Medicaid EPSDT Why is it Important to Me?
|
|
- Juniper Ford
- 5 years ago
- Views:
Transcription
1 Medicaid EPSDT Why is it Important to Me? NC Tide: 2016 Annual Conference Friday, September 9, 2016 Jane Perkins Iris Green Legal Dir., NHeLP Senior Atty., DR-NC (919) (x101) (919)
2 Pre-test How much do you know about EPSDT?
3 Case Example D.E. is an 12-year-old boy who suffers from Pervasive Developmental Delay, PTSD, ADHD, autism, and significant speech and language delays. He lives with his grandmother when he is not cycling in and out of hospital and other residential placements. Currently, he is at home. The only service he receives with any regularity is medication management. He needs a range of behavioral health and case management services.
4 Outline of the session Medicaid Overview Focus on EPSDT, with emphasis on Behavioral health How it works in NC
5 Medicaid: What Judges Say Byzantine construction makes Medicaid almost unintelligible to the uninitiated Medicaid Act is an aggravated assault on the English language Medicaid regulations so drawn they have created a Serbonian bog so ASK QUESTIONS AS WE GO!
6 Medicaid Basics Entitlement Covered population groups, e.g. Children, pregnant women, aged, blind, disabled Covered services, e.g. Hospital, physician, home health, behavioral health Due process notice and hearing rights if eligibility/services are denied/terminated
7 Why a Separate Benefit for Children & Youth? Children are not little adults Adolescents are not big children (or little adults) Time of rapid brain and body development Common behavioral health diagnoses: Attention-deficit hyperactivity disorder Depression Behavioral or conduct problems Anxiety Substance use disorders Autism spectrum disorders Tourette syndrome
8 Why a Separate Benefit for Children & Youth? Poor children are more likely to have: Vision, hearing and speech problems Untreated tooth decay Elevated lead blood levels Asthma Behavioral health problems
9 Why a Separate Benefit for Children & Youth with Disabilities? Family impact Increase in single parent households Increase in divorce Increase in behavioral problems & academic failure of siblings Financial stress 54% report family member stopped working 45% report a family member cut back working >20% report financial problems b/c of child s condition Caregiving stress 58% report spending >40 hours per week providing support 46% report more caregiving responsibilities than they can handle
10 E = Early P= Periodic S = Screening D = Diagnostic T = Treatment
11 Available at: odic-screening-diagnostic-and-treatment.html (June 2014)
12 EPSDT Coverage The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible, The goal of EPSDT is to assure that individual children get the health care they need when they need it the right care to the right child at the right time in the right setting.
13 EPSDT: Major Laws and Guidance 42 U.S.C. 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B), 1396d(r) 42 C.F.R CMS, State Medicaid Manual, part 5 CMS, EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents Youth (June 2014), /by-topics/benefits/downloads/epsdt_coverage_guide.pdf
14 A Word about Managed Care State Medicaid agencies contract with at-risk health plans to provide Medicaid services EPSDT CANNOT BE IGNORED EPSDT STILL APPLIES All EPSDT requirements (except for the procedure for obtaining services) fully apply to all behavioral health utilization review vendors and LME/MCOs. NC DMA, Health Check Billing Guide (July 2013),
15 EPSDT Requirements Early & Periodic Screening EPSDT health and developmental assessment: Finding: Providers using clinical judgment failed to identify 83% of children with a diagnosable behavioral problem NC: Formal developmental screening using scientifically validated tools such as: ASQ-3 (0-5 years), PEDS (up to age 8); PSC; SDQ; Bright Futures Adolescent; HEADSSS; and GAPS NC DMA, Health Check Billing Guide (July 2013
16 EPSDT Treatment Requirements States must arrange (directly or through referral) for corrective treatment needed as a result of a screen Federal scope of benefits Federal definition of medical necessity
17 EPSDT Federal Scope of Benefits All necessary treatment within 1396d(a) Mandatory services Optional Services Physician services Prescription drugs In-patient hospital Rehabilitation services Laboratory/x-ray Physical, speech, & other therapies Outpatient hospital Other licensed practitioners Nursing facility services Private duty nursing Home health care* Home health care* EPSDT Personal care services Case management Transportation
18 EPSDT Broad Nature of EPSDT
19 EPSDT Informing Requirements States must inform Medicaid families & children about EPSDT Informing must be effective Oral and written Translated for LEP Accessible for hearing/vision impaired Targeted (e.g. pregnant teens, non-users) Transportation & appointment scheduling assistance (prior to due date of each periodic screen) Coordinate with other entities
20 EPSDT Informing Inform Families About: Benefits of preventive care Services available through EPSDT Transport & scheduling assistance
21 EPSDT-Addressing Stubborn Barriers Monitoring Annual reporting required CMS Form 416 Report by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, 19-20) Medical screens Referrals for treatment Dental treatment Lead blood testing NC, age 6-9, % receiving any EPS: 2014: 47% 2013: 44% 2012: 45%
22 EPSDT Addressing Stubborn Barriers Resolving Complaints Administrative due process Written notice Opportunity to be heard Court action
23 EPSDT Tx NC on Medical Necessity NC DMA: Ameliorate means to improve or maintain beneficiary s health in best condition possible; Compensate for a health problem; Prevent it from worsening; or Prevent the development of additional health problems
24 EPSDT
25 EPSDT No Caps on Services
26 EPSDT No Limits on Service Location
27 EPSDT Available to CAP Waiver Recipients
28 EPSDT Operational Principles Specific coverage criteria in the DMA clinical coverage policies or service definitions do NOT have to be met if the service is necessary to correct or ameliorate, e.g. particular diagnoses, particular signs or symptoms
29
30 EPSD T Features Coverage of short-term & long-term services No waiting list for services No monetary cap on total cost No limit on number of hours or units No limit on number of MD, DDS, therapist, clinician visits No copayments
31 EPSD T Criteria Service fits within a Medicaid box Necessary to correct or ameliorate the individual child s condition Safe and effective Not experimental No less costly, equally effective & available alternative in the geographic area May require prior authorization (15 business days)
32
33 EPSDT BENEFITS NC Framing: TWO KINDS OF EPSDT BENEFITS Extensions or modifications of benefits that are listed in our State Plan. EPSDT requires the limits in the service definition be modified if medically necessary to treat or ameliorate a condition. Getting Day Treatment at the same time as Intensive In Home Getting Community Networking and Intensive In Home A child may need a service that is NOT listed in the North Carolina State Medicaid Plan but coverable under federal Medicaid law, 1905(a) of the Social Security Act for recipients under 21 years of age. This requested service is called a Non-Covered State Medicaid Plan Service. ABA
34 In N.C. EPSDT Services require Prior Authorization from the LME-MCO. For a service on the State Plan use the standard LME-MCO process. For a service not on the State Plan use the form titled Non-Covered State Plan Service Request Form for Recipients under 21 Years Old found on the LME-MCO webpage. The form must be completed by a physician, licensed clinician, or other provider.
35
36 What to Include in the Request Documentation for a service under the EPSDT Medicaid provision should show how the service will correct or ameliorate a defect, physical or mental illness, or a condition. Show how the service meets the EPSDT requirements safe, effective, not experimental and medically necessary to correct or ameliorate the condition or illness. You may use additional sheets to supply any other information you think would be helpful. Include evidence-based literature, if available.
37 Clinicians should describe the individual s condition, their need for services, alternatives that have been tried and/or rejected, and explain how the service will correct or ameliorate the child s condition.
38 The determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis. The MCO should consider the child s long-term needs, not just what is required to address the immediate situation. The MCO should consider all aspects of a child s needs. Services are covered when they have an ameliorative, maintenance purpose. CMS EPSDT Coverage Guide at pics/benefits/downloads/epsdt_coverage_guide.pdf
39 EPSD T Examples Case management is a listed EPSDT service and is available under the federal Medicaid plan. Case management must be provided to an eligible enrollee if medically necessary to correct or ameliorate a condition regardless of eligibility for a CAP or Innovations Waiver.
40 EPSD T Examples Rehabilitation/other licensed practitioner/preventive, e.g. Intensive behavioral health services (individualized, intensive, coordinated, comprehensive, culturally competent, and home and community based) ABA therapy for a child with autism Transportation, to & from facility (including related costs of attendant s meals, accommodations, gas, etc.) Personal care services, not provided by the MCO
41 Post-test How much did you learn?
42 A Strategy for Success
43 The End
Medicaid s Early and Periodic Screening, Diagnostic and Treatment Benefit. Sarah Somers Managing Attorney February 23, 2015
Medicaid s Early and Periodic Screening, Diagnostic and Treatment Benefit Sarah Somers Managing Attorney February 23, 2015 National Health Law Program (NHeLP) The National Health Law Program protects and
More informationGrievances and Appeals Under the New Medicaid Managed Care Rules
Grievances and Appeals Under the New Medicaid Managed Care Rules NDRN Webinar Sarah Somers & Jane Perkins September 27, 2016 Session Outline Medicaid background Medicaid managed care overview Necessary
More informationThe Basics of LME/MCO Authorization and Appeals
The Basics of LME/MCO Authorization and Appeals Tracy Hayes, JD General Counsel and Chief Compliance Officer July 17, 2014 DSS Attorneys Summer Conference Asheville, NC What is Smoky Mountain? Area Authority
More informationService Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note:
Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: If you are a Medicaid beneficiary and have a serious mental illness, or serious emotional disturbance, or developmental
More informationWhat are MCOs? (b)/(c) refers to the type of waiver approved by CMS to allow this type of managed care program. The
Advocating in Medicaid Managed Care-Behavioral Health Services What is Medicaid managed care? How does receiving services through managed care affect me or my family member? How do I complain if I disagree
More informationHealth Check Billing Guide 2013
North Carolina Medicaid Special Bulletin An Information Service of the Division of Medical Assistance Visit DMA on the web at http://www.ncdhhs.gov/dma Number I July 2013 Attention: Health Check Providers
More informationDiabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 2 2.2 Special
More informationSUBJECT: WIC Policy Memorandum # Medicaid Primary Payer for Exempt Infant Formulas and Medical Foods
United States Department of Agriculture Food and Nutrition Service 3101 Park Center Drive Alexandria, VA 22302-1500 September 25, 2015 SUBJECT: WIC Policy Memorandum #2015-07 Medicaid Primary Payer for
More informationFlorida Medicaid. Statewide Inpatient Psychiatric Program Coverage Policy
Florida Medicaid Statewide Inpatient Psychiatric Program Coverage Policy Agency for Health Care Administration December 2015 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority...
More informationLong Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents
Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...
More informationAlternative or in Lieu of Service Description Alliance Behavioral Healthcare
Alternative or in Lieu of Service Description Alliance Behavioral Healthcare 1. Service Name and Description: Rapid Response Crisis Services for Children and Youth Service Name: Rapid Response Procedure
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: September 15, 2014 All Plan Letter 14-011 TO: ALL MEDI-CAL
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Alabama ALABAMA (AL) Medicaid s EPSDT benefit provides comprehensive health care services to children under age 21,
More informationMedicaid and Free Care Opportunities for Covering Services in Schools
Medicaid and Free Care Opportunities for Covering Services in Schools Healthy Homes, Schools, and Communities Health Determinants of Early School Success: Leveraging Medicaid for Impact Sarah Somers, Managing
More informationFlorida Medicaid. Behavioral Health Therapy Services Coverage Policy. Agency for Health Care Administration [Month YYYY] Draft Rule
Florida Medicaid Behavioral Health Therapy Services Coverage Policy Agency for Health Care Administration [Month YYYY] Draft Rule Florida Medicaid Table of Contents 1.0 Introduction... 1 1.1 Description...
More informationNorth Carolina Innovations Clinical Coverage Policy No: 8-P Amended Date: November 1, Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 2 2.1 Provisions... 2 2.1.1 General... 2 2.1.2 Specific... 2 2.2 Special
More informationFlorida Medicaid. Evaluation and Management Services Coverage Policy
Florida Medicaid Evaluation and Management Services Coverage Policy Agency for Health Care Administration June 2016 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1
More informationHealth Care for Florida Children Cheat Sheet
Health Care for Florida Children Cheat Sheet MEDICAID a/k/a State Plan Medicaid Eligibility by DCF Administered by AHCA Federal (about 58%); State (about 42%) Mandatory (every state must cover): Inpatient
More informationMedicaid Fundamentals. John O Brien Senior Advisor SAMHSA
Medicaid Fundamentals John O Brien Senior Advisor SAMHSA Medicaid Fundamentals Provides medical benefits to groups of low-income people with no medical insurance or inadequate medical insurance. Federally
More informationNC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Comprehensive Case Management for AMH/ASU.
NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Comprehensive Case Management for AMH/ASU Table of Contents 1.0 Description of the Procedure, Product, or Service...
More informationEarly and Periodic Screening, Diagnosis, and Treatment Program EPSDT Florida - Sunshine Health Annual Training
Early and Periodic Screening, Diagnosis, and Treatment Program EPSDT Florida - Sunshine Health Annual Training EPSDT Overview EPSDT purpose and requirements mandated by the Agency for Health Care Administration
More informationEPSDT 101. June 8, Meg Comeau, MHA Co-Principal Investigator, The Catalyst Center Boston University &
EPSDT 101 June 8, 2015 Meg Comeau, MHA Co-Principal Investigator, The Catalyst Center Boston University & Member of National MCH Workforce Development Center 2 A very short history of EPSDT Boston Medicaid
More informationCOVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE
COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE This is a list of all covered services and benefits for MassHealth Standard and CommonHealth members enrolled
More informationMaryland Medicaid Program. Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012
Maryland Medicaid Program Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012 1 Maryland Medicaid In Maryland, Medicaid is also called Medical Assistance or MA. MA is a joint
More informationMEDICAL ASSISTANCE BULLETIN
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ISSUE DATE EFFECTIVE DATE NUMBER September 8, 1995 September 8, 1995 1153-95-01 SUBJECT Accessing Outpatient Wraparound
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services JENNIFER KENT DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: December 3, 2015 ALL PLAN LETTER 15-025 (SUPERSEDES ALL
More informationHealthfirst NY Medicaid Managed Care (MMC) and Child Health Plus (CHP) Benefit Grid
BENEFITS (Subject to policies and procedures) Healthfirst NY Medicaid Managed Care (MMC) and Child Health Plus (CHP) Benefit Grid **Benefit Changes are subjected to NYSDOH/CMS changes MMC Non-SSI/Non-
More informationCore Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics
Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Federally Qualified Health Centers... 1
More informationTHIS INFORMATION IS NOT LEGAL ADVICE
Medicaid Medicaid is a federal/state program that gives certain groups of people a card that can be used to get free medical care, nursing home care, and prescription drugs at reduced prices. In general,
More informationPROVIDER POLICIES & PROCEDURES
PROVIDER POLICIES & PROCEDURES EXTENDED NURSING SERVICES The purpose of this document is to provide guidance to providers enrolled in the Connecticut Medical Assistance Program (CMAP) on the requirements
More informationINTEGRATING TRAUMA- INFORMED SERVICES INTO MEDICAID. Lena O Rourke O Rourke Health Policy Strategies
INTEGRATING TRAUMA- INFORMED SERVICES INTO MEDICAID Lena O Rourke O Rourke Health Policy Strategies Why Medicaid? 2 Federal and State options to support community-based services/supports Coverage of services
More informationIntensive In-Home Services (IIHS): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions
Intensive In-Home Services (IIHS): Aligning Care Efficiencies with Effective Treatment BHM Healthcare Solutions 2013 1 Presentation Objectives Attendees will have a thorough understanding of Intensive
More informationPROVIDER POLICIES & PROCEDURES
PROVIDER POLICIES & PROCEDURES ENCLOSED BED SYSTEMS The primary purpose of this document is to assist providers enrolled in the Connecticut Medical Assistance Program (CMAP) with the information needed
More informationFlorida Medicaid. Therapeutic Group Care Services Coverage Policy
Florida Medicaid Therapeutic Group Care Services Coverage Policy Agency for Health Care Administration July 2017 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal
More informationEnhanced Mental Health Clinical Coverage Policy No: 8-A and Substance Abuse Services Amended Date: October 1, 2016.
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 2 2.2 Special
More informationMedicaid Covered Services Not Provided by Managed Medical Assistance Plans
Medicaid Covered Services Not Provided by Managed Medical Assistance Plans This document outlines services not provided by MMA plans, but are available to Medicaid recipients through Medicaid fee-for-service.
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Alaska ALASKA (AK) Medicaid s EPSDT benefit provides comprehensive health care services to children under age 21,
More informationIndividuals with Intellectual Amended Date: October 1, 2015 Disabilities (ICF/IID) Table of Contents
Individuals with Intellectual Amended Date: October 1, 2015 Disabilities (ICF/IID) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...
More informationResidential Treatment Services. Covered Services 6/30/2017 CHAPTER IV COVERED SERVICES AND LIMITATIONS. Manual Title. Page. Chapter.
Revision Date Covered Services CHAPTER COVERED SERVICES AND LIMITATIONS Revision Date 1 CHAPTER TABLE OF CONTENTS PAGE General Information... 4 Medallion 3.0... 5 Coverage for FAMIS MCO Enrollees*... 6
More informationService Review Criteria
Client Name: SAR#: Administrative Review Process notes: When documenting call outs to provider, please document the call in a patient note in Alpha the day the call is made. tes should be coded as Care
More informationFlorida Medicaid. Behavioral Health Community Support and Rehabilitation Services Coverage Policy. Agency for Health Care Administration [Month YYYY]
Florida Medicaid Behavioral Health Community Support and Rehabilitation Services Coverage Policy Agency for Health Care Administration [Month YYYY] Draft Rule Table of Contents 1.0 Introduction... 1 1.1
More informationCoverage of Behavioral Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions
Coverage of Behavioral Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions Webinar Website: http://gucchdtacenter.georgetown.edu/resources/tawebinars.html Coverage
More informationFlorida Medicaid. Behavioral Health Assessment Services Coverage Policy. Agency for Health Care Administration [Month YYYY] Draft Rule
Florida Medicaid Behavioral Health Assessment Services Coverage Policy Agency for Health Care Administration [Month YYYY] Draft Rule Florida Medicaid Behavioral Health Assessment Services Coverage Policy
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationCOVERED SERVICES FOR NHP MASSHEALTH MEMBERS
COVERED SERVICES FOR NHP MASSHEALTH MEMBERS Neighborhood Health Plan Covered Services for MassHealth Standard & CommonHealth, Family Assistance, and CarePlus Issued and effective October 1, 2015 nhp.org/member
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Florida FLORIDA (FL) Medicaid s EPSDT benefit provides comprehensive health care services to children under age 21,
More informationDivision of Mental Health, Developmental Disabilities & Substance Abuse Services NC Mental Health and Substance Use Service Array Survey
Table 1 Service Name Include any subcategories of service on a separate line In Table 2, please add service description and key terms Outpatient Treatment Behavioral Health Urgent Care (a type of outpatient)
More informationProviderReport. Managing complex care. Supporting member health.
ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be
More information#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT)
COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - Policy- QUALITY ASSURANCE #14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) Director's /{A A.. \
More informationChildren s Developmental Clinical Coverage Policy No: 8-J Service Agencies (CDSAs) Amended Date: October 1, 2015.
Children s Developmental Clinical Coverage Policy No: 8-J Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Audiological Services... 1 1.2 Nutrition Services... 1 1.3 Occupational
More informationPsychiatric Residential Treatment Facility (PRTF) Prior Authorization Request
MIS# Name: Address: City/State/Zip: Phone #: Fax #: Client Information: Psychiatric Residential Treatment Facility (PRTF) Prior Authorization Request Clinical Contact Information * * * * Attachments *
More informationTable of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Mississippi MISSISSIPPI (MS) Medicaid s EPSDT benefit provides comprehensive health care services to children under
More informationOverview of Medicaid Program
Joint HHS Appropriations Subcommittee FY 2017-19 Overview of Medicaid Program Steve Owen, Fiscal Research Division Overview of Medicaid WHAT IS MEDICAID? Medicaid is funded through Title XIX of the Social
More informationCovered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
More informationEarly and Periodic Screening, Diagnosis, and Treatment (EPSDT) Introduction
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Introduction Federal law requires state Medicaid programs to offer Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) to all Medicaid-eligible
More informationWHAT DOES MEDICALLY NECESSARY MEAN?
WHAT DOES MEDICALLY NECESSARY MEAN? Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary as defined below. Medically Necessary means appropriate and necessary
More information1.2.4(a) PURCHASE OF SERVICE POLICY TABLE OF CONTENTS. General Guidelines 2. Consumer Services 3
TABLE OF CONTENTS General Guidelines 2 Consumer Services 3 Services for Children Ages 0-36 months 3 Infant Education Programs 4 Occupational/Physical Therapy 4 Speech Therapy 5 Services Available to All
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationMedicaid & Global Commitment
Medicaid & Global Commitment Nolan Langweil, Joint Fiscal Office, Lindsay Parker, Vermont Agency of Human Services Updated January 13, 2017 1 PART ONE Medicaid Background 2 What is Medicaid? Created in
More informationSubject to change. Summary only; does not supersede manuals and formal notices and publications. Consult and appropriate Partners
Subject to change. Summary only; does not supersede manuals and formal notices and publications. Consult www.partnersbhm.org and appropriate Partners for most recent information or with questions. Gain
More informationLong-Term Care Glossary
Long-Term Care Glossary Adjudicated Claim Activities of Daily Living (ADL) A claim that has reached final disposition such that it is either paid or denied. Basic tasks individuals perform in the course
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Virginia VIRGINIA (VA) Medicaid s EPSDT benefit provides comprehensive health care services to children under age
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Oregon OREGON (OR) Medicaid s EPSDT benefit provides comprehensive health care services to children under age 21,
More informationMedicaid Funded Services Plan
Clinical Communication Bulletin 007 To: From: All Enrollees, Stakeholders, and Providers Cham Trowell, UM Director Date: May 10, 2016 Subject: Medicaid Funded Services Plan benefit changes, State Funded
More informationEPSDT and Inpatient Psychiatric Care
EPSDT and Inpatient Psychiatric Care Federal Mandate for Mental Health Services for Youth Under 21 EPSDT services: such other necessaryhealth care, diagnostic services, treatment, and other measures to
More informationProtect Medicaid Consumer Protections and Due Process. Kim Lewis, Managing Attorney Wayne Turner, Senior Attorney
Protect Medicaid Consumer Protections and Due Process Kim Lewis, Managing Attorney Wayne Turner, Senior Attorney www.healthlaw.org @NHeLP_org March 24, 2017 2 About NHeLP National non-profit committed
More informationThe Money Follows the Person Demonstration in Massachusetts
The Money Follows the Person Demonstration in Massachusetts Use of Concurrent 1915(b)(c) Waivers to Serve Elders and Adults with Disabilities Transitioning from Long-Stay Facilities HCBS Conference Arlington,
More informationMedicaid-CHIP State Dental Association
Medicaid-CHIP State Dental Association Financing Oral Health Care for Pregnant Women MARY E. FOLEY, MPH Executive Director Medicaid-CHIP State Dental Association 2013 National Oral Health Conference April
More informationBehavioral Health Services
18 Behavioral Health Services Reviewed/Revised: 10/10/2017, 02/01/2017, 02/15/2016, 08/31/2015, 09/18/2014 INTRODUCTION The State of Arizona has contracted the administration of AHCCCS mental health and
More informationManaged Care Organizations (MCOs): The Basics and Emerging Issues. Who is Disability Rights NC?
Managed Care Organizations (MCOs): The Basics and Emerging Issues Disability Rights NC Conference 2015 Jennifer Bills, Senior Attorney Lisa Nesbitt, Attorney Who is Disability Rights NC? We are the protection
More informationEarly and Periodic Screening, Diagnosis and Treatment
Early and Periodic Screening, Diagnosis and Treatment 1 Healthchek Ohio Medicaid EPSDT Services Early Periodic Screening Diagnosis Treatment Identify problems early, starting at birth Check children s
More informationPrivate Duty Nursing for Clinical Coverage Policy No: 3G-2. DRAFT Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Skilled Nursing... 1 1.1.2 Nursing Care Activities... 1 1.1.3 Substantial... 2 1.1.4 Complex... 2
More informationAlternative in lieu of Services under Managed Care
NC Tide Conference November 16, 2016 Catharine Goldsmith, Manager Children s Behavioral health Services, DMA Al Greco, Section Chief Managed Care & Waiver Reimbursement, DMA Alternative in lieu of Services
More informationHOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101
HOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101 Medicaid Background Federal and State Roles Whom Does Medicaid Serve? What Does Medicaid Cover? Medicaid Waiver Programs and Services In 1965, Medicare
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Wisconsin WISCONSIN (WI) Medicaid s EPSDT benefit provides comprehensive health care services to children under age
More informationLouisiana Medicaid Update
Louisiana Medicaid Update HFMA Region 9 Conference November 15, 2015 Origins of Medicaid Means tested entitlement program Established 1965 by Title XIX of the Social Security Act Public health coverage
More informationMedicaid Simplification
Medicaid Simplification This Act authorizes the director of the state department of health and welfare to restructure the state Medicaid program in order to achieve improved health outcomes for Medicaid
More informationFlorida Medicaid. Intermediate Care Facility for Individuals with Intellectual Disabilities Services Coverage Policy
Florida Medicaid Intermediate Care Facility for Individuals with Intellectual Disabilities Services Coverage Policy Agency for Health Care Administration July 2016 Florida Medicaid Table of Contents 1.0
More informationStatewide Medicaid Managed Care Long-term Care Program Coverage Policy
Statewide Medicaid Managed Care Long-term Care Program Coverage Policy Coverage Policy Review June 16, 2017 Today s Presenters D.D. Pickle, AHC Administrator 2 Objectives Provide an overview of the changes
More informationAbout the National Standards for CYSHCN
National Standards for Systems of Care for Children and Youth with Special Health Care Needs: Crosswalk to National Committee for Quality Assurance Primary Care Medical Home Recognition Standards Kate
More informationQUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:
QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care
More informationMedi-Cal & Children. California Association of Health Plans. Kelly Hardy August 3, 2017
Medi-Cal & Children California Association of Health Plans Kelly Hardy August 3, 2017 Overview 1) Enrollment; federal threats 2) Preventive care 3) Developmental screenings 4) Quality measurement 5) Consumer/family
More informationFlorida Medicaid. Early Intervention Services Coverage Policy. Agency for Health Care Administration August 2017
+ Florida Medicaid Early Intervention Services Coverage Policy Agency for Health Care Administration August 2017 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal
More informationMedicaid Transformation
Medicaid Transformation Debra Farrington Senior Program Manager August 18, 2017 Medicaid Managed Care Already Exists in NC What North Carolina Has Now PRIMARY CARE CASE MANAGEMENT (CCNC) Primary care provider-based
More informationAlaska Mental Health Trust Authority. Medicaid
Alaska Mental Health Trust Authority Medicaid November 20, 2014 Background Why focus on Medicaid? Trust result desired in working on Medicaid policy issues and in implementing several of our focus area
More informationEarly and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT and Bright Futures: Indiana INDIANA (IN) Medicaid s EPSDT benefit provides comprehensive health care services to children under age 21,
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 08/24/17 REPLACED: 07/06/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES APPENDIX B GLOSSARY/ACRONYMS PAGE(S) 5 GLOSSARY
GLOSSARY The following is a list of abbreviations, acronyms and definitions used in the Behavioral Health Services manual chapter. Ambulatory Withdrawal Management with Extended On-Site Monitoring (ASAM
More informationInpatient Psychiatric Services for Under Age 21 Arkansas Medicaid Regulations and Documentation
Inpatient Psychiatric Services for Under Age 21 Arkansas Medicaid Regulations and Documentation Presented by: Shelly Rhodes Shelly.Rhodes@beaconhealthoptions.com Disclaimer Disclaimer: This presentation
More informationMississippi Medicaid Autism Spectrum Disorder Services for EPSDT Eligible Beneficiaries Provider Manual
Mississippi Medicaid Services for EPSDT Eligible Beneficiaries Provider Manual Effective Date: July 1, 2017 Services for Introduction: eqhealth Solutions Services (ASD) Utilization Management Program includes
More informationIV. Benefits and Services
IV. Benefits and A. HealthChoice Benefits This table lists the basic benefits that all MCOs must offer to HealthChoice members. Review the table carefully as some benefits have limits, you may have to
More informationImproving Mental Health Services in Schools
House Select Committee on School Safety Student Health Working Group Improving Mental Health Services in Schools Mark T. Benton Department of Health and Human Services April 9, 2018 Unrecognized and untreated,
More informationMEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE SUBJECT BY NUMBER: ISSUE DATE: September 8, 1995 EFFECTIVE DATE: September 8, 1995 Mental Health Services Provided
More informationFoothills Behavioral Health Partners
A Perfect Day by Seth Brigham Foothills Behavioral Health Partners Member Handbook Page 1 50 Si usted necesita una copia de esta información en español, por favor llame al 1-866-245-1959. Non-Discrimination
More informationNovember 14, Chief Clinical Operating Officer Division of Medical Assistance Department of Health and Human Services
Department of Health and Human Services Division of Medical Assistance Response To Questions from the Adult Care Home Transition Subcommittee of the Blue Ribbon Commission November 14, 2012 Presenter:
More informationBehavioral Health Services
18 Behavioral Health Services INTRODUCTION The State of Arizona has contracted the administration of AHCCCS mental health and substance abuse services program to Regional Behavioral Health Authorities
More informationMedicaid 201: Home and Community Based Services
Medicaid 201: Home and Community Based Services Kathy Poisal Division of Long Term Services and Supports Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services Centers for Medicare
More informationBeacon Health Strategies Primary Care Provider Training
Beacon Health Strategies Primary Care Provider Training REFERRAL AND RESOURCE GUIDE Updated June 2015 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 15, 2015 1 Agenda 1. Review Medi-Cal Managed
More informationPsychiatric Services Provider Manual 10/9/2007. Covered Services and Limitations CHAPTER IV COVERED SERVICES AND LIMITATIONS. Manual Title.
Subject Revision Date CHAPTER COVERED SERVICES AND LIMITATIONS Subject Revision Date i CHAPTER TABLE OF CONTENTS Inpatient Psychiatric Services (Acute Hospital and Residential) 1 Acute Care Hospitals 1
More informationHOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will REFER you to a specialist
More information