kentucky;

201 KAR 26:125 – establishes the requirements for the granting of designation of health service provider for a licensed psychologist who supervises a psychological health care service; 201 KAR 26:130 – protects and safeguards the health and safety of the citizens of Kentucky and provides procedures for filing, evaluating, and disposing of complaints by the Board of Examiners of Psychology; 201 KAR 26:140 – establishes procedures for a hearing upon the filing of a grievance to the Kentucky Board of Examiners of Psychology alleging a violation of KRS Chapter 319; 201 KAR 26:145 – establishes a code of conduct for a person practicing psychology; 201 KAR 26:155 – establishes the requirements for applicants for licensure, and the conditions for a temporary license as a psychologist;

201 KAR 26:160 – establishes the application and renewal fees for credential holders by the Board of Examiners of Psychology; 201 KAR 26:165 – establishes the requirements for inactive status for a credential holder for a period of up to three consecutive years by the Board of Examiners of Psychology; 201 KAR 26:171 – establishes the requirements for supervision of a certified psychologist, licensed psychological associate, candidate for licensure, or a credential holder sanction by the board;

201 KAR 26:175 – establishes the continuing education requirements for renewal of a license by the Board of Examiners of Psychology; 201 KAR 26:180 – establishes the requirements for licensure as a psychologist by reciprocity; 201 KAR 26:185 – establishes the requirements for granting a license to an applicant who is licensed in another state that does not have an agreement of reciprocity with the Board of Examiners of Psychology;

201 KAR 26:190 – establishes requirements for supervised professional experience for licensure as a psychologist; 201 KAR 26:200 – establishes requirements for licensure as a psychologist; 201 KAR 26:210 – establishes educational requirements for licensure as a psychological associate;

201 KAR 26:215 – establishes the requirements for registering in Kentucky as a nonresident psychologist; 201 KAR 26:225 – establishes the renewal and reinstatement processes by the Board of Examiners of Psychology;

201 KAR 26:250 – establishes the requirements for the employment of a licensed psychological associate; 201 KAR 26:280 – establishes the requirements for applicants for licensure and the conditions for a temporary license of a psychological associate; 201 KAR 26:290 – establishes the requirements for an applicant for licensure as a psychological practitioner; 201 KAR 32:050 – establishes the code of ethics for licensed marriage and family therapists and marriage and family therapist associates; 201 KAR 32:060 – establishes the requirements for continuing education and the methods and standards for the accreditation of continuing education courses; 201 KAR 46:035 – establishes uniform standards for the licensure of individuals who perform medical imaging and radiation therapy for diagnostic and therapeutic purposes while under the supervision of a licensed practitioner of the healing arts; 201 KAR 46:040 – establishes requirements for licensure, renewal, and reinstatement for an advanced imaging professional, a medical imaging technologist, a radiographer, a radiation therapist, and a nuclear medicine technologist;

201 KAR 46:060 – delineates the requirements for continuing education and prescribes methods and standards for the approval of continuing education courses required by the Board of Medical Imaging and Radiation Therapy; 201 KAR 46:070 – establishes uniform enforcement procedures regarding the licensure of an advanced imaging professional, a medical imaging technologist, a radiographer, a radiation therapist, a nuclear medicine technologist, or a limited x-ray machine operator and penalties for violation of licensure requirements; 201 KAR 46:090 – establishes, consistent with the requirements of KRS Chapter 13B, the procedures to be followed by the Board of Medical Imaging and Radiation Therapy in hearing appeals of actions taken under the public health laws of the Commonwealth; 902 KAR 20:053 – repeals 902 KAR 20:054, Health maintenance organizations; operations and services; 902 KAR 22:011 – repeals 902 KAR 20:010 and 902 KAR 20:030 as these two administrative regulations establish responsibilities for the Kentucky Board of Family Health Care Providers that is no longer active; 902 KAR 55:076 – repeals 902 KAR 55:100, Laetrile manufacturing standards; 906 KAR 1:081 – repeals 906 KAR 1:080 because the Office of Inspector General is no longer responsible for the certification of private review agents; 906 KAR 1:091 – repeals 902 KAR 1:090 because the Office of Inspector General is no longer responsible for conducting audits to determine allowable costs and reimbursement under Kentucky’s Medicaid Program for those services listed in 906 KAR 1:090, Section 3; and 910 KAR 1:210 – establishes a statewide Long-term Care Ombudsman Program. A motion to approve the referred administrative regulations was made by Senator Alvarado, seconded by Senator Adams, and approved by voice vote.


Telehealth Care – 2017 Legislation

Representative Steve Riley stated that in Kentucky, there is an extreme shortage of physicians. House Bill 450 from the 2017 Regular Session would allow primary physicians to use technology to have visits with patients. Even though a person has an appointment, it could take several hours to get back to see the doctor. Most people cannot wait long periods of time to see the doctor, so telehealth would be a way for people to see the doctor without having to wait long periods of time for a diagnosis and treatment.


William C. Thornbury, Jr., MD, FAAFP, President, Kentucky Academy of Family Physicians, Kentucky Medical Association Board Member, and Chair of the Medicaid P&T Committee, stated that the Kentucky Academy of Family Physicians and the Kentucky Medical Association have passed a joint resolution supporting the intent of HB 450. Kentucky has one of the most chronically ill populations in the country, and there are not enough healthcare providers. Many people are utilizing emergency rooms and not seeing their own primary care physician. HB 450 would require payment for like-kind services from private insurance providers to Kentucky’s health provider if they have an established and ongoing care relationship with a patient. The intent of the legislation is to provide a fair market for telemedicine technology. Kentucky providers have a compulsory burden to build and maintain a physical plant. Studies conclude that if there is no payment parity, there is no incentive for health providers to invest in telehealth care versus in-office care. Seventy-five percent of healthcare dollars is from chronic disease care delivery. Chronic disease care cannot be provided by different off site providers, because a provider has to establish a relationship with the patient. The benefits of telemedicine include 1) saving money, time, and resources; 2) opening access, 3) leveling access to doctor; 4) easing medical manpower shortages; and 5) provides better health outcomes, quality, and lower costs by staying with the same physician.


In response to questions or comments by Senator Alvarado, Dr. Thornbury stated that there is always a potential medical liability, and providers should be compensated for taking more risks for on-line treatment. Documentation always has to be provided to insurance companies. It is not worth investing in telehealth technology if that physician is not reimbursed the same as other providers. Telemedicine can provide a more efficient delivery of care.


In response to questions by Senator Givens, Dr. Thornbury stated that Kentucky will move from a fee-for-service model to an outcome-based model with a capitated fee. There needs to be a certain amount of providers online to make healthcare more affordable.


In response to a question by Representative Marzian, Dr. Thornbury stated that Kentucky needs to do whatever is necessary to make access to broadband services available to citizens in rural and urban areas. Kentucky has no choice but to find a solution. Representative Riley stated that all stakeholders need to get together to make this come to fruition.


Pediatric Head Abuse Trauma

            Melissa L. Currie, MD, FAAP, Medical Director and Chief, Kosair Charities Division of Pediatric Forensic Medicine, and Professor of Pediatrics, Department of Pediatrics, University of Louisville School of Medicine, and Board-certified child abuse pediatrician, stated that infants with abusive head trauma (AHT) may look completely normal and uninjured on the outside, but have serious injuries on the inside. The signs and symptoms can be hard to notice and easily mistaken for a less concerning problem and therefore missed and/or misdiagnosed by medical professionals. AHT is the most dangerous and dearly form of child physical abuse. Legislation for mandatory recognition training was enacted by 2010 House Bill 285, 2014 House Bill 157, and 2015 Senate Bill 119. Global brain injury is caused by rotational or angular forces that involves shaking, impact, or both. It is not typically a one-time event. It is very rare for a child to die from or be permanently disabled from maltreatment the first time the child is abused and/or neglected. Any bruising of the torso, ears, or neck (TEN-4 exam) in a child four years of age or younger or any bruising, anywhere, on a non-mobile infant is not normal. Situations that trigger abuse include a crying baby, a child’s misbehavior, an argument or family conflict, toilet training, escalation of physical punishment, and parental stressors outside the home. The top risk factors for fatal abusive injury include substance abuse, domestic violence, criminal history, and undiagnosed or untreated mental illness among adult caregivers in the home.


Jill Seyfred, Executive Director, and Joel Griffin, Prevent Child Abuse Kentucky (PCAK), stated that its mission is to prevent the abuse and neglect of Kentucky’s children. Kentucky is ranked second in the nation in 2015 for child maltreatment. Lifetime cost for the 22,090 confirmed victim in Kentucky for Calendar Year 2016 is $4,639,165,080. The top risk factors include substance abuse and family violence. There are services available in all 120 counties. There needs to be an increase in education and awareness of child abuse. PCAK currently offers 14 different trainings on topics ranging from recognizing and reporting, internet safety, and working with families in substance abuse recovery. PCAK staff can develop a training to address a specific need or subject. Milestones in PCAK’s prevention efforts include the development of on-line web-based trainings for child care, nursing, and physicians, and the training of over 37,000 child care staff, and trained over approximately 4,000 social workers, childcare staff, and professionals in face-to-face sessions. PCAK’s goal is to provide multiple exposures to information parents need when they most need to hear it.


Hospital Peer Review

            Wesley R. Butler, Attorney, Barnett Benvenuti & Butler PLLC, stated that peer review is any process by which someone reviews a peer’s clinical practice. Many times it focuses on clinical judgment, professional judgment and skill to provide feedback to a practitioner for areas of improvement. There is no model peer review process that everyone can follow. Peer review is retrospective. The idea is to look back and evaluate the case and the clinical judgments made, and the skills used for the purpose of improving future care. Peer review influences care on future patients. It is not included in a patient’s medical record and has no influence on a patient’s care. Peer review is self-critical. It is intended to be an evaluative process about questioning how care is provided and how to improve that care in the future. Peer review is not an investigation but an evaluation of the medical record to determine the clinical judgment behind a decision. Peer review is not a disciplinary process but a quality process intended to identify ways to improve quality of care. If there are issues with the case that need to be referred to others, it goes through a separate process for disciplinary action. All 50 states and the federal government have laws that are intended to encourage medical peer review. Kentucky has had peer review legislation since 1976. In 1977, there was a case that reviewed the peer review legislation and determined that it violated Section 51 of the Kentucky Constitution because the bill’s title matches did not match subject matter. In Kentucky, generally courts have ruled that a peer review has to be accessible to discovery. Peer review happens in a robust manner when it can be done confidentially.


In response to questions by Senator Alvarado, Mr. Butler stated that the way the Kentucky courts interpreted the law, the statute was to protect the peer reviewers and not the peer review process even though the language says any civil action. There is no statute or protection that prohibits a plaintiff from the facts of a case. Information and facts are always available through discovery. Peer review is about opinions on how to improve patient care in the future and not about the facts.


In response to questions by Representative Wuchner, Mr. Butler stated that the facts, the medical record, the practitioners, and the care providers involved in the case are always available for discovery. Kentucky is the only state that does not protect the peer review process.


Senator Meredith stated that the lack of protection of the peer review is problematic for rural communities, because doctors are reluctant to be involved in a peer review of a colleague. The intent of the peer review is to improve the quality of care rendered to a community and not to be potentially required to testify against a colleague. It is to be engaged in true peer review and helping them become better practitioners.


Liz Shepherd, Kentucky Association, stated that the proposed legislation protects hospitals and nursing homes from telling the truth, shields the facts of what really occurred, and encourages and prolongs litigation because facts are unavailable.


In response to questions by Senator Alvarado, Ms. Shepherd stated that medical lawsuits are filed and won in other states. Some states have carved out exceptions.


In response to a question by Senator Buford, Ms. Shepherd stated that her interpretation of the proposed legislation is the information from an internal peer review would be shielded permanently from discovery even with the court order.


Livable Home Tax Credit Program

            Abby Carter Emanuelson, Associate Vice President for Advocacy and Activist Engagement, National Multiple Sclerosis Society, stated that most people with multiple sclerosis (MS) are diagnosed between the ages of 20 and 50 with at least two to three times more women than men being diagnosed with the disease. MS affects more than 2.3 million worldwide and nearly 6,000 in Kentucky. MS is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and the body. As the disease progresses, severity and specific symptoms may worsen which may require them to need an aid, such as a cane or crutches, and some will use a scooter or wheelchair because of fatigue, weakness, balance problems, or to assist with conserving energy. Additionally, during the course of the disease, individuals may be at risk to falls. People with MS typically fall in or around their homes and neighborhoods, usually while doing basic activities like bathing and preparing meals. The cost of skilled nursing in Kentucky is more than $6,000 per month with the state potentially picking up a portion of those costs for some of these individuals. Falls are associated with loss of confidence, social isolation, curtailment of activities, and fear of increased risk for more falls. One of the recommended responses to addressing falls is practical lifestyle adjustments, and the National MS Society believes a practical adjustment is an accessible, livable home where individuals and their families can live safely and with greater confidence.


Home modifications are changes made to adapt living spaces to meet the needs of people with physical limitations so that they can continue to live independently and safely. The modifications may include assistive technology or making structural changes to a home. For individuals with MS, an accessible home with the necessary modifications can help them cope with many of their symptoms, maintain independence and live a high-quality life. Although critical for safety and independence, home modifications can be expensive and place a large financial burden on individuals with disabilities and their families. Costs range from $100 to $50,000 depending on the scope of work. In 2015, the Kentucky median income of households that include any working-age people with disabilities was $31,800. It is estimated that the cost of living with MS and paying for the care that is required is approximately $70,000 per year per person. For a middle income wage earner, paying for accessibility modifications may be out of reach. An incentive would be an opportunity for people to receive help paying for modifications.


Georgia, Illinois, Kansas, Louisiana, Maine, Maryland, Missouri, New Hampshire, and Virginia have an existing home modification tax credit program or are in the process of developing one. Maryland and Louisiana have established a tax incentive for livable homes. Having stable, affordable, and accessible housing not only increases quality of life and promotes independence for people living with disabilities, but it allows them to remain actively engaged in the workforce and community, which benefits society as a whole.


Keith Johnson, CPA, Robbins Enterprises, and Society Trustee for the Kentucky-Southeast Indiana Multiple Sclerosis Society Chapter, stated that in 2006 he was diagnosed with a relapsing and remitting MS, and in 2013 had to start using a wheelchair full time. While he was able to afford to build a home with modifications, modifications to home can be expensive to people on a fixed income. A tax credit incentive managed by the Kentucky Department of Revenue could be offered to help people who cannot afford these modifications. A limitation could be placed on the dollar amount that a person receives or on someone’s income level.


Midwifery Legislation in the Commonwealth

Mary Katherine DeLodder, The Kentucky Home Birth Coalition, stated that it is not a matter of midwives trying to advance their profession but a matter of families asking for access to midwives who assist with home births. In the 1950s, the General Assembly passed legislation that required midwives to have a permit in order to practice. In 1975, the administrative regulations relating to that legislation were amended to say that no new permits would be issued. The idea was that nurse midwives, different from the certified professional midwives, would fill in the gaps. Currently, there are only four nurse midwives who are attending home births, and the other 85 practice exclusively in hospitals. There are approximately 700 home births per year in Kentucky that are attended by other midwives who basically have to hide their participation in the births while the medical community overlooks their participation. Concerns about the midwifery legislation introduced during the 2017 Regular Session are that some provisions included in the legislation could be addressed better in regulation and that would meet International Confederation of Midwives global standards for midwifery education requirements endorsed by the American College of Nurse Midwives and the American College of Obstetricians and Gynecologists.


In response to a question by Senator Adams, Ms. DeLodder stated that there is unclear language about the definition for a high-risk pregnancy, gestational diabetes controlled by insulin or by diet, and limitations if someone had a previous C-section birth.


In response to a question by Senator Buford, Representative Wuchner stated that legislation that will be introduced in the 2018 Regular Session is the same language introduced during the 2017 Regular Session.


Representative Addia Wuchner stated that the 2017 legislation would define certified professional midwife (CPM) and midwifery, create a Certified Professional Midwives Advisory Council under the Kentucky Board of Nursing (KBN), require CPMs to follow public health laws relating to reporting disease and recording vital statistics, require a CPM to keep appropriate medical records, list required administrative regulations to be promulgated by the KBN, permit the KBN to require a criminal background investigation of a CPM applicant, make it unlawful to provide midwifery services without permit or operate a midwifery training program or school without KBN approval, require reporting of unlawful provision of midwifery services, provide religious exemption for traditional birth attendants, list prohibited pregnancy conditions for which a CPM may not provide services, and provide immunity from liability for health care professionals from acts or omissions of a CPM.


Paula Schenk, MPH, RN, Executive Director, Kentucky Board of Nursing, stated that if it is the will of the legislature, the KBN is willing to take the responsibility of regulating permitted midwives.


Jessica Estes, President, Kentucky Coalition of Nurse Practitioners and Nurse Midwives, stated that it is appropriate for women to have alternatives to be able to choose how and when they want to give birth, but there are standards and criteria that must be met for the safety of the mother and baby. All home birth deliveries should be tracked appropriately, CPMs with appropriate education and credentialing should be licensed in Kentucky and graduate from accredited midwifery programs. The coalition cannot support vaginal births after a C-section (VBACs), multiple births, or breech births that occur in a home setting because they are high-risk and at-risk for additional complications. Given the number of CPMs that may exist in Kentucky, it is not a financially feasible model to have a separate board, but oversight could fall under a board that already is in existence.


Mark Milner R.N., BA, MHA, MBA, Chief Nursing Officer, Ephraim McDowell Regional Medical Center, and the District Director of the Kentucky Organization of Nurse Leaders, stated that CPMs should have oversight from the KBN, CPMs should be credentialed appropriately, there should be oversight for high-risk births, focus needs to be on public safety, CPMs should be accountable for the care they deliver as in any health profession, records need to be clear and shared, and there needs to be public reporting.


In response to questions by Senator Buford, Mr. Milner stated that if a police officer, fireman, or anyone else assisted in a birth, it can be handled in ways that are consistent with other liability limitations. Director Schenk stated that she did not have information on the cost of training and education of professional midwives. Senator Buford stated that the information could be given at a future meeting. Mr. Milner stated the situation as outlined in the proposed legislation in Section 7 creates a provider relationship with a CPM. The hospital would be available for support and intervene as appropriate. Representative Wuchner stated that the language was put in the proposed legislation that if something happened to a mother and/or baby while in the care of the CPM and after consultation with hospital staff and then having to be transferred to the hospital, the hospital staff would not be liable for something that took place when the mother and/or baby were in the care of someone else.


Representative Bentley stated that liability is a huge reason many doctors have quit delivering babies. Small rural hospitals are struggling and even filing bankruptcy because allot more patients are on Medicaid which has a lower reimbursement rate.


Representative Wuchner stated that if someone is going to have a VBAC at home, a hospital has to be set up and ready for that patient in case there are complications. Rural hospitals cannot afford to keep medical staff on standby 24/7 just in case there is an emergency.


In response to questions by Senator Alvarado, Dr. Estes stated that a VBAC is a high-risk delivery. Director Schenk stated that it is out of the board’s prevue to determine medical negligence if a nurse midwife knows about a VBAC and does not let anyone know and then there are complications. The incident would be investigated, and the board could find that the case did constitute a violation of the standard of practice. Mr. Milner stated that if an OB/GYN wanted to perform a VBAC in a hospital, it is the hospital’s obligation to have an operating room and team available and on standby because it is such a high-risk birth. Critical access hospitals have one operating room and one operating room team, so staff would be available for the birth, because if there are complications, the timeframe is critical. Death could occur if someone does not receive medical help ASAP.


Senator Alvarado stated that the liability for police officers and any layperson does not qualify under the definition of the bill and is outside its purview. If there is no protection from liability for a hospital and its staff, advice will not be given over the phone. The hospital staff would tell the midwife to bring the person to the hospital and the hospital would take care of the patient. Hospitals are required to take care of someone who shows up in the emergency room no matter what.


In response to questions by Senator Adams, Director Schenk nor Mr. Milner had the percentage of VBACs in hospitals that end up being an emergency C-section. Mr. Milner stated that Ephraim McDowell Regional Medical Center refers individuals to facilities who have additional resources required to perform a VBAC. Dr. Estes stated that high-risk multiple births in the western part of the state are sent to the University of Louisville, but not all multiple births are high risk.


In response to questions by Senator Kerr, none of the presenters were able to give the number of OB/GYNs available to perform home births in Kentucky. Dr. Estes stated that the challenge with nurse midwives is there are limitations on collaboration that determine what can or cannot be done including home births.


In response to questions by Senator Buford, Director Schenk stated that if there is a complaint about a cultural or religious traditional birth attendant practicing midwifery, the board would investigate and ask the attendant for verification of the cultural or religious exception. Representative Wuchner stated that the birth attendant would serve only women and families within that distinct culture or religious group.


In response to questions by Senator Meredith, Dr. Estes stated that nurse midwives are already licensed and credentialed and have malpractice insurance to cover services. The CPMs would be an additional group of non-nurses adding a license in Kentucky. Senator Meredith voiced his concern about who would be financially responsible for liability if something went wrong and the CPM does not have malpractice insurance.


Kentucky HEALTH 1115 Medicaid Waiver: Summary of Changes

Vickie Yates Brown Glisson, Secretary, Cabinet for Health and Family Services, stated that the original 1115 Medicaid waiver was filed with the Centers for Medicaid and Medicare Services (CMS) in June 2016. Revised waivers were filed with CMS in August 2016 and July 2017.


Kristi Putnam, Project Manager, Cabinet for Health and Family Services, stated that implementation of Kentucky HEALTH Phase #1 will begin January 1, 2018; Phase #2 on April 1, 2018, and Phase #3 on July 1, 2018. Kentucky HEALTH does not include traditional Medicaid recipients (aged, blind, and disabled) or former foster youth up to age 26. Kentucky HEALTH covers non-disabled adults and children covered before the expansion, pregnant women, children, and the adult expansion population.


Adam Meier, Chief of Staff for Policy, Office of the Governor, stated that proposed modifications to the original 1115 waiver application include static community engagement hours, lock-out period for failure to report a change in circumstances, and maintenance of current presumptive eligibility sites. Modification to community engagement hours were proposed to avoid confusion for members by aligning the community engagement hours with the Supplemental Nutrition Assistance Program (SNAP) requirements for non-exempt individuals. Non-exempt individuals will receive detailed communications and formal notices prior to the roll-out in their region. The information will include the initial three-month period and subsequent community engagement requirement. Even if a member enters a lock-out period, early re-entry will be offered through completing a Health Literacy or Financial Literacy course and obtaining an updated certification of eligibility. Members will be notified of their responsibility to timely report changes at application and recertification periods through the rights and responsibility documents. The expansion of presumptive eligibility is not necessary to ensure timely enrollment into Kentucky HEALTH. Fast Track provides individuals an alternative opportunity to expedite enrollment by pre-paying their premium obligations and activating coverage as early as the first of the month of application. Waiver modifications can be found at The public comment period closes on August 2, 2017 at 11:59 p.m.


In response to questions and comments by Senator Meredith, Mr. Meier stated that Kentucky ranks 47th in workforce participation rates. Forty percent of health outcomes are determined by socio-economic situations, and it is important to take an approach that does not just enroll people in Medicaid, but focuses on how to get people better health outcomes. The focus is to move people out of Medicaid not kick them off the roles. Everyone who has access to services today, will still have access to services if the Medicaid waiver is approved.


In response to a question by Representative Jenkins, Mr. Meier stated that the income requirement is not a new requirement. If there is an unreported income change, the case would be referred to the Office of Inspector General by the DCBS caseworkers. The OIG will then determine, dependent on resources, whether to pursue civil or criminal charges. Because the lock-out mechanism for an eligibility change was part of the original 1115 waiver, IT capabilities have already begun. Taking a class to re-enroll will create an automatic trigger into the eligibility system to show if someone is eligible again. There is already a rights and responsibility document available at enrollment. Some regions will be subject to SNAP employment requirement and community engagement requirement on July 1, 2018. All the other counties will be phased in after that date.


In response to a question by Senator Alvarado, Mr. Meier stated that there is a three-mouth phase in for any new member before that recipient would have to meet the 20-hour requirement. Ms. Putnam stated that, if someone meets SNAP requirements, that person is considered meeting the requirements for Medicaid services. It is not a dual requirement.


In response to questions by Representative Marzian, Mr. Meir stated that approximately 50 percent of Medicaid recipients are employed. The cabinet tried to have geographical diversity for the voluntary public forums to get feedback from the public. There should be a $20 million savings from moving from kynect to to help pay for changes in Kentucky HEALTH. Secretary Brinkman stated that there are approximately 850,000 individuals on the traditional Medicaid roles. Kentucky HEALTH has nothing to do with traditional Medicaid. Of the 440,000 Medicaid expansion recipients, approximately 200,000 are able-bodied individual not medically fragile and unemployed. If a recipient works 20 hours, the recipient is not subject to the community engagement requirement. The MCOs will work with physicians to make decisions on who is considered medically fragile.


In response to a question by Senator Danny Carroll, Mr. Meier stated that so far, there is no healthcare legislation that has been proposed by the federal government that would stop Kentucky from pursuing the 1115 waiver.



            There being no further business, the meeting was adjourned at 12:55 p.m.