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TEAMKY Demonstration

Approval Period: January 1, 2025 through December 31, 2029

Page 4 of 155 CENTERS FOR MEDICARE & MEDICAID SERVICES WAIVER AUTHORITY

NUMBERS: 11-W-00306/4

21-W-00067/4

TITLE:

TEAMKY Section 1115 Demonstration

AWARDEE: Kentucky Cabinet for Health and Family Services

Title XIX Waiver Authority

Under the authority of Section 1115(a)(1) of the Social Security Act (“the Act”), the following waivers are granted to enable Kentucky (referred to herein as the state or the State) to operate the TEAMKY (formerly KY HEALTH) Demonstration. These waivers are effective January 1, 2025 through December 31, 2029 and are limited to the extent necessary to achieve the objectives below. These waivers may only be implemented consistent with the approved Special Terms and Conditions (STCs) as set forth in the accompanying document.

Under the authority of section 1115(a)(1) of the Social Security Act (the Act), the following waivers of state plan requirements contained in section 1902 of the Act are granted for the TEAMKY section 1115 demonstration, subject to these STCs.

1. Provision of Medical Assistance

Section 1902(a)(8)

and 1902(a)(10) To the extent necessary to permit Kentucky to limit the provision of medical assistance (and treatment as eligible) for individuals described in the eligibility group under section 1902(a)(10)(A)(ii)(XX) of the Act and the state plan to only former foster care youth who are under 26 years of age, who turned 18 on or before December 31, 2022, were in foster care under the responsibility of another state or tribe on the date of attaining 18 years of age (or such higher age as the state has elected), and who were enrolled in Medicaid on that date.

2. Coverage of Certain Screening, Diagnostic, and Targeted Case Management Services for Eligible Juveniles in the 30 Days Prior to Release Section 1902(a)(84)(D)

To enable the state not to provide coverage of the screening, diagnostic, and targeted case management services identified in section 1902(a)(84)(D) of the Act for eligible juveniles described in section 1902(nn)(2) of the Act as a state plan benefit in the 30 days prior to the release of such eligible juveniles from a public institution, to the extent and for the period that the state instead provides such coverage to such eligible juveniles under the approved expenditure authorities under this demonstration. The state will provide coverage to eligible juveniles described in section 1902(nn)(2) in alignment with section 1902(a)(84)(D) of the Act at a level equal to or greater than would be required under the state plan.