Call to Order and Roll Call
The Medicaid Oversight and Advisory Committee meeting was held on Wednesday, September 21, 2016, at 1:00 PM, in Room 129 of the Capitol Annex. Representative David Watkins, Chair, called the meeting to order at 1:15 p.m.
Present were:
Members: Representative David Watkins, Co-Chair; Senator Dan Seum; Representatives Robert Benvenuti III and Joni L. Jenkins.
Guests: Stephen P. Miller, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; Eric Clark, Legislative Director, Cabinet for Health & Family Services; Deborah Anderson, Commissioner, Department for Aging and Independent Living, Cabinet for Health and Family Services; Michelle Blevins, Assistant Director, Division Of Behavioral Health, Department For Behavioral Health, Developmental & Intellectual; Sarah Nicholson; and Sarah Cawthon.
LRC Staff: Jonathan Scott and Becky Lancaster.
Kentucky HEALTH Waiver
Stephen P. Miller, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services (CHFS), stated the cabinet held three public hearings to discuss comments regarding the Section 1115 Kentucky HEALTH Waiver. The original comment period ended on July 22, 2015. CHFS extended the comment period until August 14, 2016 to allow for extra comments from the public. CHFS received over 1,400 written and verbal comments. CHFS gathered comments about non-emergency transportation, premiums, retroactivity in regards to coverage, and Substance Use Disorder (SUD) issues. CHFS received over 400 comments to preserve allergy testing. Consequently, during the revision process no changes were made to the Medicaid state plan regarding allergy testing. Private duty nursing was also maintained. Vision and dental benefits are a part of the My Rewards account to incentivize individuals to become more involved in their healthcare plan. The cabinet decided to delay the transition of eliminating vision and dental benefits for three months. The delay is to allow individuals to use the benefit and to provide time to accrue rewards.
The cabinet added GED testing costs as an additional covered benefit for members and expanded My Rewards account activities to include: caretaking responsibilities, passing the GED, completion of child preventive services (including dental and vision services), and an incentive for keeping healthcare appointments. Commissioner Miller clarified that primary caretakers of minor children as well as disabled adult dependents are exempt from the community engagement and employment initiative. Other caregiving services for non-dependent relatives or other persons with a disabling health condition will count as a qualifying activity.
The cabinet added descriptions of the groups of people not included in the waiver: former foster children up to age 26; individuals on a 1915(c) waiver; individuals in an institution; and individuals eligible for Medicaid on the basis of age, blindness, or disability, including individuals eligible for social security income (SSI). Certain populations will be automatically determined as medically frail including: individuals receiving hospice care; persons with HIV/AIDS; and individuals receiving Social Security Disability Insurance (SSDI). The cabinet’s revisions to the Kentucky HEALTH waiver stated that individuals determined as medically frail will be exempt from copayments. Premiums are only required for the medically frail as a condition of receiving a My Rewards account. Premiums will be collected on a household basis, not applied individually.
The cabinet submitted the application to Centers for Medicare and Medicaid Services (CMS) on August 9, 2016. CHFS has reached out to CMS and Health and Human Services (HSS) to set up meetings to continue the dialogue regarding the waiver. Meetings should begin in two weeks, as the 30 day federal comment period comes to an end. CHFS believes the HHS Secretary has full authority to approve this waiver as written.
Most of the Kentucky HEALTH waiver policies have been approved in other states including premiums and non-payment penalties. Kentucky would be breaking new ground on community engagement and employment initiative, open enrollment period, and increasing premiums for individuals above the 100 percent Federal Poverty Level (FPL). The new policies are consistent with general marketplace policies, as well as the underlying goals of Medicaid set forth in the Social Security Act. CHFS believes this process will better educate and prepare recipients for the transition to qualified health plans.
In response to a question from Representative Watkins, Commissioner Miller stated the three month waiting period for the vision and dental plan benefits would start when the implementation of the Kentucky HEALTH waiver goes into effect.
In response to questions from Representative Benvenuti, Commissioner Miller stated the budget projected revenue funds of $585 million in new state funds. The Medicaid budget also went up $587 million in the same two year timeframe. Additional funding will need to come from other areas of CHFS, pension plan funding, or education. The Medicaid budget went up almost 20 percent, as others’ budgets were decreased. There is a continued concern that Medicaid funding crowds out other areas of service that need attention. Commissioner Miller stated the federal guidelines do not allow CHFS to penalize or take benefits away from members that do not show up for their appointments. CHFS is trying to change behaviors and help outcomes by incentivizing Medicaid recipients to show up at their primary care provider’s office instead of going to the emergency room for non-emergency circumstances. Commissioner Miller stated the number of emergency room visits had gone up slightly from December 2013 (pre-expansion) to December 2015 (post-expansion). CHFS is trying to use incentives in the waiver to shape and steer individuals for better compliance when using an emergency room.
In response to questions from Representative Jenkins, Commissioner Miller stated CHFS is working with Managed Care Organizations (MCOs) to incentivize and stop individuals using the emergency room for primary care. The cabinet is also trying to educate members in larger cities that there are other choices; family practitioners and urgent care centers that usually have longer hours. Many people are accustomed to going to emergency rooms because they are open 24 hours a day and easily located. CHFS hopes to educate everyone to use the less expensive options. Commissioner Miller stated the cabinet could look at implementing a differing payment scale for emergency room usage for non-emergency visits.
Update on the 1915(c) Home and Community Based Waiver
Deborah Anderson, Commissioner, Department for Aging and Independent Living, Cabinet for Health and Family Services, stated the Department for Medicaid Services (DMS) operates six types of Home and Community Based Services (HCBS) waivers. The Michelle P. waiver (MPW) and the Supports for Community Living (SCL) waivers support individuals with intellectual or developmental disabilities and meet the ICF/IID level of care. The SCL waiver includes residential services, the MPW does not. There are two brain injury waivers; Acquired Brain Injury (ABI) and Acquired Brain Injury-Long Term Care (ABI-LTC). Both, ABI and ABI-LTC waivers are for adults with an acquired brain injury who meet nursing facility level of care including residential support, but ABI-LTC also supports long term care. The Model II (MIIW) waiver covers individuals who are ventilator-dependent and meet nursing facility level of care. The Home and Community Based (HCB) waiver covers individuals who are elderly or disabled who meet nursing facility level of care with primarily physical disabilities.
Waiver slots are unduplicated which means if a participant uses one service in a year, the slot cannot be reused or refilled until the following year. The ABI waiver has 383 slots, HCB waiver has 17,050 slots, and MIIW has 42 slots, all with no waiting lists. The ABI-LTC waiver has 320 slots with 176 on a waiting list. The MPW has 10,500 slots with 5,424 on a waiting list and 300 slots released in September. The SCL waiver has 4,701 slots with 2,334 on a waiting list and 240 additional slots to be added pending CMS approval. The waivers progress in different cycles, and four of the waivers are up for renewal. HCB and MIIW are not in the process to be updated. Ms. Anderson is meeting with participants, families, advocates, and provider agencies throughout the Commonwealth to assess the waivers and discuss changes that may improve the waivers. After the assessment, a workgroup made up of family members, participants, providers, and staff will provide waiver recommendations to Medicaid.
The workgroup hopes to implement short-term fixes to allow providers to better serve the participants. They are considering changing daily notes into monthly notes in some of the waivers. The SCL waiver requires daily notes and staff feel that all of their time and energy is spent writing daily notes. The exceptional rate process will be will be streamlined to allow for a less cumbersome approach to requesting an exceptional rate. Provide education so that all staff are working on a clear, concise, and consistent process for the recoupment audits.
In response to a question from Representative Watkins, Ms. Anderson stated that 11,000 to 12,000 of the 17,050 slots are filled in the HCB waiver. The cabinet is trying to build a middle level of care so the participants can stay in their homes longer and not be forced to transfer to a nursing home facility.
In response to questions from Representative Benvenuti, Ms. Anderson stated typical services provided under the MPW are personal care services, home making services, companion services, community support services, and behavioral support services. Individuals serviced by the MPW could be a person with intellectual or developmental needs, for example, someone that has down-syndrome, cerebral palsy, or autism. The cabinet is tracking the age and diagnosis of MPW participants to better understand the demographic and needs of the waiver participants.
Representative Jenkins commented that the MPW was started for adults to decrease the waiting list on the SCL waiver, it was thought that children were served in other capacities. Representative Jenkins is interested in finding out the ages of the participants to make sure that appropriate people are put into the correct waivers. She suggested that a super waiver, similar to other states, could be created to better serve people who are waiver eligible.
In response to questions from Senator Seum, Ms. Anderson stated that in regards to the MPW 300 slots to be released, released means that slots will become available in the new year. The 300 slots are a part of the initial 10,500 MPW slots. A waiver slot is only allowed to be used once a year. However, when a person leaves the waiver the slot becomes available to be released the following year. The 240 additional slots in the SCL waiver will be added to the initial 4,701 slots, those slots were funded by the legislature but are waiting on approval from CMS.
In response to a question from Representative Jenkins, Ms. Anderson stated the new payment rate under the HCB waiver is $24.00 an hour on the traditional side and $11.52 an hour on the participant-directed side. Some participants were using personal service agencies under another agency to hire someone to take care of their loved one. The participant-directed rate is not built around an agency costs. The participant-directed side is used to hire a family member or neighbor to provide care, they do not have the overhead costs of an agency. The average rate of pay for professional direct support providers is $8.00 to $10.00 an hour. Ms. Anderson stated everyone on the HCB waiver has to be at a nursing home level of care.
Roll Call
The secretary called the roll.
Adjournment
There being no further business, the meeting was adjourned at 2:07 p.m.