Kentucky – The National Academy for State Health Policy

States Enhance Children’s Mental Health Services Through Workforce Supports

September 2, 2022/in Maternal, Child, and Adolescent Health, Policy Colorado, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maine, Nebraska, New Hampshire Blogs, Featured News Home Behavioral/Mental Health and SUD /by Zack Gould

State Medicaid Financing of Home Visiting Services in Seven States

October 8, 2021/in Health Coverage and Access Colorado, Kentucky, Michigan, Minnesota, New York, Oregon, Wisconsin Charts, Featured News Home Health Coverage and Access /by Eddy Fernandez

State Approaches to Leveraging Neonatal Abstinence Syndrome Data to Inform Policymaking

August 16, 2021/in Opioid Center Kentucky, Ohio, Pennsylvania, Tennessee Featured News Home, Reports Behavioral/Mental Health and SUD, Opioid Use Disorder /by Eliza Mette, Jodi Manz, Kitty Purington and Mia Antezzo

States Advance New and Enhanced Policies to Improve Care for Pregnant and Postpartum People with SUD and Mental Health Conditions

June 21, 2021/in Behavioral/Mental Health and SUD Alabama, Kentucky, South Carolina, Virginia Blogs, Featured News Home /by Taylor Platt

Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and postpartum people in the United States, and they have far-reaching consequences for the health and well-being of parents and their children. During the COVID-19 pandemic, there has been a heightened need to ensure access to pregnancy-related and behavioral health care for pregnant and postpartum people. Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau, Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) worked with eight states (Alabama, Colorado, Kentucky, Mississippi, New Jersey, South Carolina, Texas, Virginia) to support and advance innovative policy initiatives that improve access to quality health care for Medicaid-eligible pregnant and parenting people with behavioral health needs.

Over the past two years, the multidisciplinary state teams worked together and received technical assistance from NASHP to strategize and implement policies and programs to improve care for pregnant and postpartum people with SUD and/or mental health conditions. Many state teams shifted their focus to respond to emerging needs of pregnant and postpartum people, such as access to telehealth services, due to the COVID-19 pandemic. All states were able to advance several efforts including the addition of new SUD treatment sites, trainings to increase screening and referrals to treatment, and development and dissemination of a survey on telehealth use. Highlights of states’ achievements include the following.

Alabama: The Office of Substance Abuse Treatment Services within the Alabama Department of Mental Health will be implementing a pilot project with peer doula services for pregnant mothers with SUD. Currently, two certified peer support specialists are scheduled to undergo doula training with the implementation of the peer doula service projected for 2022. Also, Alabama Medicaid expanded opportunities for Screening, Brief Intervention, and Referral to Treatment (SBIRT), which is an approach used to deliver early intervention and treatment of SUD. The Agency coordinated training opportunities for the managed care networks’ staff, the Alabama Coordinated Health Networks (ACHN). The trainings were completed in March in 2021.
Kentucky: The state Medicaid agency is currently updating the policy for the Kentucky Moms Maternal Assistance Towards Recovery (MATR) Program to extend case management services from 60 days post-partum to 6 months post-partum for women experiencing SUD.
South Carolina: The state developed a reciprocal referral and linkage model for parenting and/or pregnant women in South Carolina with or at-risk of SUD by coordinating services among the state’s Departments of Health and Human Services, Alcohol and Other Drug Abuse Services, and Health and Environmental Control. The model focuses on assessing women for SUD and providing a warm handoff for treatment.
Virginia:The state Medicaid agency planned to require SBIRT screening for pregnant and postpartum managed care members in the health plan contracts. This initiative received support but was put on hold due to pandemic-related budget restrictions. However, because of the PIP, Virginia established a multi-agency alliance that focused on SUD and maternal health, and supported several initiatives. This alliance included relationships with two large health systems in the Commonwealth. The policy academy enhanced alignment between state agencies and state SBIRT stakeholders serving pregnant and parenting people experiencing substance use. The state is also in the process of developing a doula Medicaid benefit with anticipated implementation this fall.

During the two years of the MCH PIP Policy Academy, participating states identified numerous lessons learned that may be of interest to other states interested in improving access to care for pregnant people with SUD. These strategies include the following:

Early identification of substance use or mental health conditions is a critical component in ensuring individuals receive the support and necessary treatments for healthy pregnancies and their behavioral health needs.
Providing enhanced support services (e.g., care coordination services, doulas, and case management) for pregnant persons with behavioral health conditions during the perinatal period can help improve health outcomes and birth experiences and promote health equity.
Tracking telehealth utilization by pregnant populations due to the COVID-19 pandemic may help inform future policies and programs to increase access to services.
Cross-sector partnerships (e.g., Medicaid, public health, behavioral health) are critical to advancing short- and long-term goals and initiatives given that pregnant persons with SUD are often served by multiple agencies and systems.
State initiatives need to be nimble and flexible to meet the changing needs of pregnant people with behavioral health needs, especially in times of crisis (e.g., pandemic) that can exacerbate behavioral health conditions and require need for greater cross-agency collaboration and coordination.

NASHP thanks the eight state teams for their hard work and dedication to this project over the past two years. We will continue to work with states through a second policy academy cohort focused on improving access to quality care for pregnant and parenting people. Click here to learn more about the next cohort of the MCH PIP Policy Academy.

Medicaid Agencies Implement Innovative Outreach Strategies: Lessons from Kentucky and Virginia

September 21, 2020/in COVID-19 State Action Center Kentucky, Virginia Blogs, Featured News Home CHIP, CHIP, COVID-19, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Maternal, Child, and Adolescent Health, Population Health /by Gia Gould

As the pandemic continues and more individuals lose jobs and health insurance, the demand for Medicaid and Children’s Health Insurance Program (CHIP) coverage is rising. Kentucky and Virginia – stripped of their traditional, in-person enrollment strategies – have adapted their outreach efforts to help make enrollment as easy as possible for adults and children to ensure access to critical coverage and care.

Background

A recent survey of Medicaid programs shows that between February and May 2020 all but three states experienced notable increases in enrollment.Through waivers and state plan amendments, states have the opportunity to adopt a wide range of flexibile strategies to facilitate and maintain enrollment.

However, social-distancing, tele-work, and strained state budgets have introduced new challenges for state Medicaid and CHIP agencies. A number of state Medicaid agencies have implemented furloughs or reassigned staff to contract tracing and other essential tasks related to the pandemic. Without the ability to conduct traditional outreach campaigns, which are often linked with large community gatherings and one-on-one enrollment support, state Medicaid agencies have needed to quickly pivot their outreach strategies to connect with individuals who are newly eligible for coverage.

Streamlining Enrollment and Enhancing Partnerships

Kentucky has experienced one of the most significant increases in Medicaid enrollment. Between February and May, 2020, Kentucky’s Medicaid and CHIP enrollment increased by nearly 7 percent. While some of the growth can be credited to the maintenance of effort (MOE) provisions required to secure enhanced federal Medicaid funding through the Families First Coronavirus Response Act, Kentucky has taken significant steps to enroll eligible individuals and families. State officials report that a key aspect of their successful enrollment strategy has been adopting presumptive eligibility (PE) policy flexibilities allowed by the public health emergency. By designating the state Medicaid agency as a qualifying entity to determine presumptive eligibility based on individuals’ modified adjusted gross income, and condensing its 20-page application into a one-page online form, Kentucky has enrolled over 137,000 individuals under presumptive coverage. To keep these individuals covered once their eligibility period ends, Kentucky Medicaid agents track these applications to identify when individuals’ PE periods are drawing to a close. They then make direct outreach calls to these enrollees to assist them in completing a full Medicaid application.

States have also leveraged interagency partnerships to target their outreach strategies to individuals who may be eligible for Medicaid coverage. To connect with individuals who may have lost employer coverage due to the pandemic, both Kentucky and Virginia have contacted thousands of individuals who have applied for state unemployment insurance. The states also added easily accessible links to their unemployment agency websites to help individuals to apply for health coverage.

In Virginia, partnership efforts have been bolstered through a renewed connection with the Virginia Health Care Foundation’s (VHCF) Project Connect, which funds local outreach efforts to enroll individuals in Medicaid and CHIP. Through this partnership, representatives from Virginia Medicaid and VHCF have provided support at virtual job fairs and rapid response online events, and they plan to continue to collaborate to serve those who have been affected by COVID-19’s economic consequences.

Like Kentucky, Virginia has also experienced a significant increase in Medicaid enrollment in recent months, and state officials credit the persistence and creativity of their community outreach coordinators as critical to their enrollment success. They have redesigned their approach to safely conduct outreach and enrollment support by leveraging existing community contacts to distribute informational materials electronically and organizing online meetings with community groups. The outreach coordinators have also sought to develop new partnerships with charity, community, and faith-based organizations, retailers, and hospitality groups, as well as schools and colleges. In some rural areas with lower COVID-19 infection rates, the coordinators are beginning to conduct some outreach efforts at churches, fast food chains, and other retailers.

A crucial focus of this work in both states has been developing targeted outreach strategies and building relationships with communities of color who have been disproportionately affected by the economic and health impacts of COVID-19. Virginia has developed ad campaigns designed specifically to reach Latinx families. Kentucky relies on its data analytics team to guide the state’s outreach efforts and recently launched a marketing campaign targeting seven counties with the highest Black, uninsured population.

Modifying Back-to-School Outreach Efforts

For children, who represent 51 percent of total Medicaid and CHIP enrollment, access to health coverage is of paramount importance to ensure that developmental milestones are met and vaccines are administered. Traditionally, school partnerships have provided Medicaid and CHIP agencies with the ability to identify eligible children and families and to distribute resources from a trusted source. A report conducted by the Urban Institute at the Robert Wood Johnson Foundation in 2016 found that almost half of individuals who are eligible for Medicaid or CHIP live in families with at least one school-aged child, making schools a valuable venue to conduct outreach for both children and adults.

Historically, the back-to-school season provided an opportunity for Medicaid and CHIP programs to convene large enrollment events where promotional flyers and branded materials are distributed to children and parents. However, this year, without traditional events such as summer camps or sports registration, there are fewer chances to connect with families to provide coverage options and underscore the importance of care.

In addition to hosting events, Medicaid and CHIP agencies often provide schools with informational packets to slip into student’s backpacks or include with school registration materials. But with fewer students returning to traditional classroom settings and tighter restrictions on the number of individuals allowed into schools, these tested outreach methods have needed to be re-examined and reformulated.

To minimize physical contact, Kentucky has limited school outreach to a group of professionals from the Division of Family Resource and Youth Service Coalition (FRYSC) within the Cabinet for Health and Family Services. Representatives from FRYSC have established relationships with schools and are able to distribute outreach materials without prolonged contact at socially distanced drive-through school events. In recent weeks, FRYSC representatives have begun distributing materials, which include more than 200,000 protective face masks displaying KCHIP marketing for children.

In Virginia, the Medicaid agency has revamped its back-to-school campaign by investing in digital resources for students and families. Working with schools, VA Medicaid has created widgets that will send parents from school webpages to the Medicaid and CHIP back-to-school pages. Their reformulated back-to-school websites acknowledge the constraints caused by the pandemic and include information for parents about how to enroll their children in health coverage in both English and Spanish as well as outreach resources for schools, such as social media messaging. When the back-to-school campaign formally ends in December, these dedicated back-to-school pages will be built into their website and remain active throughout the year.

The state is also coordinating with a digital engagement contractor to send text messages aimed at parents and advocates to encourage enrollment in CHIP and Medicaid. In addition to outreach efforts through school’s web pages, Virginia Medicaid printed 1.3 million copies of its enrollment materials to cover every school-age child in every public school in the state. Prior to the pandemic, Virginia Medicaid requested that the materials be distributed in back-to-school informational packets, but this year, due to the variability in which districts are electing to return to school, it asked teachers and administrators to distribute the material in any way they saw fit.

In response to the limitations of the pandemic, states have demonstrated flexibility in their approaches to outreach and enrollment. Kentucky’s efforts highlight the importance of making enrollment as easy as possible for individuals. Virginia state officials noted that despite the challenges and constraints, COVID-19 has provided the state with an opportunity to reassess and improve its outreach strategies. As Medicaid programs continue to serve as one of the primary safety nets for millions of Americans whose livelihoods have been uprooted by the economic consequences of the pandemic, states are creatively adapting their outreach and enrollment efforts to help ensure access to coverage and care.

Three Approaches to Opioid Use Disorder Treatment in State Departments of Corrections

September 2, 2020/in Policy Kentucky, Maine, Pennsylvania Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Medicaid Expansion, Population Health, Social Determinants of Health /by Jodi Manz and Eliza Mette

As drug overdose fatalities continue to rise and incarceration rates remain high nationwide despite recent declines, states are increasingly developing opportunities for incarcerated individuals to access evidence-based opioid use disorder (OUD) treatment in state prison facilities.

While the forced abstinence during incarceration can temporarily pause substance use itself, providing comprehensive treatment that includes medications for opioid use disorder (MOUD) during incarceration is shown to result in better treatment engagement as well as long-term recovery upon re-entry. Providing this kind of treatment during incarceration represents a shift in criminal justice approaches to substance use disorders (SUD), one that relies on partnerships between state agencies and providers, as well as the adoption of an understanding of OUD as a chronic-yet-treatable disorder with effective medical interventions.

Any discussion of this shift toward reframing people with OUD as individuals in need of Treatment – including those incarcerated as a result of their substance use – must also recognize that racial bias across systems affects sentencing policies. While Black people use illicit drugs at similar or lower rates than the rest of the population, they are incarcerated at over five times the rate of White people. Black Americans have also been disproportionately affected by recent increases in overdose fatality due to synthetic opioids, underscoring inequitable systemic responses to prevention, treatment, and recovery for Black individuals with OUD. The incarceration-based treatment approaches emerging today stand in stark contrast to the policy response to the crack-cocaine epidemic and subsequent sentencing guidelines of the previous generation that saw millions of Americans, approximately 80 percent of whom were Black men, incarcerated without a similar focus on treatment.

Policymakers are currently charting a different course by offering evidence-based treatment that is initiated alongside incarceration, recognizing that systems can work together to support people with SUD. These programs represent an opportunity to address both the SUD that may be at the root of criminalized behavior, and the racial disparities in sentencing that foster health disparities.

Developing programs that emphasize treatment instead of incarceration ultimately requires not just a shift in perspective about the nature of SUD, but also the will of leadership to implement new policies and clinical practices – and the funding to do so. The National Academy for State Health Policy (NASHP) talked to leaders from three states – Kentucky, Maine, and Pennsylvania – about their approaches to SUD treatment within their state prison populations and how these approaches are evolving.

Maine

In early 2019, the Maine Department of Corrections (ME DOC) developed a pilot program to begin providing MOUD, starting in one secure state facility and two pre-release state facilities. Part of the impetus for this program was a 2018 lawsuit filed by the American Civil Liberties Union (ACLU) on behalf of an individual with OUD who was entering a Maine state prison and was going to be denied treatment, despite having been in recovery for five years with the assistance of prescribed medication.* ME DOC ultimately settled the case, agreeing to continue providing the individual with necessary medication. Prior to this, the state’s correctional facilities focused on providing residential and out-patient level of substance use treatment and continuity of care in the community upon release, but had no internal, evidence-based program that provided MOUD. In 2019, a new governor and administration initiated different priorities, including new approaches to address Maine’s opioid epidemic. Additionally, the state had just expanded Medicaid, which helped ME DOC to develop protocols that would ensure continuity of care upon release by enrolling participants in Medicaid coverage immediately upon re-entry.

To inform its planning process and learn about successful incarceration-based MOUD programming, Maine’s corrections leadership visited Rhode Island, a leading state in SUD treatment with incarcerated populations. ME DOC launched its buprenorphine pilot in July 2019 by engaging 50 individuals in the program, each of whom was three months from release. The size and scope of the initial pilot phase were intentional, as the state was limited to operating within its existing budget, staffing, and medical services contract. By November, with additional funding, a second facility was added, expanding the program to 75 to 90 participants, and by the end of that year, 115 individuals had successfully initiated treatment while incarcerated and transitioned back into the community.

In 2020, ME DOC expanded the program to all secure and pre-release state facilities and has nearly 200 participants enrolled in the program on average. ME DOC continued to expand eligibility policy over time. Currently, if a behavioral health or medical provider refers an individual for induction, regardless of entry or release date, ME DOC is able to provide MOUD. All program participants are released with a naloxone kit and a continuity of care plan in place, and internal data has shown that 84 percent of program participants attended their initial treatment appointment post-release.

Pennsylvania

Pennsylvania’s Department of Corrections (PA DOC) began offering injectable naltrexone in 2014 through a small pilot with women who were re-entering the community from one state correctional facility. Within two years, PA DOC had expanded this program to other facilities, identifying individuals at risk of overdose and providing injectable naltrexone prior to re-entry, as well as connections to Medicaid enrollment to support continued treatment in the community.

On June 1, 2019, PA DOC continued this development of treatment services through a formal policy change that supports provision of buprenorphine to anyone coming into state custody who was on a verified prescription upon entry, though not yet to other incarcerated individuals with OUD. While this did not replace the naltrexone program, it did introduce a second form of MOUD into the state corrections system, creating entirely new protocols and challenges and with them, opportunities. PA DOC also began inducting those individuals who entered prison due to technical parole violations on injectable buprenorphine before they returned to the community as an alternative to detoxing onsite. Buprenorphine provision, however, experienced serious disruption with the temporary loss of a provider to prescribe the drug, followed by the emergence of COVID-19, which has affected clinical and procedural protocols across the board for PA DOC.

Pennsylvania also brought on a full time medication-assisted treatment (MAT) coordinator for corrections in 2016, a move that led to planning and exploration of expanded treatment provision development, bringing significant growth to the program. In the first year, the state had fewer than 80 individuals receiving MOUD, but participation has grown annually and is on track to include over 1,000 people in all 24 state prisons in 2020.

Kentucky

Kentucky’s Department of Corrections (KY DOC) currently maintains about 6,000 SUD treatment beds within the state’s correctional facilities, though most of those do not include the provision of MOUD and instead promote an abstinence-only approach. In 2018, the state developed the Substance Abuse Medication Assisted Treatment (SAMAT) project in which at-risk individuals are identified pre-release and provided injectable naltrexone or buprenorphine. While still incarcerated, they are connected to Kentucky Medicaid and enrolled in a managed care plan, and prior authorization is completed for necessary continuity of medication upon re-entry.

In 2020, looking for ways to further support and sustain comprehensive treatment in state prisons, the Kentucky legislature passed a budget that included language directing the state Medicaid agency to develop and submit an 1115 demonstration waiver to the Centers for Medicare & Medicaid Services (CMS). This waiver is intended to create a mechanism for Medicaid coverage of SUD treatment while an individual is incarcerated, an approach that is currently prohibited by language known as the “inmate exclusion” in the Social Security Act.

This means that policymakers in Kentucky are simultaneously designing a DOC treatment program and the mechanism to administer and fund it. State leaders are currently exploring proposals to amend the current 1115 waiver to address anticipated clinical and policy challenges to providing MOUD, especially buprenorphine, to people who are incarcerated. All of this must be done while maintaining the budget neutrality required by 1115 waivers. This process also raises questions about when Medicaid coverage would begin, and what services would be absorbed by the DOC budget as opposed to those that would be reimbursable by Medicaid. A mechanism to provide Medicaid coverage to individuals within a 30- to 60-day window prior to release may mitigate some of these concerns. This approach would ultimately increase resources for KY DOC to improve its quality of services by moving toward a more evidence-based approach that includes MOUD.

Considerations for States

All three of the featured states started small, beginning their DOC-based MOUD provision in pilot programs, and with initial success and additional funding, scaled those programs up to meet demand. States had to account for multiple factors in deciding which forms of MOUD to use in their programs, including the expectations of DOC clinical providers, security within facilities, and community treatment supports upon re-entry.

Widespread concerns among corrections officials about potential diversion, as well as stigma about using agonists and partial agonists for treatment, has resulted in a slower adoption of their use in incarceration-based treatment. Though naltrexone has been more widely embraced by correctional facilities than agonists and partial agonists like buprenorphine and methadone, each state has included or is working to include at least two forms of MOUD. Beyond this, state officials also developed clinical protocols and program components based on state resources and needs, and certain experiences and design elements were common across the states.

Decisions around specific forms of MOUD. Maine’s program currently primarily utilizes buprenorphine, recognizing that methadone provision would require significant administrative and clinical policy change. Federal methadone treatment regulations require accreditations and standards that are challenging to meet for an existing correctional facility. ME DOC is, however, exploring opportunities to expand the program to include methadone over time. Additionally, because naltrexone has limited availability in the community for individuals upon release, policymakers were concerned that a program utilizing naltrexone may make connections to ongoing treatment challenging.

While Maine has had success with buprenorphine, current PA DOC policy does not provide for induction on buprenorphine to most incarcerated individuals with OUD – a challenge that is both clinical and administratively-based. Like many states, Pennsylvania contracts for medical care in state prisons, and the current contract was not written to include the provision of MOUD, particularly buprenorphine, which can be clinically intensive and comes with provider waiver requirements.

Per the Request for Applications (RFA) issued by PA DOC, the next iteration of the contract will include a requirement that the state’s corrections medical provider provide MOUD. The RFA stipulates that:

An Addiction Specialist, certified through the American Board of Preventative Medicine, be identified among the contractor’s leadership to support SUD treatment needs;
All providers are educated in SUD treatment;
The contractor must register each correctional institution in the Risk Evaluation and Mitigation Strategies (REMS) program in order to safely order, store, and administer buprenorphine.
Subcontracts are developed with opioid treatment programs to provide methadone at certain facilities; and
A sufficient number of provider staff hold a waiver to prescribe buprenorphine.

Regardless of current challenges, Pennsylvania is prioritizing buprenorphine induction for individuals with OUD who are re-entering communities, similar to the way in which they are currently providing naltrexone. Further, there is a push to be able to induct those who are using contraband opioids, often as a means of harm reduction, while incarcerated. While the state uses injectable buprenorphine for a small minority of program participants, state leaders are awaiting the late 2020 release of a shorter-acting, non-refrigerated formulation that may be less cumbersome to administer.

Attention to correctional workforce needs. Recognizing that addressing staff concerns about the provision of MOUD, including issues of security and diversion, would be necessary for the program to succeed, ME DOC leadership arranged a second site visit specifically for security staff to meet with their counterparts in Rhode Island. To gauge staff culture, ME DOC leadership also conducted an internal survey among staff to assess the general understanding of MOUD, the results of which were used to tailor subsequent staff training and education prior to program implementation.

Kentucky is contemplating the development of new workforce protocols to provide these services as part of the state’s proposed Medicaid waiver. The current approach uses KY DOC counseling staff who are not licensed as behavioral health professionals. The state may consider developing a new provider type of DOC-based professionals, requiring new or amended professional licensing regulations, reimbursement policy changes, and facility licensure changes if needed. The state is also deliberating what utilization of peers may look like in such a program, as well as what supervision for unlicensed staff would include.

Ensuring continuity of care upon re-entry. Individuals leaving incarceration face a host of risk factors for return to substance use and potential overdose, including lack of access to treatment and limited financial resources. In recognition of this, all three states ensure that program participants are enrolled in Medicaid coverage, safeguarding their access to continued treatment in the community. The ME DOC also contracts with Groups Recover Together, a community recovery organization that helps to ensure that individuals are connected to and engaged in recovery services upon re-entry.

Pennsylvania is also considering how individuals progress with treatment upon re-entry based on the treatment provided to them while still incarcerated. Currently, PA DOC is providing up to three naltrexone doses prior to release and is reviewing state Medicaid treatment data to understand the impact of multiple doses versus one dose on treatment outcomes in the community.

Coordination between state leadership. Because these programs often emerge from previously existing social or abstinence-based approaches, the development of protocols and resources must be coordinated under the direction of high-level state leadership. Officials in all three states indicated they had leaders who not only authorized but championed treatment in incarceration settings. These leaders were critical to developing treatment policy, and their continued focus on OUD-related initiatives was a key component to maintaining services. In 2018, Pennsylvania’s governor declared the overdose epidemic a statewide disaster, and he continues to renew that declaration to ensure that initiatives it supports – including treatment within PA DOC – are maintained. The declaration established a cross-agency Opioid Unified Coordination Group composed of cabinet-level health and public safety officials that meets weekly.

Kentucky is one of few states to have a dedicated Office of Drug Control Policy, which led the charge for them to be among the first states to fund and implement an incarceration-based naltrexone program in corrections. The state legislature is unique in the nation in its decision to direct the state Medicaid agency to explore and submit a Medicaid waiver to provide SUD treatment to incarcerated individuals.

Maine’s current governor appointed a cabinet-level State Opioid Response Director, and she included incarceration-based treatment among her top priorities for the state upon assuming office. The governor’s second Executive Order, signed less than a month into her term, directed the development of OUD treatment in criminal justice settings, and the state’s DOC commissioner was working to implement this within the first few weeks of her administration.

Funding and Support for Incarceration-Based Treatment Sustainability

Because of the inmate exclusion that prevents correctional facilities from receiving Medicaid reimbursement for services in incarceration settings, states are relying primarily on federal grant funding to support these programs.

Maine launched its pilot program without using any additional funds beyond its internal budget, receiving an additional $1 million in funding from the Maine Office of Behavioral Health’s federal substance abuse block grant to support the program later in 2019. Concurrently, ME DOC realized savings in its health care budget as a result of the state’s recent Medicaid expansion. With these additional funding streams, Maine was able to make its final program expansion by adding its last remaining correctional facility to the program and expanding program eligibility to allow individuals who entered a facility from a local jail to continue on a course of MOUD that had been established previously. This also allowed Maine to expand treatment to individuals who are 180 days pre-release.

Kentucky’s initial provision of naltrexone was supported through state legislation that allocated $3 million to the program, and the current program is supplemented through federal State Opioid Response funds provided via the Kentucky Opioid Response Effort (KORE). Pennsylvania similarly uses their SOR funding to support current programming.

Looking Ahead

States are looking to the future as they plan what OUD treatment services for incarcerated populations will look like, as well as how to fund such services with increasingly limited resources and current reliance on federal grants. There may be an emerging appetite to address the inmate exclusion and develop new approaches through Medicaid, though as the COVID-19 pandemic increases Medicaid enrollment and drives state revenues down, any new Medicaid-funded services will be challenging to state budgets.

Even in successful corrections treatment programs, lack of insurance coverage upon re-entry is a barrier to long-term treatment and recovery outcomes. A House bill introduced in 2019, known as the Re-entry Act, was written to allow states to reinstate eligibility for Medicaid for incarcerated individuals in jails and state prisons up to 30 days prior to re-entry. Recognizing that the COVID-19 pandemic has disrupted, if not altogether halted, re-entry services across the country, the bill’s language was integrated into pandemic response legislation as a part of the Heroes Act, which has yet to be passed.

Treatment programs in incarceration settings are helpful tools that states are using in hopes of reducing opioid overdoses, but also in reducing the stigma around SUD and the racial disparities in health outcomes for people with OUD. As states continue to take steps to tackle the opioid epidemic, state corrections settings are proving to be an innovative access point for evidence-based treatment.

*See Smith V. Fitzpatrick, et al. The lawsuit argued that the DOC was violating the Constitution and the Americans with Disabilities Act by denying treatment to prisoners with OUD. At the time, the Maine DOC had a policy generally prohibiting medication-assisted treatment, under which Smith would have been prevented from taking his medication and forced into acute withdrawal.

Acknowledgements: The National Academy for State Health Policy is providing this case study with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. Further, the authors would like to thank Allen Brenzel, medical director of the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities; Steven Seitchik, Statewide Medication Assisted Treatment Coordinator for the Pennsylvania Department of Corrections, and Ryan Thornell, Deputy Commissioner of the Maine Department of Corrections for contributing their expertise and state experiences to this brief.

Kentucky’s Public-Private Initiative Promotes Employment as a Critical Opioid Recovery Tool

January 6, 2020/in Policy Kentucky Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health System Costs, Population Health, Social Determinants of Health /by NASHP Staff

When Beth Kuhn and Kentucky Chamber of Commerce officials meet with employers, their goal is to get them to hire people who are in recovery from opioid use disorder (OUD). “Many people became addicted to painkillers as a result of workplace injuries,” she tells business leaders, “therefore, you share the responsibility to help them in their recovery.”

As chief engagement officer for Kentucky’s Cabinet for Health and Family Services, Kuhn’s job is to help the business community reduce its stigma about opioid addiction and encourage leaders to take a chance on the tens of thousands of Kentuckians who have fallen victim to the state’s devastating opioid tsunami. Employment, and the critical connection to community it engenders, is a critical leg of recovery programs.

In 2017, opioid overdoses killed 1,565 people in Kentucky and the state ranked fourth in the nation for overdose deaths. That same year, Kentucky doctors wrote 86.8 opioid prescriptions for every 100 residents and the state spent so little on treatment that it was ranked the worst in the nation for dollars spent on state substance abuse agencies.

In 2017:

About 68% of injured workers were prescribed opioids – making these painkillers the most prescribed medication in Kentucky’s workers compensation system.
Opioid prescriptions accounted for 20% of the decline in men’s workforce participation and 25% for women.

Appointed by the director of Kentucky’s Office of Drug Control Policy in 2018, Kuhn’s job is to reduce employment barriers and add an essential tool to strengthen the state’s recovery system-of-care programs. Kuhn discussed her program at NASHP’s annual health policy conference in August 2019, and took time to answer questions about how the program moved from “a good idea” to a fully staffed and funded program that works across state agencies and in close partnership with the state’s Chamber of Commerce to encourage employers to join the recovery movement.

Why did Kentucky think it could convince its conservative business community to hire individuals with OUD?

Here in Appalachia, we’re in this epidemic’s epicenter. This has been a wrenching, traumatic issue that has made us open to solutions and big ideas that you may not find in other states. We had pioneering leaders promoting employment and also had providers who were very outspoken in arguing that employment was a critical fourth leg of any treatment program. [The four legs of recovery programs include addressing anxiety, shame, and trauma, and promoting connection.]

And of course, the economy is a driver. Unemployment is low and employers are now willing to consider some people as job candidates whom they wouldn’t have considered when unemployment was at 8 percent. And lastly, we had effective state leaders asking employers, “addiction is a chronic illness, would you turn down a job applicant who had diabetes?”

Which state department is spearheading this?

When this was designed in 2018, we had an alignment of cabinet leaders – justice and public safety, education and workforce development, and health and family services, which I’m a part of. We’re not siloed, we work hand in hand and aggressively partnered to address this crisis. I am leading this as chief engagement officer and my job is to lead policy and operational efforts to better integrate workforce, health, and human service programs.

How was this funded and implemented?

We spent about one year planning, designing, and hiring for the initiative, with funding through September 2020 for 18 employment specialists across the state. Twelve staff are placed in career centers to help employers and job seekers find each other, and we will have six success coaches embedded at employer sites to provide support and resources to individuals to ensure their retention once they are employed or back at work after treatment. Some of our employment specialists work in the state corrections system to link individuals who are being released from jail to the business community. We really worked to do this in a big-picture, comprehensive way.

The program is funded by three sources:

The Kentucky Office of Drug Control Policy/General Funds/Tobacco Settlement provides $1.29 million.
The federal Substance Abuse and Mental Health Services Administration/Kentucky Opioid Response Strategy provides $1.37 million.
And employers have provided about $20,000 to date, for a total program budget of $2.66 million.

The funding from employers is small, but aspirational for us. Part of our model is to place our success coaches in employer sites to help with hiring, training, and supporting workers. Based on past success with a similar national “Employer Resource Network” model, we are confident that funding for those jobs will come from employers.

Who has been your most critical partner?

The Kentucky Chamber of Commerce has been an invaluable partner. The Kentucky Chamber Workforce Center held a statewide opioid summit last summer that they thought would attract 75 to 100 employers, instead they got 300. It speaks to their power as conveners, but this is also a visceral issue in Kentucky with many people out of the workforce because of opioid addiction. With the Kentucky cabinets for Health and Family Services and Justice and Public Safety, the biopharmaceutical company Alkermes, and Aetna, the chamber launched the Opioid Response Program for Business, with members that include Toyota, GE, and Anthem Blue Cross Blue Shield. The program works directly with employers auditing their policies and recommending best practices to maintain a drug-free workplace while supporting a recovery-friendly culture.

How else are you and the chamber making workplaces more friendly to people in recovery?

Some of the things we’ve been discussing with the chamber’s task force. Is how do you change workers compensation and prescribing policies so you’re not part of the problem [about 68 percent of injured workers are prescribed opioids in Kentucky]. Another area is how to change HR policies if a positive drug test occurs in an employee. Historically, the person would be fired, but is that the right way to respond? How about putting that person on medical leave and helping them find treatment? And if someone is in recovery and fails a drug test because of medication-assisted treatment (MAT), what should the response be? In 2019, I think employers are now rethinking whether firing people who fail a random drug test is really appropriate.

To addition to promoting the hiring of people in recovery, Kentucky’s state chamber has endorsed:

-Expanding the number of needle exchange programs beyond the state’s current 45.

-Creating local collaboratives with community and business leaders to discuss the opioid problem and identify innovative solutions.

-Encouraging employment of those in recovery to not only boost workforce participation but to serve as a strong symbol to people with OUD that a productive life beyond drug abuse is possible if they enter treatment.

Another issue is background checks. While some businesses like to be known as second-choice employers, usually it’s for minor offenses, when an applicant fails a background check and it turns out they served time in prison for drug use, often the employer pulls the job offer. Our bigger companies (e.g., Toyota parts suppliers) are now saying they will stop this automatic exclusion if an applicant fails a background check and instead they will review applicants on a case-by-case basis with their attorney and hiring manager. That is what we need when we talk about transformational employment. These discussions can be had by us and the chamber, and they can lead to real change and move that background check needle.

Which employers have been most open to hiring individuals in recovery?

Manufacturers are definitely needy of workers, while construction companies have had a mixed response. On the one hand construction workplace injuries have contributed to a high incidence of illegal drug issues, but on the other hand, many of them get squeamish about hiring people on MAT. Are they safe operating machinery? How we and the chamber respond is, “well you let people with diabetes use the equipment, why not people in recovery?”

The health care industry is tricky, there are some licensing issues around drug offenses and employees’ access to drugs. But phlebotomists, for example, have no access to drugs, some of these restrictions are worth reviewing by state policymakers.

What remains the biggest barrier to employing people in recovery?

I think fear and some inaccuracies employers hold about MAT, but stigma remains the biggest barrier. That is why encouraging partnerships between business organizations is so important. It’s hard for me if I’m from the state or a nonprofit to make that argument, we’re the do-gooders. The chamber is in a different a position, they have the ability to make that argument very effectively.

Kentucky CHIP Fact Sheet

December 5, 2019/in Policy Kentucky /by NASHP Staff

Recent State Action on Medicaid Expansion, Work Requirements, and Block Grants

October 22, 2019/in Policy Georgia, Idaho, Kentucky, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, South Dakota, Utah, Virginia Blogs, Featured News Home Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, Work Requirements /by Anita Cardwell

This year, many states have continued to pursue federal approval for a range of proposals affecting Medicaid coverage, such as seeking modifications to the Affordable Care Act’s (ACA) Medicaid expansion or adding Medicaid work requirements.

Currently, nine states have implemented expansion through Section 1115 waivers to impose conditions such as monthly premiums, lock-out provisions for non-payment, and work requirements on certain Medicaid enrollees. While some Medicaid waivers approved by the federal government that include work requirements have faced legal challenges, other states — including those that have not implemented Medicaid expansion — are continuing to seek federal approval to condition Medicaid eligibility on work, with nine additional proposals currently pending.

The following is an overview of some of the current state Medicaid coverage waiver activity and other state actions affecting health coverage, including Tennessee’s recent block grant proposal.

State Changes to Medicaid Expansion Passed by Ballot Initiatives

Earlier this year, Idaho’s governor signed into law a number of changes to the Medicaid expansion ballot measure approved by voters in November 2018. One component of the law required the state to seek a 1332 waiver to enroll individuals eligible for expanded Medicaid who had income between 100 to 138 percent of the federal poverty level (FPL) in subsidized exchange coverage, although these individuals could opt for Medicaid coverage instead. However, in late August the Centers for Medicare & Medicaid Services (CMS) rejected the state’s waiver request, citing that it did not meet the deficit neutrality guardrails required of 1332 waivers. State officials have indicated that they will resubmit the application with additional information, although CMS noted in its letter that even a revised application would likely still not demonstrate compliance with those guardrails. Another aspect of Idaho’s law modifying the voter-approved Medicaid expansion directs the state to seek a waiver to implement Medicaid work requirements for most expansion enrollees, and the state recently submitted this 1115 waiver request for federal approval. If the waivers are not approved by Jan. 1, 2020, the state law requires implementation of traditional Medicaid expansion.

Similar to Idaho, voters in Utah passed a measure last November to implement Medicaid expansion, and in February state legislators enacted a law that significantly alters the voter-approved expansion in a number of ways. The law requires the state to seek a series of waivers, outlined in the state’s implementation toolkit, through a potentially four-step process, depending on what CMS approves. In March, CMS approved the state’s first request — the Bridge Plan — to expand Medicaid to only those earning 100 percent of FPL at the state’s regular federal medical assistance percentage (FMAP) rate, include an enrollment cap if projected costs exceed state appropriations, require individuals with access to employer-sponsored insurance (ESI) to enroll in that coverage with Medicaid premium assistance, and add work requirements in 2020. In May, the state submitted the second waiver proposal for the enhanced FMAP that the ACA provides for the expansion population while keeping the expansion eligibility level at 100 percent FPL, but CMS indicated that it would not provide the enhanced FMAP for a partial expansion. This second proposal also maintains the enrollment cap, work requirements, and ESI premium assistance from the initial waiver, adds in 12-month continuous eligibility and lock-out provisions for non-compliance with certain activities, and notably requests to implement a per capita cap model for receiving federal Medicaid funds for the new eligibility group. Although CMS did not approve the enhanced FMAP for the partial Medicaid expansion, the governor issued a statement that the state would move forward with requesting approval of the other proposal components, and the state submitted the waiver request in late July. If CMS does not approve this per capita cap proposal, the state plans to request permission to implement a “fallback” plan — the third step in the state’s implementation plan — that expands Medicaid to the ACA’s 138 percent of FPL eligibility threshold and provides the state with the enhanced expansion FMAP, and includes work requirements, an enrollment cap, and lock-out provisions. The final option – if this third plan is not approved – is implementing traditional Medicaid expansion through a state plan amendment, as was passed by the voters.

Nebraska was the third state in 2018 to pass Medicaid expansion through a ballot initiative, and while state legislators there did not follow the same route as Idaho and Utah, expansion in Nebraska has not yet occurred because the state intends to seek modifications to the expansion. State officials submitted a state plan amendment for expansion this past April, indicating the state would seek a waiver to modify its existing managed care program to include the expansion population and provide different benefit packages based on whether enrollees complete certain wellness requirements. Expansion will occur no later than Oct. 1, 2020, and the plan eventually will also incorporate work requirements for eligible individuals wishing to remain in the “prime” coverage option, which offers more robust benefits such as dental and vision services.

Activity in Medicaid Expansion States

Montana originally implemented Medicaid expansion through a waiver because the state requires certain individuals to pay premiums. The expansion was scheduled to sunset in July of this year, but in April the legislature passed a bill, signed by the governor in May, to continue expansion that added work requirements for most enrollees. The state’s waiver amendment also seeks to maintain the original waiver’s implementation of 12-month continuous eligibility and modify the monthly premium structure to be based on the amount of time an individual is enrolled. The federal comment period for the waiver amendment recently closed.

In Virginia, Democratic Gov. Ralph Northam and Republican state legislators negotiated a compromise to expand Medicaid with work requirements in 2018. Coverage became effective in January of this year, but the work requirements were not implemented as the state needed to seek federal permission through a waiver. The state is now negotiating to receive federal funding for employment supports, as Northam’s administration has indicated that the state cannot afford to implement the work requirements without these federal dollars. Some Republican state legislators are characterizing the request for this federal funding as an effort to backtrack on the compromise struck last year between them and the governor.

While New Mexico originally implemented the ACA’s traditional Medicaid expansion, the state sought and received approval in December 2018 to add premium and copayment requirements and waive retroactive eligibility for certain expansion enrollees. However, under Gov. Lujan Grisham, the state is now requesting to amend the waiver and remove the copayments, premiums, and waiver of retroactive eligibility.

Activity in Non-Medicaid Expansion States

Like last year, voters in some nonexpansion states will have the chance to consider expansion in 2020. Groups in Oklahoma indicated that they have gathered enough signatures to put expansion before voters in 2020. Medicaid expansion proponents in other states — specifically Missouri and South Dakota — are also attempting to place the issue before voters in 2020. Additionally, in Mississippi’s upcoming gubernatorial election in November, voters will decide between a Republican who opposes expansion and a Democratic who supports it.

North Carolina’s Democratic Gov. Roy Cooper vetoed the state budget in June in part because it did not include Medicaid expansion. However, in mid-September state legislators in the House voted to override the governor’s veto. While the Senate still needs to hold a vote on the veto override, a bill to expand Medicaid with work requirements and premiums has been added back to the legislative calendar.

Georgia is currently drafting two waiver proposals as part of a law signed by the governor in March. The state is expected to submit an 1115 waiver proposal to expand Medicaid to only those earning 100 percent of FPL, as well as seek federal approval through a 1332 waiver to implement a reinsurance program.

Beyond continuing efforts to expand Medicaid or modify laws to do so, block grants have surfaced again. Tennessee has developed a draft proposal to shift federal funding for most of the state’s Medicaid program into a version of a block grant, which would be a significant change and is based on a state law passed earlier this year. Under the plan, the state would receive a capped amount of federal Medicaid funding for low-income parents, children, and individuals with disabilities. Unlike a traditional block grant — which the state acknowledges its plan differs from — the state is requesting additional funding if enrollment rises above a certain threshold, but the funding amount would not be reduced if enrollment declined. Additionally, the funding cap does not include state spending on individuals dually eligible for Medicaid and Medicare, disproportionate share hospital (DSH) payments, outpatient prescription drug expenses, or administrative costs, and any savings achieved from the financing model would be divided evenly between the state and the federal government (the state’s current federal match rate is 65 percent). The state is also requesting additional flexibilities, such as modifying the amount, duration, and scope of benefits without federal approval or public comment and implementing a closed formulary for prescription drugs. The waiver request also proposes to exempt the state from federal regulations for managed care plans. Some policy analysts have identified that federal law does not allow Medicaid’s financing model to be restructured through the 1115 waiver authority, and if CMS does approve the waiver it is expected to face legal challenges. Tennessee also submitted a separate waiver request in December 2018 seeking to implement Medicaid work requirements for low-income parents and caretakers, which is still awaiting federal approval.

Legal Challenges to Medicaid Work Requirements

Medicaid waivers containing work requirements approved by CMS have been halted by court rulings earlier this year in Arkansas, Kentucky, and New Hampshire, and a legal challenge was recently filed against Indiana’s approved work requirements. Earlier this month, a three-judge panel heard oral arguments on the federal government’s appeal of the Arkansas and Kentucky rulings, and the judges noted that the administration had not considered the coverage losses resulting from work requirements. The ruling by this federal appeals court will have significant implications for Medicaid work requirements overall, and while they did not provide specific information about timing for the decision, it is expected before the end of the year. The court challenges are already beginning to have some implications — on Oct. 17, 2019, Arizona informed CMS that it would postpone implementation of the state’s approved Medicaid work requirements due to the litigation in other states. Additionally, a recent study conducted by the Government Accountability Office (GAO) recommended that CMS should improve its oversight of the administrative costs associated with work requirement waivers, which GAO found can be significant, ranging from under $10 million to over $250 million.

In addition to the next round of court decisions on Medicaid work requirements, states are waiting to see if federal guidance on Medicaid block granting will be issued soon — which is currently under review at the Office of Management and Budget. Similar to how states are seeking to implement Medicaid work requirements despite legal challenges, if CMS provides guidance and approves Tennessee’s block grant proposal, other states may also pursue this financing model, even if the block grant is challenged in court. Also, whether CMS and states that have been hesitant to expand will be able to find a middle ground on Medicaid expansion remains a question, and how decisions play out in Idaho and Utah in particular, will be significant for future actions. Similar to this past year, in 2020 states are expected to continue to seek new ways to test the boundaries of Medicaid coverage waivers and manage their Medicaid programs.

For more information about each state’s Medicaid expansion activity, explore NASHP’s map, and for up-to-date information about states’ Medicaid work requirement proposals, review this NASHP chart.

Ten States Selected to Attend Palliative Care Summit in Chicago

June 18, 2019/in Policy Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, Texas Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.