Last week, for the first time the Centers for Medicare & Medicaid Services (CMS) approved a Medicaid waiver application that includes work and community engagement requirements as a condition of Medicaid eligibility for certain enrollees. Approval of Kentucky HEALTH’s Medicaid waiver proposal, which will run through Sept. 30, 2023, came one day after CMS released guidance allowing states to implement these types of requirements.
The following outlines key components in the state Medicaid program’s work and community engagement requirements and other aspects in the approved Medicaid demonstration project:
Work and Community Engagement Requirements:
- Applicable population groups: Able-bodied adults aged 19-64
- Exempt population groups: Former foster care youth; pregnant women; primary caregivers of a dependent (either minor child or disabled adult; limited to only one exemption per household); medically frail individuals; individuals diagnosed with acute medical conditions that would prevent them from compliance with requirements (validated by a medical professional); full time students
- Amount of hours required: 80 hours/month to maintain eligibility
- Qualifying activities: Subsidized or unsubsidized employment; self-employment; job skills training; job search activities; enrollment in educational program related to employment (e.g. management training); general education (e.g. high school, GED, college or graduate education, English as a second language); vocational education and training; community work experience; community service/public service; caregiving services for a non-dependent relative or other individual with chronic, disabling health conditions, or participation in substance use disorder treatment
- Enrollees meeting these requirements: Some enrollees will be deemed as satisfying requirements by the following:
- Individual meets requirements of the Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) employment initiatives or is exempt from having to meet those requirements
- Individual is enrolled state’s Medicaid employer premium assistance program (a spouse or dependent of beneficiary enrolled in premium assistance program is also exempt)
- Individual is employed at least 120 hours per month
- Reporting frequency:
- Enrollees must document participation in any one or combination of qualifying activities on at least a monthly basis.
- Individuals deemed as satisfying the requirements will not be required to actively document participation in qualifying activities, although they will need to timely report changes in eligibility.
- Penalties for noncompliance:
- After a one-month opportunity to come back into compliance, individuals who fail to meet requirements for a month will have their benefits suspended unless a good-cause exemption is met.
- Individuals can reactivate eligibility on the first day of the month after the individual complies with the requirements in a 30-day period or completes a state-approved health literacy or financial literacy course.
- Individuals who, during a suspension period, become pregnant, are determined to be medically frail, become a primary caregiver of a dependent (either minor child or disabled adult — limited to only one exemption per household), are diagnosed with an acute medical condition that would prevent them from compliance with requirements (validated by a medical professional), or become a full-time student, or become eligible for Medicaid under an eligibility group not subject to the work and community engagement requirements can reactivate benefits, with an effective date aligned with their new eligibility category or status.
- Individuals with suspended benefits at the time of their re-determination date who do not qualify for an exemption will have their enrollment terminated and will have to submit a new application to regain coverage.
- Implementation details:
- Requirements will be implemented on a regional basis. The state will assess areas that experience high rates of unemployment, limited economies and/or educational opportunities, and those with a lack of public transportation to determine whether there should be further exemptions from the work and community engagement requirements and/or additional mitigation strategies.
- Kentucky HEALTH beneficiaries who have not been subject to the requirements in the past five years will be provided a three-month period prior to being subject to the requirements.
Other Notable Waiver Components Include:
- Disenrollment and a six-month non-eligibility period for individuals who do not provide necessary documentation/information to complete annual eligibility redetermination or report a change in circumstance that would affect eligibility, with some exceptions;
- Use of My Rewards Accounts, which allows enrollees to earn incentives to use for enhanced benefits;
- Premiums charged as a condition of eligibility for enrollees earning more than 100 percent of the federal poverty level (FPL), with disenrollment and six-month non-eligibility period for nonpayment (exceptions include pregnant women, former foster care youth, and medically frail individuals). Individuals earning below 100 percent of FPL are also subject to premiums, but not as a condition of eligibility (nonpayment results in requirement to pay copayments for services and lack of access to My Rewards Account for six months);
- Access to certain substance use disorder treatment services through an opioid/substance abuse program;
- Waiver of non-emergency medical treatment for certain populations and services; and
- Waiver of retroactive eligibility for certain populations.
Note: Kentucky initially implemented the Affordable Care Act’s (ACA) traditional Medicaid expansion under Democratic Gov. Steve Beshear. In 2016, newly-elected Republican Gov. Matt Bevin sought a waiver to modify the state’s Medicaid expansion model.
Last week, the Centers for Medicare & Medicaid Services (CMS) issued guidance outlining a new policy that allows states to implement work and community engagement requirements for certain Medicaid enrollees. States would be permitted to seek federal approval to require non-elderly, non-pregnant adults who are not eligible for Medicaid due to a disability to participate in these types of activities as a condition of Medicaid eligibility or to qualify for certain aspects of Medicaid coverage.
CMS indicated that it will support state demonstration projects implementing these types of requirements to test whether they assist individuals in securing stable employment or other “productive” community engagement, and if this in turn leads to improved health outcomes. States may also design projects to include the additional goals of promoting independence and reducing poverty.
The new policy allows states to use Medicaid’s Section 1115 waiver authority to attach work and community engagement requirements to different factors such as:
- As a condition of eligibility
- A condition of coverage
- A condition of receiving additional or enhanced benefits, or
- A condition of paying lower premiums or cost sharing
Before the guidelines were released, 10 states had submitted proposals to CMS to implement work requirements in their Medicaid program (AZ, AR, IN, KS, KY, ME, NH, NC, UT, and WI) for Affordable Care Act (ACA) expansion populations or other Medicaid-eligible individuals. Kentucky’s waiver was approved Jan. 12, 2018, and it is expected that other waivers will be approved soon and that additional states will submit similar waiver requests. The following summarizes key information outlined in the guidance.
Definition of scope of work and community engagement activities:
The guidance does not identify a specific set of work and community engagement requirements that CMS would approve; instead it suggests states should consider a range of different types of activities in addition to employment, such as volunteering. Additionally, CMS does not specify guidelines, such as the number of hours that individuals would need to complete to be compliant, any penalties for noncompliance, or how often individuals would need to document compliance. Decisions about these program parameters would be made by states and proposals would be evaluated by CMS on a case-by-case basis.
Because many states have existing structures to implement work and community engagement requirements — such as those for Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP) — CMS would support alignment of Medicaid work and community engagement conditions with these, if they are consistent with Medicaid objectives. States might consider alignment strategies when addressing exempted populations, protections and supports for individuals with disabilities and others who may not be able to comply with the requirements, the types of activities and the number of hours of participation that qualify as meeting the requirements, modifications to requirements due to certain economic or regional-specific factors, enrollee reporting requirements, and the availability of work support programs such as transportation or child care. Also, the guidance states that individuals who are complying with or who are exempt from a TANF or SNAP work requirement must be deemed as meeting Medicaid work and community engagement requirements.
States will be allowed to phase in or suspend aspects of their work and community engagement programs when needed due to factors such as local employment market forces or regions that lack adequate transportation.
In their proposals, states will also need to outline their approach to helping enrollees meet the work and community engagement requirements, such as strategies to connect individuals to child care assistance and transportation resources. However, states are not permitted to use Medicaid funds to pay for these types of services.
Other populations exempt from work and community engagement requirements:
While the work and community engagement requirements do not apply to individuals eligible for Medicaid based on a disability, CMS notes that some other Medicaid-eligible individuals could have an illness or disability as defined by other federal statutes that could affect their ability to comply with Medicaid work and community engagement requirements. States must make sure these individuals are not denied Medicaid due to any inability they may have to comply with the requirements and they must provide reasonable modifications for these individuals. Also, individuals whom the state determines as medically frail or who have acute medical conditions that would prohibit them from adhering to the requirements should be exempt from Medicaid work and community engagement requirements.
The guidance also specifically acknowledges the opioid addiction crisis facing many states, and requires states to implement reasonable modifications to the work and community engagement requirements for individuals with opioid addiction and other substance use disorders, as well as access to necessary Medicaid coverage and treatment services.
CMS will require states with approved work and community engagement demonstration projects to perform outcomes-based, independent program evaluations to determine whether these requirements are connected to improved health and well-being for individuals (and to also evaluate the independence goal if a state decides to incorporate this criteria). In addition to measuring whether the demonstration project is achieving its objectives, evaluations must also examine the effect of the program requirements on Medicaid enrollees and individuals who have a lapse in coverage or eligibility during the demonstration period because of the new requirements.
States will also need to include an assessment of how the requirements influence enrollees’ capacity to attain sustainable employment, and whether enrollees who transition from Medicaid obtain other health insurance coverage, as well as how these types of transitions affect enrollee health and well-being. Absent from the federal evaluation requirements is an analysis of the cost to states to administer the new policy.
Questions and issues for states:
There are a number of policy and operational questions and issues that states seeking to implement these types of requirements in their Medicaid programs should consider:
- General operational issues:
- What additional staffing and amount of agency resources would be needed to implement work and community engagement requirements? With no additional federal matching funds, states interested in pursuing these requirements will need to carefully weigh these factors, given the Medicaid administrative match rate is only 50 percent and that there could be considerable staffing needs.
- Tracking compliance and exceptions for certain individuals:
- How will states’ integrated eligibility and enrollment systems accommodate tracking enrollees’ participation in work and community engagement activities? Some states may opt to track compliance with these types of requirements monthly, whereas Medicaid eligibility is generally determined annually. Although CMS suggests that aligning Medicaid work and community engagement requirements with those in TANF and SNAP could reduce the administrative burden on states and enrollees, and that states’ integrated systems may be well-positioned to streamline verification processes, significant changes to eligibility determination systems and procedures would still be necessary. Additionally, not all enrollees may be able to provide electronic verification of compliance with the requirements and instead might need to submit paper documentation, which would be a challenge for individuals and an administrative burden for states.
- How will states manage the process of determining which populations are exempt from the work and community engagement requirements or eligible for reasonable modifications to the requirements? This could be challenging for determining exceptions related to individuals with opioid addiction or other substance use disorders.
- Beneficiary education:
- How will states design effective beneficiary education initiatives, both to inform enrollees of specific program requirements and to assist individuals in identifying whether they might qualify for an exemption?
- Beneficiary supports:
- How will states finance the requirement to provide supports, including links to resources such as child care and transportation to help enrollees comply with work and community engagement requirements?
- Measuring impact:
- Although the CMS guidance indicates that the evaluation measures of health outcomes should use nationally-recognized sources and measure sets, how specifically will states be able to attribute health outcomes to the work and community engagement requirements?
- How will states measure the administrative costs and other potential challenges of implementing the work and community engagement requirements?
NASHP will be conducting additional analysis to better understand the potential administrative implications and operational issues for states that may be interested in implementing work and community engagement requirements in Medicaid.
Beginning in October, 2013, states initiated their first open enrollment period for health coverage under the ACA. While state approaches varied, all states implemented new rules, system interfaces, and data reporting methods required under the ACA. What are states learning so far about what works to enroll eligible individuals and what are their top-line priorities getting ready for the next open enrollment period in November 2014? This webinar provides an opportunity to learn about promising strategies and innovations states are piloting related to enrollment and retention into insurance affordability programs, including through state-based exchanges and coordination with the federally facilitated marketplace (FFM). State panelists from Kentucky, Montana and Washington share experiences and enrollment successes. NASHP also shares new findings from research with 10 states documenting promising strategies, common challenges and trends in state enrollment experience as part of the Enrollment 2014 project.
- Anne Gauthier, Director, State Health Exchange Leadership Network, National Academy for State Health Policy (Moderator)
- Alice Weiss, Director, Enrollment 2014 Project, National Academy for State Health Policy
- Carrie Banahan, Executive Director, Office of Kentucky Health Benefit Exchange (Kynect)
- Christina Goe, General Counsel, Montana Commissioner of Insurance
- Nathan Johnson, Division Director, Health Care Policy, Washington Health Care Authority
Federal Support: Kentucky has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Last Updated: April 2014
- As of July 1, 2011, there were 823,133 beneficiaries enrolled in Kentucky Medicaid. Of these, 735,978 were enrolled in managed care. All Medicaid managed care beneficiaries were also enrolled in a Transportation Prepaid Ambulatory Health Plan (PAHP). Medicaid beneficiaries who are in nursing homes or waiver programs do not receive managed care services
- Medicaid beneficiaries in in Louisville, Jefferson County and the 15 surrounding counties receive services through the Kentucky Medicaid Health Care Partnership Program, a prepaid capitated managed care system authorized by a CMS Section 1115 Waiver Demonstration.
- Children ages 3-21 who are eligible under the Individuals with Disabilities Education Act (IDEA) are eligible for School-Based Health Services, which include evaluative, diagnostic, preventive and treatment services. Children who receive these services are not excluded from receiving services through the EPSDT program.
|Medical Necessity||According to the Kentucky Administrative Regulations, to be medically necessary or a medical necessity, a covered benefit shall be:
|Initiatives to Improve Access
|Reporting & Data Collection||
Kentucky Medicaid managed care contract language requires contractors to submit encounter data for each of their members who receive EPSDT services, as well as quarterly and annual reports on EPSDT services for CMS reporting
Behavioral health services for Medicaid enrollees in Kentucky (including children) are provided primarily through a network of 14 regional mental health centers and four psychiatric hospitals maintained by the state Department of Behavioral Health, Developmental and Intellectual Disabilities, though managed care organizations can provide access to additional behavioral health service providers.
Medicaid managed care contract language requires plans to employ a Behavioral Health Director who coordinates all efforts to provide behavioral health services to plan members. The Behavioral Health Director must meet monthly with the state’s mental health agency to discuss substance abuse protocols, rules, and regulations.
Plans are also required to establish a protocol for coordination of physical and behavioral health services for members with behavioral health or developmental conditions.
Kentucky implemented the Supports for Community Living (SCL) waiver program to provide alternatives to institutional care for Medicaid-eligible children and adults with intellectual and developmental disabilities. The program provides a variety of supports and services, including children’s day habilitation, community living supports, psychological services, and residential supports. As of January 1, 2014, additional community supports and services are available through the SCL2 Waiver.
|Support to Providers and Families||
At minimum, Medicaid managed care plans must train providers on “the components of an EPSDT assessment, EPSDT Special Services, and emerging health status issues among members which should be addressed as part of EPSDT services to all appropriate staff and providers.”
Medicaid children younger that 21 who are diagnosed with severe emotional disabilities receive case management services from the Child Targeted Case Management Program. These services are provided by qualified case managers in 14 community mental health centers across the state. Covered services include, among others:
Kentucky’s Medicaid managed care contract requires plans to provide an EPSDT coordinator who’s responsible for coordinating and overseeing case management services and continuity of care. Plans must also coordinate care for children receiving school-based health services in order to avoid duplicative services.
||The Kentucky Medical Dental Program provides oral health services to Medicaid-enrolled children. The state provides information on participating dental providers, billing of oral health services under the EPSDT benefit, and Kentucky’s regulations for oral health service delivery to children on the Dental Services webpage.|
Dowload presentation here (PDF)
Health insurance exchanges or marketplaces need to be prepared to serve children’s needs as well as adults. The Children’s Health Insurance Program (CHIP), an already established and tested program, offers features that can help states meet ACA exchange requirements while establishing good coverage for children. With support from the David and Lucile Packard Foundation, NASHP analyzed federal statutes, regulations, and guidance for CHIP and exchanges, and interviewed state and national experts to inform this work. The resulting brief offers options for drawing on CHIP as a tool to inform exchange design and the companion piece compares selected CHIP and exchange requirements and identifies ways the program requirements align. This webinar geared toward state exchange officials includes a discussion of options on ways CHIP could be used to inform the design of Essential Health Benefits, provider networks and more. Officials working with all types of exchanges—State Based, Partnership, and Federally Facilitated—are encouraged to listen.
Moderator: Catherine Hess, Managing Director for Coverage and Access, NASHP
Presenter: Maureen Hensley-Quinn, Program Manager, NASHP
Miriam Fordham, Director, Health Care Policy Administration
William Nold, Deputy Director, Kentucky Health Benefit Exchange
Lisa Lee, Director, Kentucky CHIP Program
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email firstname.lastname@example.org.
Last updated: October 2012
No HIE Strategic Plan available yet.