OutreachKentucky Medicaid

Lisa Lee, Deputy CommissionerProgram Director, Kentucky Children’s Health

Insurance ProgramMay 7, 2013

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

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)

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

KY Medicaid

CURRENT LANDSCAPE

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

Population Covered by Medicaid

• Children under age 18

• Blind

• Elderly individuals over age 65

• Disabled

• Pregnant Women

• Must meet income criteria

203 Monthly FPL Limits

FAMILY 100% FPL 133% FPL 185% FPL 200% FPLSIZE        

                  1 $958 $1,274 $1,772 $1,915 2 $1,293 $1,720 $2,392 $2,585 3 $1,628 $2,165 $3,011 $3,255 4 $1,963 $2,611 $3,631 $3,925 5 $2,298 $3,056 $4,251 $4,595 6 $2,633 $3,502 $4,871 $5,265 7 $2,968 $3,947 $5,490 $5,935 8 $3,303 $4,393 $6,110 $6,605

         ADDITIONAL $335 $446 $620 $670 MEMBER        ADD        

Medicaid Members

• SFY13 1st quarter Average Members

MCOs702,530

Fee for Service123,778

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

Expenditures

Kentucky DemographicsOf Kentucky’s 120 counties, 98 are classified as rural

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)

Provider Locations

CHANGES IN HEALTHCARE DELIVERY

• 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

Impact in Rural Areas

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

Sample Network Adequacy

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

Vaccinations

 

12 Months Prior to Managed Care

12 Months Following

Managed Care Improvement

Pneumococcal and Meningococcal 26,595 26,711 0.44%

Chicken Pox 60,709 63,375 4%

Rabies 137 173 26%

Preservative Free Flu Vaccines for Children 21,909 29,146 33%

HPV Vaccine 18,355 20,870 14%Hemophilus Influenza b Vaccine 34,022 37,214 9%

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%

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

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