Outreach

1. Outreach Kentucky Medicaid Lisa Lee, Deputy Commissioner Program Director, Kentucky Children’s Health Insurance Program May 7, 2013

2. Background • Medicaid was signed into law July 30, 1965 by President LBJ. • Created to provide healthcare for: • Low income children deprived of parental support and their caretaker relatives • Elderly (age 65 and older) • Blind • Disabled

3. Moving Forward Recognized need to provide health care to additional populations which resulted in changes to system: • 1986 – Pregnant women and infants (under age 1) at or below 100% of federal poverty level (FPL) was established as a state plan option under Medicaid; • 1989 – Pregnant women and children under age 6 and at 133% of FPL federally mandated under Medicaid; • 1997 – Balanced Budget Act of 1997 created the State Children’s Health Insurance Program (SCHIP)

4. Why SCHIP? • Estimated 10 million children lacked health insurance nationwide in 1997 • SCHIP was created for uninsured children who are not eligible for Medicaid because their families’ incomes are too high, but they also do not make enough money to pay for private health insurance • Contained specific provisions for outreach

5. KY Medicaid CURRENT LANDSCAPE

6. KY Medicaid Administration • Federal/State Partnership • Governed by Federal Regulations • Services outlined in State Plan Amendment (SPA) approved by Center for Medicaid and Medicare Services (CMS) • State-wideness • Waivers

7. Population Covered by Medicaid • Children under age 18 • Blind • Elderly individuals over age 65 • Disabled • Pregnant Women • Must meet income criteria

8. 203 Monthly FPL Limits

9. Medicaid Members • SFY13 1st quarter Average Members

10. Covered Services • Inpatient Hospital • Outpatient Hospital • Emergency Services • Outpatient Surgery • Physician, Nurse Practitioner and Primary Care Services • Early and Periodic Screening, Diagnosis and Treatment (Well Child Care and Special Services) • Preventive Services in Health Departments • Vision Care • Hearing Care • Dental Services • Family Planning Services • Pharmacy • Lab and X-ray • Home Health • Therapies (Physical, Speech and Occupational--limited settings) • Medical Equipment and Supplies • Transportation (emergency and non-emergency) • Renal Dialysis • Hospice • Nursing Home Care • Inpatient Mental Health Services • Outpatient Mental Health Services • Early intervention for infants and toddlers with disabilities • Services provided by school districts for children with disabilities • FQHC and RHC

11. Expenditures

12. Kentucky Demographics Of Kentucky’s 120 counties, 98 are classified as rural

13. Rural vs Urban • Common Factors: • Population is diverse • Children of all ages are represented • Approximately 6 in 10 eligible children have family income below 100% of FPL (Source: Characteristics of Rural and Urban Children who Qualify for Medicaid or CHIP But are not Enrolled, North Carolina Rural Health Research and Policy Analysis Center, Brief July 2009) • Differences: • Rural areas have higher rate of poverty • Rural areas have less health and social services infrastructure • Resources (source: http://ruralhealth.hrsa.gov/pub/chip2.htm)

14. Provider Locations

15. CHANGES IN HEALTHCARE DELIVERY Impact in Rural Areas • Managed Care Initiative – access standards in contracts • potential for provider specific contracts • Health Care Reform • potential to increase enrollment of newly eligible population through Medicaid Expansion • funding (increased federal funds for Medicaid and CHIP) • Health Benefits Exchange

16. MCO Access Standards • Primary Care Provider (PCP) delivery sites that are: • no more than thirty (30) miles or thirty (30) minutes from Members in urban areas • no more than forty-five (45) minutes or forty-five (45) miles from Member residence in rural areas; with a member to PCP (FTE) ratio not to exceed 1500:1 • PCP to member ratio not to exceed 1500:1 • Hospital care for which transport time shall not exceed: • 60 minutes in rural areas • 30 minutes in urban areas • Dental services transport time not to exceed one hour • Vision, laboratory and radiology services transport time not to exceed one hour • Pharmacy services • travel time not to exceed one hour or • the delivery site shall not be further than fifty (50) miles from the member’s residence

17. Sample Network Adequacy

18. MCO Quality • Contract with Island Peer Review Organization (IPRO) • Monitor overall quality and financial performance • Monitor the quality improvement programs and plans • Monitor performance improvement projects and goals • Maintain a data platform and system to enable all functions of the EQRO • Conduct special ad hoc analysis • Report study and analytical findings • Provide consultation and support to DMS and MCO’s • Assist in the development of quality improvement action plans

19. Vaccinations

20. MCO Specific Improvements • Coventry • Increased immunizations rates for adolescents from 41% to 56% • WellCare • Increased EPSDT participation rates from 33% to 43% • KY Spirit • Increased cervical cancer screenings from 25.22% to 37.4%

21. KY Health Ranking • 50th in smoking • 40th in obesity • 43rd in sedentary lifestyles • 41st in diabetes • 48th in poor mental health days • 49th in poor physical health days • 50th in cancer deaths • 49th in cardiac heart disease • 43rd in high cholesterol • 48th in heart attacks • 50th in preventable hospitalizations • 43rd in low birth weight • 44th in premature death • 44th overall in America’s Health Rankings

22. Summary • Healthcare landscape continues to change • More flexibility in delivery method • Medicaid movement towards partner rather than payer • Focus on improvement and quality • Elevate the health status of all Kentucky citizens