kentucky mental health system guidebook€¦ · a.5. behavioral health safety-net delivery system...

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KentuckyMental Health System Guidebook

December 2018 MRC2.CORP.X.03182

The information provided by PsychU is intended for your educational benefit only. It is not intended as, nor is it a substitute for medical care or advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.2

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You should seek independent, qualified professional advice to ensure that your organization is in compliance with the complex legal and regulatory requirements governing health care services, and that treatment decisions are made consistent with the applicable standards of care.

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A. Executive SummaryA.1. Kentucky Physical Health Care Coverage Map A.2. Kentucky Behavioral Health Care Coverage MapA.3. Medicaid System OverviewA.4. Medicaid Care Coordination InitiativesA.5. Behavioral Health Safety-Net Delivery SystemA.6. Behavioral Health Safety-Net Delivery System (Continued)A.7. Behavioral Health Safety-Net Delivery System: CMHC Regions

B. Kentucky Health Financing System OverviewB.1. Population DemographicsB.2. Population CentersB.3. Population Distribution By Payer National vs. State B.4. Largest Kentucky Health Plans By EnrollmentB.5. Largest Kentucky Health Plans By Estimated SMI EnrollmentB.6. Health Insurance Marketplace

C. Medicaid Administration, Governance & OperationsC.1. Medicaid Governance: Key LeadershipC.2. Medicaid Expansion StatusC.3. Medicaid Program Benefits

D. Medicaid Financing & Service Delivery SystemD.1. Medicaid Financing & Service Delivery SystemD.2. Medicaid Service Delivery System Enrollment By Eligibility GroupD.3. Medicaid FFS Program: OverviewD.4. Medicaid FFS Program: Behavioral Health BenefitsD.5. Medicaid FFS Program: SMI PopulationD.6. Medicaid Managed: Care Program OverviewD.7. Medicaid Managed Care Program: Behavioral Health Benefits

D. Medicaid Financing & Service Delivery System (Continued)D.8. Medicaid Managed Care Program: SMI PopulationD.9. Medicaid Program: Care Coordination InitiativesD.10. Medicaid Program: Demonstration & Care Management WaiversD.11. Medicaid Program: Section 1915 (c) HCBS Waivers

E. State Behavioral Health Administration & Finance System E.1. DBHDID: Organization Chart E.2. DBHDID: Key LeadershipE.3. Mental Health & Addiction Hospital Bed DistributionE.4. State Psychiatric InstitutionsE.5. State Psychiatric Institutions (Continued)

F. State Behavioral Health Stakeholder OrganizationsF.1. Accountable Care Organizations

G. AppendicesAcronym LegendGlossary Of TermsSources

Behavioral Health Market Profile Overview

For acronym definitions, please see Appendices.


A. Executive SummaryReturn to the Table Of Contents


A.1. Kentucky Physical Health Care Coverage Map

Total Kentucky Population- 4,436,974Estimated SMI Population- 217,799



A.2. Kentucky Behavioral Health Care Coverage Map



A.3. Medicaid System Overview

Medicaid Financial Delivery System Enrollment

Total Medicaid Population Distribution • As of November 2018: 9% in FFS, 91% in managed care

SMI Population Inclusion In Managed Care

• Kentucky does not specifically preclude individuals with SMI from enrolling in managed care, therefore, the majority of the SMI population is enrolled in managed care

• Estimated 5% of population in FFS, 95% in managed care

Dual Eligible Population Inclusion In Managed Care

• Managed care is mandatory for dual eligibles receiving LTSS• Estimated 31% of population in FFS, 69% in managed care

Medicaid Financing & Risk Arrangements: Behavioral HealthService Type FFS Population Managed Care Population

Traditional Behavioral Health Covered FFS by the state Included in the health plan’s capitation rate

Specialty Behavioral Health Covered FFS by the state Included in the health plan’s capitation rate

Pharmaceuticals Covered FFS by the state Included in the health plan’s capitation rate

LTSS Covered FFS by the state Covered FFS by the state



A.4. Medicaid Care Coordination Initiatives

Medicaid Care Coordination Entities For Chronic Care Populations (Including SMI)

Care Coordination Entity Active Program Description

Managed Care Health Plan The state requires the health plans to provide care coordination

PCCM None

ACO Program None

ACA Model Health Home None

PCMH None



A.5. Behavioral Health Safety-Net Delivery System

• The Health Care Access Branch within the Department For Public Health within the Kentucky CHFS administers programs that provide physical health services to the safety-net population

Physical Health Services

• The DBHDID provides services to the uninsured population through 14 CMHCs

Mental Health & Addiction Treatment Services

State Agency Responsible For Uninsured Citizens & Delivery System Model



• KRS 210 established 14 regional boards, called MHID boards, to provide mental health, addiction disorder, and developmental disability services to uninsured populations

• MHID boards are private, non-profit organizations, which serve residents of designated multi-county regions through eponymous CMHCs

• CMHC services include the following:a. Inpatient servicesb. Outpatient servicesc. Therapeutic rehabilitation servicesd. Emergency services

• CMHCs operate through a combination of state, local, and federal funds, and accept both Medicaid and sliding-scale fees as payment

A.6. Behavioral Health Safety-Net Delivery System(Continued)



Community Mental Health Center Regions

Region 1 Region 2 Region 3 Region 4 Region 5

Region 6 Region 7 Region 8 Region 9/10 Region 11

Region 12 Region 13 Region 14 Region 15

A.7. Behavioral Health Safety-Net Delivery SystemCMHC Regions



B. KentuckyHealth Financing System Overview

Return to the Table Of Contents


138% of poverty level

Population Distribution By Income To Poverty Threshold Ratio

200% and above

139% to 199%

101% to 138%

100% and below

B.1. Population Demographics

26thmost populous

state in the nation 1% of the U.S. population

Median Income

Kentucky$46,659

U.S.$57,617

KY U.S.

Kentucky & U.S. Racial CompositionPopulation Distribution By Age

Under 18(1,012,467)

23%

Ages 18 to 64(2,736,992)

62%

Age 65+(687,525)

15%

Total Kentucky Population- 4,436,974Estimated SMI Population- 217,799


7% 6%

15% 13%

14% 11%

63% 70%

61%

85%

12%

8%

18%

3%

9%

4%

U.S.

KY

White Black Hispanic Other


Evansville

Owensboro

Clarksville

Bowling Green

Elizabethtown-Fort Knox

Louisville/Jefferson County

Lexington-Fayette

Cincinnati

Huntington-AshlandMSA

South Bend-Mishawaka

B.2. Population Centers


Urban 4%

Rural 96%

Distribution Of Land Area

Urban58%

Rural 42%

Distribution Of PopulationMetropolitan Statistical Areas (MSAs)

MSA Kentucky Residents

Percent Of Population

Total MSA Population 2,603,630 59%

Louisville/Jefferson County, KY-IN 999,183 23%

Lexington-Fayette 506,751 11%

Cincinnati, OH-KY-IN 442,184 10%

Bowling Green 171,122 4%

Elizabethtown-Fort Knox 149,538 3%

Owensboro 117,959 3%

Clarksville, TN-KY 86,615 2%

Huntington-Ashland, WV-KY-OH 84,025 2%

Evansville, IN-KY 46,253 1%


B.3. Population Distribution By PayerNational vs. State


56%

54%

17%

21%

2%

2%

1%

2%

10%

13%

11%

5%

2%

2%

U.S.

KY

Commercial Medicaid Full Duals Partial Duals Medicare Uninsured Other Public


Plan Name Plan Type Enrollment*Anthem Health Plans Of Kentucky Commercial ASO 1,298,317

Medicare FFS Medicare 620,754

WellCare Medicaid 440,834

Anthem Health Plans Of Kentucky Commercial 391,238

Passport Medicaid 308,207

Aetna Medicaid 220,815

Humana Medicaid 144,573

TRICARE Other Public 142,423

UnitedHealth Commercial ASO 132,780

Anthem Medicaid 127,540

B.4. Largest Kentucky Health Plans By Enrollment

* Medicaid enrollment as of November 2018; TRICARE as of April 2018; Commercial as of 4th quarter 2017; Medicare enrollment as of September 2017



Plan Name Plan Type Enrollment* Estimated SMI Enrollment Medicare FFS Medicare 620,754 88,768

WellCare Medicaid 440,834 39,234

Anthem Health Plans Of Kentucky Commercial ASO 1,298,317 29,861

Passport Medicaid 308,207 27,430

Aetna Medicaid 220,815 19,653

Humana Medicaid 144,573 12,867

Anthem Medicaid 127,540 11,351

HumanaChoice Medicare 68,396 9,781

Anthem Health Plans Of Kentucky Commercial 391,238 8,998

TRICARE Other Public 142,423 7,976

B.5. Largest Kentucky Health Plans By Estimated SMI Enrollment

* Medicaid enrollment as of November 2018; TRICARE as of April 2018; Commercial as of 4th quarter 2017; Medicare enrollment as of September 2017



B.6. Health Insurance Marketplace

Health Insurance Marketplace

Type Of Marketplace State-based using federal platform

Individual Enrollment Contact

https://www.healthcare.gov/

1-800-318-2596

Small Business Enrollment Contact

No small group plans are available through the marketplace

Employers must purchase coverage directly from an insurance carrier or through an insurance broker

2018 Individual Market Health Plans1. Anthem Health Plans Of KY (Anthem BCBS)2. CareSource Kentucky

2018 Small Group Market Health Plans

None



C. Medicaid Administration, Governance & Operations



C.1. Medicaid GovernanceKey Leadership

Name Position Department

Vickie Yates Brown Glisson Secretary CHFS

Timothy Feeley Deputy Secretary CHFS

Carol H. Steckel Commissioner, State Medicaid Director Department For Medicaid Services

Veronica Cecil Deputy Commissioner Department For Medicaid Services

Vickie Yates Brown Glisson Secretary CHFS



C.2. Medicaid Expansion Status

Medicaid Expansion

Participating In Expansion Yes

Date Of Expansion January 2014

Medicaid Eligibility Income Limit For Able-Bodied Adults

133% of the FPLNote: The PPACA requires that 5% of income be disregarded in eligibility determination

Legislation Used To Expand Medicaid None; Medicaid expansion was authorized by the governor in 2013 through an executive order

Number Of Individuals Enrolled In The Expansion Group (December 2016)

466,193

Number Of Enrollees Newly Eligible Due To Expansion 466,193

Benefits Plan For Expansion Population

• Currently, the Kentucky ABP is identical to the state plan; the state plans to submit a revised ABP to the state that does not include dental, vision, or over-the-counter medications

• Medically frail individuals must be offered the full array of state plan services• Individuals with SMI or chronic addiction are considered to be medically frail



C.3. Medicaid Program Benefits

Federally Mandated Services1. Inpatient hospital services other than services in an IMD2. Outpatient hospital services 3. Rural Health Clinic services4. FQHC services5. Laboratory and x-ray services6. Nursing facilities for individuals 21 and over7. EPSDT8. Family planning services and supplies9. Free standing birth centers10. Pregnancy-related and postpartum services11. Nurse midwife services12. Tobacco cessation programs for pregnant women13. Physician services14. Medical and surgical services of a dentist15. Home health services16. Nurse practitioner services17. Non-emergency transportation to medical care

Kentucky’s Optional Services1. Podiatrists’ services2. Chiropractors' services3. Other practitioners’ services4. Private duty nursing5. Clinic services6. Dental services7. Physical and occupational therapy8. Services for individuals with speech, hearing, and language

disorders9. Prescribed drugs 10. Prosthetics and eyeglasses11. Diagnostic, screening, and preventive services12. Rehabilitative services13. Services for individuals age 65 or older in IMDs14. Services in an ICF/IDD15. Inpatient psychiatric facilities for individuals under age 2216. Hospice care



D. Medicaid Financing & Service Delivery System



D.1. Medicaid Financing & Service Delivery System

Total Medicaid: 1,361,420 | Total Medicaid With SMI: 119,451


Medicaid System CharacteristicsCharacteristics Medicaid FFS Medicaid Managed Care

Enrollment (2017) 119,451 1,241,969

SMI Enrollment• Kentucky does not specifically preclude individuals with SMI from enrolling in managed care,

therefore, the majority of the SMI population is enrolled in managed care• It is estimated 5% of the SMI population in FFS, 95% in managed care

Management Department Of Medicaid Services Five Health Plans

Payment Model FFS Capitated Rate

Geographic Service Area Statewide Statewide


D.2. Medicaid Service Delivery System Enrollment By Eligibility Group


Population Mandatory FFS Enrollment Option To Enroll In FFS Or Managed Care

Mandatory Managed Care Enrollment

Parents & Caretakers X

Children X

Blind & Disabled Individuals X

Aged Individuals X

Dual Eligibles X (Partial Benefit) X (Full Benefit)

Medicaid Expansion X

Individuals Residing In Nursing Homes X

Individuals Residing In ICF/IDD X

Individuals In Foster Care X

Other Populations

• Enrolled in another managed care program• Participate in state’s HCBS waivers• Recipients in the Breast & Cervical Cancer program• Individuals on spenddown • Working disabled• Time limited aliens


• FFS enrollment as of November 2018 was 119,451

D.3. Medicaid FFS ProgramOverview



D.4. Medicaid FFS ProgramBehavioral Health Benefits


FFS Addiction Treatment Benefits1. Inpatient services2. Residential services3. SBIRT4. Screening5. Assessment6. Psychological testing7. Crisis intervention 8. Mobile crisis9. Residential crisis stabilization 10. Day treatment11. Peer support12. Intensive outpatient program13. Individual, group, and family outpatient therapy14. Partial hospitalization

FFS Mental Health Benefits1. Inpatient services2. Service planning3. Assertive community treatment4. Comprehensive community support services5. Therapeutic rehabilitation program6. Screening7. Assessment8. Psychological testing9. Crisis intervention 10. Mobile crisis11. Residential crisis stabilization 12. Day treatment13. Peer support14. Intensive outpatient program15. Individual, group, and family outpatient therapy16. Partial hospitalization



• It is estimated 5% of the SMI population in FFS

D.5. Medicaid FFS ProgramSMI Population



• Managed care enrollment as of November 2018 was 1,241,969

• The health plans deliver physical health and behavioral health benefits for most populations, including families and children, Medicaid expansion adults, and aged and disabled adults

• There are five health plans available statewide and individuals have their choice of plan

• The state submitted a community engagement and cost-sharing waiver for the Medicaid expansion and parent/caretaker population, which was approved by CMS in January 2018– The requirements were challenged in court, and the court required CMS to review the waiver– CMS re-approved the waiver on November 20, 2018, with an effective date of April 2019

D.6. Medicaid Managed Care ProgramOverview



D.7. Medicaid Managed Care ProgramBehavioral Health Benefits


All behavioral health and pharmacy benefits are included in the health plan’s capitation rate

Managed Care Addiction Treatment Benefits1. Inpatient services2. Residential Services for SUD3. SBIRT4. Screening5. Assessment6. Psychological testing7. Crisis intervention 8. Mobile crisis9. Residential crisis stabilization 10. Day treatment11. Peer support12. Intensive outpatient program13. Individual, group, and family outpatient therapy14. Partial hospitalization

Managed Care Mental Health Benefits1. Inpatient services2. Service planning3. Assertive community treatment4. Comprehensive community support services5. Therapeutic rehabilitation program6. Screening7. Assessment8. Psychological testing9. Crisis intervention 10. Mobile crisis11. Residential crisis stabilization 12. Day treatment13. Peer support14. Intensive outpatient program15. Individual, group, and family outpatient therapy16. Partial hospitalization



• It is estimated that as of October 2018, 95% of the SMI population was enrolled in managed care

D.8. Medicaid Managed Care ProgramSMI Population



ACO Program ACA Health Home PCMH Other Care Coordination Initiative

D.9. Medicaid ProgramCare Coordination Initiatives

None NoneNone None



D.10. Medicaid ProgramDemonstration & Care Management Waivers


Waiver Title Waiver Description WaiverType

Enrollment Cap

EffectiveDate

ExpirationDate

Kentucky HEALTH Authorizes the state to implement community engagement and cost sharing requirements. Its also allows the state to provide addiction treatment in IMDs

1115 None 04/01/2019 09/30/2023

Kentucky MCO (KY-07) Authorizes the state to provide Medicaid services through health plans 1915 (b) None 11/01/2015 06/30/2018

Kentucky HSTD (NEMT) (KY-06)

Allows the state to limit choice of non-emergency medical transportation provider for eligible Medicaid, Vocational Rehabilitation, & Department Of The Blind recipients

1915 (b) None 07/01/2016 06/30/2018

The state’s 1115 demonstration waiver Kentucky HEALTH, in addition to imposing work and community engagement requirements, allows the state to provide addiction treatment services in IMDs

Provider organizations will also be required to use the six dimensions of the ASAM criteria to assess and develop treatment plans for individuals


D.11. Medicaid ProgramSection 1915 (c) HCBS Waivers


Waiver Title Target Population2018Enrollment Cap

Operating UnitConcurrent Management Authority

KY HCBS (0144.R05.00) Individuals over the age of 65 and between the ages of 18-64 who are physically disabled 17,050 Department For Aging &

Independent Living No

KY Michelle P. Waiver (0475.R02.00) Individuals with I/DD of any age 10,500 DBHDID No

KY Supports For Community Living (0314.R04.00) Individuals with I/DD over the age of three 4,941 DBHDID No

KY HCBS Transitions (0967.R00.00)

Individuals over the age of 65 and between the ages of 18-64 who are physically disabled 500 Department For Medicaid Services No

KY Acquired Brain Injury (0333.R04.00) Individuals with brain injury over the age of 18 383 Department For Medicaid Services No

KY Model Waiver II (40146.R06.00)

Individuals who are technology dependent of any age 100 Department For Medicaid Services No


E. State Behavioral Health Administration & Finance System



E.1. DBHDIDOrganization Chart



E.2. DBHDIDKey Leadership


Name Position DepartmentVickie Yates Brown Glisson Secretary CHFS

Wendy Morris Commissioner DBHDID

Allen Brenzel, MD Medical Director DBHDID

Dee Werline Deputy Commissioner DBHDID

Stephanie Craycraft Deputy Commissioner DBHDID


E.3. Mental Health & Addiction Hospital Bed Distribution

Mental Health & Addiction Treatment Bed Capacity

Total number of hospitals with mental health and addiction beds

32

Number of mental health and addiction beds 1,788

Number of mental health and addiction beds per 100,000 population

40.30

0.00

0.01 to 10.00

10.01 to 30.00

30.01 to 50.00

More than 50.00

Mental Health & Addiction Hospital Beds Per 100,000 Population



E.4. State Psychiatric Institutions


State Psychiatric Institutions

Institution Location 2017 Licensed Beds

2017 Beds In Operation

2017 Average Daily Census

Appalachian Regional Hospital Psychiatric Center Hazard 100 100 56

Central State Hospital Louisville 192 112 60

Eastern State Hospital Lexington 195 140 112

Kentucky Correctional Psychiatric Center (Forensic) LaGrange 97 76 57

Western State Hospital Hopkinsville 495 160 106

Total 1,079 588 391


E.5. State Psychiatric Institutions (Continued)


ARH Psychiatric Center Central State Hospital Eastern State Hospital Western State Hospital


F. State Behavioral Health Stakeholder Organizations



F.1. Accountable Care Organizations


Medicare Shared Savings Program1. ACO Health Partners2. Aledade West Virginia ACO3. Ampliphy Of Kentucky ACO4. Arkansas High Performance Network

Of FQHC 5. Ascension Care Management Health

Partners Evansville6. Baptist Health Care Partners7. Bluegrass Clinical Partners8. Bon Secours Good Helpcare

9. Central US ACO 10. Eastern Kentucky Clinical Partners 11. Genesis Healthcare ACO12. Healthcare Solutions Network13. Indiana Rural ACO14. Jackson Purchase Medical Associates15. Kentucky Good Help ACO16. Kentucky Physicians For Accountable

Care17. Kentucky Primary Care Alliance Region 2

18. Mercy Health Select19. Owensboro ACO20. Pioneer Health Alliance21. Pricare ACO22. Quality Independent Physicians23. Southern Kentucky Health Care Alliance

ACO24. The Health Network Of Western Kentucky 25. Western Kentucky Clinical Partners26. Winding River ACO

CommercialACO Commercial InsurerNorton Healthcare Humana

Medicare Next Generation ACO1. Deaconess Care Integration LLC2. KentuckyOnehealth Partners LLC


G. AppendicesReturn to the Table Of Contents


Acronym Definition Acronym Definition Acronym Definition

ABP Alternative Benefit Plan FPL Federal Poverty Level MHID Mental Health Or Individuals With An Intellectual Disability

ACA / PPACA Patient Protection & Affordable Care Act FQHC Federally Qualified Health Center MSA Metropolitan Statistical Area

ACO Accountable Care Organization HCBS Home & Community Based Services OH Ohio

ASAM American Society Of Addiction Medicine HMO Health Maintenance Organization PCCM Primary Care Case Management

ASO Administrative Services Organization I/DD Intellectual / Developmental Disabilities PCMH Patient-Centered Medical Home

BCBS Blue Cross Blue Shield ICF / IDD Intermediate Care Facilities For Individuals With Intellectual Disabilities SBIRT Screening, Brief Intervention, & Referral To

Treatment

CHFS Cabinet For Health & Family Services IMD Institution For Mental Disease SMI Serious Mental Illness

CMHC Community Mental Health Center IN Indiana SNP Special Needs Plan

CMS Centers For Medicare & Medicaid Services KY Kentucky SUD Substance Use Disorder

DBHDID Department For Behavioral Health, Developmental, & Intellectual Disabilities KRS Kentucky Revised Statutes TN Tennessee

EPSDT Early & Periodic Screening & Diagnosis & Treatment LTSS Long-Term Services & Supports WV West Virginia

FFS Fee-For-Service MCO Managed Care Organization

Acronym Legend

44


Glossary Of Terms

Word Abbreviation Definition

Alternative BenefitPlan ABP

State designed benefit package for the Medicaid expansion population (childless adults with income below 138% of the FPL). The benefit package must include the ten essential benefits as laid out in the PPACA. The Medicaid expansion population deemed medically frail (including those with SMI) are exempt from receiving benefits through the ABP.

Accountable Care Organizations ACO

ACOs are groups of providers—such as physicians and hospital systems—that form an agreement to coordinate care for a set group of consumers. If the ACO delivers high quality care—measured through performance metrics—and lowers the cost of providing care against a baseline, then the organization receives a portion of the savings generated. ACOs can exist alongside all payment structures (fee-for-service and managed care delivery systems) and payers (Medicare, Medicaid, commercial).

Administrative Services Organization ASO An arrangement in which an organization hires a third party to deliver administrative services to the organization,

such as claims processing and billing. The organization bears the risk for all claims.

Capitation A set amount of money paid per enrollee per month to a health care entity to cover the cost of health care services. Generally the entity assumes full-risk for the cost of each enrollee's care.

Carve-outA Medicaid financing model where some portion of Medicaid behavioral health benefits— mental health outpatient, psychiatric inpatient, addiction treatment, pharmacy, etc. —is separately managed and/or financed. This can either be on an at-risk basis by another organization, or retained by the state Medicaid agency on a fee-for-service basis.

Certified Community Behavioral Health Clinic

CCBHC

Behavioral health clinics specially certified in a demonstration established by section 223 of the Protecting Access to Medicare Act of 2014. The clinics are designed to provide community-based mental health and addiction treatment services, to advance the integration of behavioral health with physical health care, and to provide care coordination across the full spectrum of health services.


Glossary Of Terms


Community Mental Health Center CMHC

An organization that can demonstrate that it is actively providing all services in section 1913(c)(I) of the Public Health Services Act, including a.) Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of the CMHC’s mental health service area who have been discharged from inpatient treatment at a mental health facility; b.) 24 hour-a-day emergency care services; c.) Day treatment, or other partial hospitalization services, or psychosocial rehabilitation services; and d.) Screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission. Additionally, the organization must meet the specifications for the state where it provides services.

Delivery SystemReform Incentive Payment

DSRIP

A program that administers federal and state 1115 waiver savings to provider organizations to develop and implement transformative delivery systems through infrastructure development and innovative care models. The goals of these transformations is to improve care for individuals, improve care for populations, and lower costs through efficiencies.

Disproportionate Share Hospital DSH Hospitals that serve an above average number of low-income and uninsured patients. State Medicaid programs

provide DSH payments to these hospitals to ease the burden of serving low-income and uninsured patients.

Dual EligibleAn individual who is eligible for Medicare (Part A and B) and Medicaid. Medicare serves as the individual's primary insurance, and Medicaid acts as a supplement. Dual eligibles are sometimes referred to as Medicare-Medicaid enrollees (MMEs).

Federal Poverty Level FPLThe U.S. Department of Health and Human Services sets a standard level of income that is used to determine eligibility for services and benefits, including Medicaid. In 2018, the FPL is $12,140 for an individual and $25,100 for a family of four.

Fee-For-Service FFS A system in which provider organizations are reimbursed for each covered service such as an office visit, test, or procedure according to rates set by the payer.


Glossary Of Terms


Health Home

A “whole person” care coordination model that specifically targets populations with chronic conditions including those with SMI. Health homes provide six essential functions: 1.) Comprehensive care management; 2.) Care coordination and health promotion; 3.) Comprehensive transitional care from inpatient to other settings, including appropriate follow-up; 4.) Individual and family support; 5.) Referral to community and social support services; 6.) Use of health information technology to link services.

Health Insurance Marketplace HIM

Created by the PPACA, the health insurance marketplace is an online service where individuals and small businesses can purchase health insurance. The federal government subsidizes coverage purchased on the marketplace through premium tax credits for individuals with income up to 400% of the FPL.

Home- & Community-Based Services HCBS

Long-term services and supports provided in the home or community in order to avoid institutionalization. Traditionally provided through 1915(c) waivers, HCBS services are usually limited to specific populations and a specific number of people. HCBS services include skilled nursing care, personnel care services, assistance with activities of daily living, and custodial care.

Institutions For Mental Disease IMD

A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including addiction. Federal financial participation is available for Medicaid IMD services for individuals under the age of 21 and age 65 and over. In recent years, CMS has relaxed the rules prohibiting payments in IMDs for individuals age 21-64. Medicaid health plans may provide up to 15 days of IMD services per month in lieu of state plan services if medically appropriate, cost effective, and consented to by the individual. Additionally, states may be granted a 1115 waiver authority to allow individuals to receive residential addiction treatment in IMDs.

Long-Term Services & Supports LTSS

Services provided in the home, community, or institutional setting to those who experience difficulty living independently and completing activities of daily living as a result of cognitive disabilities, physical impairments,disabling chronic conditions and/or age.


Glossary Of Terms


Managed Care/ Managed CareOrganization

MCO

A health care delivery and financing system designed to manage cost, utilization, and quality. In Medicaid, states generally implement managed care through contracts with health plans, which provide a limited set of benefits to enrollees through a capitated or per person per month (PMPM) rate. The health plans generally assumes full-risk for the cost of treatment, and therefore usually contracts with a network of provider organizations to provide care at the most efficient rate possible while still maintaining member health.

Medicaid

Medicaid is a joint federal-state program that provides health coverage to economically disadvantaged populations, such as low-income adults, children, and aged, blind, and disabled (ABD) individuals. States establish their own eligibility standards, benefit packages, provider payment policies, and administrative structures under broad federal guidelines. Financing is a shared responsibility of the federal government and the states.

Medicaid Waiver Granted by CMS, waivers allow states to make temporary changes to their Medicaid State Plan in order to test out new ways to deliver health coverage. Importantly, the waivers must be budget neutral.

Medicaid Waiver Section 1115 1115 waiver Known as research and demonstration waivers, states can apply for program flexibility to test new or existing

approaches to financing and delivering Medicaid and CHIP.

Medicaid Waiver Section 1915(b) 1915(b) waiver States can apply for waivers to provide services through managed care delivery systems, or otherwise limit

people's choice of providers.

Medicaid Waiver Section 1915(c) 1915(c) waiver States can apply for waivers to provide long-term care services in home and community-based settings, rather than

institutional settings.

Medicaid WaiverConcurrent Section 1915(b) & 1915(c)

States can apply to simultaneously implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all Federal requirements for both programs are met.


Glossary Of Terms


Medical HomeA medical home is not a physical place, but a model for care coordination. Medical homes provide primary care services, care coordination, enhanced access to care, and care that is culturally and linguistically appropriate. Medical homes exist across multiple payers.

MedicareFederal health insurance for individuals over the age of 65, individuals with certain disabilities, and individuals with end stage renal disease. Medicare covers most acute care services (which may include psychiatric care), but does not cover LTSS or non-physician behavioral health services.

Medicare Advantage MAMedicare Part C - also known as Medicare Advantage - is a program which allows individuals who are eligible for Medicare Parts A and B to elect a private health plan to provide their Medicare coverage. The federal government pays the plan's premiums up to a set level, and individuals are responsible for the difference.

Medicare Advantage Special Needs Plan SNP

A special type of Medicare Advantage plan that is designed to provide targeted coordinated care to individuals who are a) institutionalized; b) dual eligible; and/or c) meet the severe chronic disabled conditions set forth by CMS. Plans emphasize improved care primarily through continuity of care and care coordination.

Medicare Part AHospital Insurance: Covers hospital, skilled nursing care, hospice, and home health care for most eligible individuals at no cost. Financed through payroll tax and deductibles, copayments are only charged if a stay becomes long-term.

Medicare Part B Supplementary Medical Insurance: Covers most outpatient services, and consumers pay a premium based on income level.

Medicare Part CMedicare Part C - also known as Medicare Advantage - is a program which allows individuals who are eligible for Medicare Parts A and B to elect a private health plan to provide their Medicare coverage. The federal government pays the plan's premiums up to a set level, and individuals are responsible for the difference.


Glossary Of Terms


Medicare Part D Outpatient Prescription Drug Benefit: Private plans contract with Medicare to provide coverage for prescription drugs. Most consumers pay premiums based on their income.

MetropolitanStatistical Area MSA An urbanized area of 50,000 or more population plus adjacent territory that has a high degree of social and

economic integration as measured by commuting ties.

Patient-Centered Medical Home PCMH See Medical Home.

Patient Protection & Affordable Care Act

PPACA or ACA

U.S. health care reform signed into law in 2010. The legislation regulates certain aspects of private and public health insurance programs and authorizes an individual mandate to secure essential health coverage, premium tax credits for the purchase of private health insurance, and increased insurance coverage of preexisting conditions. In 2012 the Supreme Court ruled that state participation is optional for provisions of the law expanding Medicaid coverage to adults ages 18 to 64 with incomes under 138% of the FPL. In 2017, Congress repealed the tax penalties associated with the individual mandate essentially ending the mandate.

Pay-For-Performance P4P A health care payment model that offers financial rewards to organizations that meet or exceed pre-determined quality benchmarks. Typically, services continue to be reimbursed FFS.

Primary Care Case Management PCCM

A health care delivery system model with limited utilization and cost control. Under the PCCM model, Medicaid enrollees choose a primary care physician who acts as a gatekeeper for more intensive services. The primary care physician generally receives a per person per month (PMPM) fee for care coordination, and is reimbursed fee-for-service for all medical services provided. Some states consider PCCM a managed care delivery model, while other states consider it an FFS delivery model.


Glossary Of Terms


Program Of All Inclusive Care For The Elderly

PACE

PACE serves populations over the age of 55 who are eligible for skilled nursing home care by utilizing a comprehensive delivery system of social, medical, and long-term care services to keep enrollees in the community for as long as possible. PACE is an optional state Medicaid program, and may only be available in certain states, or regions within states.

Serious Mental Illness SMI

A mental, behavioral, or emotional disorder that lasts for a sufficient duration of time and causes impairment of major life activities. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD), and borderline personality disorder.

SupportedEmployment

Provides services and supports to help individuals with disabilities become employed in an integrated or competitive work environment, and retain that employment.

Supported Housing

Housing provided for as long as needed at little or no cost to individuals with mental illness, or other vulnerable populations who are homeless or at-risk for homelessness. Mental health and social services are offered to participants, but are not a condition for participation in the program. The goal is to allow individuals to live as self-sufficient, independent lives as possible.

Value-BasedReimbursement VBR

Reimbursement model in which payers financially reward or penalize health care provider organizations for performance on quality and cost of care. VBR payment mechanisms include P4P; capitation; shared savings models; shared risk models; and payments based on clinically-defined episodes, called episodes of care or bundled payments.


A. Executive SummaryA.1. Kentucky Physical Health Care Coverage Map – Information compiled from sources provided throughout the profile

A.2. Kentucky Behavioral Health Care Coverage Map– Information compiled from sources provided throughout the profile

A.3. Medicaid System Overview– Information compiled from sources provided throughout the profile

A.4. Medicaid Care Coordination Initiatives– Information compiled from sources provided throughout the profile

A.5. Behavioral Health Safety-Net Delivery System– Information compiled from sources provided throughout the profile

A.6. Behavioral Health Safety-Net Delivery System (Continued)– State Of Kentucky. Regional Community Mental Health Program. Retrieved December 14, 2018 at http://www.lrc.ky.gov/statutes/chapter.aspx?id=38158– Kentucky CHFS. Regional Boards for Mental Health or Individuals With an Intellectual Disability. Retrieved December 14, 2018 at http://dbhdid.ky.gov/cmhc/

A.7. Behavioral Health Safety-Net Delivery System: CMHC Regions– Kentucky CHFS. (2017, April). Kentucky State Psychiatric Hospital/Community Mental Health Center Regions. Retrieved December 14, 2018 at

http://dbhdid.ky.gov/cmhc/documents/RegionsMap.pdf

Sources

http://www.lrc.ky.gov/statutes/chapter.aspx?id=38158

http://dbhdid.ky.gov/cmhc/



B. Kentucky Health Financing System OverviewB.1. Population Demographics– United States Census Bureau. 2016 American Community Survey 1-Year Estimates K200104 Population By Age. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml– United States Census Bureau. 2016 American Community Survey 1-Year Estimates K200104 Population By Age. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml– United States Census Bureau. 2016 American Community Survey 1-Year Estimates B03002 Hispanic or Latino Origin By Race. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml– United States Census Bureau. 2016 American Community Survey 1-Year Estimates S1903 Median Income In the Past 12 Months. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml– United States Census Bureau. 2017 Current Population Survey Annual Social and Economic Supplement POV-46 Poverty Status By State. Retrieved November 29, 2017 from

https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-pov/pov-46.html

B.2. Population Centers– United States Census Bureau. Percent Urban and Rural in 2010 By State. Retrieved December 4, 2017 from https://www.census.gov/geo/reference/ua/urban-rural-2010.html– United States Census Bureau. 2016 Annual Estimates of Residential Population-Metropolitan and Micropolitan Statistical Area GCT-PEPANNRES. Retrieved December 21, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml– United States Department Of Commerce. (2013, February 28). Counties in Metropolitan Statistical Areas. Retrieved December 21, 2017 from

https://www.bea.gov/regional/docs/msalist.cfm?mlist=45

B.3. Population Distribution By Payer National vs. State – OPEN MINDS. (2018). Serious Mental Illness Prevalence Estimates.

B.4. Largest Kentucky Health Plans By Enrollment– OPEN MINDS. (2017, December). Health Plans Database.– TRICARE. (2018, April 16). Beneficiaries by Location. Retrieved May 4, 2018 from http://www.tricare.mil/About/Facts/BeneNumbers/States– Health Plans USA. (2017, September). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx– Kentucky Cabinet For Health & Human Services. (2018, November). Monthly Membership Counts by County. Retrieved December 14, 2018 at

https://chfs.ky.gov/agencies/dms/dafm/Medicaid%20Stats%20Documents/KY%20Data%20Warehouse%20Monthly%20Membership%20Counts%20by%20County2018-11-05-20-46-05.pdf

Sources

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml




https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-pov/pov-46.html

https://www.census.gov/geo/reference/ua/urban-rural-2010.html


https://www.bea.gov/regional/docs/msalist.cfm?mlist=45

http://www.tricare.mil/About/Facts/BeneNumbers/States

http://www.markfarrah.com/products/health-plans-usa.aspx



B. Kentucky Health Financing System Overview (Continued)B.5. Largest Kentucky Health Plans By Estimated SMI Enrollment– OPEN MINDS. (2017, December). Health Plans Database.– TRICARE. (2018, April 16). Beneficiaries by Location. Retrieved May 4, 2018 from http://www.tricare.mil/About/Facts/BeneNumbers/States– Health Plans USA. (2017, September). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx– Kentucky Cabinet For Health & Human Services. (2018, November). Monthly Membership Counts by County. Retrieved December 14, 2018 at


B.6. Health Insurance Marketplace– United States Department Of Health & Human Services. (2017, October 25). Plan Year 2018 Individual Medical Coverage Landscape. Retrieved November 1, 2017 from

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-Indi-Land-10-23-2017/hd64-a3rh– United States Department Of Health & Human Services. (2017, October 25). Plan Year 2018 SHOP Medical Landscape. Retrieved November 1, 2017 from

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-SHOP-Land-10-23-2017/7r3j-8gie

C. Medicaid Administration, Governance & OperationsC.1. Medicaid Governance: Key Leadership– Kentucky CHFS. (2018, October). SPA #KY 18-0011. Retrieved December 14, 2018 at https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-

Amendments/Downloads/KY/KY-18-011.pdf– Kentucky CHFS. (2018, June). SPA #KY-18-008. Retrieved December 14, 2018 at https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-

Amendments/Downloads/KY/KY-18-008.pdf

C.2. Medicaid Expansion Status– Centers For Medicare & Medicaid Services. (2017, December). MACStats: Medicaid and CHIP Data Book. Retrieved January 2, 2018 from https://www.macpac.gov/macstats/– Centers For Medicare & Medicaid Services. (2017, December). Medicaid Enrollment Data Collected Through MBES. Retrieved February 2, 2018 from

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/enrollment-mbes/index.html– US Government Publishing Office. (2011, October 1). Code of Federal Regulations Title 42. Retrieved February 2, 2018 from https://www.gpo.gov/fdsys/granule/CFR-2011-title42-

vol4/CFR-2011-title42-vol4-sec440-315– CHFS. (2018, November). Kentucky HEALTH. Retrieved December 14, 2018 at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=39258

Sources

http://www.tricare.mil/About/Facts/BeneNumbers/States

http://www.markfarrah.com/products/health-plans-usa.aspx


https://data.healthcare.gov/dataset/QHP-PY2018-Medi-Indi-Land-10-23-2017/hd64-a3rh

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-SHOP-Land-10-23-2017/7r3j-8gie

https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/KY/KY-18-011.pdf

https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/KY/KY-18-008.pdf

https://www.macpac.gov/macstats/

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/enrollment-mbes/index.html

https://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol4/CFR-2011-title42-vol4-sec440-315

https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=39258


C. Medicaid Administration, Governance & Operations (Continued)C.3. Medicaid Program Benefits – Medicaid & CHIP Payment & Access Commission. Mandatory and Optional Benefits. Retrieved December 6, 2017 from https://www.macpac.gov/subtopic/mandatory-and-optional-

benefits/– Kentucky CHFS. Kentucky Medicaid State Plan. Retrieved December 14, 2018 at https://chfs.ky.gov/agencies/dms/dafm/Documents/KYMedicaidStatePlanr1.pdf

D. Medicaid Financing & Service Delivery SystemD.1. Medicaid Financing & Service Delivery System– Information compiled from sources provided throughout the profile

D.2. Medicaid Service Delivery System Enrollment By Eligibility Group– Kentucky CHFS. (2015). Kentucky MCO (KY-07). Retrieved December 14, 2018 at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-

list/?entry=24309

D.3. Medicaid FFS Program: Overview– Kentucky Cabinet For Health & Human Services. (2018, November). Monthly Membership Counts by County. Retrieved December 14, 2018 at


D.4. Medicaid FFS Program: Behavioral Health Benefits– Kentucky CHFS. Kentucky Medicaid State Plan. Retrieved December 14, 2018 at https://chfs.ky.gov/agencies/dms/dafm/Documents/KYMedicaidStatePlanr1.pdf

D.5. Medicaid FFS Program: SMI Population– OPEN MINDS. SMI Estimates.

D.6. Medicaid Managed Care Program: Overview– Kentucky CHFS. (2018). Managed Care Organization (MCO) Contracts. Retrieved December 14, 2018 at https://chfs.ky.gov/agencies/dms/dpqo/Pages/mco-contracts.aspx– CHFS. (2018, November). Kentucky HEALTH. Retrieved December 14, 2018 at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=39258– Kentucky CHFS. (2015). Kentucky MCO (KY-07). Retrieved December 14, 2018 at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-

list/?entry=24309

Sources

https://www.macpac.gov/subtopic/mandatory-and-optional-benefits/

https://chfs.ky.gov/agencies/dms/dafm/Documents/KYMedicaidStatePlanr1.pdf




https://chfs.ky.gov/agencies/dms/dpqo/Pages/mco-contracts.aspx




D. Medicaid Financing & Service Delivery System (Continued)D.7. Medicaid Managed Care Program: Behavioral Health Benefits– Kentucky CHFS. (2015). Kentucky MCO (KY-07). Retrieved December 14, 2018 at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-

list/?entry=24309– Kentucky CHFS. Kentucky Medicaid State Plan. Retrieved December 14, 2018 at https://chfs.ky.gov/agencies/dms/dafm/Documents/KYMedicaidStatePlanr1.pdf

D.8. Medicaid Managed Care Program: SMI Population– OPEN MINDS. (2018). SMI Estimates.

D.9. Medicaid Program: Care Coordination Initiatives– Information compiled from sources provided throughout the profile

D.10. Medicaid Program: Demonstration & Care Management Waivers– Centers For Medicare & Medicaid Services. Demonstrations and Waivers. Retrieved January 5, 2018 from https://www.medicaid.gov/medicaid-chip-program-information/by-

topics/waivers/waivers_faceted.html– Kentucky CHFS. (2018, November). Federal Government Approves Kentucky’s Plan for Innovation in Medicaid Substance Use Disorder (SUD) Services. Retrieved December 14,

2018 at https://chfs.ky.gov/News/Documents/sud.pdf

D.11. Medicaid Program Section: 1915 (c) HCBS Waivers– Centers For Medicare & Medicaid Services. Demonstrations and Waivers. Retrieved January 5, 2018 from https://www.medicaid.gov/medicaid-chip-program-information/by-

topics/waivers/waivers_faceted.html

E. State Behavioral Health Administration & Finance System E.1. DBHDID: Organization Chart – Kentucky CHFS. (2018, December). Department For Behavioral Health, Developmental & Intellectual Disabilities Organization Chart. Retrieved December 14, 2018 at

https://personnel.ky.gov/DHRAOrgCharts/OC-53729.pdf

E.2. DBHDID: Key Leadership– Kentucky CHFS. (2018, January). The Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities. Retrieved December 14, 2018 at

http://dbhdid.ky.gov/kdbhdid/documents/YearInReview.pdf

Sources



https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html

https://chfs.ky.gov/News/Documents/sud.pdf

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html

https://personnel.ky.gov/DHRAOrgCharts/OC-53729.pdf

http://dbhdid.ky.gov/kdbhdid/documents/YearInReview.pdf


E. State Behavioral Health Administration & Finance System (Continued) E.3. Mental Health & Addiction Hospital Bed Distribution– OPEN MINDS. (2017, May). Hospital Database.

E.4. State Psychiatric Institutions– Kentucky CHFS. (2018, July). 2017 Kentucky Annual Hospital Utilization and Services Report. Retrieved December 14, 2018 at

https://chfs.ky.gov/agencies/os/oig/dcn/Documents/2017%20Annual%20Hospital%20Utilization%20and%20Services%20Reports.pdf

E.5. State Psychiatric Institutions (Continued)– Kentucky CHFS. (2017, April). Kentucky State Psychiatric Hospital/Community Mental Health Center Regions. Retrieved December 14, 2018 at


F. State Behavioral Health Stakeholder OrganizationsF.1. Accountable Care Organizations– OPEN MINDS. (2018). Stakeholder Database.

Sources

https://chfs.ky.gov/agencies/os/oig/dcn/Documents/2017%20Annual%20Hospital%20Utilization%20and%20Services%20Reports.pdf
