Federal health officials have again approved Gov. Matt Bevin's plan to revamp the state Medicaid program by introducing work requirements, premiums, co-payments and other changes for "able-bodied" members who weren't covered until then-Gov. Steve Beshear expanded the program in 2014.

The previous version of the plan was blocked in late June by a federal judge in Washington, D.C., who said the officials had not dealt with the state's projection that the changes would leave the Medicaid rolls with 95,000 fewer members in five years than they would have without the changes.

District Judge James Boasberg said the officials "never adequately considered whether" the plan "would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid." Now he is likely to hear more arguments from state and federal officials and lawyers for the 16 Kentuckians who filed the lawsuit. Just what will be litigated remains unclear; the language of the Centers for Medicare and Medicaid Services approval is likely to be a major point.

The lengthy letter "makes clear that the version CMS just approved is substantially the same as the original with a few different nuances, such as a more explicit monitoring requirement about its effects," reports Amy Goldstein of The Washington Post.

CMS said in a news release that the state could begin rolling out the program regionally no earlier than April 1, the state Cabinet for Health and Family Services said in a news release. The state calls the plan Kentucky HEALTH, for "Helping to Engage and Achieve Long Term Health." It would operate under an administrative waiver of normal Medicaid rules, and after more than a year of debate is often called "the waiver."

State Health Secretary Adam Meier said in the release that the plan “offers a customized path based on individual needs that will help beneficiaries gain better health, engagement in their communities, improved employability, and success through long-term independence.” He said it has “flexibility and procedural protections that will ensure Medicaid is able to provide beneficiaries access to services and opportunities, while utilizing a holistic approach to addressing barriers and challenges that affect overall health.”

The plan calls for beneficiaries to pay small, income-based premiums, and has "community engagement" requirements for "able-bodied" beneficiaries who are not primary caregivers: work, volunteering, job training or drug treatment at least 80 hours a month. Failure to pay premiums or report community engagement would result in loss of eligibility, which could be regained by taking a course in financial or health literacy.

“Reapproving a waiver that makes hard-working Kentuckians jump through hoops to keep their coverage will no doubt have the opposite effect," said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of interest groups. “Kentucky’s historic gains in health coverage have led to real progress in our economic recovery and our health – especially in struggling rural areas – and CMS’s decision today turns the clock back on those gains.”

Deborah Yetter of the Louisville Courier Journal notes that CMS's decision "comes as advocates have expressed increasing concern about the impact in Arkansas, which introduced work requirements earlier this year and has seen thousands cut off Medicaid enrollment as a result." Boasberg is also hearing a case challenging the Arkansas plan.

Marcie Timmerman, executive director of Mental Health America of Kentucky, said in the Vice for Health news release, “I continue to be concerned with the complexity of Kentucky HEALTH’s many administrative requirements. Kentucky quickly moved the proverbial needle on substance abuse and behavioral treatment access when we adopted Medicaid expansion. Single adults without dependents were finally able to access care. Many sought help for the first time in their life. I’m concerned many will fail to understand the new requirements and so will not be able to maintain their coverage, putting them back where they started – in our jails and on our streets instead of in treatment.”

Other stakeholders were more equivocal. Terry Brooks, executive director of Kentucky Youth Advocates, said in a release, “When it comes to this – or any policy – our question is always the same – 'Is it good for kids?" And the key to this significant policy change's success or failure lies in its implementation. Kentucky HEALTH's initial rollout and ongoing management must be family-centric." While the plan doesn't have new rules for children, pregnant women, and transition-aged youth in foster care, he said, research shows that insured parents are likelier to have insured children.

Brooks said the Bevin administration "has shown a commitment to children and families, and, as a result, we hope for and expect a family-friendly roll-out. The success story for Kentucky's kids of late has been more and more gaining access to health insurance coverage, and this plan's implementation must be a catalyst rather than an inhibitor to that trajectory of progress."

The Foundation for a Healthy Kentucky said it "remains committed to assisting Medicaid beneficiaries with their efforts to understand and comply with the waiver's requirements." In May, the foundation and the Bevin administration announced a partnership in which the foundation would pay premiums for those who cannot afford them, and work with employers and others to expand the availability of community-engagement activities in all areas of the state.

"It will take a collective effort by the state, providers, community organizations, and all those involved with the new Medicaid waiver to ensure Kentuckians are successful in meeting its requirements, so they do not lose health coverage," foundation President and CEO Ben Chandler said in a news release.

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