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Early Periodic Early Periodic Screening, Screening,
Diagnosis and Diagnosis and Treatment Treatment (EPSDT)(EPSDT)
Virginia Department of Medical Virginia Department of Medical Assistance Services (DMAS)Assistance Services (DMAS)The Arc of Virginia Annual
ConventionAugust 11, 2011 1
Website TipsWebsite Tips dmasva.dmas.virginia.govdmasva.dmas.virginia.gov
Program information
on many programs, this points to Maternal and Child
Health which
houses EPSDT
Find Provider Manuals and Memos at this link to the Medicaid Web Portal. 2
http://http://dmasva.dmas.virginia.gov/dmasva.dmas.virginia.gov/
Content_pgs/mch-Content_pgs/mch-home.aspxhome.aspx
Find EPSDT forms here
3
Eligibility CriteriaEligibility Criteria
EPSDT services are available to EPSDT services are available to Medicaid/FAMIS Plus enrollees Medicaid/FAMIS Plus enrollees under 21 years of age and FAMIS under 21 years of age and FAMIS fee for service enrollees under the fee for service enrollees under the age of 19age of 19 The individual must be enrolled in The individual must be enrolled in
Medicaid/FAMIS Plus or FAMIS Fee for Medicaid/FAMIS Plus or FAMIS Fee for ServiceService
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What is EPSDT? What is EPSDT? Medicaid’s Early Periodic Screening Diagnosis Medicaid’s Early Periodic Screening Diagnosis
and Treatment Program is the benefit plan for and Treatment Program is the benefit plan for children under the age of 21children under the age of 21
Preventive care, traditional diagnostic and Preventive care, traditional diagnostic and treatment services are the backbone of the treatment services are the backbone of the programprogram
There is no special application process for There is no special application process for EPSDT.EPSDT.
Children are automatically eligible for EPSDT Children are automatically eligible for EPSDT when enrolled in the Medicaid or FAMIS Fee-when enrolled in the Medicaid or FAMIS Fee-for-Service benefit plansfor-Service benefit plans
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What is EPSDT? What is EPSDT?
The requirement to “correct and The requirement to “correct and ameliorate” health conditions is a ameliorate” health conditions is a unique feature of the EPSDT unique feature of the EPSDT program. This requirement of the program. This requirement of the program is included in many of the program is included in many of the services that DMAS provides for services that DMAS provides for childrenchildren
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Scope of ServicesScope of Services
Individualized health care, diagnostic Individualized health care, diagnostic services, and “treatment” as listed in the services, and “treatment” as listed in the Federal Medicaid statute, must be Federal Medicaid statute, must be provided when medically necessary to provided when medically necessary to correct and ameliorate (improve) physical correct and ameliorate (improve) physical and mental conditions discovered during and mental conditions discovered during screening services whether or not screening services whether or not included in the Medicaid state planincluded in the Medicaid state plan
The program does not cover services that The program does not cover services that are experimental or investigationalare experimental or investigational
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Safety Net FunctionSafety Net Function
EPSDT covers medically necessary EPSDT covers medically necessary treatments when:treatments when: Not available to certain disability groupsNot available to certain disability groups Not covered by Medicaid/FAMIS PlusNot covered by Medicaid/FAMIS Plus
Including FAMIS FFS which get Medicaid Including FAMIS FFS which get Medicaid benefitbenefit
Examples:Examples: Eating Disorders TreatmentEating Disorders Treatment Residential Substance Abuse TreatmentResidential Substance Abuse Treatment Behavioral Treatments Behavioral Treatments
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Specialized ServicesSpecialized Services
The following Services are covered only The following Services are covered only under EPSDT and require service under EPSDT and require service authorization:authorization: Hearing AidsHearing Aids
Medicaid/FAMIS MCO member = Request Medicaid/FAMIS MCO member = Request through MCOthrough MCO
Assistive TechnologyAssistive Technology Medicaid MCO member = Request through Medicaid MCO member = Request through
MCOMCO Available through DME benefit for FAMIS MCO Available through DME benefit for FAMIS MCO
member = Request through MCOmember = Request through MCO
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Specialized ServicesSpecialized Services In Home Behavioral TherapyIn Home Behavioral Therapy
Medicaid MCO member = Request services through Medicaid MCO member = Request services through EPSDTEPSDT
FAMIS MCO = not covered serviceFAMIS MCO = not covered service Residential Behavioral Treatment Residential Behavioral Treatment
Medicaid MCO member = Request services through Medicaid MCO member = Request services through EPSDTEPSDT
Not available for FAMIS MCO member (Level C)Not available for FAMIS MCO member (Level C) Substance Abuse Residential Treatment Substance Abuse Residential Treatment
Medicaid MCO member = Request services through Medicaid MCO member = Request services through EPSDTEPSDT
Not available for FAMIS MCO memberNot available for FAMIS MCO member
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Specialized ServicesSpecialized Services
Personal CarePersonal Care Medicaid MCO member = Request services Medicaid MCO member = Request services
through EPSDTthrough EPSDT FAMIS MCO member = Not available for FAMIS MCO member = Not available for
FAMIS MCO memberFAMIS MCO member Private Duty NursingPrivate Duty Nursing
Medicaid/FAMIS MCO member = Request Medicaid/FAMIS MCO member = Request through MCOthrough MCO
All EPSDT Specialized Services for FFS All EPSDT Specialized Services for FFS Medicaid/FAMIS Plus/FAMIS = request Medicaid/FAMIS Plus/FAMIS = request through EPSDTthrough EPSDT
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What is Not Covered?What is Not Covered?
Services must be deemed as medically Services must be deemed as medically necessarynecessary Ex: Personal care would be medically necessary Ex: Personal care would be medically necessary
if a child meets the EPSDT personal care criteriaif a child meets the EPSDT personal care criteria Certain services are not covered by EPSDT Certain services are not covered by EPSDT
due to Federal Limitationsdue to Federal Limitations Respite CareRespite Care Environmental ModificationsEnvironmental Modifications Vocational ServicesVocational Services Educational ServicesEducational Services
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Specific Specific Program Program
GuidelinesGuidelines
Please refer to the EPSDT Program Please refer to the EPSDT Program manuals and fact sheets for more manuals and fact sheets for more information about these servicesinformation about these services
www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManualwww.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManualClick on Provider manuals and select specific manual from drop Click on Provider manuals and select specific manual from drop down menu.down menu.
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Personal CarePersonal Care
Assistance with activities of daily Assistance with activities of daily living (ADLs): living (ADLs):
ADL categories: ADL categories:
bathing bathing eating/feedingeating/feeding
dressingdressing toiletingtoileting
transferstransfers continencecontinence
ambulationambulation
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Personal CarePersonal Care
Health conditions cause limitations Health conditions cause limitations in performing in performing three or morethree or more ADLs. ADLs.
This is a great service for those on This is a great service for those on the waitlist for Medicaid waivers the waitlist for Medicaid waivers such as Intellectual Disability Waiversuch as Intellectual Disability Waiver
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EPSDT NursingEPSDT Nursing
EPSDT nursing is private duty EPSDT nursing is private duty nursing deemed medically necessary nursing deemed medically necessary by the attending physicianby the attending physician
EPSDT nursing can provide for EPSDT nursing can provide for assessing and providing assessing and providing interventions, maintaining nursing interventions, maintaining nursing care and communicating with the care and communicating with the physician regarding changes in the physician regarding changes in the individual's medical statusindividual's medical status
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EPSDT Nursing Medical EPSDT Nursing Medical NeedsNeeds
Require skilled intervention or medical Require skilled intervention or medical monitoring from a medical professional monitoring from a medical professional in order to maintain physical health or in order to maintain physical health or to prevent imminent physical harmto prevent imminent physical harm
Have chronic nursing needs that are not Have chronic nursing needs that are not intensive enough to meet eligibility for intensive enough to meet eligibility for the Technology Assisted Waiver the Technology Assisted Waiver
Needs are intermittent or the Needs are intermittent or the illness/injury related nursing is not illness/injury related nursing is not covered by the Home Health Programcovered by the Home Health Program
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Assistive Technology
Specialized medical equipment, supplies, devices, controls, and appliances not available under the regular Medicaid program
Enable members to increase their abilities to perform ADLs or to perceive, control, or communicate with the environment in which they live
Assistive Technology
If member enrolled in Waiver which covers AT, must request coverage first through waiver If not covered, then may be requested through
EPSDT (this process is done internally with the ID and DD waivers)
Home/environmental modifications are not covered
If AT is requested during school hours, documentation must be presented to EPSDT why school not covering under IDEA
Assistive Technology
Request for services: Letter of medical necessity from the child's
physician A DMAS-352 (Certificate of Medical
Necessity) completed by the DME or AT provider and signed by the child's physician
An itemized quote or invoice from the child's physician/AT provider Include warranty, repairs, servicing, time
frame that AT may be needed
Audiology and Hearing Audiology and Hearing AidsAids
Digital and analog hearing aids are Digital and analog hearing aids are coveredcovered
FM amplification systems are FM amplification systems are covered as necessary to aid covered as necessary to aid language developmentlanguage development
Cochlear implants are covered for all Cochlear implants are covered for all agesages
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Audiology and Hearing Audiology and Hearing AidsAids
Fact sheet Fact sheet http://dmasva.dmas.virginia.gov/Conhttp://dmasva.dmas.virginia.gov/Content_atchs/mch/mch-epsdt_ssi6.pdftent_atchs/mch/mch-epsdt_ssi6.pdf
Manual Manual http://websrvr.dmas.virginia.gov/Prohttp://websrvr.dmas.virginia.gov/ProviderManuals/ManualChapters/GeneviderManuals/ManualChapters/General/prm-EPSDT_Hear_Audio.pdfral/prm-EPSDT_Hear_Audio.pdf
22
Behavioral Therapy Behavioral Therapy ServicesServices
EPSDT Behavioral Therapy allows EPSDT Behavioral Therapy allows reimbursement for treatment reimbursement for treatment interventions related to developmental interventions related to developmental delays and/or health conditions which, delays and/or health conditions which, if left untreated, would lead to if left untreated, would lead to significant long term impairments in significant long term impairments in adaptive functioningadaptive functioning
Behavioral Treatment is available Behavioral Treatment is available either in a primarily home based either in a primarily home based setting or in a residential treatment setting or in a residential treatment settingsetting
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Service GoalsService Goals
Behavioral treatment services are Behavioral treatment services are intended to increase adaptive behaviors intended to increase adaptive behaviors of the childof the child
Increasing communication skills and Increasing communication skills and impulse control are main targets for impulse control are main targets for these servicesthese services
Services should integrate other clinical Services should integrate other clinical and medical services with the behavioral and medical services with the behavioral treatment protocol to increase the treatment protocol to increase the enrollee’s adaptive functioningenrollee’s adaptive functioning
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Treatment CoordinationTreatment Coordination
Services such as speech therapy, Services such as speech therapy, occupational therapy or psychiatric occupational therapy or psychiatric care must be coordinated with and care must be coordinated with and integrated with the behavioral integrated with the behavioral treatment plantreatment plan
All services must be evidence based, All services must be evidence based, measureable and medically measureable and medically necessary to specifically improve necessary to specifically improve components of adaptive functioningcomponents of adaptive functioning
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Provider Participation Provider Participation RequirementsRequirements
(In Home)(In Home) In Home Behavioral Treatment In Home Behavioral Treatment
providers must be licensed to providers must be licensed to provide one of the following provide one of the following services: services: Intensive In-Home Services Intensive In-Home Services Outpatient ClinicOutpatient Clinic Day TreatmentDay Treatment
26
EPSDT EPSDT Inpatient Inpatient TreatmentTreatment
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EPSDT Case ExamplesEPSDT Case Examples
Conditions served through EPSDT:Conditions served through EPSDT: Severe Behavioral problems and health Severe Behavioral problems and health
problems associated with:problems associated with: AutismAutism Brain InjuryBrain Injury Eating Disorders Eating Disorders
(when inpatient treatment is necessary) (when inpatient treatment is necessary) Chronic Illnesses that require inpatient Chronic Illnesses that require inpatient
treatmenttreatment Substance Abuse DisordersSubstance Abuse Disorders
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How to Access How to Access Behavioral Treatment Behavioral Treatment
ServicesServices
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Eligibility Eligibility Criteria/Physician ReferralCriteria/Physician Referral
The individual must have a medical The individual must have a medical need for behavioral treatment. The need for behavioral treatment. The need for residential behavioral need for residential behavioral treatment must be identified by the treatment must be identified by the child’s physician through an Inter-child’s physician through an Inter-periodic/problem-focused visit or an periodic/problem-focused visit or an EPSDT screening/well-child visit. EPSDT screening/well-child visit.
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Managed Care Managed Care Organization EnrolleesOrganization Enrollees
DMAS contracted Managed Care DMAS contracted Managed Care Organizations (MCOs) are not required Organizations (MCOs) are not required to provide coverage for behavioral to provide coverage for behavioral treatment servicestreatment services
Services (such as psych, OT, SLP, MD) Services (such as psych, OT, SLP, MD) other than those that are carved-out of other than those that are carved-out of the MCO contract should be coordinated the MCO contract should be coordinated as usual through the MCO in which the as usual through the MCO in which the child is enrolledchild is enrolled
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Managed Care Managed Care Organization EnrolleesOrganization Enrollees
Behavioral Treatment services for Behavioral Treatment services for children who are enrolled in a children who are enrolled in a Medicaid/FAMIS Plus MCOs are Medicaid/FAMIS Plus MCOs are available to the member through available to the member through DMAS and not the member’s MCODMAS and not the member’s MCO
FAMIS MCO members do not have FAMIS MCO members do not have Behavioral Treatment as covered Behavioral Treatment as covered serviceservice
32
Approval AllowancesApproval Allowances
DMAS will generally authorize 6 months DMAS will generally authorize 6 months for the initial service authorizationsfor the initial service authorizations
Continuation of services will generally be Continuation of services will generally be authorized in 3 month incrementsauthorized in 3 month increments
Less time may be approved when DMAS Less time may be approved when DMAS must request specific clinical information must request specific clinical information to decide if continuation of treatment is to decide if continuation of treatment is effective or clinically necessary effective or clinically necessary
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Where to Send Service Where to Send Service RequestsRequests
Requests for services may be faxed to: Requests for services may be faxed to:
(804) 612-0043 (804) 612-0043
Requests for services may be mailed Requests for services may be mailed to:to:
DMAS DMAS Maternal and Child Health DivisionMaternal and Child Health Division
600 E. Broad St., Ste 1300600 E. Broad St., Ste 1300Richmond VA, 23219Richmond VA, 23219
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Service RequestsService Requests
DMAS processes all typical requests DMAS processes all typical requests within 10-15 business days within 10-15 business days
MCO’s use their own PA processesMCO’s use their own PA processes To find MCO contact numbers use this To find MCO contact numbers use this
link:link:
http://www.dmas.virginia.gov/http://www.dmas.virginia.gov/downloads/mcrguides/downloads/mcrguides/
Chapter_8.pdfChapter_8.pdf35
EPSDT ContactsEPSDT Contacts Brian Campbell, EPSDT Brian Campbell, EPSDT
Services SupervisorServices Supervisor(804) 786-0342(804) [email protected]@dmas.virginia.
govgov
Anne Young, EPSDT Nursing Anne Young, EPSDT Nursing and Preauthorization and Preauthorization ClinicianClinician(804) 371-2635(804) [email protected]@dmas.virginia.gov
Shirlene Harris, EPSDT Shirlene Harris, EPSDT Preauthorization Preauthorization (804) 225-3124(804) [email protected]@dmas.virginia.g
ov ov
Tabitha Taylor, MCH Tabitha Taylor, MCH Program AnalystProgram Analyst(804) 225-3231(804) [email protected]@dmas.virgini
a.gova.gov
Jeff Beard, MCH Program Jeff Beard, MCH Program AnalystAnalyst(804)371-7981(804)[email protected]@dmas.virginia.go
vvUse the Web to find forms Use the Web to find forms and more information!and more information!
http://dmasva.dmas.virginia.gov/
DMAS Portal: DMAS Portal: www.virginiamedicaid.dmas.virginia.gov/wps/porta
l
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