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Overview

In November 2011, Kentucky enrolled approximately ninety percent (90%) of the Medicaid population in managed care, through which Medicaid Managed Care Organizations (MCOs) are paid a fixed monthly capitated rate per enrollee and are at financial risk for recipient use and service expenditures. The MCOs are responsible for managing both physical and behavioral health services for their members.

The Kentucky Department for Medicaid Services (DMS) currently contracts with five (5) Managed Care Organizations (MCOs) to provide coverage for most of Kentucky’s Medicaid recipients. The Medicaid population in Kentucky is approximately 90% managed care with the remaining 10%, comprising mostly individuals in Long Term Care and Waiver programs.

There are five Managed Care companies supporting Kentucky managed care: Aetna, Anthem, Passport, WellCare, and Humana CareSource. As of the end of October 2019, enrollment in Kentucky’s five managed care plans is as follows:

 

Humana CareSource: 139,501

Aetna: 205,455

Anthem: 125,741

Passport: 293,729

WellCare: 421,030

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Eligibility

Traditional Medicaid in Kentucky provides full health care coverage to individuals with low income. Members in the following categories will be covered by Traditional Medicaid and their claims will be paid on a FFS basis:

  • Individuals on certain 1915(c) waivers:
    • Home and Community Based Waiver
    • Michelle P. Waiver
    • Acquired Brain Injury (ABI) and ABI Long-term Care Waiver
    • Model Waiver II
    • Supports for Community Living
  • Individuals determined eligible for Supplemental Security Income
  • Individuals in the Medicaid buy-in program for working disabled adults
  • Individuals covered by a Home and Community Based Waiver or residing in a Long Term Care Facility
  • Individuals on Medicare
  • Children in foster care or receiving subsidized adoption
  • Individuals participating in the Breast and Cervical Cancer Treatment Program

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Coverage

CareSource Kentucky covered services include:

  • Doctor/physician visits

  • Chiropractic

  • Allergy care

  • Pain Management

  • Ambulance

  • Diagnostic & Radiology service

  • Hearing aids

  • Immunizations for children and adults

  • Maternity Services

  • Pharmacy via a preferred drug list

  • Lab and X-ray services
  • Podiatry
  • Dental, Oral Surgery & Orthodontics
  • Durable Medical Equipment (DME)
  • Behavioral and Mental Health services
  • Early Periodic Screening Diagnosis and Testing (EPSDT)
  • Family Planning services
  • Nursing Facility services
  • Hospital services
  • Bariatric surgery (medical necessity required)
  • ESRD and transplants
  • Hysterectomy
  • Mammogram
  • Obesity Health services
  • Emergency services
  • Emergency transportation
  • Vision
  • Hospice care (non-institutional)
  • Physical/Occupational/Speech services

Data Considerations

HMS receives all claims data from CareSource Kentucky, with the exception of Dental, which we stopped receiving in 2015. It is important to note that since HMS receives claims data directly from CareSource Kentucky, we are receiving actual claims data as opposed to encounter only data. However, providers for this claim population are not paid on a Fee-For-Service basis. Rather providers receive payment directly from CareSource, which may pay more or less than the Medicaid FFS rate.

HMS does not receive the FFS claims data for services covered by traditional Medicaid in Kentucky under its contract with CareSource Kentucky.

 

 

Sources

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