In Kentucky:
  • As of July 1, 2011, there were 823,133 beneficiaries enrolled in Kentucky Medicaid. Of these, 735,978 were enrolled in managed care. All Medicaid managed care beneficiaries were also enrolled in a Transportation Prepaid Ambulatory Health Plan (PAHP). Medicaid beneficiaries who are in nursing homes or waiver programs do not receive managed care services
  • Medicaid beneficiaries in in Louisville, Jefferson County and the 15 surrounding counties receive services through the Kentucky Medicaid Health Care Partnership Program, a prepaid capitated managed care system authorized by a CMS Section 1115 Waiver Demonstration.
  • Children ages 3-21 who are eligible under the Individuals with Disabilities Education Act (IDEA) are eligible for School-Based Health Services, which include evaluative, diagnostic, preventive and treatment services. Children who receive these services are not excluded from receiving services through the EPSDT program.
As of 2013, 514,298 individuals were eligible for Kentucky’s Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT. According to 416 data from 2013, Kentucky achieved an EPSDT screening ratio of 83% and a participation ratio of 57%. 236,830 children received dental services of any kind, with 208,783 receiving preventive dental services.
The EPSDT benefit is divided in two components: EPSDT Screenings, and EPSDT Special Services. Preventive care, such as routine physicals or well-child check ups, is provided under the Screenings Program. The Special Service component provides treatment coverage for items which are medically necessary and which are not covered in Medicaid.
Last updated May 2014
Medical Necessity According to the Kentucky Administrative Regulations, to be medically necessary or a medical necessity, a covered benefit shall be:

  1. Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition; including pregnancy;
  2. Appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice;
  3. Provided for medical reasons rather than primarily for the convenience of the individual, the individual’s caregiver, or the health care provider, or for cosmetic reasons;
  4. Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided;
  5. Needed, if used in reference to an emergency medical service, to exist using the prudent layperson standard;
  6. Provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C 1396d(r) and 42 C.F.R. Part 441 Subpart B for individuals under twenty-one (21) years of age; and
  7. Provided in accordance with 42 C.F.R. 440.230.
Initiatives to Improve Access

Reporting & Data Collection
Kentucky Medicaid managed care contract language requires contractors to submit encounter data for each of their members who receive EPSDT services, as well as quarterly and annual reports on EPSDT services for CMS reporting
Behavioral Health
Behavioral health services for Medicaid enrollees in Kentucky (including children) are provided primarily through a network of 14 regional mental health centers and four psychiatric hospitals maintained by the state Department of Behavioral Health, Developmental and Intellectual Disabilities, though managed care organizations can provide access to additional behavioral health service providers.
Medicaid managed care contract language requires plans to employ a Behavioral Health Director who coordinates all efforts to provide behavioral health services to plan members.  The Behavioral Health Director must meet monthly with the state’s mental health agency to discuss substance abuse protocols, rules, and regulations.
Plans are also required to establish a protocol for coordination of physical and behavioral health services for members with behavioral health or developmental conditions.
Kentucky implemented the Supports for Community Living (SCL) waiver program to provide alternatives to institutional care for Medicaid-eligible children and adults with intellectual and developmental disabilities. The program provides a variety of supports and services, including children’s day habilitation, community living supports, psychological services, and residential supports. As of January 1, 2014, additional community supports and services are available through the SCL2 Waiver.
Support to Providers and Families
At minimum, Medicaid managed care plans must train providers on “the components of an EPSDT assessment, EPSDT Special Services, and emerging health status issues among members which should be addressed as part of EPSDT services to all appropriate staff and providers.”
Care Coordination
Medicaid children younger that 21 who are diagnosed with severe emotional disabilities receive case management services from the Child Targeted Case Management Program. These services are provided by qualified case managers in 14 community mental health centers across the state. Covered services include, among others:
  • A written comprehensive assessment of the child’s needs
  • Arrangement of the delivery of needed services
  • Assistance in accessing needed services
  • Preparation and maintenance of case records
  • Case consultation; and
  • Crisis assistance.
Managed Care
Kentucky’s Medicaid managed care contract requires plans to provide an EPSDT coordinator who’s responsible for coordinating and overseeing case management services and continuity of care. Plans must also coordinate care for children receiving school-based health services in order to avoid duplicative services.
Oral Health
The Kentucky Medical Dental Program provides oral health services to Medicaid-enrolled children. The state provides information on participating dental providers, billing of oral health services under the EPSDT benefit, and Kentucky’s regulations for oral health service delivery to children on the Dental Services webpage.