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 perkins@healthlaw.org iris.green@disabilityrightsnc.org (919) 968-6308 (x101) (919) 856-2195
Pre-test How much do you know about EPSDT?
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.
Outline of the session Medicaid Overview Focus on EPSDT, with emphasis on Behavioral health How it works in NC
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!
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
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
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
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
E = Early P= Periodic S = Screening D = Diagnostic T = Treatment
Available at: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/early-and-peri odic-screening-diagnostic-and-treatment.html (June 2014)
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.
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. 441.50-441.62 CMS, State Medicaid Manual, part 5 CMS, EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents Youth (June 2014), http://www.medicaid.gov/medicaid-chip-program-information /by-topics/benefits/downloads/epsdt_coverage_guide.pdf
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), http://www2.ncdhhs.gov/dma/healthcheck/hc-billing_guide_2013.pdf
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
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
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
EPSDT Broad Nature of EPSDT
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
EPSDT Informing Inform Families About: Benefits of preventive care Services available through EPSDT Transport & scheduling assistance
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%
EPSDT Addressing Stubborn Barriers Resolving Complaints Administrative due process Written notice Opportunity to be heard Court action
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
EPSDT
EPSDT No Caps on Services
EPSDT No Limits on Service Location
EPSDT Available to CAP Waiver Recipients
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
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
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)
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
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.
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.
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.
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 http://www.medicaid.gov/medicaid-chip-program-information/by-to pics/benefits/downloads/epsdt_coverage_guide.pdf
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.
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
Post-test How much did you learn?
A Strategy for Success
The End