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admission, including an assessment of medical, behavioral, and social needs, along with defined goals and regular reviews. The TEAMKY Recuperative Care Pilot ensures that medical necessity is continuously evaluated, leveraging ongoing monitoring and assessments to address the dynamic needs of patients. This patient-centered approach, supported by highly trained staff and structured processes, allows the program to effectively provide targeted care for vulnerable populations, while fostering recovery and stability. Eligibility Screening The state’s comprehensive assessment tool is designed to support Kentucky residents in identifying and addressing their needs across various SDOH. The tool will have a bi-directional connection with Kentucky’s health information exchange to share SDOH information captured by a patient’s provider to resources, so community providers can better understand resident needs. The assessment tool will also allow for a closed-loop referral process to guide improved outcomes, strengthen partnerships, and promote wrap around services to residents. By using the eligibility assessment, Kentucky residents can proactively identify areas where they need support and connect with the appropriate local resources. This valuable tool not only helps individuals address their immediate needs, but also empowers them. Clinical Criteria Considerations for Kentucky’s Recuperative Care Pilot The TEAMKY Recuperative Care Pilot establishes robust clinical criteria and an administrative process to streamline eligibility determination and ensure effective communication among community partners. This integrated approach ensures that Kentucky Medicaid members receive timely, medically necessary services while maintaining alignment with program requirements and Medicaid guidelines. Eligibility Determination and Administrative Coordination Eligibility for the TEAMKY Recuperative Care Pilot is based on a comprehensive evaluation of clinical and social criteria, including homelessness or risk of homelessness as defined by 24 CFR 91.5 except for the annual income requirement in 24 CFR 91.5 (1)(i). Individuals must be at least 18 years old, independently mobile (with or without assistive devices), able to perform ADLs and possess a primary medical diagnosis. Additionally, the pilot targets those at risk of hospitalization or readmission who require post-acute care, pre-procedural preparation, or episodic treatment such as chemotherapy. To facilitate this process, Kentucky Medicaid will designate a centralized point of contact to validate member eligibility. Providers initiate the eligibility verification process by submitting referrals to this point of contact, who ensures alignment with the established criteria. This administrative entity communicates verified eligibility to relevant individuals, including physical and behavioral health providers, Managed Care Organizations (MCOs), and Recuperative Care