EPSDT POWERFUL FEDERAL LAW FOR CHILDREN 0-21

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1 EPSDT MEDICAID PROGRAM (AGE 0-21): UNDERSTANDING BY PCPS, SPECIALISTS, THERAPISTS, AND FAMILIES CAN ENHANCE OUTCOMES JERIE BETH KARKOS, MD DOUGLAS MCNEAL, MD Joint Federal/state-specific funding + state specific interpretation of Federal EPSDT mandates + state specific Medicaid Waivers =uneven access to home/community based services in USA. EPSDT language and resources are available to advocate more successfully for necessary services in home and community for eligible children EPSDT POWERFUL FEDERAL LAW FOR CHILDREN 0-21 Medicaid rules are DIFFERENT for children 0-21 Covers the FULL RANGE of Health Care and Long Term Care Services and Supports States are required to cover services and supports under EPSDT even if coverage for the same service/support is optional or limited for adults under the state plan. There are NO optional Medicaid services for children 0-21 years under EPSDT. Confusion comes from state-specific variability in program implementation and interpretation of federal law in addition to those of other payor sources, related and unrelated. 1

2 FUNDING Private Duty Nursing Private Insurance--variable Medicaid HMO may not cover, but is a mandated service EPSDT Medicaid CHIP state specific, may not cover. Personal Care Aide Private Insurance--variable Medicaid HMO may not cover, but is a mandated service EPSDT Medicaid CHIP variable, similar to private insurers Habilitation/DME/Medical Supplies. FUNDING MEDICAID WAIVERS TEFRA/Katie Becket Waiver Children must be 18 years old or younger Meet State s definition of institutional level of care Have medical care needs that can be safely provided outside of institutional setting Cost of care in the community cannot exceed cost of institutional care. Children qualify without regard to family income for Medicaid States cannot cap enrollment Caveat: State participation is optional. (State specific data at 2

3 FUNDING: MEDICAID WAIVERS VOLUNTARY STATE PROGRAMS, MODEST STANDARDIZATION States CAN apply for additional programs to pay for health care in Medicaid and CHIP, but NOT mandatory. Most common for children are: Section 1915 (C) Home and Community based services Waivers. Provide long-term care services in home and community settings instead of institution. Eligibility and availability vary by state: Children qualify without regard to family income if: Require institutional level of care Meet state specific criteria for diagnosis/condition (i.e. dev. disability, technology dependency, etc.) Caveat: Enrollment can be capped (i.e. wait list). 3

4 California 1915(c) Waivers Official Program Name In-Home Operations (IHO) (0457) Waiver Authority 1915(c) Expiration Date December 31, 2014 Summary Provides case management/coordination, habilitation services, home respite, waiver personal care, community transition, environmental accessibility adaptations, facility respite, family training, medical equipment operating expense, PERS installation and testing, PERS, private duty nursing including shared services, transitional case management for medically fragile and technologydependent individuals, ages 0 - no maximum age. For participants that have been receiving continuous care in a hospital for 36 months or more and have physician-ordered direct care services that are greater than those available in the nursing facility/acute hospital waiver for the participant s assessed level of care. Official Program Name Nursing Facility/Acute Hospital Waiver (NF/AH) (0139) Waiver Authority 1915(c) Expiration Date December 31, 2016 Summary Provides case management, personal care, habilitation, home respite, facility respite, community transition, environmental accessibility adaptations, family training, PERS, PERS installation and testing, private duty nursing including shared services, transitional case management, medical equipment operating expenses for individuals aged individuals 65 years and older, physically disabled under age 65 years, and medically fragile and technology-dependent individuals with no maximum age. Official Program Name Waiver for Persons with Developmental Disabilities (0336) Waiver Authority 1915(c) Expiration Date March 28, 2017 Summary Provides behavioral intervention, community living arrangements, day service, home health aide, homemaker, prevocational services, respite care, supported employment (enhanced habilitation), chore, communication aides, communitybased training, dental, environmental accessibility adaptations, FMS, non-medical transportation, nutritional consultation, optometric/optician services, PERS, prescription lenses and frames, psychology services, skilled nursing, specialized medical equipment and supplies, specialized therapeutic services, speech/hearing and language services, transition/set up expenses, vehicle mods and adaptations for individuals w/autism, DD, IID ages 0 - no max age. Official Program Name Pediatric Palliative Care Waiver (0486) Waiver Authority 1915(c) Expiration Date March 31, 2017 Summary Provides care coordination, home respite care, expressive therapies, family counseling, family training, out-of-home respite care for medically fragile and technology-dependent individuals ages SCHIP PROGRAM-1997 Buy in program for families with modest incomes and do not qualify for Medicaid. State options Medicaid expansion (7 states, DC, 5 territories Separate Child Health Insurance program (17 states) Combination of the above (26 states) Benefits: States can choose benchmark, benchmark equivalent, or Secretary approved coverage. Standard BCBS PPO service benefit to Federal Employees State Employee Coverage plan HMO plan with largest, commercial non-medicaid Enrollment in state. State specific Chip Benefits Caveat: Essential Health Benefits(EHB) are NOT comparable to EPSDT EHB 4

5 EPSDT POWERFUL FEDERAL LAW FOR CHILDREN 0-21 Medicaid rules are DIFFERENT for children 0-21 Covers the FULL RANGE of Health Care and Long Term Care Services and Supports States are required to cover services and supports under EPSDT even if coverage for the same service/support is optional or limited for adults under the state plan. There are NO optional Medicaid services for children 0-21 years under EPSDT. Confusion comes from state-specific variability in program implementation and interpretation of federal law. EPSDT ALL MEDICALLY NECESSARY SERVICES MUST BE PROVIDED FOR CONDITIONS DISCOVERED BY THE SCREEN Key is Conditions discovered by the screen.when PCP conducts the Healthy Children and Youth Evaluation, condition must be listed on the EPSDT screen to be covered. Medical necessity for home care requires level of care which exceeds family s ability to care for the individual at home. EPSDT contains outreach and education requirements for each state. States must seek out eligible families and inform them of the benefits of EPSDT and the health and long-term care services and assistance available under the broad parameters of EPSDT law. 42 USC 1396a(a)(43) (examples of stateto-state variation in HO OH & AR) 5

6 MEDICAL LEGAL PARTNERSHIP FOR CHILDREN/TOLEDO-- A PARTNERSHIP: LEGAL AID OF WESTERN OHIO, INC., ADVOCATES FOR BASIC LEGAL EQUALITY, INC., MERCY CHILDREN S HOSPITAL, AND UNIVERSITY PEDIATRICS AT THE UNIVERSITY OF TOLEDO MEDICAL CENTER. What is EPSDT? EPSDT is the Federal Medicaid Act s Early and Periodic Screening, Diagnosis and Treatment benefit available to children under the age of 21. In Ohio, we call this Healthchek. EPSDT requires that states cover services necessary to correct or ameliorate a child s physical or mental condition. 42 U.S.C. 1396d(r)(5). What does Ameliorate mean? To improve or maintain the recipient s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. What does Medicaid for Children Cover?» Early and Periodic Screening (well-child visits);» Vision screenings and services;» Dental screenings and services;» Hearing screenings and services; and» Other necessary care as identified through screening:» Rehabilitative services for developmental disabilities; PT and OT services; Speech pathology services;» Mental health and substance abuse services;» Medical and adaptive equipment glasses, helmets, wheelchairs, communication devices;» Transportation to medical appointments;» In-home nursing, personal care, specialized therapies;» Out-of-home residential, facility and hospital services;» Other medically necessary care. Restrictions of EPSDT services:» Must be determined to be medical in nature;» Must be generally recognized as an accepted method or medical practice or treatment;» Must not be experimental, investigational;» Must be safe and effective. Physician Strategies to Increase Patient Access to Healthcare:» (in addition to recommendations on writing LOMN, requesting peer-to-peer review and arguing to overturn decisions, explicit information is in the document)»» Appeals can be filed directly with the Managed Care plan and/or or with the Department of Job and Family Services (file within 15 days to maintain coverage, 90 day appeal deadline).» If the appeal filed with Managed Care plan is denied, another appeal can befiled with the Department of Job and Family Services (90 day deadline).» For urgently needed care, make sure to request an expedited appeal» Refer the family for legal assistance with appeal and provide family with documentation in support of the necessity of the service. Resources: Gives specifics and concrete examples to improve access to EPSDT mandated services for CSHCN MLPC-Toledo mlpc.lawolaw.org (888) Disability Rights Ohio disabilityrightsohio.org (800) National Health Law healthlaw.org ARKANSAS LEGAL SERVICES PARTNERSHIP MEDICAID AND EPSDT What is Medicaid s EPSDT? The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's child health program of prevention and treatment for people under the age of 21. It includes periodic screening, vision, dental, and hearing services. The goal of the EPSDT program is to assess a child's health needs through initial and regular examinations and evaluations, and also to assure that the health problems found are diagnosed and treated early, before they become more complicated and expensive. What benefits does the EPSDT include? Screening services must include all of the following services: Comprehensive health and developmental history -- (including assessment of both physical and mental health development); Comprehensive unclothed physical exam; Appropriate immunizations; Laboratory tests -- to be performed by medical providers for particular age or population groups; Lead Toxicity Screening - All children are considered at risk and must be screened; Health Education; Vision Services -- At a minimum, include diagnosis and treatment for defects in vision, including eyeglasses. Dental --At a minimum, include relief of pain and infections, restoration of teeth and maintenance of dental health. See also "The Guide to Children s Dental Care in Medicaid;" Hearing Services -- At a minimum, include diagnosis and treatment for defects in hearing, including hearing aids; and Other Necessary Health Care Necessary health care, diagnosis services, treatment, and other measures to correct or treat defects, and physical and mental illnesses and conditions discovered by the screening services. Do I Qualify for EPSDT? If you have a Medicaid Card you can apply for items under EPSDT through local Medicaid. It is important to get the proper documentation together when making an application through a service provider in order to avoid delays. The materials that you may need to accompany an EPSDT application include: 1. A physician's order (on a prescription pad). Info is vague and geared toward needs of typically developing child with vague references services/dme CSHCN NO info for appeal. 2. A Letter of Medical Necessity from a physician, physical therapist or other qualified personnel. This letter should include: Patient history; A diagnosis and prognosis; A description of the benefit to the patient (particularly important, should be very thorough); and How long the patient will need the item. 3. Product information. Any product information that is applicable should be provided. A description of how the particular item will fit the needs of the patient should be supplied as well as pictures, preferably with the patient using the item. 4. Prices from different manufacturers with comparable products that might fit the patient's needs. Contact MEDICARE for more information. The ALSP Law Series is produced by the Center for Arkansas Legal Services, Legal Aid of Arkansas, Inc., and Arkansas Volunteer Lawyers for the Elderly. These agencies provide free legal services to eligible Arkansans. Additional information can be found at: http\\ or call LAW AID. This fact sheet is given to you as a guide to help you generally understand the way legal matters are handled. Local courts interpret things differently. The information and statements of law contained in this fact sheet are not intended to be used as legal advice. Before you take any action, talk to an attorney and follow his or her advice. Always do what the court tells you to do. 6

7 What the state advertises Prescription and some over-thecounter medicines (with a prescription) Dietitian services Rides to the doctor Extra medical supplies and equipment with a doctors prescription (such as tube feeding supplies) Help for children who are homebound due to long-term physical problems Counseling Eye exams as needed Eyeglasses and repairs (some limitations apply) Hearing screens and hearing aids (some limitations apply) Routine teeth cleaning, including x-rays Fluoride treatment (some limitations apply) Sealants, fillings, and teeth pulled [most above are duplicates only 8 types listed] What EPSDT actually covers!!! Full Scope of Medicaid EPSDT Law Inpatient Hospital Care (other than in an institution for mental disease). 42 USC 1396d(a)(1). Outpatient Hospital Care. 42 USC 1396d(a)(2)(A). Rural Health Clinic Services. 42 USC 1396d(a)(2)(B). Federally Qualified Health Center (FQHC). 42 USC 1396d(a)(2)(C). Nurse Midwife Services. 42 USC 1396d(a)(17). Family Planning Services. 42 USC 1396d(a)(4)(C). Physician s Services can be furnished in the office, the patient s home, a hospital, nursing facility, or elsewhere. 42 USC 1396d(a)(5)(A). Medical and surgical services furnished by a dentist. 42 USC 1396d(a)(5)(B). Laboratories and X-Ray Services. 42 USC 1396d(a)(3). Pediatric and Family Nurse Practitioner Services. 42 USC 1396d(a)(21). Early Periodic Screening, Diagnosis and Treatment for Persons Under Age USC 1396d(a)(4)(B). EPSDT services are defined in 42 USC 1396d(r). These services include: Screening services (includes appropriate immunizations); Vision services; Dental services Hearing services Optometrist Services and Eyeglasses. 42 USC 1396d(a)(12). Chiropractor Services. 42 USC 1396d(g). Medical care services provided by other licensed health care providers. 42 USC 1396d(a)(27). Home health services. 42 USC 1396d(a)(7). Home health nursing services. 42 USC 1396d(a)(7). Home health aide services. 42 USC 1396d(a)(7). Home health physical therapy services. 42 USC 1396d(a)(7). Home health occupational therapy services. 42 USC 1396d(a)(7). Home health speech pathology services. 42 USC 1396d(a)(7). Home health audiology services. 42 USC 1396d(a)(7). Private Duty Nursing (in the home, hospital or skilled nursing facility). 42 USC 1396d(a)(8). Clinic Services. 42 USC 1396d(a)(9). Dental Services. 42 USC 1396d(a)(10). Physical Therapy (includes Occupational Therapy and services for individuals with speech, hearing, and language disorders). 42 USC 1396d(a)(11). Prescription Drugs. 42 USC 1396d(a)(12). Dentures. 42 USC 1396d(a)(12). Prosthetic Devices. 42 USC 1396d(a)(12). Diagnostic Services Screening Services Preventive Services Rehabilitative Services #s include any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level. 42 USC 1396d(a)(13). Intermediate Care Facility Services for Persons with Mental Retardation/Developmental Disabilities and Related Conditions. 42 USC 1396d(a)(15). Inpatient Psychiatric Services for Persons under Age USC 1396d(a)(16). Personal Care Services furnished in a home or other location. 42 USC 1396d(a)(24). Hospice Care. 42 USC 1396d(a)(18). Case Management Services. 42 USC 1396d(a)(25). Respiratory Care Services. 42 USC 1396d(a)(20). Certified pediatric nurse practitioner services. 42 USC 1396d(a)(21). Certified family nurse practitioner services. 42 USC 1396d(a)(21). Community Supported Living Arrangements*. 42 USC 1396d(a)(23). * the scope of these services is defined in 42 USC 1396u Home and Community Based Services. 42 USC 1396n(c)(1), 42 CFR Primary care case management. 42 USC 1396d(a)(25). Medical care, or any other type of remedial care recognized under State law. 42 USC 1396d(a)(6), 42 CFR Mental Health Services. See 42 U.S.C. 1396d(r)(5). Transportation and Scheduling Assistance. 42 CFR Non-medical religious healing. 42 CFR Emergency hospital services. 42 CFR Skilled nursing facility services for individuals under CFR Vaccinations. 42 USC 1396d(r)(1)(B)(iii). Such other necessary health care, diagnostic services, treatment, and other measures... to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan. Any other medical care, and any other type of remedial care recognized under State law, specified by the Secretary. 42 USC 1396d(a)(28). USING EPSDT=EASY 1, 2,3 1. List the condition/diagnosis pertinent to the prescription on the EPSDT Screen form. (State specific sample in this handout) 2. List amount, duration, scope of service or support needed. 3. Write Letter of Medical Necessity documenting need per EPSDT mandates (Sample LOMN in this handout) 7

8 EPSDT CRITERIA FOR MEDICAL NECESSITY Eligible for habilitation in addition to curative/rehabilitative when: Services maintain or improve the current health condition Maintenance services (services that sustain or support rather than cure or improve) are needed. Services which prevent a condition from worsening or prevent additional health problems are needed Physical and occupational therapy services when they have an ameliorative or maintenance purpose. CMS: EPSDT- A Guide for States, June 2014 page 10 8

9 LETTERS OF JUSTIFICATION When you write a letter to Medicaid delineating medical necessity, it may help to cite the category of the federal Medicaid Law discussed above and the reference. Consider using the following language citing the federal law when prescribing care in the home setting: As you are aware, federal EPSDT law requires states to cover all services within the broad scope of Medicaid. Specifically home health services are mandated pursuant to 42 USD 1396d(a)(7). Document why it is medically necessary. (Sample LOMN follows). 9

10 EPSDT: MEDICAL NECESSITY SHOULD BE DETERMINED BY THE CHILD S PHYSICIAN Determination that a service is medically necessary lies primarily with the treating physician or other care provider. State must review the physician's determination as to medical necessity. If the state s expert does not agree the service is medically necessary for a particular child, the state is responsible for making a decision based on the evidence. Decision can be appealed by the child or the family under the State s fair hearing procedure CMS: EPSDT-A GUIDE FOR STATES, JUNE 2014 If a state or managed care entity takes an action to deny, terminate, suspend or reduce a requested treatment or service, it must give the beneficiary written notice of the action and of their right to a hearing. 10

11 DENIALS. Each state has an official Protection and Advocacy Program providing FREE legal and advocacy support for persons with disabilities (ADA, Rehabilitation Act Medicaid Act, IDEA, etc.) 501c3 Public interest, legally-based advocacy agency. Empowered by federal law to advocate for civil and legal rights of persons with disabilities. Part of the national network of federally mandated and funded protection and advocacy systems. Special powers to investigate abuse and neglect. Web site: ADDITIONAL ADVOCACY OPTIONS WHEN MEDICALLY NECESSARY SERVICES /DME ARE DENIED FOR CHILDREN COVERED BY EPSDT MANDATES Request a physician peer-to-peer review by person with specific specialty background when possible Obtain information about the reviewers credentials and expertise at time of arranging meeting (if possible. Be prepared to give additional data, evidence based when possible, at time of the review. Advise Parent to file an appeal Adhere to deadlines For urgently needed care, request an expedited appeal Involve Medical-Legal Partnership 262 partnerships in 36 states. 11

12 REFERENCES AND RESOURCES CMS Medicaid Guidelines on ABA/ASD Guidance/Downloads/CIB pdf Partners for Children Waiver, California FCReferringPhysicianFlyer.pdf TEFRA/Katie Beckett Waiver: Catalyst Center State at a Glance Chartbook Waivers by state in Medicaid and CHIP Program-Information/By- Topics/Waivers/Waivers_faceted.html 1915 Waivers by State Education/American-Indian-Alaska- Native/AIAN/LTSS-Roadmap/Resources/State- Federal-Relationships/1915c-Waivers-by- State.html EPSDT: A Guide for States: Coverage in the Medicaid Benefit for Children and adolescents Program-Information/By- Topics/Benefits/Downloads/EPSDT_Coverage_Gu ide.pdf Protection and Advocacy System: National Disability Rights Network Administration for Community Living (HHS ) PA/Contacts.aspx National Center for Medical-Legal Partnership. Disability Rights Center of Kansas Guidelines for Pediatric Home Health Care 2 nd Edition, American Academy of Pediatrics AAP Section on Home Health Care. Edited by Russell C. Libby, MD,FAAP and Sonia O. Imaizumi, MD,FAAP, Physicians often unaware that Medicaid pts. qualify for home care services t/35/1/1.3.full.pdf+html 12