KY’s state fiscal year begins on July 1 and ends on June 30. This differs from the federal fiscal year of October 1 through September 30. The budget is based on state fiscal year 2024. KY requires a balanced budget at the end of each fiscal year. Reporting of actual expenditures may differ from the reported budget due to state fiscal year carryover and grant year amount variations. Funds unused within the state fiscal year will be spent in the 4th quarter of the federal fiscal year, which is the 1st quarter of the state fiscal year. Other differences may include additional expenditures from other revenues and budget adjustments made throughout the year, which are generally minor.

Block grant funding and expenditures and explanations for significant variations in the expenditure data of 10% or greater compared to the previous year are provided by the state, as reported in Forms 2 and 3. Expenditures for this section are based on actual expenditures for state fiscal year 2022, which ended June 30, 2022. The variance in budgeted versus expended in FY2022 was $3,871,652. Expenditures were less than budget in financial system and will be adjusted to fit within the budget.

The COVID pandemic continued to impact the LHD’s ability to focus on any work other than mitigating the spread of infection in their communities. However, this was lessened from the previous fiscal year. The state has made significant efforts to provide flexibility where allowable under the federal block grant to provide for indirect work related to COVID that supports the MCH populations. For instance, the state continued to eliminate the required match for purchase of cribs to relieve the demands of that requirement. This enhanced the LHDs’ ability to provide safe sleep environments for families in critical need.

KY has funded total expenditures of 7.0% from federal funds and 93.0% from state funds (general, agency, and tobacco), $7.4M and $105M, respectively. Maintenance of effort and match comprises total State General Funds and Agency Funds. Details of these sources are found in Form 2.

As reported on Form 3, KY utilizes Title V funds to reach for direct, enabling, and population health services. Title V funding is a payor of last resort.

As reported on Form 5, per DPH Custom Data Processing report, 143 pregnant women were served through the LHD. Of these, 15.5% had coverage with Title XIX, 2.7% had services covered with private or other payors, 80.5% had not recorded payor source, and 1.3% had an unknown payor source. LHDs assist women in applying for Medicaid services and linkage to community resources.

For infants under 1 year, 2,342 had direct services by the LHDs in WIC, medical nutrition, HANDS, immunization, well child, or childhood lead screening. Of these, 65.6% were served by Title XIX, 3.4% had private or other coverage, 30.1% had no known coverage, and 0.9% was unknown. For this population, LHDs also assist with Medicaid enrollment and linkage to community resources.

For children 1-21 years of age, 80,104 encounters were found. Of these, 64.1% were served by Title XIX, 10% by private or other coverage, 25.9% had no coverage, and 0.0% were unknown. LHDs can meet gap-filling services with the well child program, WIC, HANDS, and Vaccines for Children Program. Many also do childhood lead screenings and other services such as school health nursing or other direct services using the local tax base or contractual agreements.

For children with special health care needs, 76,552 individuals received services through the OCSHCN offices or other clinic services as per contractual agreements. In OCSHCN clinics, direct services were provided to 8,281 children; 76.0% were served through Title XIX, 17.0% had private or other payor sources, 7.0% had no coverage, and 0.0% had unknown coverage. OCSHCN ensures that those needing services who meet qualifications have services provided by OCSHCN or contractual partners. For those meeting guidelines, 100% of service is provided at no cost or a reduced cost.

For 2020, pregnant women, infants, and children counts changed significantly as LHD transformation from direct services to population health programming changed. Additionally, the pandemic response limited the number of in-person direct services provided by LHDs, and families were hesitant to seek preventive health services for fear of exposure to COVID-19. Initially, Kentucky LHDs shut down all but essential or emergent visits, limiting the number of Kentuckians reached. MCH best practice initiatives (packages) in previous years have broad community outreach in schools, community organizations, childcare agencies, hospitals, and providers. These efforts became almost non-existent in rural areas with limited PH workforce. In FY21, OCSHCN typical outreach efforts continued to be curtailed for population health due to the COVID-19 pandemic. OCSHCN continues outreach through virtual meetings, phone, and email.

LHDs deliver Title V services for their respective county’s community MCH populations. Greater than half of the MCH Title V funds go directly to expenditures for services at the LHDs. MCH’s goal is to assure some level of flexibility for LHDs to meet community needs while maintaining accountability for Title V funding.

Promotion of enabling, population-based, and system services within the changing healthcare landscape of KY is being utilized by the KY Title V Program to offset the decreasing direct services to MCH populations. Title V funding is used as the linchpin for many population-based activities for mothers and children in the local communities. LHDs are encouraged to partner with community providers, federally qualified health centers, and especially primary care providers to ensure MCH services are available. In FY18, LHD funding was designated for use only in population health measures or the enabling service of activities provided with the Cribs for Kids package or dental varnish for children package. Title V funds are not used for direct services.

Title V federal funds to LHDs are managed through allocations from KDPH and monitored by the system-wide financial structure capturing all LHD expenses. LHDs report activities directly to the MCH Title V Program. The MCH coordinator reviews these monthly to ensure activities and expenses align to meet MCH population needs. Beginning with FY19, LHD reimbursements are held for lack of reporting activities.

Expenditures for Federal MCH Title V Program Services are divided by MCH service types provided. The following percentages include administrative costs for Kentucky’s Title V Block Grant.

• 0% Direct Health Care for preventive and primary care for pregnant women, mothers, and infants up to 1 year of age
• 0% Direct Health Care for preventive and primary care services for children
• 7.2% Services for CSHCN
• 46.6% Enabling services
• 46.2% Public health services and systems

The percentages provided are estimates based on available data since KY accounting systems do not specifically identify these services. Expenses for best practice initiatives are identified in the accounting system to better allow for monitoring of expenses by the LHDs. These percentages do not include other MCH activities funded by other federal funding sources.

Title V funds are not used for reimbursing for direct medical claims. Previous fiscal years allowed Title V funds to be used as payor of last resort. With expanded Medicaid and aggressive outreach/referral, it is rare for LHDs to pay for deliveries. To reduce probability of this need, LHDs aggressively assist with presumptive eligibility. LHDs continue to contract with local providers, hospitals, and labs or provide in-house prenatal services to ensure the needs of this population are met. Title V funds are not used for in-hospital services as hospitals must serve the uninsured.

KY’s fiscal responsibilities in the face of rising pension costs and decreasing state revenue have created a need to review processes within MCH and with LHDs to find mechanisms of change to improve efficiencies with care coordination, program provisions, and utilization of community resources. As stated in previous sections, KY LHDs are at risk of insolvency in FY21.

It should be noted that KY’s largest non-federal investment in encounter-driven primary and preventive services for pregnant women, mothers, and infants is the $7.0M dedicated to the core HANDS home visiting program for first-time parents funded by Master Settlement Tobacco Funds. These funds provide the opportunity to leverage an additional $32M in federal and Medicaid funds to support KY’s Core HANDS home visitation services. Since 2019, KY has received Maternal, Infant, and Early Childhood Home Visiting (MIECHV) federal funding to provide home visitation services to high-risk families in 120 counties deemed at highest risk. The most recent MIECHV award was $3.6M. An additional $6.0M was appropriated in KY General Funds to expand multigravida services to the remaining KY counties not covered by MIECHV grant funding. This funding provides assessments and professional and paraprofessional visits to nearly 11,000 families annually for prenatal populations and children through age three. Eighty-five percent of families enter this program during pregnancy. With ongoing need to address the growing population of NAS, this program provides strong support toward a plan of safe care for the infant/child. This KY investment is not part of the Title V budget forms as it is used for the MOE requirement for MIECHV. This investment is a significant part of Title V programming.

To address needs of children, public health nurses provide well child exams, screenings, health education, and other preventative primary services. They are trained to provide fluoride varnish services in populations in which dental providers are limited, enabling this service for the school-age population. Title V funds support assurance for specialty services for comprehensive developmental evaluations at university-based, multidisciplinary child evaluation centers. Non-federal MCH funds support access to specialty visits for genetics, oral health services, and Part C Intervention services (not covered by Medicaid). Non-federal funding supports the KY Metabolic Foods and Formula Program to provide foods and formula for children with metabolic disorders who cannot pay for life-saving specialized nutrition.

Enabling services supported by Title V include support for 23 LHDs to assist pregnant women completing Medicaid presumptive eligibility, promotion of early entry into prenatal care, and assessment of need and referral for services through HANDS, WIC, smoking cessation, substance use treatment, or domestic violence counseling. This referral process is foundational to LHD programming and is supported by nonfederal dollars in some capacity by all LHDs.

Non-federal funding is used for:

• KY Newborn Screening Program to include referral, counseling, and follow-up to the point of confirmatory diagnosis with the specialty provider
• KY Metabolic Foods and Formula programming to provide medically prescribed metabolic foods/formulas as a payor of last resort
• KY Childhood Lead Poisoning Prevention Program case management and prevention activities for children with elevated lead levels

The final amount of federal and non-federal funding in MCH supports Public Health Services and Systems. An example of this is funding utilized for various programs to support safe sleep education to community partners and childcare centers. Title V funds support workforce development training for prenatal and public health programs.

OCSHCN continues to preserve infrastructure and serve families and children in need of programs and services available. Our office will continue to build partnerships and heightened awareness of community resources. In addition to MCH Title V Block Grant dollars, OCSHCN receives funding from the state general funds, agency funds, a CDC grant, and two HRSA grants. Agency funds comprise other agencies’ reimbursements, dividends, a cost report settlement, and third-party patient billings for direct patient care and care coordination.

The KY Title V block grant is spent in compliance with the federal requirements for use of the funds. KY budgeted 43.8% of the FY2024 budget to support preventive and primary care for children and 46.7% for children with special health care needs. Administrative costs are budgeted at 10% of the block grant funding, but spending is often less with certain administrative costs met through state match.

The total required $4 federal/$3 state match for KY is $8,430,000 (based on $11,240,000 average award), which includes OCSHCN and MCH. OCSHCN is responsible for their portion of the match (34.9%, or $2,942,070), and the remainder ($5,487,930) is the responsibility of MCH. Both agencies have more than adequate funds from state funds to meet the match requirement. KY’s total maintenance of effort from 1989 is $22,552,700. KY’s MCH effort far exceeds the match and maintenance of effort requirements. Maintenance of effort and match comprises State General Funds and Agency Funds.

KY’s total budget for State FY24 increased 17.9% based on expenditures from FY22. For FY24, the total MCH block grant budget was funded from:

• 57.0% -- Other Federal Funds (1200; $144,990,631)
• 38.6% -- State Funds (13XX, 0100, 65XX); $98,014,552)
• 4.4% -- Federal MCH Block Grant (1200; $11,240,000)

MCH feels certain that state and agency funds required for the 1989 maintenance of effort level of $22,552,700 and the match of $8,430,000 will continue to be available in the conceivable future.

For the FY24 budget, $5,000,000 of the MCH Title V Grant allocation has been allocated to LHDs to provide direct, enabling, and public health services/system-building, depending on needs of the local MCH populations. The state ensures these funds will be used appropriately through a select list of MCH Evidence-Informed Strategies as options, and some of the funding remains categorical. The remainder of the MCH allocation is budgeted for public health services and systems. These include surveillance (maternal mortality, child fatality review); regionalized perinatal care; information technology systems for data collection; workforce development and training; and technical assistance to LHDs and other agencies for pediatric injury prevention.

Other federal funding received includes funding from the CDC, HRSA, USDA, and the Department of Education. These federal agencies contribute an additional $144,990,631 in support of Kentucky’s MCH population.

Non-federal program funding MCH receives includes funding from the state’s general fund, agency revenue from fees and Medicaid claims, and tobacco master settlement agreement funds. These state sources contribute an additional $98,014,552 in support of Kentucky’s MCH population.