Background

Opioids are natural, synthetic, or semi-synthetic chemicals that interact with specific, opioid receptors on nerve cells in the body and brain¹. This interaction reduces the intensity of pain. Commonly prescribed opioids include hydrocodone (Vicodin®), oxycodone (OxyContin®, Percocet®), oxymorphone (Opana®), morphine (Kadian®, Avinza®), and codeine (used in cough suppressants). Methadone, also a prescribed opioid, can be part of a medication-assisted treatment plan for opioid use disorder². Similarly, the opioid fentanyl — which is used to treat severe pain because it is 100 times more potent than morphine — can be obtained with a prescription. Illegally obtained fentanyl is primarily manufactured in foreign, illicit labs and then smuggled into the United States. In this form, fentanyl is often mixed with other illicit drugs and made into pills to resemble prescription opioids³.

The increase in opioid overdose deaths in the United States due to any opioid can be outlined in three distinct waves. The initial, gradual increase started in the 1990s and was closely tied to a rise in commonly prescribed opioid medications. In the 2010s, a rapid increase of opioid overdose deaths was attributed to heroin specifically. Most recently, beginning in 2013, the data shows a rapid surge in opioid overdose deaths due to other synthetic opioids, including tramadol and fentanyl.

Data specific to Kansas mirrors the national trend. According to testimony provided to the House Committee on Corrections and Juvenile Justice in February 2023 by the Kansas Department of Health and Environment (KDHE) and the Kansas Department for Aging and Disability Services (KDADS), synthetic opioid overdose deaths have increased from 39 deaths reported in 2012 to 347 deaths in 2021, a 790 percent increase⁴. This increase is primarily seen in the last two years of available data: The number of deaths more than doubled both years, from 70 in 2019 to 161 in 2020, and then to 347 in 2021.

As of 2021, when taking into account age distribution and population size of a state, West Virginia has the highest drug overdose mortality rate, at 90.9 deaths per 100,000, followed by Louisiana, Tennessee, and Kentucky, at 55.9, 56.6, and 55.6 deaths per 100,000, respectively. Kansas is considerably lower, at 24.3 deaths per 100,000.

Federal Actions to Address Opioids

President Obama signed into law the Comprehensive Addiction and Recovery Act and appropriated funds to each of the 50 states through the 21st Century Cures Act. Several hundred bills have been introduced in the 115th Congress that address the opioid epidemic in some capacity. President Trump issued an executive order that created a national opioid commission, and Congress, through 2017 HR 244, appropriated $113.0 million to combat the opioid crisis.

Congress passed a spending package in December 2022 that removed the federal requirement for health care practitioners to have a waiver to prescribe medication for opioid use disorder, allowing practitioners to more easily prescribe buprenorphine and increasing access to treatment. Buprenorphine is the first medication to treat opioid use disorder that can be prescribed or dispensed in physician offices. It is an opioid partial agonist that produces effects of euphoria and respiratory depression at low to moderate doses. The effects of buprenorphine are weaker than those of full opioid agonists, such methadone. When taken as prescribed, buprenorphine diminishes withdrawal symptoms and physical dependency on opioids.

In March of 2023, the U.S. Food and Drug Administration (FDA) approved the first over-the-counter nalaxone nasal spray. (see “Nalaxone Access” below for more information on nalaxone.)

Addressing Opioids in Kansas

In 2017, Governor Brownback signed HB 2217 into law, amending the Kansas Pharmacy Act to allow first responders to carry nalaxone.

In 2021, the Kansas Legislature passed the Kansas Fights Addiction Act (HB 2079), which authorized the State to use money recovered through Kansas opioid settlements to tackle substance abuse and provide addiction services across the state. The settlement funds are split into two funds: 75 percent to the Kansas Fights Addiction fund, and 25 percent to the Municipalities Fight Addiction Fund (MFAF), with $200,000 dedicated annually to K-TRACS, the Kansas prescription drug monitoring program.

In October 2022, Governor Kelly announced that the State of Kansas and the Kickapoo Tribe in Kansas (KTIK), together, have received $17.2 million in federal grant funding to address the opioid crisis. The funding will be used by KDADS and KTIK through September 2024 to increase access to treatment for substance use disorders; remove barriers to public health interventions, such as naloxone; and expand access to recovery support services.

Kansas Opioid Treatment Programs

KDADS maintains a list of Kansas Opioid Treatment Programs. Programs are primarily located in eastern Kansas, including the Kansas City area, Lawrence, Overland Park, Topeka, and Wichita. The Substance Abuse and Mental Health Services Administration (SAMHSA) also maintains an Opioid Treatment Program Directory. According to SAMHSA, every state has at least one federally certified treatment location. However, the laws concerning the programs and requirements vary by state.

Medication-assisted treatment (MAT) works to normalize brain chemistry and body functions, block the euphoric effects of opioids, and relieve physiological cravings. Through September 2025, buprenorphine, methadone, and naltrexone are considered Medicare Part B MAT drugs for opioid treatment programs.

Kansas Prescription Drug and Opioid Advisory Committee

The Kansas Prescription Drug and Opioid Advisory Committee (Committee) was formally established in 2017. It is facilitated by DCCCA, Inc., and supported by KDADS and KDHE. The Committee is a multidisciplinary stakeholder group composed of state and local government, health systems, professional associations, community-based organizations, academic institutions, public safety and first responders, and others.

In December of 2022, the Committee released the second iteration of the Kansas Overdose Prevention Strategic Plan for 2022–2027. This plan was developed with contributions from the Committee, subject matter experts, and more than 55 organizations. The plan is centered on six overarching priorities:Treatment and Recovery, Linkages to Care, Prevention, Harm Reduction, Providers and Health Systems, and Public Safety and First Responders. These six priorities intersect across strategies, including data and surveillance; policy development, evaluation, and advocacy; stigma reduction; and health equity.

The objectives, strategies, and recommendations presented within each priority reflect best or promising practices, are driven by Kansas-specific data, and aim to address multiple levels of impact. Specific strategies are targeted to increase education and awareness, prevent substance misuse and use disorder, connect individuals who use drugs with substance abuse disorder treatment and wraparound services, scale up treatment services, advance harm reduction, and expand services for justice-involved populations. The full plan can be accessed here.

With the release of the current plan, the Committee also shared their progress on strategic indicators identified during the first iteration of the plan, which was 2018 to 2022.

Table 1. Previous Strategic Plan Indicators That Met or Exceeded 2022 Target Value⁵

State-level Indicator	Baseline	Target	2021 Value
Provider Education
Percent of patients prescribed long-acting/extended release opioids who were opioid-naive	8.70%	5.20%	4.8% (2022 Q3)
Treatment and Recovery
Number of Buprenorphine waivered prescribers practicing in Kansas	97	150	218
Rate of Kansas prescribers who prescribed buprenorphine indicated for Medication-assisted Treat (MAT) per 100,000 residents	7.1	9.1	22.4 (2022)
Law Enforcement
Percentage of law enforcement agencies responding to the naloxone survey that indicated they allowed carry and use of naloxone	̶	50.00%	65.30%

Table 2. Previous Strategic Plan Indicators Made Progress in Intended Direction⁶

State-level Indicator	Baseline	Target	2021 Value
Morbidity
Age-adjusted All Drug Non-Fatal Overdose Hospitalization Rate per 100,000 population	116.8	105.1	112.5
Age-adjusted Non-Fatal Opioid Overdose (excluding heroin)	23.8	21.4	18.9
Hospitalization associated with opioid abuse or dependence (age-adjusted rate per 100,000 population)	83	74.7	71.5
Prevention
Percentage of youth in Kansas in grades 6th, 8th, 10th,and 12th reporting use of prescription medications not prescribed to them in the past 30 days	3.70%	1.20%	1.60%
Percentage of youth in Kansas in grades 6th, 8th, 10th,and 12th who report there is “no risk”	10.00%	6.80%	7.40%
Neonatal Opioid Withdrawal Syndrome (NOWS) (Formerly NAS)
Incidence rate of NOWS in Kansas, per 1,000 birth hospitalizations	3.4	2.6	2.9 (2020)
Provider Education
Total morphine milligram equivalents (MME) dispensed to patients per capita	196.8	75	104.2 (2022 Q3)
Rate of patients with 5+ prescribers and 5+ dispensers in a 6-month period	15.40%	0.4	1.5 (2022 Q3)
Percent of patients with 90+ daily MME of opioids	11.10%	2.20%	6.0% (2022 Q3)
Treatment and Recovery
Percentage of Kansas counties with perscribers who prescribed buprenorphine indicated for medication assisted treatment (MAT)	27.00%	100.00%	35.00%

Kansas Prescription Drug Monitoring Program

K-TRACS, the state prescription drug monitoring program (PDMP) authorized by law in 2008 (KSA 65-1683), has been operating since April 1, 2011. The program provides a database of controlled substance prescriptions that have been dispensed by Kansas pharmacies and from out-of-state pharmacies to Kansas residents. The purpose of the database is to provide up-to-date web-based patient information to assist prescribers in providing appropriate treatment to patients. Additionally, drugs classified as schedule II through IV are monitored.

The program requires pharmacists to document prescription-dispensing data on every written controlled substance prescription. It also allows both prescribers and pharmacists to check prescription histories to determine, in advance, if patients are acquiring drugs from multiple prescribers or pharmacies.

Drug Treatment Courts in Kansas

In 2022, the Kansas Legislature passed Senate Sub. for HB 2361, which required the Kansas Supreme Court to adopt rules for establishment and operation of specialty court programs within the state, including drug courts for people with substance use disorder. Drug treatment courts are established as an alternative to incarceration for those convicted of misdemeanors. They offer treatment, support, and counseling. With oversight from the court, a person with substance use disorder can complete a drug treatment program and work on lifestyle changes, often in lieu of going to jail.

As of 2023, while there is not a statewide program, the cities of Kansas City, Topeka, and Wichita have developed their own municipal- or county-level programs, and 11 of the 31 judicial districts have drug treatment courts, which includes Allen, Chase, Cowley, Douglas, Ellis, Geary, Johnson, Lyon, Reno, Riley, Sedgwick, Shawnee, and Wyandotte counties.

Strategies Used by Other States

Prescription Drug Monitoring Programs

With the launch of Missouri’s PDMP in 2023, all 50 states have PDMPs in place to track the prescribing and dispensing of all controlled substances. State requirements vary concerning who and what is tracked, who is required or authorized to check or submit information, and the frequency information needs to be checked and updated. Many states share their data with other states’ PDMPs and authorized users in those states. However, there are no federal regulations requiring states to share their information with other states or the federal government.

Limiting Prescriptions

As of 2022, 32 states have enacted a limit on initial opioid prescriptions, ranging from a three-day supply (Florida, Kentucky, Tennessee, and ⁷West Virginia) to a 14-day supply (Nevada, specifically for prescriptions meant to treat acute pain). A seven-day initial supply is the most common limit, with 24 states implementing a seven-day limit on all or specific types of opioid prescriptions, such as those intended for minors. Several states impose different limits depending on the prescriber or reason for treatment. For example, Pennsylvania limits prescriptions originating in emergency rooms and urgent care or those written for minors to a seven-day initial supply.

Opioid Intervention Court

Buffalo, New York, created the nation’s first opioid crisis intervention court in 2017 after determining its ordinary drug treatment court was not enough to combat the opioid crisis. The court admits people into treatment in a matter of hours instead of days, requires them to check in with a judge every day for one month, and utilizes strict curfews. It has been funded via a U.S. Justice Department grant with the intent of treating 200 people in a year. During the first nine months of the program, only one of the 92 people in the program had overdosed. Since its establishment, the state of New York has expanded the model and established a total of 35 new opioid courts through its Unified Court System, and similar specialty courts have been created in Arizona, Pennsylvania, and Wisconsin.

Good Samaritan Overdose Immunity Laws

As of May 2023, the Network for Public Health Law⁸ reports that 48 states and the District of Columbia have enacted at least one overdose Good Samaritan law. These laws provide immunity from arrest, charge, or prosecution for certain controlled substance possession and paraphernalia offenses when someone is either experiencing an opioid-related overdose or calling 911 to seek medical attention for someone else experiencing an opioid-related overdose. What is covered under the law varies depending on the state. Kansas’ good Samaritan law (KSA 65-2891) is limited specifically to health care providers rendering emergency services at the scene of an accident or emergency. Kansas and Wyoming are the only two states that do not have a Good Samaritan Law specific to drug overdoses.

Naloxone Access

All 50 states have passed legislation to expand access to naloxone in some form. Naloxone, also known by the brand name Narcan, is an opioid antagonist that can bind to opioid receptors and reverse or block the effects of other opioids, thereby reversing opioid-induced overdoses. It can be administered via nasal spray or injected into the outer thigh muscle, veins, or under the skin. New evidence has shown that opioid-related deaths have been reduced by 9.0 to 11.0 percent in states that have promoted naloxone. Some states, such as Arizona, Maryland, and New Mexico, have utilized Medicaid to purchase naloxone to promote access for the public. Some states are also providing naloxone to at-risk inmates, as well as training on how to use it upon their release from jail. Officials hope this will reduce overdose deaths and expand the community’s knowledge about naloxone and how to use it.

Needle Exchanges

Forty-three states and the District of Columbia have some form of a needle exchange program. Currently, only 1 in 4 drug users obtains needles from a sterile source. With the increase in the use of heroin and other drugs injected via needle, there is also a rise in the number of cases of HIV and hepatitis B and C. One way to help combat the spread of disease is to facilitate access to sterile needles via needle exchanges. The federal government lifted a ban on federal funding for needle exchanges in early 2016. Some states have also followed suit by making it easier to establish needle exchanges, as well as helping people enter a program who want to find treatment.

1. https://www.cdc.gov/opiods/basics/terms.html ↩︎
2. dea.gov/factsheets/fentanyl ↩︎
3. cdc.gov/stopoverdose/fentanyl/index.html ↩︎
4. kslegislature.org/li/b2023_24/committees/ctte_h_corr_juv_jus_1/documents/testimony/20230215_23.pdf ↩︎
5. https://www.kdhe.ks.gov/DocumentCenter/View/12040/2022—2027-Kansas-Overodse-Prevention-Strategic-Plan-PDF ↩︎
6. https://www.kdhe.ks.gov/DocumentCenter/View/12040/2022—2027-Kansas-Overodse-Prevention-Strategic-Plan-PDF ↩︎
7. West Virginia’s law limits initial opioid prescriptions written by dentists or optometrists to three days. ↩︎
8. https://www.networkforphl.org/wp-content/uploads/2023/07/Legal-Interventions-to-Reduce-Overdose-Mortality-Overdose-Good-Samaritan-Laws-2.pdf ↩︎

by Amanda Prosser
Fiscal Analyst
785-296-7879

Child Welfare Professionals

The American Academy of Pediatrics defines child welfare professionals as foster parents and kin caregivers, pediatricians, other physicians in medical specialties, child advocates, psychologists, and therapists. In Kansas, this definition can be expanded to Kansas Department for Children and Families (DCF) employees who conduct child protective service investigations, staff who support grantee organizations, staff members of the Kansas Protection Report Center, and case management and prevention services staff through grantees.

Child welfare professionals vary in their education level, employment, role within the system, and location. However, each professional is impacted by legislative requirements and DCF policies.

Barriers to the Workforce

In 2020, stakeholders reported various barriers that contribute to the current state of the workforce within Kansas’ child welfare system. Some of the common reasons stated for the high turnover rate of child welfare professionals are burnout, unmet needs, and lack of support.

A National Association of Social Workers (NASW) report on child welfare described challenges to recruitment and retention of child welfare professionals, including low salaries, high caseloads, administrative burdens, risk of violence, and inadequate supervision. Although salaries tend to increase with experience, many professionals do not stay in the child welfare system for an extended amount of time.

Many child welfare professionals spend more time on paperwork than with their clients; however, they do recognize that some paperwork is necessary. The number of cases per worker can range from 10 to 100 across the country; best practice recommends no more than 15 cases per caseworker. Additionally, child welfare supervisors often have their own caseload or manage a significant number of employees, which may leave employees without the support or guidance some professionals need.

Considerations

The Child Welfare League of America introduced the National Blueprint for Excellence in Child Welfare, which addresses workforce needs. Some of these needs include orientation and training programs, continuing education, annual performance evaluation, and reasonable workloads. Additionally, the Blueprint indicates employers should encourage self-care and provide wellness opportunities and stress management strategies.

During a presentation before the Special Committee in 2020, a representative of the Kansas chapter of the NASW suggested the State consider increasing recruitment and retention of child welfare professionals by offering financial incentives such as student loan forgiveness, tuition reimbursement, and free continuing education units. It was also recommended an annual survey be conducted to determine which incentives are utilized. The representative further recommended the State consider career readiness at the middle and high school level to introduce students to the profession, career paths within the system that provide opportunities for advancement, and field placement experiences to assist the tenure of the Kansas child welfare workforce. To assist with the unmet needs regionally, the representative recommended expansion of the Rural Opportunity Zone Student Loan Repayment Program to additional communities where there is a greater need of support. Other suggestions included ensuring professionals have a work-life balance, maintain the recommended caseload size of no more than 15 cases, and have access to supervisors and self-care in order to combat burnout, compassion fatigue, and secondary traumatic stress.

Legislative Changes

Beginning in 2019, Kansas enacted the following bills striving to positively impact the child welfare workforce.

In 2019, House Sub. for SB 25 (the appropriations bill) created 16 additional full-time equivalent (FTE) child welfare staff positions. DCF reported that these positions lowered caseloads for frontline child protective services staff and increased the efficiency of service delivery. Additionally, DCF made policy changes to decrease the supervisor-to-caseworker ratio across the state to be more in line with the Council on Accreditation best practices.

Also in 2019, SB 15 provided for licensure by reciprocity for social workers at baccalaureate, master’s, and specialist clinical levels and amended the requirements for licensure by reciprocity for other professions regulated by the Behavioral Sciences Regulatory Board (BSRB). Applicants who are deficient in the qualifications or in the quality of educational experience required for licensure are allowed to obtain provisional licenses to allow the applicants time to fulfill remedial or other requirements prescribed by the BSRB. For several professions, the bill amended provisions related to temporary licenses for applicants who have met all licensure requirements except for taking the required licensing examination. The bill also amended the licensure requirements for a specialist clinical social worker to reduce the number of hours of postgraduate supervised professional experience required.

In 2020, SB 66 (the appropriations bill) added $710,838 State General Fund (SGF) and 10.0 FTE positions for additional Protection and Prevention Services program staff for FY 2021 at DCF. The bill also added $7.5 million, including $3.8 million SGF, and 8.0 FTE positions for Family First Prevention Services Act services at the agency.

In 2021, Senate Sub. for HB 2208 was enacted. Among other things, this bill reduced the barriers to becoming a social worker by amending the licensure requirements to reduce the number of clinical hours required to become a licensed specialist clinical social worker.

In 2023, enacted Sub. for SB 131, among other things, changed licensure requirements for multiple professionals regulated by the BSRB, including reducing the number of months of practice prior to being eligible for reciprocity of license from 48 of the past 54 months to 12 months for a social worker; increased the months of validity to 24 months for a temporary license for both bachelor’s and master’s social workers; and added a definition for “extenuating circumstances” which may permit a current licensee an additional 3 months to complete continuing education requirements. The bill also reduced the number of continuing education hours after July 1, 2025, for certain licensees who diagnose and treat mental disorders.. The bill also permitted both the temporary reinstatement of an expired license and the issuance of temporary license for social work candidates for 24 months if they have completed their education at an education program undergoing accreditation. Additionally, the bill created a new community-based temporary license for multiple professionals including social workers who are employed by community mental health centers, federally qualified health centers, psychiatric residential treatment facilities, and private treatment facilities. The community-based temporary license is valid for 24 months, may not be renewed, and requires supervision by a BSRB-regulated professional who practices at an independent level.

by Amanda Prosser
Fiscal Analyst
785-296-7879

Family First Prevention Services Act

The federal Family First Prevention Services Act (FFPSA) was signed into law in 2018. FFPSA enables states to use funds under Title IV-E and Title IV-B of the Social Security Act (SSA) to provide enhanced support to children who are at risk of entering foster care. The bill authorizes federal reimbursement of prevention services for up to 12 months. The bill also includes new restrictions on federal reimbursement for children placed in a nonfoster home. The National Conference of State Legislatures (NCSL) provides a more detailed explanation of the FFPSA, which can be found here: https://www.ncsl.org/human-services/family-first-prevention-services-act.

State Requirements

States may use Title IV-E funding of FFPSA to provide prevention services to a child who is a “candidate for foster care,” meaning a child who is at imminent risk of entering foster care but who can remain safely in the child’s home as long as services or programs are provided, a child whose adoption or guardianship arrangement is at risk of disruption or dissolution (SSA Section 475(13)), a child in foster care who is pregnant or parenting foster youth (SSA Section 471(e)(2)(B)), or parents or kin caregivers (SSA Section 471(e)(1)). Funding may also be used if a child is placed with a parent who is in a licensed residential treatment facility for substance abuse (SSA Section 472(j)).

Services provided must be trauma-informed, evidence-based programs offered by qualified clinicians within the specific categories of mental health, substance use disorder treatment, kinship navigator, and parent skill-building. In order to receive federal reimbursement, the Title IV-E Prevention Services Clearinghouse must rate the prevention services as either “promising,” “supported,” or “well-supported.”

Any service provided must meet the following general practice requirements:

• The practice has a book, manual, or other available writings that specify the components of the practice protocol and describe how to administer the practice;
• There is no empirical basis suggesting the practice constitutes a risk of harm to those receiving it when compared with its likely benefits;
• If multiple outcome studies have been conducted, the overall weight of evidence supports the benefits of the practice;
• Outcome measures are reliable and valid, and are administrated consistently and accurately across all those receiving the practice; and
• There is no case data suggesting a risk of harm that was probably caused by the treatment and that was severe or frequent.

States are required to collect and report information regarding each child for whom, or on behalf of whom, mental health and substance abuse prevention and treatment services or in-home parent skills-based programs are provided. This information must include the specific services or programs provided, the duration of services, the child’s placement status at the beginning and at the end of the one-year period, and whether the child entered foster care within two years after being determined a candidate for foster care.

Federal Payments

Prevention services are reimbursable at 50.0 percent from federal fiscal year (FFY) 2020 to FFY 2026. This includes allowable administrative costs necessary for the proper and efficient administration of the state plan, in addition to training costs for personnel employed or preparing for employment by the state agency or local agency administering the plan. Beginning FFY 2027, prevention services will be reimbursable at the applicable Federal Medical Assistance Percentages (FMAP) rate. Additionally, at least 50.0 percent of the amount paid to a state in any fiscal year must be for prevention services that meet the well-supported practice criteria.

Maintenance of effort is required for foster care expenditures. States electing to provide Title IV-E prevention services and programs must maintain the same level of state foster care prevention expenditures each fiscal year as the expenditure amount in FFY 2014. States must report state foster care expenditures for each fiscal year that a state participates in the Title IV-E prevention program. State foster care prevention expenditures include Temporary Assistance for Needy Families (TANF), Title IV-B, Social Services Block Grant (SSBG), and any other state or local agency funds used for prevention services and activities (SSA Section 471(e)(7)).

Approved kinship navigator programs are eligible for Title IV-E payments so long as the program is operated in accordance with promising, supported, or well-supported practices.

Other Changes Made by FFPSA

Additional changes made by FFPSA include:

• Requiring states to report on steps taken to track and prevent child maltreatment death;
• Limiting foster care maintenance payments to two weeks for placements that are not foster homes or qualified residential treatment programs (QRTP). QRTPs must have a trauma-informed treatment model, registered or licensed nursing staff on-site to the extent the program’s treatment model requires, facilitate outreach to family members, document family integration into the treatment process, and provide discharge planning and family-based care support for six months after discharge (SSA Section 472(k)(4)). A trained professional or licensed clinician must complete an assessment for each child placed in a qualified residential treatment center to determine if the placement is appropriate. The assessment must determine the strengths and needs of the child using age-appropriate, evidence-based validated functional assessment tools approved by HHS. A state will only receive federal payments on behalf of the child in a qualified residential treatment facility if the assessment is completed within 30 days. Additionally, if the assessment determines the placement in the QRTP is no longer appropriate, the child returns home, or the child is placed in a foster home or adoptive placement, federal payments will only be made on behalf of the child during the period necessary to transition the child home or to a new placement. The state will not receive any federal payment after 30 days of the determination that the placement in the QRTP is no longer appropriate; and
• Redefining the term “foster family home” to mean the home of any individual or family that is licensed or approved by the state where the foster child resides, adheres to the reasonable and prudent parenting standard, provides 24-hour substitute care for the child, and provides care for no more than six foster children (with some exceptions for parenting youth, siblings, meaningful relationships with a family, and special training) (SSA Section 472(c)).

FFPSA also makes the following changes to Title IV-B funding:

• Eliminates the time limit for family reunification services while in foster care and permits time-limited family reunification services when a child returns home from foster care (SSA Section 431(a)(7));
• Requires states to implement an electronic interstate case processing system for children in foster care, guardianship, or adoption by 2026 (SSA Section 471(a)(25));
• Provides grants in FFY 2018 for states to develop the electronic interstate case processing system (SSA Section 437(b)); and
• Reauthorizes regional partnership grants that work to alleviate substance abuse and support parents for five years. These grants can be used on a statewide basis and can be awarded to both nonprofit and state programs (SSA Section 437(f)).

Kansas Families First

States that chose to provide Title IV-E prevention services were required to submit a Prevention Services and Programs five-year plan as part of the state’s Title IV-E plan (SSA Section 471(3)(5)). In Kansas, the plan was submitted by the Department for Children and Families. It can be accessed here: https://www.dcf.ks.gov/services/pps/pages/ffpsa.aspx. The Kansas Department for Children and Families has awarded Families First Prevention Service grants to 12 community partners and stakeholders that provide programs in communities statewide.

In addition to the plan, Kansas is required to have a well-designed and rigorous evaluation strategy. The KU School of Social Welfare and the KU Center for Public Partnerships and Research (CPPR) have partnered with the Kansas Department for Children and Families to evaluate the Families First Program in Kansas. The most recent report can be found here: https://socwel.ku.edu/family-first-prevention-services-act.

by Amanda Prosser
Fiscal Analyst
785-296-7879

Medicaid

Medicaid is a partnership between the federal government and the states with shared authority and financing, created by Congress in 1965 (Title XIX of the Social Security Act) alongside Medicare. The program was designed to jointly fund health care coverage for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid has become the nation’s largest source of funding to provide health services to low-income people. Medicaid is administered by states, according to federal requirements.

State participation in Medicaid is optional. However, the federal government’s financial share of Medicaid financing creates an incentive for the states. To date, no state has declined to participate. All 50 states, the District of Columbia, American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands participate and administer their own Medicaid plans. Although all states participate, eligibility varies widely because the states can choose to cover additional people and services above and beyond the federal minimum requirements.

The Children’s Health Insurance Program (CHIP) was signed into law in 1997 and provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who cannot afford private coverage.

KanCare

Kansas administers Medicaid through the program known as KanCare. The current KanCare contracts began in January 2013 and will end December 31, 2024. A request for proposal was announced October 2, 2023, for procurement of the next KanCare contract which will begin January 1, 2025. Some of the services provided under KanCare include doctor’s office visits, including wellness and sick; hospital care; pregnancy, birth, and newborn care; behavioral health services; prescription drug coverage; nursing facility services; mental health services; substance use disorder treatments; dental care; and contractor specific value-added services such as dental care, farmers market vouchers, and transportation assistance.

Historically, KanCare had around 415,000 members. However, during the Public Health Emergency (PHE) for COVID-19, states were not permitted to conduct their annual renewal reviews to determine eligibility. This resulted in members remaining in KanCare. The PHE ended in early 2023, and beginning in April 2023, the “unwinding” or a return to annual eligibility reviews was reinstated. Kansas will complete the renewal process for all members of KanCare over a 12-month period ending in March 2024. As of August 2023, KanCare beneficiaries for the calendar year totaled 496,402, which is a decrease from the same time period in 2022 which had 500,490 beneficiaries.

The Kansas Department of Health and Environment (KDHE) and the Kansas Department for Aging and Disability Services (KDADS) administer the KanCare program.

KDHE maintains financial management and contract oversight as the single state Medicaid agency. KDADS administers the Medicaid waiver programs for disability services, mental health, and substance abuse and operates the state hospitals and institutions. Kansas contracts with three managed care organizations (MCOs) to coordinate health care for nearly all Medicaid members. In June 2018, KDHE awarded contracts to Sunflower State Health Plan, UnitedHealthcare Community Plan of Kansas, and Aetna Better Health of Kansas, Inc., to serve as the State’s MCOs. These contracts began January 1, 2019, and were scheduled to end December 31, 2023; however, a one-year extension was granted and the contracts will now end December 31, 2024.

Each KanCare member is enrolled with one of the KanCare MCOs. Members have the option during the annual open enrollment period to select a different MCO or remain with their current MCO.

History of Home and Community Based Services

The federal government enacted Medicaid in 1965. Prior to Medicaid, states often housed individuals with mental health, intellectual, or developmental disabilities in large institutional settings. After the passage of Medicaid, and throughout the second half of the 20^th century and into the 21st century, states began to shift toward a model of care that prioritized home and community settings. In 1982, Kansas received authorization to start its Home and Community Based Services (HCBS) waiver program.

The Kansas Mental Health Reform Act of 1990 mandated that community mental health centers (CMHCs) serve as the primary points of entry into the mental health system, including state institutions. [Note: During the 2021 Legislature, a new certification for CMHCs was enacted – Certified Community Behavioral Health Clinics (CCBHCs). See memorandum The Differences between CMHCs and CCBHCs.]¹

In 1990, President George H. W. Bush signed into law the Americans with Disabilities Act (ADA), which prohibits discrimination based on disability. Title II of the ADA prohibits discrimination against individuals with disabilities by public entities, including state and local governments.

In 1999, the U.S. Supreme Court ruled in Olmstead v. L.C. 527 U.S. 581 (1999) that the ADA protected the right of individuals with mental disabilities to live in their community rather than institutional settings. The Court wrote that Title II of the ADA required states “to provide community-based treatment for persons with mental disabilities when the State’s treatment professionals determine that such placement is appropriate, the affected persons do not oppose such treatment, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.”

In response to Olmstead, the Centers for Medicare and Medicaid Services (CMS) issued letters that stipulated states should take reasonable steps to accommodate individuals if treatment professionals determine an individual could live in a community setting with appropriate support services. In one of those letters, CMS also issued guidance that said states can limit the number of individuals who receive services under a HCBS waiver.

Types of Medicaid Waivers Approved by CMS

Sections 1115 and 1915(b) and (c) of the Social Security Act give the U.S. Secretary of Health and Human Services (HHS) authority to waive provisions of the law to encourage states to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP). A state must apply for and receive approval from CMS in order to operate a waiver.

Section 1115 Experimental, Pilot, or Demonstration Projects

Section 1115 of the Social Security Act gives the Secretary of HHS authority to approve experimental, pilot, or demonstration projects that are found by the Secretary to be likely to assist in promoting the objectives of the Medicaid program. With a 1115 proposal, a state receives additional flexibility to design and improve their programs while demonstrating and evaluating state-specific policy approaches to better serve Medicaid populations. The proposal must be “budget neutral” or during the course of the project, federal Medicaid expenditures will not be more than federal spending without the demonstration. CMS policy requires the demonstration’s budget ceiling to be rebased using recent cost data and growth trends at every extension and will also limit carry-forward of accumulated savings from one approval period to the next. In general, Section 1115 waivers are approved for an initial five-year period and can be extended for an additional three to five years.

CMS performs a case-by-case review of each proposal to determine whether its stated objectives are aligned with those of Medicaid. CMS also considers whether proposed waiver and/or expenditure authorities are appropriate and consistent with federal policies, including the degree to which they supplant state-only costs for existing programs or services and can and should be supported through other federal and non-federal funding sources.

Kansas was initially approved December 27, 2012, with an effective date of January 1, 2013. The current expiration date is December 31, 2023. KDHE submitted a renewal of the State’s 1115 Waiver on December 28, 2022. Per CMS as of November 3, 2023, it remains pending.

Section 1915(c) Waivers

The HCBS waiver program is authorized under Section 1915(c) of the Social Security Act. Through the HCBS waiver program, a Medicaid beneficiary can receive a wide range of services designed to allow the individual to live in their home or community rather than receive institutionalized care. Section 1915(c) waivers must:

• Demonstrate that providing waiver services will not cost more than providing these services in an institution;
• Ensure the protection of people’s health and welfare;
• Provide adequate and reasonable provider standards to meet the needs of the target population; and
• Ensure that services follow an individualized and person-centered plan of care.

KanCare HCBS Waivers

KanCare allows the State to provide all HCBS through managed care by seven separate 1915(c) waivers. Under the HCBS waiver program, Kansas is able to waive certain Medicaid program requirements, allowing the state to provide supports and services for people who might not otherwise be eligible under Medicaid. Through the waivers, Kansas targets services to people who need long-term services and supports. Individuals receive services through individual providers, contracted through the MCOs. Providers are reimbursed through KanCare for their services.

The seven 1915(c) waivers are Autism (AU), Frail Elderly (FE), Intellectual and Developmental Disability (I/DD), Physical Disability (PD), Serious Emotional Disturbance (SED), Technology Assisted (TA), and Brain Injury (BI). KDADS regularly publishes the number of recipients of each waiver, as well as the AU, I/DD, and PD waitlists on its website.

KDADS has available an HCBS Access Guide that explains the process to apply for a waiver, as well as a HCBS Service Summary that highlights the services available for each waiver.

Eligibility

To be eligible for any HCBS waiver, the individual must be financially and functionally eligible for Medicaid. Individuals with income above the limitation per month must share in the cost of care, called the “client obligation,” which is paid by the client to a medical provider. The consumer’s share of cost (client obligation) is based on the consumer’s gross monthly income and the protected income limit (PIL) for the program. [Note: The PIL is a Medicaid eligibility pathway that enables individuals with income above the Medicaid limit to become HCBS eligible.] Deductions, income allocation, and expenses may be applied to reduce the share of cost. If the consumer’s income is over 300 percent of the SSI (Supplemental Security Income) one person standard, the cost of care or cost of services for the consumer must be higher than the share of cost or the consumer may be reviewed for a different program.

Autism Waiver

The AU waiver provides intensive early intervention treatment to children with autism and respite for their primary caregivers for children up to age six who have been diagnosed with autism spectrum disorder, Asperger’s syndrome, or a pervasive developmental disorder not otherwise specified.

As of October 13, 2023, 67 individuals were eligible to receive services under the AU waiver, and 524 were proposed recipients of the waiver as of September 30, 2023.

Frail Elderly Waiver

The FE waiver provides services to Kansas seniors as an alternative to nursing facility care. Services include personal care, household tasks, and health services. The program promotes independence within the community and helps to offer residency in the most integrated environment. The waiver is for people who are at least 65 years of age and meet requirements for long-term care. The FE waiver has approximately 12 service categories, which generally represent various personal care services and life management services. Services vary in reimbursement frequency and range from 15-minute increments for personal care services to once-a-month for more specialized services. As of October 13, 2023, 7,052 individuals were eligible to receive services under the FE waiver.

Intellectual/Developmental Disability Waiver

The I/DD waiver serves people with intellectual and/or developmental disabilities. Services are designed to help people with I/DD maintain their physical and mental health in their home and community. People age five or older who have an I/DD or are eligible for care in an intermediate care facility for individuals with developmental disability may be eligible for the I/DD waiver. In general, those with intellectual disabilities may be eligible if they have a diagnosed intellectual disability resulting in impaired function in at least two adaptive skills areas. Those with a developmental disability may be eligible if their disability started before age 22 and they have a substantial limitation 3 areas of life functioning.

Services for the I/DD waiver are divided into approximately 14 service categories, which generally represent various personal care services and life management services. Services vary in reimbursement frequency and range from 15-minute increments for personal care services to once-a-month for more specialized services. As of October 13, 2023, 8,902 individuals were eligible to receive services under the I/DD waiver, and 5,137 were on the waiver waitlist.

Physical Disability Waiver

The PD waiver serves people ages 16 to 64 who meet the level-of-care criteria for nursing facility placement, need assistance to accomplish the normal tasks of daily life, and have been determined disabled by the Social Security Administration. The PD waiver has 7 service categories, which generally represent personal care and life management services. Services vary in reimbursement frequency and range from 15-minute increments for personal care services to once-a-month for more specialized services. As of October 13, 2023, 6,100 individuals were eligible to receive services under the PD waiver, and 2,352 were on the waiver waitlist.

Serious Emotional Disturbance Waiver

The SED waiver provides children who have some mental health conditions with special intensive support so they may remain in their homes and communities. The waiver is for individuals ages 4 to 18 who have a diagnosed mental health condition that substantially disrupts their ability to function socially, academically, and/or emotionally and are at risk of inpatient treatment. The SED waiver has approximately six service categories, which representvarious therapy types and short-term respite care. As of October 13, 2023, 3,306 individuals were eligible to receive services under the SED waiver.

Technology Assisted Waiver

The TA waiver provides community-based services to people through age 21 who require substantial and ongoing daily care comparable to the care provided in a hospital. The TA waiver has approximately seven service categories, which represent various attendant care services. As of October 13, 2023, 774 individuals were eligible to receive services under the TA waiver.

Brain Injury Waiver

The BI waiver provides services for people who have an acquired or traumatic brain injury to ensure they can stay in their homes and be as independent as possible in a safe, healthy environment. The BI waiver is for people ages 0 to 65 who have a brain injury that has caused temporary or permanent impairment to their behavioral, cognitive, or physical functions and would otherwise require institutionalization in a rehabilitation facility. The BI waiver has approximately nine service categories, which generally represent various personal care services and life management services. Services vary in reimbursement frequency and range from 15-minute increments for personal care services to once-a-month for more specialized services. As of October 13, 2023, 965 Kansans were eligible to receives services under the BI waiver.

Recent Changes to HCBS Provider Reimbursement Rates

Appropriation highlights may be found in the Kansas Legislative Research Department’s annual publication “Fiscal Facts.” In recent years, multiple rate increases have been appropriated for various HCBS waivers.

During the 2023 Session, the Legislature:

• Added $17.7 million, including $7.1 million from the State General Fund (SGF), to standardize rates across waivers for FY 2023 to match the FE waiver rate increase approved by the 2022 Legislature;
• Added $13.0 million, including $5.2 million SGF, to increase the HCBS FE waiver reimbursement rates by 10.0 percent for FY 2024;
• Added $11.2 million, including $4.5 million SGF, to increase the Targeted Case Management (TCM) rate for individuals with I/DD from $43.24 per hour to $75.00 per hour for FY 2024;
• Added $9.3 million, including $3.8 million SGF, to increase the traumatic brain injury rehabilitation facility rates from $700 per day to $1,400 per day for FY 2024; and
• Added language requiring the agency to submit to CMS an application for a community support waiver for individuals with I/DD for FY 2024.

1. https://klrd.gov/2023/11/30/community-mental-health-centers-and-certified-behavioral-health-clinics/ ↩︎

by Elizabeth Cohn
Senior Research Analyst
785-296-4382

State Hospitals and Institutions

Oversight

The Kansas Department for Aging and Disability Services (KDADS) is responsible for the administration of state-owned and -contracted facilities. The Kansas Department for Health and Environment (KDHE) licenses the facilities. Oversight and certification are provided by the federal Centers for Medicare and Medicaid Services (CMS).

State Mental Health Hospitals (SMHH)

Osawatomie State Hospital (OSH) was established in 1855. OSH provides services to adults diagnosed with psychiatric disorders, regardless of ability to pay or legal status.

Larned State Hospital (LSH) was established in 1914. LSH is the largest psychiatric facility in Kansas, serving the western two-thirds of the state. LSH provides services to adults with serious and persistent mental illnesses, most of whom have been deemed a danger to themselves or others. LSH also houses the Sexual Predator Treatment Program (SPTP), established in 1994. [See State Hospitals]

Since 2015, OSH and LSH have been the only SMHHs. OSH and LSH generally serve Kansans who require longer-term inpatient acute care. The Care and Treatment Act for Mentally Ill Persons (KSA 59-2945 et seq.) provides definitions and guidance for admission to the state hospitals.

Regional State Hospital Project

The 2022 Special Committee on Mental Health Beds recommended that $15 million from the State General Fund (SGF) be released to construct a facility for up to 50 inpatient beds in the Sedgwick County area. The State Finance Council released the $15 million to KDADS on December 21, 2022. Additionally, $25 million from the Strengthening People and Revitalizing Kansas (SPARK) fund was awarded to Sedgwick County for construction costs. The project is for 25 beds for forensic competency evaluations and restorations and 25 beds for acute inpatient psychiatric care, with consideration of expanding to 100 total beds. On August 28, 2023, Governor Kelly issued Executive Order 23-05, which created a 14-member panel to gather public input and make recommendations about the proposed hospital building.

The South Central Regional Psychiatric Hospital Advisory Panel is charged with gathering public input on needs and location of a regional state psychiatric hospital, including how a state hospital would fit with existing services in Sedgwick County, and researching existing resources, gaps in services, and barriers to care to improve access and delivery of services in south central Kansas.

State Institutional Alternative (SIA)

In 2020, a new provider classification, State Institutional Alternatives (SIAs), was developed by KDADS and KDHE in response to lifting the moratorium on admissions at OSH to expand regional capacity for adults and youth who meet the criteria for state hospital admissions.

SIAs are private psychiatric hospitals or community hospitals that agree to accept patients with mental illness who have been screened for admission to a state hospital. These SIA hospitals are paid a per diem rate for each patient day instead of the regular Medicaid rate. SIAs submit an application to the State to be able to enroll in Medicaid and be reimbursed on a per diem rate for any patients successfully screened for SMHH admission, and they receive state funds for the care of the uninsured.

SIAs provide regional hospital alternatives to LSH and OSH, allowing for care closer to home for patients and reducing demand on SMHHs, as well as reducing wait times for admissions. As of October 2023, there are ten contracted SIA facilities with seven facilities currently admitting a mix of geriatric, youth, and adult populations.¹

Residential Treatment, Training, and Care

The State of Kansas operates two residential treatment, training, and care facilities for individuals with intellectual disabilities. Primary funding for these facilities is from CMS.

Parsons State Hospital and Training Center (PSH&TC) was opened in 1903. PSH&TC serves adult and youth individuals with intellectual and developmental disabilities whose circumstances require specialized residential service provisions. Certification as a Hospital is from the Kansas Hospital Association as a Special Mental Hospital and by the State Department of Education as a Special Purpose School.

Kansas Neurological Institute (KNI) was established in 1959. KNI provides both a treatment center and residence for adults with intellectual and developmental disabilities who require a high level of ongoing support. Many residents require intensive physical and medical supports; about one-third are unable to eat by mouth and receive their nutrition through feeding tubes. Services from KNI, including outreach services, must be requested and approved through the Community Developmental Disability Organization (CDDO) for the county in which the person lives and must be services that cannot be provided or arranged through the community services system.

Community Inpatient and Structured Care

Community inpatient care and structured care environments are the two levels directly below the state hospitals on the adult continuum of care. Structured care environments include crisis stabilization services, nursing facilities for mental health, residential care facilities, sobering beds, and social detox beds. Community inpatient care includes crisis intervention, community inpatient psychiatric beds, medical detox beds, and substance use disorder treatment.

In 2017, the Kansas Legislature enacted the Crisis Intervention Act, which allows adults to stay involuntarily in crisis intervention centers for up to 72 hours for emergency evaluation and treatment. The Crisis Intervention Act also requires a center to file an affidavit with the district court within 48 hours of admission if the patient meets the criteria to be retained. Crisis intervention centers must discharge the patient if they no longer meet the criteria or if 72 hours has passed since admission. For more information on the Crisis Intervention Act and associated issues, see the article on Mental Health and the Criminal Justice System.

Kansas also has six established crisis stabilization centers located in Kansas City, Topeka, Wichita, Salina, Manhattan, and Hays. Crisis stabilization centers provide the highest level of care, and the beds are traditionally filled with individuals who pose an immediate risk to themselves or others and are receiving treatment voluntarily. These centers provide patients short-term mental health crisis care of less than 72 hours before they can transition to community-based care. Crisis stabilization is not traditionally provided in hospitals, but it can be an alternative to psychiatric hospitalization.

Community-Based Care

Community Mental Health Centers

In 1963, President John F. Kennedy signed the Community Mental Health Act, which led to the establishment of Community Mental Health Centers (CMHCs) across the nation. The Kansas Mental Health Reform Act of 1990 initiated the state’s transition from institutional to community-based mental health care. The Kansas Mental Health Reform Act deemed that Kansas residents in need of mental health services should receive the least restrictive treatment and the most appropriate community-based care through coordination between CMHCs and state hospitals.

Since 1990, CMHCs have served as the primary points of entry into the mental health system. CMHCs are mental health facilities that are statutorily identified to provide community-based public mental health services. CMHCs provide outpatient services to adults and children, as well as behavioral health screening for patients. CMHCs are subject to licensure and must also conform to CMS standards and audits. The 26 CMHCs in Kansas also serve as the gatekeepers for admission to state mental health hospitals. KDADS maintains a directory of CMHCs in their Directory of Mental Health Resources in Kansas. As more patients have used community-based services, the need for state hospital beds has declined.²

Kansas has 26 CMHCs that primarily serve adults with severe and persistent mental illness, children and adolescents with severe emotional disturbance, and other individuals at risk of requiring institutional care. Anyone experiencing a mental health crisis who lacks a mental illness diagnosis can seek treatment at a CMHC.³ According to KDADS, CMHCs offer “comprehensive mental health rehabilitation services, such as psychosocial rehabilitation, community psychiatric support and treatment, peer support, case management, and attendant care.”⁴

Certified Community Behavioral Health Clinics

Certified Community Behavioral Health Clinics (CCBHCs) are defined by the National Council for Mental Wellbeing as “a specially-designated clinic that provides a comprehensive range of mental health and substance use services.”⁵ CCBHCs are Medicaid provider clinics and are required to meet certain requirements in order to earn certification, which include providing evidence-based practices to their clients, as well as serving the “whole person.”

Generally, a CCBHC is required to provide a certain set of core services. These include, but are not limited to:

• Person-centered and family-centered care;
• Crisis services;
• Outpatient mental health and substance use services; and
• Screening, assessment, diagnosis, and risk assessment.

Currently, there are 20 CCBHCs certified in Kansas, with six more scheduled to be certified in state fiscal year (SFY) 2025. In July 2024, KDADS announced it had received a CCBHC Demonstration Grant. [Note: A CCBHC may also be a CMHC.]

Mental Health Intervention Team Grant

The Mental Health Intervention Team (MHIT) Grant is administered by the Kansas State Department of Education to help break down barriers in place for youth to receive mental health services. The MHIT focuses on K–12 students and their families by identifying students, helping families navigate mental health services, and linking them to the existing statewide behavioral health system and resources within the Mental Health Providers network. Additionally, the MHIT focuses additional resources on foster students in need of mental health services. The program consists of liaisons who “bridge” sharing educationally appropriate information with providers and classrooms, help families navigate waivers and paperwork, and schedule services. Communication between the mental health professional and school is permitted through both a memorandum of understanding (MOU) and, if the parent agrees, a release.

The MHIT Grant has been funded through a proviso bill beginning in 2018; 75 percent of funding goes to liaison salaries and benefits, and 25 percent of the total request flows through the school district to the CMHC. The MHIT began in 9 districts servicing 1,708 students in the 2018–2019 school year. In the 2022–2023 school year, the MHIT was in 66 districts, served 6,014 students including 552 foster students, and had 150 liaisons. For the 2023–2024 school year, 90 school districts applied, which included 24 new districts, and 182 liaisons are anticipated to participate.⁶

Suicide Prevention

Kansas Youth Suicide Prevention Coordinator

Among the provisions in 2019 HB 2290 was the creation of the position of Kansas Youth Suicide Prevention Coordinator within the Office of the Attorney General. The Office of the Attorney General, in partnership with The Jason Foundation, has developed the “Kansas – A Friend AsKS” app, which is a free smartphone app that provides information, tools, and resources to help an individual who may be struggling with thoughts of suicide.

Kansas Department of Health and Environment (KDHE)

In August 2020, KDHE was awarded a Zero Suicide in Health Care Systems grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). It is a five-year, $700,000-per-year grant, and it was the first of its kind for KDHE. The target audience for the grant is adults 25 years and older, and the activities of the grant are developed in accordance with the Zero Suicide Framework. KDHE publishes the Kansas Suicide-Related Data Dashboard on their website.

Kansas Department for Aging and Disability Services (KDADS)

988 Suicide Prevention and Mental Health Crisis Hotline

KSA 75-5964 through 75-5971 established the Living, Investing in Values and Ending Suicide (LIVES) Act, which laid the groundwork for implementation of 988 Suicide Prevention and Mental Health Crisis Hotline in Kansas. Kansas has a network of four 988 Contact Centers that provide coverage for Kansans, and a fifth is under development as of August 2023.

Suicide Prevention Coordinators

KDADS secured a five-year Garrett Lee Smith Youth Suicide Prevention Grant in 2023 that will help fund suicide prevention programs in Wyandotte and southeast Kansas counties. Additionally, the grant includes a federally funded full-time equivalent (FTE) position for a grant coordinator. KDADS also has a dedicated FTE for a State Suicide Prevention Coordinator that is state funded.

Kansas Suicide Prevention Plan

The Kansas Suicide Prevention Plan (2021–2025) outlines the activities and responsibilities necessary to accomplish suicide prevention goals and objectives across the lifespan. The primary purpose of this State Suicide Prevention Plan is to reduce death by suicide in Kansas. This plan will be renewed every five years, with reviews occurring at least annually, as needed, and based on any significant changes in data or resources.

Youth-Only Services

Youth have access to several mental health treatment options throughout the state. Options include psychiatric residential treatment facilities (PRTFs), the Medicaid Home and Community Based Services (HCBS) waiver for Serious Emotional Disturbance, and Professional Resource Family Care. Each option is detailed in more depth below.

Psychiatric Residential Treatment Facilities (PRTFs)

PRTFs provide out-of-home residential psychiatric treatment to children and adolescents whose mental health needs cannot be effectively and safely met in a community setting. These programs are intended to provide active treatment in a structured therapeutic environment for children and youth with significant functional impairments resulting from an identified mental health diagnoses, substance use diagnoses, sexual abuse disorders, or mental health diagnoses with co-occurring disorders (i.e., substance-related disorders, intellectual and developmental disabilities, head injury, sexual misuse disorders, or other disabilities that may require stabilization of mental health issues).

The residential treatment facility is expected to work actively with the family and other agencies to offer strengths-based, culturally competent, trauma-informed, medically appropriate treatment designed to meet the individual needs of the residents.

There are currently nine PRTFs in the State of Kansas, all overseen by KDADS. A list of current PRTFs is available on the KDADS website in their Directory of Mental Health Resources in Kansas.

Medicaid Home and Community Based Services (HCBS) Serious Emotional Disturbance Waiver

The Serious Emotional Disturbance (SED) waiver is for children 4 to 18 years of age who have a diagnosed mental health condition that substantially disrupts their ability to function socially, academically, or emotionally; are at risk of inpatient psychiatric treatment; meet medical assessment criteria; and are financially eligible for Medicaid. The application is completed through a local CMHC.

Services and supports under the SED waiver may include attendant care, independent living and skills building, short-term respite care, parent support and training, professional resource family care, and wraparound facilitation. As of October 13, 2023, KDADS reported there were 3,306 participants eligible to receive HCBS SED waiver services.⁷

Funding for Mental Health Services

CMHCs

Medicaid provides the largest source of state funding for community-based mental health services. CMHCs use certified Medicaid match funds to provide services for children with SED, children referred to CMHCs by children and family service contractors, and all other children and adults who are Medicaid eligible. Medicaid covers targeted case management, comprehensive medication services, personal care services, pre-admission screens, activity therapy, group and individual psychotherapy, training and educational services, crisis intervention, community transition, and respite care. [Note: The current KanCare Contract ends in December 2024. The procurement process for KanCare began October 2, 2023, with the issuance of a request for proposal, and the new KanCare Managed Care Organization contracts will begin January 1, 2025. It is unknown at this time how services will be impacted.]

Additional details on the CMHC and CCBHC changes are available in the KLRD memorandum on Differences between CMHCs and CCBHCs, which includes funding details.⁸

Crisis Stabilization Services

Crisis stabilization services are funded with 75 percent of revenue from Kansas Lottery vending machines. Additionally, COMCARE (Wichita), Valeo (Topeka), and RSI (Kansas City) receive funding independent of the Lottery vending machine revenue.

Family First Prevention Services Act

In 2018, President Trump signed into law the Family First Prevention Services Act, which encourages the maintenance of families to preempt a child’s entrance into the foster care system. The Act allows for federal reimbursement for mental health services, substance use treatment, and in-home parenting skills training.

Appropriations for SFY 2024

The annual KLRD publication Kansas Fiscal Facts includes a budget overview for Human Services as well as Session Highlights.

1. https://kdads.ks.gov/state-hospitals-and-institutions/state-institution-alternatives-(sias) ↩︎
2. 2018 Mental Health Task Force Report ↩︎
3. According to the National Alliance on Mental Illness, a “mental health crisis is any situation in which a person’s behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community.” ↩︎
4. https://kdads.ks.gov/kdads-commissions/behavioral-health/community-mental-health-centers ↩︎
5. https://www.thenationalcouncil.org/program/ccbhc-success-center/ccbhc-overview/ ↩︎
6. Kansas State Department of Education testimony to the 2023 Special Committee on Mental Health ↩︎
7. https://kdads.ks.gov/kdads-commissions/long-term-services-supports/home-community-based-services-(hcbs)-programs (updated monthly) ↩︎
8. https://klrd.gov/2023/11/30/community-mental-health-centers-and-certified-behavioral-health-clinics/ ↩︎

by Elizabeth Cohn
Senior Research Analyst
785-296-4382

Background

During the 2021 Session, the Legislature passed Senate Sub. for HB 2208, which included a requirement for the Kansas Department for Aging and Disability Services (KDADS) to establish a certification process for certified community behavioral health clinics (CCBHCs), a Medicaid provider type, and complete the transition to the CCBHC model by SFY 2025.

KDADS certified six CCBHCs in SFY 2022, three in SFY 2023, 11 in SFY 2024, and has six planned in SFY 2025. Currently, 20 of the planned 26 CCBHCs are certified in Kansas.

Community Mental Health Centers

Community Mental Health Centers (CMHCs) are mental health facilities that are statutorily identified to provide community-based public mental health services, and largely serve as the main entry points for the mental health system. CMHCs provide outpatient services to adults and children, as well as behavioral health screening for patients. The 26 CMHCs in Kansas also serve as the gatekeepers for admission to state mental health hospitals. KDADS maintains a directory of CMHCs.¹

Currently, a CMHC bills and will receive reimbursement for each different service it provides. That reimbursement rate covers the cost for the provider to provide that service and does not cover any administrative costs the CMHC might have. This type of funding is known as the “service reimbursement model.”

KDADS has indicated that the service reimbursement model can place a CMHC in a situation where it might not be able to provide more-intensive services. Due to reimbursement the CMHC might receive for certain services, and how frequently the services are utilized, this could reduce the services offered in certain areas, such as the western part of the state.

Certified Community Behavioral Health Clinics

Certified Community Behavioral Health Clinics (CCBHCs) are defined by the National Council on Mental Wellbeing as “a specially-designated clinic that provides a comprehensive range of mental health and substance use services.”² CCBHCs are Medicaid provider type clinics and are required to meet certain requirements in order to earn certification, which includes providing evidence-based practices to their clients, as well as serving the “whole person.”

Generally, a CCBHC is required to provide a certain set of core services. These include, but are not limited to:

• Person-centered and family-centered care;
• Crisis services;
• Outpatient mental health and substance use services; and
• Screening, assessment, and diagnosis, and risk assessment.

Currently, there are 20 CCBHCs certified in Kansas, with six more scheduled to be certified in SFY 25. In July 2024, KDADS announced it had received a CCBHC Demonstration Grant. [Note: A CCBHC may also be a CMHC.]

A CCBHC is funded using a Prospective Payment System (PPS) rate. The Kansas Department of Health and Environment (KDHE) developed the PPS rate, and it was approved by the federal Centers for Medicare and Medicaid Services. The Kansas state plan amendments by KDADS and KDHE were also approved.

The PPS rate is a cost-based payment methodology in which the Medicaid payment is based on a predetermined, fixed amount. It is calculated as:

Annual Allowable Costs	=PPS Rate
Annual Daily Visits

Phased Plan for CCBHC Implementation

During the 2021 Legislative Session, KDADS indicated it would implement a phased approach to certify CCBHCs. Its plan would begin in FY 2022 and continue through FY 2025.

IMPLEMENTATION OF CCBHC CERTIFICATION
	All Funds			SGF			Number of CCBHCs
FY 2022 Actuals	$	6,537,076		$	2,206,917		6
FY 2023 Approved	$	58,833,683		$	22,706,918		9
FY 2024 Approved	$	88,584,619		$	33,954,484		26
TOTAL	$	153,955,378		$	58,865,319		26

1. https://kdads.ks.gov/kdads-commissions/behavioral-health/community-mental-health-centers ↩︎
2. https://www.thenationalcouncil.org/program/ccbhc-success-center/ccbhc-overview/ ↩︎

by Elizabeth Cohn
Senior Research Analyst
785-296-4382

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, jointly referred to as the Affordable Care Act (ACA), passed in March 2010, included a section that addressed the expansion of the Medicaid program. This historical memorandum is a synopsis of the ACA as to Medicaid Expansion and the immediate impact of the U.S. Supreme Court decision through federal fiscal year (FFY) 2013. The memorandum does not address the current status of Medicaid expansion adoption in states.

Medicaid Expansion

Eligibility Requirements

To participate in Medicaid, states are required by federal law to cover the following groups: pregnant women and children under the age of six with family incomes below 133 percent of the federal poverty level (FPL), children ages six through 18 with family incomes at or below 100 percent of the FPL, parents and caretaker relatives who meet certain financial eligibility guidelines, and elderly and disabled individuals who qualify for Supplemental Security Income benefits as a result of low income and resources.

Expanded Eligibility for New Group

The Medicaid expansion for adults, scheduled to commence on January 1, 2014, in conjunction with the health insurance exchange, was structured to extend Medicaid coverage to a newly eligible group consisting of nearly all non-disabled adults under the age of 65 whose household income fell at or below 133 percent of the FPL with a variance of plus or minus 5 percent. Under the 2013 FPL, a family of four making $31,322 and an individual making $15,282 would be at 133 percent of the FPL. A family of four making $32,499 and an individual making $15,856 would be at 138 percent of the FPL.

Federal Government Funding

Under the ACA provisions, states were required to participate in the Medicaid expansion for the newly eligible group or risk losing all Medicaid funding. Instead of providing federal matching funds to states to provide Medicaid-covered services to the new group under the existing federal share structure, known as the Federal Medical Assistance Percentage (FMAP), the federal government would cover 100 percent of the states’ costs for the newly expanded group from 2014 through 2016, and gradually reduce the federal share to 90 percent in 2020 and after.

The provisions of the federal Medicaid Act that grant authority to the Secretary of the Department of Health and Human Services (HHS) to withhold all or part of a state’s federal matching funds for non-compliance with federal requirements were unchanged by the ACA.

Court Challenge to Medicaid Expansion

In Florida v. HHS, 26 states, several individuals, and the National Federation of Independent Business (NFIB) brought suit in Federal District Court challenging the Medicaid expansion and the constitutionality of the individual mandate. At least 25 other cases were filed in federal district courts, but only in the Florida case did the petitioners assert that the ACA’s Medicaid expansion was “unconstitutionally coercive.” Both the Florida Federal District Court and the 11th Circuit Court of Appeals upheld the Medicaid expansion provision. The 11th Circuit’s decision stated states have a choice to participate in the Medicaid program, and the Medicaid expansion was within Congress’ spending clause power to impose conditions on its grants to states. The case reached the U.S. Supreme Court, which heard oral arguments in the case on March 26, 27, and 28, 2012. The Supreme Court’s decision in the case is cited as National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al., 132 S. Ct. 2566 (2012).

Arguments Before Supreme Court

Among the four issues addressed by the Supreme Court was whether Congress unconstitutionally coerced states into expanding the Medicaid program by threatening to withhold states’ federal funding.

The state petitioners argued Medicaid expansion was coercive because the states felt the need to participate in the program due to the importance of Medicaid funding and would then be required to comply with the new expansion requirements. The states asserted Congress may not coerce states to adopt policies through the Spending Clause of the Constitution when Congress does not have power to force states to do so directly. The state petitioners argued that limits should be placed and enforced on Congress’ spending power to protect state sovereignty and restore the balance of power between Congress and the states. The states stressed the Medicaid expansion was unprecedented because Congress had never mandated what they believed was an across-the-board Medicaid financial eligibility floor.

In the Supreme Court case, the federal government argued Congress has the authority to place conditions on the receipt of federal funds by the power granted under the Spending Clause of the Constitution. Further, the federal government argued the Supreme Court has recognized Congress’ power to attach conditions on the receipt of federal funds disbursed under its spending power. The federal government also argued the federal Medicaid statute has contained mandatory coverage requirements for participating states and Congress previously has required states to cover new categories of individuals.

Summary of State Options for Medicaid Ruling

The U.S. Supreme Court upheld nearly all of the ACA, affirming the law’s mandate that most everyone carry insurance, but striking down a provision that would have allowed the federal government to withhold all Medicaid funds to any state that did not comply with the new Medicaid eligibility requirements.

Section 1396c of the Medicaid Act provided that if a state’s Medicaid plan did not comply with the Act’s requirements, the Secretary of Health and Human Services could declare that “further payments will not be made to the State.”¹ A state that opted out of the Affordable Care Act’s expansion in health care coverage stood to lose all of its Medicaid funding. Section 1396c gave the Secretary of Health and Human Services the authority to withhold all “further [Medicaid] payments… to the State” if it was determined that the state was out of compliance with any Medicaid requirement, including those contained in the expansion.²

A majority of the justices voted that the government could not compel states to expand Medicaid by threatening to withhold federal money to existing Medicaid programs stating “When, for example, such conditions take the form of threats to terminate other significant independent grants, the conditions are properly viewed as a means of pressuring the States to accept policy changes.”³And “[T]he Secretary cannot apply §1396c to withdraw existing Medicaid funds for failure to comply with the requirements set out in the expansion.”⁴

The expansion is valid, however, if the penalty is limited to the loss of new funds. The ACA’s provision withholding all Medicaid funding from any state that did not agree was unconstitutionally coercive on the states stating “The threatened loss of over 10 percent of a State’s overall budget, in contrast, is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion.”⁵

Congress had not revised an existing program but essentially created a whole new one, and therefore was not entitled to withhold longstanding funding for states that would not go along with the changes stating “[T]he manner in which the expansion is structured indicates that while Congress may have styled the expansion a mere alteration of existing Medicaid, it recognized it was enlisting the States in a new health care program.”⁶

The Court ruling limited the Medicaid expansion provisions, but did not invalidate them. The Medicaid expansion is now optional for states, and states will no longer be required to implement those provisions stating “Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.”⁷

The Court upheld the ACA’s major expansion of the joint federal-state Medicaid health insurance program but limited the possible penalty for states that opt to forgo expansion provisions outlined in the law stating “The Court today limits the financial pressure the Secretary may apply to induce States to accept the terms of the Medicaid expansion. As a practical matter, that means States may now choose to reject the expansion; that is the whole point.”⁸

According to Kaiser Health News, the Court’s ruling on Medicaid funding took away one of the federal government’s primary inducements to get states to participate in its expanded health coverage for low-income people. The ACA would have allowed the government to withhold all Medicaid money to states that did not expand Medicaid coverage to those who earned up to 133 percent of the FPL, which is about $31,000 for a family of four under the 2013 FPL stating “The Court today limits the financial pressure the Secretary may apply to induce States to accept the terms of the Medicaid expansion.”⁹

State Decisions

The Supreme Court’s health reform ruling ended months of speculation and uncertainty, but it also raised key questions for Kansas policymakers. Among the most pressing was the question of Medicaid expansion. If policymakers chose not to comply with the eligibility changes called for in the law, an estimated 130,000 low-income adult Kansans might remain uninsured. States had to make a series of political, fiscal, and policy decisions moving forward to determine if Medicaid expansion made sense for them. Currently in Kansas, adults who are not elderly or disabled and who are not caretakers are not eligible for Medicaid at any income level. Adults who are caretakers with incomes up to roughly 27 percent of the FPL—then at around $6,000 per year—were eligible for Medicaid.

The ACA originally required states to expand eligibility for their Medicaid programs to all non-elderly individuals with incomes up to 133 percent of the FPL— about $31,000 for a family of four. The Court’s decision prohibiting the federal government from withholding Medicaid funding from states that did not comply with the Medicaid expansion requirement had the effect of making the expansion optional. Of the approximately 356,000 then-uninsured Kansans, 151,000 could qualify for the expanded Medicaid program if implemented by the State. Of those, an estimated 130,000 were low-income adult Kansans who did not qualify for Medicaid and who would be made eligible by the expansion.

The HHS had yet to promulgate guidance on the Medicaid expansion provision issue of how “current funding” was defined, which was another key consideration for the State. However, the issues of what constitutes expansion and whether partial expansion was allowed were addressed.

In a letter to Governors dated December 10, 2012, HHS Secretary Kathleen Sebelius clarified states would not receive 100 percent federal funding for partial Medicaid expansion. Secretary Sebelius’ December 10, 2012, posting on the HealthCare.gov blog addressed whether receipt of 100 percent of federal matching funds would be available to states choosing to expand to less than 133 percent of the FPL. She clarified that the law does not create an option for enhanced match for a partial or phased-in Medicaid expansion to 133 percent of poverty. Secretary Sebelius noted HHS would consider broad-based state innovation waivers at the regular matching rate then and again in 2017 when the 100 percent federal funding for the expansion group would be slightly reduced.

There were many questions to contemplate as Kansas weighed the decision of whether to expand the Medicaid program:

• Should the State not opt to expand Medicaid, how many of the 130,000 Medicaid expansion population would be subject to the individual mandate?

A person would be exempt from the individual mandate if they could not find coverage for less than eight percent of their annual income; for a family of four earning $31,000 (133 percent of the FPL), that was approximately $2,400 yearly, or $200 per month. Theoretically, many in this population would be unable to find “affordable” coverage and would have been exempt from the mandate.

• How will Disproportionate Share Hospital payment reductions apply?

The ACA began lowering what are known as “Disproportionate Share Hospital” or “DSH” payments in 2014. These are payments made to hospitals to help offset the costs of providing care to uninsured and low-income patients. The payments were being reduced under the theory that, as more people get insurance through the ACA, DSH payments would become less necessary. The reductions were set to be calculated based on the states’ rate of uninsured, but it was not clear how calculations would be made in states that did not expand the Medicaid program.

HHS’ Center for Medicare and Medicaid Services (CMS) issued the final rule on DSH reduction on September 18, 2013. The ACA required the use of a DSH Health Reform Methodology (DHRM) to determine the percentage reduction in each annual state DSH allotment in order to meet the required aggregate annual reduction in federal DSH funding. The statute required annual aggregate reductions in federal DSH funding from FY 2014 through FY 2020. The aggregate annual reduction amounts were as follows: $500 million for FY 2014; $600 million for FY 2015; $600 million for FY 2016; $1.8 billion for FY 2017; $5 billion for FY 2018; $5.6 billion for FY 2019; and $4 billion for FY 2020.

CMS expected states that did not expand Medicaid would have relatively higher rates of uninsured, and more uncompensated care than states that expanded. According to CMS, because states expanding Medicaid would likely have reductions in the rates of uninsurance, the reduction in DSH funding may be greater for those states than for states that do not expand. CMS anticipated hospitals in states that did not expand that serve Medicaid patients might experience a deeper reduction in DSH payments than they would if all states were to expand Medicaid, but those effects would not be experienced until after FY 2014 and FY 2015, based on then existing data reporting timelines.

As such, the DHRM proposed only for the first two years of DSH funding reductions (2014 and 2015) did not include a method to account for differential coverage expansions in Medicaid. Given the reduction on funding for Medicaid DSH in the ACA, in future rulemaking, CMS intended to account for the different circumstances among states in the formula for DSH allotment reductions for FY 2016 and later, when the relevant data would be available.

CMS notes that although the rule would reduce state DSH allotments, management of the reduced allotments largely remains with the states. Given that states would retain the same flexibility to design DSH payment methodologies under the state plan and individual hospital DSH payment limits would not be reduced, CMS noted it could not predict if or how states would exercise their flexibility in setting DSH payments given their reduced allotments and the effect that would have on providers.

• Can the state high-risk pool accommodate more persons when the federal high-risk pool ends in Calendar Year 2014?

In Kansas, the federal high-risk pool had around 470 enrollees (as of June 30, 2013, as reported by CMS), but the state high-risk pool had 1,305 (as of October 28, 2013, as reported by the Kansas Insurance Department). Both of these high-risk pools terminated member coverage effective December 31, 2013, when standard health coverage became available to all individuals under the ACA, regardless of health status. Open enrollment for health insurance policies available on the Health Insurance Marketplace began October 1, 2013. Individuals could go to the Marketplace and select a new plan without having to report a preexisting condition, with coverage beginning as early as January 1, 2014.

• What federal funding would be provided to states for Medicaid expansions?

If Kansas chose to expand the Medicaid program, the federal government would cover the cost of the newly eligible enrollees for the first three years. Over time, the federal government’s share would drop to 90 percent.

Year	Federal Share	State Share
2014	100%	0%
2015	100%	0%
2016	100%	0%
2017	97%	3%
2018	95%	5%
2019	93%	7%
2020 and Beyond	90%	10%

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Early Adopters of Expansion

Some states planned for and implemented the Medicaid expansion as of FFY 2013.

States Getting an Early Start on the Medicaid Expansion, April 2010–May 2012

	Coverage Authority	Effective Date	Income Limit	Enrollment
CA	Waiver	Nov 1, 2010	200% FPL	251,308
CT	ACA Option	Apr 1, 2010	56% FPL	74,752
CO	Waiver	Apr 1, 2010	10% FPL	10,000
DC	ACA Option Waiver	July 1, 2010 Dec 1, 2010	133% FPL 200% FPL	40,776 3,411
MN	ACA Option Waiver	March 1, 2010 Aug 1, 2011	75% FPL 250% FPL	80,200 41,811
MO	Waiver	Jul 1, 2012	133% FPL	0
NJ	Waiver	Apr 14, 2011	23% FPL	53,490
WA	Waiver	Jan 3, 2011	133% FPL	50,920

Kansas Action on Expansion in the 2013 Legislative Session

Kansas has not opted to expand Medicaid to date. Section 203 of 2013 SB 171 (the approved budget bill that made supplemental appropriations for FY 2013 [and FY 2014 for selected fee-funded agencies] and appropriations, including capital improvements for FY 2014 and FY 2015) addressed the issue of Medicaid eligibility expansion. Section 203 expressly prohibited the use of moneys appropriated from the State General Fund (SGF) or from any special revenue fund or funds for FY 2013, 2014, and 2015, to expand eligibility for receipt of benefits under Medicaid, as provided for in the ACA, unless the Legislature expressly consented to the expansion of Medicaid services.

In addition, several concurrent resolutions and one bill were proposed during the 2013 Legislative Session addressing Medicaid expansion, either directly or indirectly, as outlined below. However, no final action was taken on any of these measures.

House Concurrent Resolution No. 5013 was proposed, stating the will of the Kansas Legislature is that the State not expand Medicaid above its current eligibility levels. The resolution was heard before the House Committee on Appropriations, at which time testimony was presented both supporting and opposing the resolution, as well as testimony indicating the State should wait to see what flexibility the federal government might allow to make Medicaid expansion a Kansas-based program. The Committee recommended the resolution be adopted, but no further action was taken prior to the end of the session.

Also proposed during the 2013 Legislative Session were Senate Concurrent Resolutions (SCR) 1612 and 1613. SCR 1612 proposed Article 15 of the Kansas Constitution be amended to expressly reserve to the State and its citizens all powers not delegated to the United States by the U. S. Constitution or prohibited to the states by the U.S. Constitution. Health care was listed as included in these reserved powers. SCR 1613 made an application to the U.S. Congress to call a Constitutional Convention to consider an amendment to the U.S. Constitution with respect to states’ rights. The proposed amendment stated the State and its citizens have the sole and exclusive authority to regulate directly, and to regulate indirectly through taxes, several subjects, including health care and all forms of insurance. Both resolutions were referred to the Senate Committee on Federal and State Affairs, but no hearing was held on either.

Further, HB 2032 was proposed to expand Medicaid eligibility to 133 percent of the FPL, effective January 1, 2014, for adults under the age of 65 who are not pregnant. However, no bill hearing occurred.

Other State Actions on Expansion through Federal Fiscal Year 2013

States have flexibility to start or stop the expansion, but the federal match rates paid are tied by law to specific calendar years. As outlined in the ACA, for the first three years of the expansion, the federal government would pay for 100 percent of the costs of covering the newly eligible Medicaid population. However, that federal contribution declined to 90 percent by the year 2020, with the state picking up the remaining 10 percent.

According to CMS, as of October 24, 2013, 25 states and the District of Columbia had decided to move forward with Medicaid expansion, while 25 states were not expanding as of that date. Arkansas, Iowa, and Pennsylvania were exploring expansion alternatives.

Arkansas submitted a Medicaid expansion Section 1115 demonstration waiver application (Arkansas Health Care Independence Demonstration) to CMS, which received conceptual approval. As part of the final approval process, CMS accepted public comments on the proposal until September 7, 2013. The statewide demonstration would operate during calendar years 2014, 2015, and 2016. Under the proposed demonstration waiver, Arkansas would use premium assistance funds to purchase coverage within qualified health plans in its state and federal partnership exchange that were available in the individual market for certain individuals eligible for Medicaid coverage. These individuals would be either childless adults ages 19 to 65 with incomes at or below 138 percent of the FPL or parents between the ages of 19 and 65 with incomes between 17 and 138 percent of the FPL. Arkansas estimated approximately 225,000 individuals would be eligible for the demonstration.

Iowa also submitted a Medicaid expansion Section 1115 demonstration waiver application, which, like Arkansas’, would use Medicaid funds as premium assistance to purchase coverage for some newly eligible Medicaid beneficiaries in Marketplace (or Exchange) Qualified Health Plans. Like Arkansas, Iowa proposed to make premium assistance enrollment mandatory for affected beneficiaries and would exempt beneficiaries who are medically frail. However, Iowa proposed waiving wrap-around benefit requirements. The Iowa plan would limit coverage to newly eligible Medicaid beneficiaries between 101 percent and 138 percent of the FPL and would require enrollees to pay a premium of $20 per month, which may be waived if certain conditions were met. Additional details of the Iowa and Arkansas demonstration waiver are available in fact sheets prepared by the Kaiser Commission on Medicaid and the Uninsured, entitled Medicaid Expansion in Arkansas (February 12, 2015) and Medicaid Expansion in Iowa (November 20, 2015).

On September 16, 2013, Pennsylvania’s Governor proposed an insurance expansion, Healthy Pennsylvania. The Daily Pennsylvanian reported on October 8, 2013, that a policy report had been issued. Healthy Pennsylvania would serve 520,000 then-uninsured individuals. The proposal would rely on a health insurance exchange that would allow private insurance companies to compete for enrollees, whose premiums would be subsidized by the federal government. However, unlike Medicaid, the proposal would require enrollees to pay up to $25 per month in insurance premiums and create additional work requirements not present in Medicaid coverage. The work conditions included requiring able-bodied Medicaid beneficiaries to prove they are searching for employment, a requirement not allowed under federal law.

State Budget Concerns with Expansion

Matt Salo, then-Executive Director of the National Association of Medicaid Directors, stated that while politics is a factor, states have legitimate budget concerns when weighing Medicaid expansion. He stated that many state officials were already struggling to pay for the entitlement program, which typically is the largest or second-largest state expense. And while a state’s future share may sound small, it represents billions in new spending that could require cutbacks of other more popular programs, such as education or transportation, or require raising taxes.

The Congressional Budget Office projected states would pay approximately $73 billion, or 7 percent of the cost of the Medicaid expansion, between 2014 and 2022, while the federal government would pay $931 billion, or 93 percent.

Concerns over startup costs, the likelihood that millions of unenrolled persons already eligible for Medicaid would enroll as a result of publicity about the expansion, and the potential that a deficit-focused Congress would scale back the federal share caused states to evaluate whether they should opt for the expansion.

The woodwork effect—the possibility those individuals who were already eligible for Medicaid would enroll due to publicity about expansion—was of particular concern, because states would only receive the traditional federal funding match, averaging 57 percent, for those individuals.

The Kansas Department of Health and Environment contracted with Aon Hewitt to perform an independent analysis on the potential enrollment and costs of the ACA implementation to the state’s Medicaid and Children’s Health Insurance Program. The analysis, published on February 13, 2013, indicated the ACA (without Medicaid expansion) would cost the state an increase of $513.5 million from the SGF for calendar years 2014 through 2023. The ACA with Medicaid expansion over the same time period would cost the state an estimated increase of $1.1 billion from the SGF. The estimated cost increases for the SGF would have been lower in the early years of expansion due to the 100 percent federal share paid.

On April 5, 2013, in a KHI News Service article, Governor Brownback said he continued “active conversations with people” about the potential benefits and risks of expanding the state’s Medicaid program. He stated, “[e]xpansion would have to be addressed by the Legislature. They would have to budget it.” He indicated concerns that the federal government could eventually shift much of the program’s costs onto states. The Governor indicated he was aware of the federal government’s pledge to fully cover each state’s expansion cost for the first three years and to limit states’ responsibility to no more than ten percent thereafter, but that could change if federal funds were not available. Governor Brownback had not indicated whether he would decide on Medicaid expansion in 2013.

Health Care Provider Support for Expansion

Health care providers who treat low-income patients strongly supported the coverage expansion.

Richard J. Umbdenstock, then-President of the American Hospital Association (AHA), in a July 2012 New York Times article stated that hospitals around the country would lobby for the Medicaid expansion. “If states do not avail themselves of this opportunity, the federal money will go to other states, and hospitals will be left with large numbers of the uninsured,” he said.

After the Obama Administration’s announcement in July 2013 of a one-year delay on the ACA requirement that medium and large employers provide insurance coverage for their workers or face fines, Mr. Umbdenstock issued a statement on behalf of the AHA on July 3, 2013, in which he noted the AHA is “concerned that the delay further erodes the coverage that was envisioned as part of the ACA. This delay comes at a time when there is significant uncertainty regarding Medicaid expansion. We will continue to work with Congress and the administration on the implementation of the law to make sure that the coverage needs for the uninsured are met,” he said.

Nancy M. Schlichting, then-Chief Executive of the Henry Ford Health System in Detroit, said the July 2012, New York Times article, she “absolutely will lobby” for the expansion of Medicaid. She stated in a September 2, 2013, Detroit Free Press article, the expansion would provide “needed revenue for our health system and needed coverage for the people we serve.”

A report produced by researchers at Regional Economic Models, Inc., and The George Washington University released by the Kansas Hospital Association (KHA) in February 2013, Economic and Employment Effects of Expanding KanCare in Kansas, estimated the federal funding associated with KanCare expansion would help create approximately 3,400 new jobs in 2014 and 4,000 new jobs by 2020. According to the KHA, the report showed that expansion could help grow the Kansas economy and “documents the importance of Kansas carefully considering all aspects of expansion and making a decision that is best for Kansas.”

Per the KHA Media release of February 18, 2013, the report indicated expanding KanCare could actually result in a net cost savings for the state of $82 million from 2014 to 2020. Tom Bell, then-President and Chief Executive Officer of the KHA, stated, “[a] decision to forego Medicaid expansion is more than just a decision to refuse the federal funding associated with Medicaid expansion. In fact, it amounts to additional real cuts to hospitals that are currently serving as the primary safety net for many uninsured individuals, and it comes at a time when the uncompensated care burden on the hospitals continues to grow at an alarming rate.”

State Flexibility in Medicaid Expansion Participation

CMS has indicated there is much to consider in deciding whether to expand Medicaid, and there is no deadline by which states must make that determination. CMS stated states are expected and encouraged to look at their choices and options. CMS also stressed Medicaid expansion by states to include low-income adults is voluntary. CMS indicated this means a state can decide when to expand, if to expand, and whether to terminate the expansion. Since Medicaid expansion is voluntary, if a state adopts the expansion and determines at a later time, for whatever reason, it does not want to maintain the expansion, the state can also decide to discontinue the expansion. CMS noted that all other aspects of the Medicaid expansion program remain intact, including the favorable federal match rate available, and states need to think through the costs and benefits of expansion before making a decision.

1. 42 U. S. C. §1396c ↩︎
2. 42 U. S. C. §1396c ↩︎
3. 132 S. Ct. at 2604 ↩︎
4. 132 S. Ct. at 2607 ↩︎
5. 132 S. Ct. at 2605. ↩︎
6. 132 S. Ct. at 2606. ↩︎
7. 132 S. Ct. at 2607. ↩︎
8. 132 S. Ct. at 2608. ↩︎
9. 132 S. Ct. at 2608. ↩︎

by Elizabeth Cohn
Senior Research Analyst
785-296-4382