2018 EPSDT. Program Description. Our mission is to improve the health and quality of life of our members

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1 2018 EPSDT Program Description Our mission is to improve the health and quality of life of our members

2 Early and Periodic Screening, Diagnosis, and Treatment Program Description I. Purpose The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is designed to provide a comprehensive preventive health care package to members from birth to age 21 and the early diagnosis and treatment of medical conditions which, if undetected, could result in serious medical conditions and/or costly medical care. Interventions are focused on the member, the clinician, and the community. II. Rationale EPSDT is a federally mandated program that entitles children and adolescents (from birth to age 21) covered under Medicaid and Kentucky Children's Health Insurance Program (KCHIP) to a broad package of health care benefits, administered with an emphasis on prevention and aggressive outreach to bring children and adolescents in for care. Approximately 45% of the Passport Health Plan (Passport) membership is under the age of 21, making this a vital program for the health and welfare of the Passport s children. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population. This service is listed as EPSDT Special Services. The EPSDT Special Services Program allows coverage for items, or services, which are medically necessary and which are not covered somewhere else in Medicaid. The comprehensive benefits of EPSDT include periodic well-child medical, dental, vision, and hearing assessments (health screenings); immunizations; laboratory tests; health education, developmental assessment, and anticipatory guidance. Through the EPSDT Program, states are required to offer the full scope of mandatory and optional Medicaid benefits to children. III. Program Goals Increase the five (5) measures where we achieved Quality Compass 75 th Percentile to the 90 th Percentile: Body Mass Index (BMI) Documentation Childhood Immunizations Combo 2 Childhood Immunizations Combo 3 Immunizations for Adolescents Combo 1 Lead Screening 4/4/18 FINAL Page 1 of 6

3 Increase the one (1) measure where we achieved Quality Compass th Percentile to the 75 th Percentile: Annual Dental Visits Increase the four (4) measures where we achieved Quality Compass 50 th Percentile to the th Percentile: Childhood Immunizations Combo 4 Childhood Immunizations Combo 5 Counseling for Nutrition Counseling for Physical Activity Increase the eight (8) measures where we achieved Quality Compass rd Percentile to the 50 th Percentile: Childhood Immunizations Combo 6 Childhood Immunizations Combo 7 Childhood Immunizations Combo 8 Childhood Immunizations Combo 9 Childhood Immunizations Combo 10 Immunizations for Adolescents Combo 2 Well-Child in the First 15 Months of Life Well-Child in the Third, Fourth, Fifth, and Sixth Years of Life Increase the one (1) measure where we achieved Quality Compass 25 th Percentile to the rd Percentile: Adolescent Well Care Visits The specific definitions related to achieving HEDIS goals will include: Increasing the percentage of members receiving at least one EPSDT screen during the measurement year and all age-appropriate EPSDT screens; all childhood and adolescent immunizations. Increasing the percentage of members receiving an annual dental visit. Increasing the number of members receiving a lead screening based on the periodicity schedule. Increasing the number of members receiving a well-child visit in the first 15 months of life, the third, fourth, fifth, and sixth years of life, and an adolescent visit. Increasing the number of members receiving appropriate vaccine series as recommended by Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Care periodicity schedule as adopted by the Center for Disease Control (CDC). 4/4/18 FINAL Page 2 of 6

4 Improving clinician adherence to documented evidence of BMI percentile. Improving clinician adherence to documented percentile plotted on a BMI growth chart or BMI percentile documented with that includes height and weight. Promoting counseling for nutrition, physical activity, risk behavior related to sexual activity, alcohol, substance abuse, mental health assessment/screening and tobacco use, and follow-up for special services as a result from an EPSDT screening. Promoting adherence to documented evidence of a depression screening based on the periodicity schedule and appropriate referral and follow up as a result from an EPSDT screening. IV. Population Identification All Passport members, from birth to age 21, are eligible for EPSDT preventive services and are identified through enrollment files received monthly from the State of Kentucky. All Passport members, from birth to age 21, are also eligible for EPSDT Special Services, except for members eligible under the KCHIP Phase III determination. V. Member Participation and Opting Out of the Program EPSDT outreach services are automatically provided to all EPSDT eligible members and members receive interventions without having to specifically request them. For this reason, enrollment is considered passive. Participation, however, is voluntary and the member has the right to decline or opt out of the entire outreach program, or any part of it. Information on how to opt out is provided in the new member welcome packet that is sent to all new members. VI. Member Contact Passport provides targeted outreach to EPSDT eligible members who are non-compliant with the recommended schedule of health screens, immunizations, and annual participation. To increase member adherence with EPSDT health screens and immunizations, Passport has developed a formal outreach program. The EPSDT Program utilizes a specialized application to track member s adherence with all components of the health screen and follow up related to an EPSDT screen according to the periodicity schedule which is based on the Bright Futures/AAP Recommendations for Preventive Pediatric Care and contractual agreement between Passport and Department for Medicaid Services (DMS). In addition, all written program material sent to members includes contact information for the EPSDT Program/Care Connector Team. The outreach components include: Postcard notifications are mailed to caregivers of all newborn members advising of EPSDT screens. Auto dialer system is utilized to contact members regarding the availability of preventive dental care, the recommended schedule for EPSDT screens and immunizations, and the importance of follow up when referred for special services. 4/4/18 FINAL Page 3 of 6

5 An additional outreach is made by the Care Connector Team to those members who were unable to be reached from the Auto dialer system. Home visit outreach is provided to non-compliant members unable to be reached telephonically (contracted through the Departments of Health). Outreach and education provided at community events, (i.e., back to school events and community health fairs). Leverage PHP Health Plus program and Health Plus care conferences to educate and influence provider practice in EPSDT HEDIS goal movement, proper coding, and ESPST education for providers within the Health Plus program. VII. Clinician Notification and Involvement Clinicians are notified of the program by the following: Quick Reference Guide, Provider Orientation Kit, EPSDT Orientation Kit, The Passport Provider Manual, Provider EPSDT Education Toolkit, The Passport Provider Provider enews, and Provider outreach visits by Provider Network Account Manager. The Provider Network Account Manger conducts orientation sessions for EPSDT clinicians on a regular basis and provides ongoing support to EPSDT clinicians regarding the administration of EPSDT preventive care, billing and claims processes for EPSDT, the required components of a complete EPSDT screening, and the importance of outreach and education to EPSDT eligible panel members and their families. Provider Network Account Manager also conducts Provider Workshops and the Provider Roundtable meetings. Monthly reports are made available to EPSDT clinicians of children who are due for health screens and immunizations. 4/4/18 FINAL Page 4 of 6

6 The Quality Department conducts EPSDT education sessions, and provides ongoing support for EPSDT clinicians and office staff on a regular basis regarding the requirements of an EPSDT per the periodicity schedule and required medical record documentation to support EPSDT services provided. The Quality Department conducts EPSDT claims audits to measure adherence in accordance with adopted preventive health guidelines based on the Bright Futures/AAP Recommendations for Preventive Pediatric Care. Clinician interventions include: Ongoing education to clinicians through site visits, telephonic outreach, and written notifications. Education includes: o Distributing the EPSDT training tool for each required encounter form. o Reviewing the most common denial patterns identified through the monthly claims review. o The periodicity schedule and the target days. o The days calculator based on the members birthday and designed to assist clinicians in determining the age interval screen the child is due to receive. EPSDT Orientation Packet with numbers for Member Services, Provider Services, Provider Network Account Manager and Care Connector Team. Conducting on-site EPSDT outreach visits to EPSDT clinicians. Posting updates on the Passport Provider website at to support efforts to increase EPSDT participation and compliance rates, and identified health outcomes. EPSDT Claims Random Audit. VIII. Annual Evaluation The annual evaluation of the EPSDT Program is conducted by Passport s EPSDT Program Manager, Director of Quality, and the Chief Medical Officer, or their designee. Objectives, activities and outcomes are evaluated at a minimum of annually to: Demonstrate whether the EPSDT Program has shown improvement in the member and clinician adherence in the AAP/Bright Futures Recommendations for Preventive Pediatric Care and quality of care provided to members. Explore and remove barriers and limitations to the member through adherence of the EPSDT Program. Revise areas as needed to improve effectiveness of the EPSDT Program. Evaluate the overall effectiveness of the EPSDT Program. More frequent barrier analyses are performed on an ongoing basis and adjustments to the EPSDT Program are made accordingly. 4/4/18 FINAL Page 5 of 6

7 Formal measurements are performed annually through the HEDIS 1 reviews using HEDIS methodology and include: Childhood Immunization Status Weight Assessment and Counseling for Nutrition & Physical Activity for Children and Adolescents Well-Child Visits in the first 15 months of Life Well Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Immunizations for Adolescents Lead Screening in Children Adolescent Well Care Visits Annual Dental Visits Formal measurements are performed annually during the HEDIS reviews using mutually agreed upon technical specifications from DMS, Island Peer Review Organization (IPRO), and Passport and include: Healthy Kentuckians Child and Adolescents Healthy Kentuckians Adolescent Preventive Screening and Counseling Healthy Kentuckians Height/ Weight Assessment/ BMI Assessment/ Assessment/ Counseling for Nutrition and Physical Activity for Children and Adolescents In addition, the Cabinet for Health Services (CHS), DMS and Centers for Medicare and Medicaid Services (CMS) require Passport to report EPSDT compliance and participation rates annually, according to the Federal Fiscal Year (CMS 416). Final approval by the Quality Medical Management Committee: June 5, 2007 June 3, 2008 August 4, 2009 March 2, 2010 March 1, 2011 July 20, 2012 June 4, 2013 May 28, 2014 May 12, 2015 May 10, 2016 April 18, HEDIS is a registered trademark of the National Committee of Quality Assurance (NCQA). 4/4/18 FINAL Page 6 of 6

8 Appendices A. Periodicity Schedule 2017 B. Member Withdraw Letter C. Member Specialist Appointment Letter D. Member Unable to Contact Letter

9 EPSDT Program Description Appendix A Periodicity Schedule 2017

10 EPSDT Program Description Appendix A Periodicity Schedule 2017

11 EPSDT Program Description Appendix B Member Withdraw Letter [DATE] Dear Parent or Guardian of [member s name], Thank you for recently talking with us about Passport s Early, Periodic Screening, Diagnosis and Treatment (EPSDT) Outreach Program. We value your wishes and see that you do not want us to contact you at this time. To stop receiving EPSDT reminders, calls and home visits, please mail us a letter using the enclosed postage-paid envelope. Your letter must state that you wish to leave the EPSDT Outreach Program. You may rejoin at any time. We re here to help! If you change your mind and want us to help you keep track of your child s care, please call We are ready to set up your appointments and remind you of all the important tests and shots your child needs to grow up healthy. To learn more about the benefits your child can get through EPSDT, please read the enclosed brochure. If you have any questions, you can reach us at We would like to thank you for choosing Passport and for being one of our valued members! Sincerely, [Rep s Name] EPSDT Outreach Representative Passport Health Plan HLTH40143 APP_9/19/2014

12 EPSDT Program Description Appendix C Member Specialist Appointment Letter [Date] [Parent/Guardian Name] [Member Name] [Member Address] [Member Address] Don t Forget Schedule Your Child s Specialist Appointment! Dear Parent or Guardian of [ ], Our records show that your child received an EPSDT well-child checkup and was referred to a specialist as a result of this visit. We ve been trying to reach you to remind you to set up an appointment with your child s specialist. If you have any questions or need help setting up this appointment, please call us at As a Passport member, your child has special benefits through our EPSDT program. EPSDT is a well-child program that stands for Early and Periodic Screening, Diagnosis, and Treatment. Our EPSDT program helps make sure your child is getting the needed checkups and screenings for his or her age. Thank you for being a Passport member. We look forward to helping you! Sincerely, EPSDT Outreach Representative EVOH63037 APP_11/17/2016

13 EPSDT Program Description Appendix D Member Unable to Contact Letter [Date] Special Benefits for Your Child! Dear Parent or Guardian of [ ], We have been trying to reach you with some great news! As a Passport member, your child can receive benefits through our special EPSDT program. EPSDT is a well-child program that stands for Early, Periodic, Screening, Diagnosis, and Treatment. The EPSDT program helps make sure your child gets the care he or she needs. Through the EPSDT program, your child will receive these benefits at no cost: Regular Office Visits (Well-Child Visits)* Physical Exams Eye Tests Hearing Tests Dental Checkups *During a well-child visit, the primary care provider (PCP) will check your child s height, weight, vision and hearing. These visits may also include immunizations (shots). Well-child visits make sure your child is growing up healthy. If the PCP finds a problem, he or she will watch it and treat it early. We re Here for You To learn more about EPSDT and when your child is due for shots, please see the brochure included with this letter. If you need help setting up a PCP visit, please call us at We re ready to help you! Sincerely, EPSDT Outreach Representative PLAN14195 APP_5/27/2014

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