Kentucky’s Health Care Delivery Environment and the Role of Title V

The Kentucky state capital, Frankfort, Kentucky (KY), is the location of the Cabinet for Health and Family Services (CHFS), which houses the KY Department for Public Health (KDPH). The Division of Maternal and Child Health (MCH) administers the Title V grant and program.  MCH is one of seven divisions of the KDPH.

KY operates a decentralized public health system, with independent and district local health departments (LHDs) serving all 120 counties that are accountable to their local board of health. KDPH operates the personnel and financial systems for LHDs and supports their role in state and federally funded programs via allocations, standards of practice, training, and technical assistance. The Office for Children with Special Health Care Needs (OCSHCN) is the agency that administers the state’s Children and Youth with Special Health Care Needs (CYSHCN) program. OCSHCN’s central office is located in the state’s largest city, Louisville, with eleven regional sites throughout the state (serving all 120 counties), and six other satellite clinic locations.

Recent changes in the health care landscape for KY include:

• 2011: Implementation of Managed Care Organizations (MCOs) for Medicaid beneficiaries
• 2014: Implementation of provisions for coverage for mental health and substance abuse services, as required by the Affordable Care Act (ACA) in the Medicaid State Plan utilizing a state based health exchange (KYNECT)
• 2016: Transition to the federal insurance exchange (Healthcare.gov) secondary to cost of maintaining the state-based exchange
• 2017: Section 1115 Medicaid Waiver (KHW) was submitted to the Centers for Medicare and Medicaid Services (CMS) for approval. The KHW did not change benefits for pregnant women or children 
• 2018: Received approval from CMS for the KHW entitled “Kentucky Helping to Engage and Achieve Long Term Health”.  In June 2018, a federal ruling blocked KHW.  Therefore, 2018, KHW was revised and a tentative start date set for April 2019 if approved.
• March 27, 2019:  Federal district court blocked the re-approval of the KHW.  However, the benefits for pregnant women and children continue without change through KY Medicaid

The Medicaid program in KY has historically focused on providing health care to subgroups of the lowest income individuals including the elderly, disabled, children, and pregnant women. In 2013, KY chose to expand Medicaid by extending coverage to individuals with incomes up to 138% of the federal poverty level (FPL). KY’s decision to expand Medicaid eligibility had three goals:

• reducing the number of low-income residents who lacked health care
• improving the health status of Kentuckians – especially low-income residents without prior access to health care coverage
• boosting KY’s economy

The enrollment of non-elderly adults in KY Medicaid increased 72.7%, from 376,956 in the first quarter of Medicaid expansion to 650,867 in the third quarter of 2016 (State Health Access Data Assistance Center, 2017). During this same period, there was an increase in births covered by Medicaid expansion, but it was offset by a decline in births in traditional Medicaid (State Health Access Data Assistance Center, 2017). This shift may be the result of women who enrolled in expanded Medicaid and later became pregnant. Although Medicaid expansion did not have a direct impact on Medicaid eligibility for pregnant women (at 185% FPL in KY), it did allow more women to be covered in the preconception and interconception care periods.

In January 2014, KY implemented provisions of the ACA to provide coverage for mental health and substance abuse services. This new State Medicaid Plan amendment utilized a state based health exchange (KYNECT) and opened up the Medicaid provider network to add multiple mental health and substance abuse provider types. Since implementing the ACA requirements, more than 300 new behavioral health providers have enrolled in Medicaid and at least 13,000 individuals with a substance abuse disorder have received related treatment services (Deloitte Development LLC, 2015). This was positive improvement for access to these critical services for MCH populations and addressing the epidemic of substance abuse, a major priority indicated by the MCH needs assessment. In 2015, when the state held needs assessment meetings, focus groups and families expressed difficulties in finding local providers based upon MCO choice and the lack of coverage to access treatment for mental health and substance use disorders (SUD). The only mental health or substance abuse treatment paid by Medicaid was through Kentucky’s community Mental Health Centers. The KHW includes a SUD program to improve quality care and health outcomes for Kentuckians with SUD.

It became evident that the cost of the state run exchange was not sustainable long-term. In 2016, enrollment with MCOs began transitioning to the Healthcare.gov platform, and by November 2017, exclusive enrollment occurred. KY currently contracts with five Managed Care Organizations (MCOs) to provide healthcare services for Kentuckians eligible for Medicaid. During the 2018 enrollment period, 89,569 people enrolled in coverage, more than a 10%, increase over 2017 enrollment, a decrease from 2016. For 2018, enrollees had two choices of insurers:  CareSource (61 counties) and Anthem (59 counties).  Both insurers had rate increases with CareSource increasing 19.4% and Anthem 4.3% from 2017 (healthinsurance.org, 2018). 

The Kentucky HEALTH Waiver (KHW) was planned to change KY’s traditional Medicaid expansion. As of March 2019, the federal courts blocked the re-approval. Kentucky benefits for women and children remains unchanged. In January 2018, beneficiaries were able to begin earning credit for My Rewards Account (MRA) activities for preventive health services. MRA works like a Health Spending Account and beneficiaries may use earned dollars to pay for preventive dental/vision services and some gym/fitness activities. During the KHW appeal process, beneficiaries have continued to earn MRA credits.

Medicaid expansion has been successful. National data indicates that KY experienced the largest decrease of any state in its adult uninsured rate from 2013-2016, dropping from 20.4% to 7.8% (Witters, 2017). The aggressive outreach and marketing efforts, along with support from LHDs, OCSHCN, area development districts, community mental health centers, community action agencies, faith-based organizations, hospitals, clinics and other health care providers, were likely responsible for KY exceeding targeted enrollment for Medicaid expansion (Deloitte Development LLC, 2015). The Title V program has continued to promote this effort. OCSHCN regional offices, the Family to Family Health (F2F) Information Centers, and several LHDs have staff trained to facilitate customers accessing the exchange for enrollment. In other communities, they know the locations to send families for this service.

Title V continues to assist mothers and children with access to care. One action of the prenatal MCH package, chosen by various LHDs, was to ensure referral for Medicaid to assist with presumptive eligibility and assessment of need for other services with linkage to care through HANDS, WIC, and obstetric care, or to local resources for smoking cessation and substance abuse treatment. One district health department continues to contract with a university adolescent health program to bring mental health screenings to the middle and high schools in their district.

Since the inception of the national exchange (Healthcare.gov), OCSHCN affiliated navigators have completed 12-15 hours of training on the exchange and recertify annually.

The 2015 Needs Assessment survey data showed that OCSHCN respondents are less likely than other MCH populations to experience problems obtaining insurance via the exchange. Subsequent OCSHCN surveys have indicated that OCSHCN enrollees are more satisfied with the adequacy of their child’s coverage than CYSHCN families sampled through the National Survey of Children’s Health (2016). OCSHCN contracts with a trusted nonprofit, Patient Services, Inc., to provide insurance case management and premium assistance solutions for those with eligible conditions, specifically bleeding disorders and cystic fibrosis. Insurance coverage is an issue among MCH populations and a disparity of adequacy exists in terms of CYSHCN. OCSHCN is working toward greater (appropriate) coverage by guiding and advocating for CYSHCN on an individual basis and on a state level, participating in ongoing dialogue with Medicaid and the MCOs to reach solutions for any issues (such as pre-authorization requirements for medical procedures from which CYSHCN may previously have been exempted). OCSHCN continues to participate in learning collaborative opportunities alongside Medicaid partners, state partners, and national experts.

State Health Agency Priorities

Since being sworn into office, in December 2015, Governor Matthew Bevin maintains that creating a Healthier Kentucky is a priority. Governor Bevin and Kentucky’s first lady are supportive of children’s issues, and work with local Department of Community based Services (DCBS) offices and various programs to benefit foster children.

In 2017, KDPH evaluated target areas of concern for the state.  Stakeholders identified the focus needs to improve the health of Kentuckians which include substance use disorder, tobacco use, obesity, adverse childhood experiences and integration to health access.  All of these have significant impact on mothers and children.  With the rising opioid epidemic, a focus remains on decreasing rates of neonatal abstinence syndrome, reduction of Sudden Unexpected Infant Deaths (SUID), and ongoing identification and treatment for pregnant woman with substance use disorder.

In 2018, KDPH began meeting with every local health department and stakeholders to address Public Health Transformation based on Public Health 3.0 principals.  This transformation is working to address fiscal instability within local health departments, many of which face insolvency in one to two years.  Public Health Transformation has set a goal to improve public health leadership, prevent duplication of services, and support data driven decisions to promote positive community health outcomes.

Challenges for Delivery of Services

Healthy People 2020 notes, “Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities”. In KY, disparity affects all MCH indicators in areas of racial, ethnic, economic or geographic location, and access to care. 

Kentucky’s population is 87.8% Caucasian, 8.4% African American, and 3.7% Hispanic. The poverty rate is 17.2%. More than 41% of Kentuckians live in a rural area (Quick Facts Kentucky, 2019). The US Census Bureau 2018 Population Estimates for KY is 4,468,402. Health disparities are addressed by place based initiatives such as the Federal Healthy Start program in Louisville, Federally Qualified Health Centers (FQHCs) such as Bluegrass Community Health Center in Lexington that provides a medical home for migrant workers in Central KY, or other FQHCs in the eastern part of KY serving underserved populations with comprehensive services.

The Appalachian Regional Commission (ARC) monitors the economic status of Appalachian counties in all 13 Appalachian states. A designation of a “distressed county means” this area has a median family income no greater than 67% of the United States average and a poverty rate 150% of the US average or greater. Per the ARC, there are 81 distressed counties in 13 states, with 38 counties located in eastern Kentucky (ARC-Designated Distressed Counties, Fiscal Year 2019).

Appalachian communities are unique and deserve special attention given the rural, resource-limited, socio-economically impoverished nature of families in this part of KY. This effects access to employment, health care, higher education and other services. Limited access to local providers (especially for specialized care) and transportation are barriers imposed by a rural community. The rurality of the population created a need for communities to rely on LHDs for primary care and prevention services. With PH Transformation, LHDs are evaluating how to move from preventive and primary care services to population health measures.  Kentucky’s poverty rate is 17.2% with one of four KY children living below the Federal Poverty Level (United States Census, 2019).  This rate is higher in the rural areas of KY.

Identified distressed counties correspond with higher indicators of poor health.

Kentucky has three primarily urban areas: Louisville, Lexington, and Northern Kentucky.  Both Louisville and Lexington have a children’s hospital providing comprehensive pediatric care. Kentucky has one specialty hospital, Shriners Hospital for Children serving children (regardless of ability to pay) with orthopedic conditions. Shriners accepts referrals for services from OCSHCN.  The number of providers in KY’s health program shortage areas (HPSA) are listed below:

Shaping our Appalachian Region (SOAR) is a non-partisan economic development agency instituted in 2013 to “expand job creation, enhance regional opportunity, innovation, and identity, improve the quality of life, and support all those working to achieve these goals in Eastern Kentucky”. SOAR promotes collaboration and innovation (SOAR 2018). Now co-led by Congressman Hal Rogers and Governor Bevin, this initiative has drawn millions of dollars of investments from many state and federal agencies providing funding for a variety of projects in the 54 Appalachian counties to improve access to technology, telehealth initiative in Hazard, KY, food collaborative, farmers market, broadband access, and more. Soar’s Healthy Communities Advisory Council has a focus on reduction of physical and economic impact of obesity, diabetes, and substance abuse. In 2014, the SOAR Health Committee completed 16 “listening sessions” across KY resulting in a report on health prioritization areas of concern. These included: Coordinated School Health, Environmental Health, Smoke-Free Initiatives, Substance Abuse, Wellness Initiatives (Healthy Eating & Water First), a regional Health Clearinghouse, Adverse Childhood Experiences (ACEs), Transportation/Access, Children’s Oral Health, and Physical Education in Schools. In 2017, SOAR published a blueprint to organize the findings from all SOAR reports into goals and corresponding objectives for coordination of activities. In the SOAR Regional Blueprint, four goals were established to meet the health mission. The four objectives for this goal are:

• Implement innovative evidence-based programs to address regional health disparities in access, quality of care, and health outcomes
• Strengthen community partnerships and collaborations with stakeholders to increase focus on health and disease prevention throughout the region
• Reduce the scope and impact of substance abuse and related consequences through education, awareness, prevention, and access to services
• Increase access to healthy, affordable foods and opportunities for physical activity

These objectives align with the needs identified by the 2015 Title V Needs Assessment and ongoing work of Title V in KY. Health disparities to include racial, ethnic, economic and geographic disparities continue to dominate the concerns for KY MCH population.

Process Description

An extensive needs assessment process, which included multiple levels of inputs, was designed to align the major health efforts at the state level with the Title V Needs Assessment.

KY’s Title V 2015 needs assessment process included a review of quantitative data on numerous indicators, consumer surveys that were conducted in LHDs and OCSHCN sites across KY, focus groups with local staff from the LHD and OCSHCN, and stakeholder input. Potential priorities were identified for the five MCH population domains of women/maternal health, perinatal/infant health, child health, adolescent health, and children and youth with special health care needs. The ranking of those topics across the domains was assessed to determine their importance for each domain, or if it had impact on all MCH populations and was crosscutting. Each successive step in the process helped reinforce the issues identified as most important from our consumers and stakeholders shaping a clear picture of the needs of the Title V populations. These were aligned with the new Title V structure and the priorities of the state, as described above.

Through ongoing needs assessments, stakeholder meetings, KDPH accreditation, and data review, the previously identified areas of concerns and emerging concerns remain the focus of work. KY is striving to reduce non-medically indicated cesarean sections, and maternal morbidity and mortality review became a priority task in 2018. As identified in the 2015 needs assessment and noted in the prior update, NAS and substance use continues to require community engagement on all levels to address the growing needs of this population. Hepatitis C and HIV cases have increased; and they are associated with the rise of substance use in Kentucky. LHDs work diligently with needle exchange programs to address these issues.

State Statutes and Other Regulations that Have Relevance to Title V Program Authority

KY Revised Statutes (KRS) and KY Administrative Regulations (KAR) of relevance to KYs Title V program authority are described in this section to provide the basis for MCH programs and their required activities.

• KRS 211.180 gives the CHFS the responsibility and authority to formulate, promote, establish and execute policies, plans and programs relating to all matters of public health. This KRS supports MCH population efforts.  It states that the CHFS is responsible for “the protection and improvement of the health of expectant mothers, infants, preschool, and school-aged children” and “the protection and improvement of the health of the people through better nutrition”
• KRS 211.180 authorizes MCH to protect and improve the health of expectant mothers. Decades ago, the legislature provided funding to MCH with the intent that no pregnant woman in KY will go without prenatal care due to lack of ability to pay
• 902 KAR 4:100 established the public health prenatal program to administer these funds and set the financial eligibility for those in need of prenatal care at 185% and below of the FPL who are not covered by Medicaid or any other funding source. The public health prenatal program serves as a core public health service and is the primary strategy for reducing maternal morbidity and mortality, and infant morbidity and mortality
• KRS 211.755 stipulates that a mother may breastfeed her baby or express breast milk in any location, public or private, where the mother is otherwise authorized to be, this is in addition to the nutrition provisions in KRS 211.180
• KRS 344.030-.10 prohibits employment discrimination in relation to an employee’s pregnancy, childbirth, and related medical conditions.  It required reasonable accommodations for the employee and is the first lactation accommodation requirement in KY. This law becomes effective June 27, 2019.
• KRS 214.160 requires Hepatitis C screening for all pregnant women and documented in the infant’s medical record to assure the child receives serologic testing at the 24-month well-child exam.
• KRS 214.160 permits the provider to administer toxicology screening to the pregnant woman or infant after delivery if the provider has reason to believe there was prenatal exposure of newborn or that the mother used any substance for a nonmedical purpose.  Positive toxicology findings shall be evaluated by the provider to determine if abuse or neglect of infant occurred and referred to DCBS as per KRS 600.020(1)
• KRS 344.030-.110 establishes the Pregnant Workers Act which prohibits discrimination to an employee for pregnancy, childbirth, or other related medical conditions and is the first lactation accommodation requirement in KY
• KRS 214.155 requires Newborn Screening (NBS) and authorizes the NBS program to collect data for inborn errors of metabolism and other hereditary disorders by and allows the state to add any conditions to the panel that are recommended by the American College of Medical Genetics. KY currently screens for 58 disorders
• KRS 304.17 establishes the Metabolic Foods and Formula program to provide needed supplements and special foods to children with metabolic disorders as a payor of last resort. Medicaid and insurance companies are required to provide these for their enrolled patient population up to a cap of $25,000
• KRS 211.645, 211.647, and 216.2970 established the Early Hearing Detection and Intervention Program (overseen by OCSHCN) which screens newborns for hearing loss prior to discharge from Kentucky birthing hospitals
• KRS 211.651 authorizes the Kentucky Birth Surveillance Registry to obtain data on all children up to the age of five years with congenital anomalies or disabling conditions. Reporting sources include acute care hospitals, outpatient records, and laboratory reporting
• KRS 211.192 directs KDPH to make available up-to-date information on spina bifida.

• KRS 211.676 requires birthing hospitals to report all diagnosed NAS cases to KDPH
• KRS 211.690 established HANDS as a voluntary home visitation for first time, at-risk parents as a primary service delivery strategy in 2000
• 902 KAR 4:120 sets the definitions, eligibility criteria and provider qualifications for the HANDS program
• 907 KAR 3:140 established HANDS funding from the Master Tobacco Settlement and in accordance with Medicaid. Since 2011, the HANDS program has had federal support from the MIECHV grant
• KRS 200.654 allows MCH, as part of the CHFS, to administer state and federal funds to the First Steps Program (Part C of the Individuals with Disabilities Education Act) to provide early intervention services for infants and toddlers with disabilities and their families
• 902 KAR 30:150 defines First Step provider qualifications
• KRS 211.901 addresses the statewide Childhood Lead and Poisoning Prevention Program (CLPPP) for the prevention, screening, diagnosis and treatment of lead poisoning
  • KRS 211.900 defines at-risk populations for lead poisoning
  • KRS 211.903 specifies the intervals of screening of at-risk children
  • KRS 211.904 states that the CHFS shall establish an educational program to inform multiple of the dangers, frequency, and sources of lead poisoning and the methods of preventing such poisoning
• KRS 211.686 established the Public Health Local Child Fatality Review (CFR) Program in 1996.  This statute allows local teams to assist the coroner in determining an accurate manner and cause of death
• KRS 213.161 initiated grief counseling through LHDs for families who have lost an infant to Sudden Infant Death Syndrome (SIDS)
• KRS 211.686 was amended in 2018 to add Maternal Mortality Review to the child fatality review allowing for review of cases of maternal death to establish prevention activities and align with best practice guidelines as defined by the CDC. The legislation for child and maternal mortality protects against discoverability of review information
• KRS 199.8945 establishes technical assistance for childcare providers through the Healthy Start in Child Care Program. This statute mandates training and education of child care providers in child health and safety to increase awareness and education for parents of children who attend child care
• KRS 211.190 (11) requires CHFS to provide public health services that include water fluoridation programs for the protection of dental health
  • 902 KAR 115:010 sets forth the requirements for the water fluoridation program. KY has the highest percentage of fluoridated water systems in the country, at 98%
• KRS 313.040 created a special licensure category for Public Health Registered Dental Hygienists (RDH) that expands the scope of preventative dental work that the public health RDH can do without requiring the presence of a dentist on site
• KRS 156.160 requires that all children entering public school have a dental assessment; while this is the responsibility of the KDE, the MCH State Dental Director provides training and technical assistance
• KRS 156.501 establishes a full time position in the KDE for a school nurse consultant, to develop protocols for health procedures, quality improvement, and health data collection in schools. MCH funds half of this position and collaborates to develop guidance for health management in schools
• KRS 200.460-200.499 established program authority for CYSHCN services. The authorizing statute reads in part: that OCSHCN “shall provide through contractual agreement, or otherwise, such services as may be necessary to locate, diagnose, treat, habilitate, or rehabilitate children with disabilities, and may include any necessary auxiliary services”. Remaining statutes address conditions of acceptance for children, payment for care, confidentiality of records, and reporting.
• OCSHCN has been in the process of creating three new Kentucky Administrative Regulations (KAR) in order to provide greater transparency to the public. OCSHCN has filed the three new KARs and filed to repeal another two KARs. The new KARs cover applying to OCSHCN, issues pertaining to medical staff, and OCSHCN billing and fees. OCSHCN anticipates these will be enacted after the July 19, 2019 meeting of Kentucky’s Interim Joint Committee on Health, Welfare, and Family Services. If enacted, the new KARs may be found at https://apps.legislature.ky.gov/law/kar/TITLE911.HTM