Call to Order and Roll Call
The Medicaid Oversight and Advisory Committee meeting was held on Wednesday, August 16, 2017, at 2:00 PM, in Room 131 of the Capitol Annex. Senator Ralph Alvarado, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Ralph Alvarado, Co-Chair; Representative Kimberly Poore Moser, Co-Chair; Senators Danny Carroll, Morgan McGarvey, and Stephen Meredith; Representatives Jim Gooch Jr., Joni L. Jenkins, and Melinda Gibbons Prunty.
Guest Legislator: Representative Ken Fleming.
Guests: Stephen P. Miller, Commissioner, Jill R. Hunter, Deputy Commissioner, Lori Gresham, Clinical Program Manager Senior, and Donna Little, Department for Medicaid Services (DMS), Cabinet for Health and Family Services (CHFS); Jim Pettersson, Managing Director, Anne Jacobs, Managing Director, Holly Brown, Project Manager, and Jason Gerling, Home and Community Based Services (HCBS) Team Lead, Navigant Healthcare; Frank Huffman, Board Member, Protection and Advocacy for Persons with Developmental Disabilities (PADD); Arthur Campbell Jr., Activist; Johnny Callebs, Kentucky Association of Private Providers; Mary Hass, Advocacy Director, Brain Injury Association of Kentucky; Diane Schirmer, M.Ed., Corporate Director of Brain Injury Services, New Vista Behavioral Healthcare; Loretta McGinty, Hosparus Health; Kitty Davidson, Tri-Generations; and Diana Merzweiler, Executive Director, Down Syndrome of Louisville, Inc.
LRC Staff: Jonathan Scott and Becky Lancaster.
Approval of the Minutes from the July 17, 2017 Meeting
A motion to approve the minutes of the July 17, 2017 meeting was made by Senator Meredith, seconded by Senator Carroll, and approved by voice vote.
Status of Kentucky's 1915(c) Medicaid Waiver Programs
Stephen P. Miller, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services, testified that Kentucky has 1.4 million people on Medicaid, of which 90 percent are covered by five Managed Care Organizations (MCOs). The other 10 percent are covered by Medicaid waivers and long-term care and represent $3 billion a year. The Department of Medicaid’s goal is to have the 1915(c) HCBS waivers better organized and more cohesive. Commissioner Miller stated that moving the 1915(c) waivers to the MCOs is only one option that may be recommended during the redesign process. He stated the department will diligently review all options recommended.
Lori Gresham, Clinical Program Manager Senior, Department for Medicaid Services, Cabinet for Health and Family Services, stated from its inception in 1965, Medicaid has provided comprehensive long-term care, however, care was only provided in an institutional setting. In 1981, the 1915(c) HCBS waiver program was authorized by the Centers for Medicare and Medicaid Services (CMS) as an alternative to institutional care. CMS requires a state to ensure the same level of care in the community as provided in an institutional setting. States receive matching federal funds for services in the home or the community. States must provide ongoing quality assurance to demonstrate that the services are being rendered per the approved waiver and regulation to continue receiving the federal match and to retain what has been provided.
Ms. Gresham stated that two waivers, the Acquired Brain Injury (ABI) waiver and the ABI Long-Term Care (LTC) waiver, target individuals who have acute and long-term care acquired brain injuries. The Home and Community Based (HCB) waiver is for individuals who are elderly or disabled and meet nursing facility level of care. The Michelle P. Waiver (MPW) and the Supports for Community Living (SCL) waiver target individuals with intellectual or developmental disabilities. The Model II Waiver (MIIW) is for individuals who are ventilator-dependent and meet nursing facility level of care. DMS serves approximately 23,272 individuals and 8,180 are on a waitlist for a waiver slot.
The ABI waiver provides intensive services and support to adults with acquired brain injuries working to re-enter community life. Services are provided exclusively in community settings. The 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. The HCB waiver program provides services and supports to elderly people, children, and adults with disabilities to help them to remain in or return to their homes. The MPW program requires a protected environment while learning living skills, having educational experiences, and developing awareness of their environment. The MIIW requires ventilator support for at least 12 hours per day. The SCL waiver participant must meet the requirements for residence in an intermediate care facility for people with intellectual disabilities.
Potential Changes to Kentucky's 1915(c) Medicaid Waiver Programs
Jill R. Hunter, Deputy Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services, stated the goal of the waiver system is to serve the most fragile citizens of the Commonwealth. DMS followed model procurement established in KRS Chapter 45A. A request for proposal (RFP) was written last March and had several respondents. A team of individuals, with experience dealing with waivers and work for Kentucky Medicaid, evaluated the RFP responses. Navigant Healthcare was the chosen vendor. Navigant began working with DMS in April. Navigant suggested not only looking at the waivers but also to look at the people who work with the waivers. Navigant suggested that DMS work with other branches of CHFS, such as the Department for Aging and Independent Living (DAIL) and the Department for Community Based Services (DCBS). DMS wants to talk with other stakeholders also, such as recipients, providers, and providers’ staff. DMS is scheduling ten meetings across the Commonwealth in September and October. The meetings will be in a smaller, focus group format. Information will also be gathered by emails and phone calls received.
Kentucky Medicaid Contract with Navigant Healthcare
Anne Jacobs, Managing Director, Navigant Healthcare, stated Navigant works with 1915(c) HCBS subject matter experts, as well as additional subject matter experts available as required, and an operational assessment team. Navigant’s Government Health Solutions team has supported 49 states in a variety of Medicaid program areas. She stated one of the common 1915(c) program focus areas for states is streamlining waiver eligibility timeframes while targeting individuals most in need or at-risk. Kentucky is unique because Navigant sees that the legislative requirements in the program design features of payment, provider types, and service definition. This impacts the ability of the agency to manage the program and the agency’s ability to change the design as it works to improve the program. Navigant has worked with states to ensure conflict free case management. Navigant is working to refine rate methodology and reimbursement approaches. Driving statewide service delivery network adequacy is another focus area for Navigant. CHFS has announced meetings across the Commonwealth to enhance stakeholder engagement.
Ms. Jacobs stated the Navigant team is working to access all six 1915(c) waiver programs. The project has two work streams; operational redesign and waiver redesign. The waiver redesign will include using the Kepner-Tregoe decision making approach used in other states. Navigant has met with leadership from DMS, DAIL, and Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) and conducted interviews with CHFS staff, approximately 30 individual staff members. Navigant will compile a report of outcomes from staff interviews, select operational workflows for enhancement across DMS, DBHDID and DAIL, and review waiver redesign options to achieve CHFS goals. Remaining steps will include assessing and recommending enhancements to several operational workflows across the cabinet, culminating in the establishment of standard guidelines.
In response to questions from Senator McGarvey, Ms. Jacobs stated Navigant is discussing how to run agencies and workflows to allow Medicaid waiver processes to be more efficient and effective for participants and providers. Jason Gerling, HCBS Team Lead, Navigant Healthcare, stated the focus is on how the three agencies, DMS, DBHDID and DAIL, have combined to operate the waivers. The initial assessment has found a gap in areas of opportunity for the agencies to work together. He stated many of the processes in the operation of the HCBS waivers circulate through three different departments and three different sets of staff. The process can create challenges that pertain to who is the lead, who is making decisions, and who is getting the tasks completed. Jim Pettersson, Managing Director, Navigant Healthcare, stated the requirements that govern the waivers refer to program efficiency not necessarily provider efficiency. Navigant believes the providers are doing everything they can to economize and that the providers have to work with rates they are given.
Mr. Gerling stated early solutions include communication protocols, operating procedures that clearly define roles and responsibilities, and reviewing how calls are managed when they come into the system. Navigant has worked in other states and found it is common to look at interagency collaboration. Navigant is looking to align these agencies so that CHFS is performing at maximum potential. Mr. Pettersson stated there different ways to define and analyze quality. The cabinet has an opportunity to economize when coordinating referrals and service provisions.
In response to questions from Senator Meredith, Mr. Gerling stated Navigant will structure the stakeholder engagements by creating smaller focus groups to obtain the targeted feedback. Navigant will intentionally seek information and input from consumers to get to the core of how services are directed. Navigant will examine if people that are receiving services are satisfied and their needs are being met by the waiver programs.
In response to questions from Senator Carroll, Ms. Jacobs stated Navigant will be reviewing the differentiation between waivers in terms of requirements and regulations governing those waivers. Navigant will examine where there may be opportunities to streamline and simplify the waivers, keeping in mind that each of the waivers serves a very unique and distinct population. Mr. Pettersson stated that not only is it inefficient to have competing priorities but it affects the providers which means additional costs. Navigant must find a balance between trying to consolidate waivers to make them effective not just from an economic perspective but also from a quality perspective. Navigant will need to decide if it can achieve that balance through waiver redesign or by improving internal operation effectiveness of the waiver programs. He stated he has seen the combining of waivers into a mega-waiver be successful within the intellectual disabilities population and the aged population separately.
Mr. Gerling stated there are inherent challenges to a mega waiver because the needs of the population that is eligible for skilled nursing care versus people who require an intermediate care facility (ICF) and have more intellectual developmental disabilities and some medical frailties. He testified that it can be very difficult to set parameters that accurately pinpoint what the different populations need and the protections needed in the waivers for those populations. He stated Navigant is also reviewing an option for new waivers that are more specific to a different populations. He stated all options are being reviewed and examined. Mr. Gerling stated Navigant, along with CHFS, will be reviewing what work flows and work areas the cabinet wants to target, based on what is most distressing both internally and externally for providers and participants
In response to questions from Representative Jenkins, Ms. Jacobs stated Navigant has assisted other states in establishing and communicating its recommendations. Navigant’s evaluation process is transparent with goals established, released, and stated publicly. Deputy Commissioner Hunter stated the cabinet is partnered with Navigant to do what is best for recipients and stakeholders. CHFS is accountable to the Legislature, providers, and participants.
In response to questions from Senator Alvarado, Deputy Commissioner Hunter stated Navigant will submit suggestions and new ideas to the cabinet as it has done in other states. Commissioner Miller stated there are approximately 5,000 individuals on the waiting list for the MPW. He testified that up until a few months ago, none of the 5,000 on the waiting list had been evaluated. He stated many people are on the waiting list only to find out years later that they do not meet the level of care to be qualified for the waiver. Commissioner Miller stated there was legislation previously passed for additional slots to be added to the waiver programs. He stated it was not clear as to whether or not those slots had been funded. While discussing the funding of those slots, the cabinet started to look at the overall waiver environment through a redesign.
In response to questions from Senator Carroll, Commissioner Miller stated there are additional slots available in the MPW. CHFS is back filling available slots as quickly as possible. The process has been slowed down because individuals on the wait list were not evaluated at the beginning of the process and many do not meet the level of care required. The cabinet is working with the community mental health centers to start pre-screening applicants. Commissioner Miller stated the process of pre-screening should allow CHFS to process the waiting list and fill available slots in a timely manner. He stated the cabinet will evaluate more individuals than slots are available because it is finding that only a small percentage of applicants will meet the actual level of care requirement.
Frank Huffman, Board Member, Protection and Advocacy for Persons with Developmental Disabilities (PADD), stated he wanted the committee to understand the importance of Navigant reviewing the waivers. He invited the cabinet, Navigant, and the committee members to a PADD board meeting, which is comprised of individuals with disabilities who are on the waivers.
Arthur Campbell Jr., activist, stated that he wanted to remind the cabinet and Navigant to include people with disabilities through the process of rewriting the Kentucky Medicaid waiver programs. He hopes the cabinet will give disabled people a chance to express their concerns and give suggestions on what the disability community needs because they can provide first-hand input.
Mary Hass, advocate, Brain Injury Association of America, testified that the Brain Injury Association of America wants to be a part of the waiver redesign process. She stated many families are scared and want to be sure they are represented in the waiver program discussions.
Diane Schirmer, M.Ed., Corporate Director of Brain Injury Services, New Vista Behavioral Healthcare, testified that a brain injury is a chronic condition recognized by the World Health Organization (WHO) and other medical organizations. She stated typically people with brain injuries are treated with intense rehabilitation at the beginning of the injury only, however, these individuals change with age. Patients should have opportunities for intense rehabilitation at different periods of their life.
Diana Merzweiler, Executive Director, Down Syndrome of Louisville, Inc. (DSL), stated DSL became a provider for Medicaid services approximately five years ago. She stated her organization sees people with and without waiver services. DSL raises additional funds to supplement programs for all members. DSL is concerned when it is mentioned that waivers were not initially designed for children. She stated any waiver or program should be given on a needs based requirements and not according to age. DSL serves its members for their entire life. She stated efficiencies are needed at the point of entry to the waiver programs. DSL has adequate meeting space and resources available to hold forums for the waiver redesign effort.
Adjournment
There being no further business, the meeting was adjourned at 3:32 PM.