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“Securing Health Rights for Those in Need”
Children’s Services Under Medicaid:Ensuring EPSDT coverage & accountability
On-line meeting: OH, MI, & WV
November 14, 2008Jane Perkins
About NHeLP
• Non-profit public interest law firm working to increase access to quality health care on behalf of limited income individuals, including children, women, the elderly, and people with disabilities
• Litigation & policy expertise includes: Medicaid; managed care; EPSDT; civil and disability rights; court access
• www.healthlaw.org
Presentation overview
• Medicaid Basics• Focus on EPSDT
– Explain the benefit– Explore ways to assure EPSDT’s promise (government
accountability)
Medicaid %*#)@
• “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”
Medicaid Basics
• “Cooperative federalism”– Shared funding:
• OH: 62.14% MI: 60.27% WV: 73.73% (FY ’09)
– Shared administration:• Federal: Centers for Medicare & Medicaid Services (CMS)
• States:
– OH Dep’t of Job & Fam. Serv.
– MI Dep’t of Community Health– WV Department of Health & Human Resources
• “Entitlement”
Medicaid Basics
• Mandatory & optional eligibility groups, e.g.– children aged 6 to 19 with incomes < FPL
• Mandatory & optional services
Why EPSDT?
• Children are not little adults
• Adolescents are not big children
• Poor children are more likely to have: Vision, hearing and speech problems Untreated tooth decay Elevated lead blood levels Sickle cell disease Behavioral Health problems Asthma And more . . .
EPSDT coverage
• Mandatory Medicaid services for children and youth under age 21
– Covers more than one in four children in US• Covers more than one in three children in WV
– Over 30% of all pediatrician visits
A Word about WV Mountain Health Choices
• Non-disabled, non-pregnant women & children• Member responsibility agreement: Enhanced benefits• No member responsibility agreement: Basic benefits, e.g.
– Home health -- 25/year – PT -- 20/year – Weight management -- not covered– Rx – 4/month– Transportation – 10/year
A Word about WV Mountain Health Choices
– 93% of children in Basic Plan (CCF, Aug. 2008)
– EPSDT CANNOT BE IGNORED– EPSDT STILL APPLIES
A Word about Managed Care(OH, MI, WV)
– State Medicaid agencies contract with at-risk health plans to provide Medicaid services
– EPSDT CANNOT BE IGNORED– EPSDT STILL APPLIES
EPSDT Requirements— Medical, vision, hearing, dental screening
Medical Screens Health and developmental assessment Unclothed physical exam Immunizations Lab tests, including lead blood tests Health education and anticipatory guidance
EPSDT Requirements— Medical, vision, hearing, dental screening
• Additional Required ScreensVision, including eyeglasses
Hearing, including hearing aids
Dental, including relief of pain, restoration of teeth and maintenance of dental health
EPSDT Requirements—Early and Periodic screening
• Periodic Screens Set according to age Set by medical and dental expertsDifferent for medical, dental, hearing and vision
• Interperiodic “as needed” Screens• States must provide or arrange for the
provision of screening services in all cases there they are requested
Features of “E” & “P”
• Medical screen = 5 components• Provider need not deliver all services• Up to date periodicity schedules
– Bright Futures, 3d edition (www.aap.org)• No cost sharing • Appointment & transportation assistance• No prior authorization• Any encounter=Interperiodic screen*
Advocating for EPSDT Screening in West Virginia
• Up-to-date periodicity schedules?• Age-appropriate screening forms?
– OH, MI -- ? – WV form – up to date? part of EMR? Mental health
form being used?
• Limiting providers to all EPSDT services?• Adequate screening for developmental
delay/substance abuse?
EPSDT Screening in West Virginia—what to look for
• Periodicity Schedules Age AAP WV<1 7 7 1-2 4 43-5 3 36-9 2 ?10-14 3 ?15-18 2 ?19-20 1 ?
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 Services—Federal Scope of Benefits
All necessary treatment within 1396d(a)Mandatory services Optional Services
Physician services Prescription drugs
Laboratory/x-ray Dental services
In-patient hospital Physical and other therapies
Outpatient hospital Private duty nursing
Nursing facility services Home health care*
Home health care* Rehabilitation services
EPSDT Personal care services
Case management
Transportation
EPSDT Services—Federal Definition of Medical Necessity
Treatment and services “necessary … to correct or ameliorate physical and mental illnesses and conditions”
• Deference to treating provider“…the physician is the key figure in determining utilization of health services . . . it is a physician who is to decide upon admission to a hospital, order tests, drugs and treatments and
determine the length of stay.” S. Rep. No. 404, 89th Congress, 1st Session
Advocating for the “T”
• Diagnosed during an EPSDT screen?• On the list of covered services?• Medically necessary?• Not experimental?• No less costly, equally effective alternative
available in the geographic area?
• Written justification from physician (e.g. Rx pad) & treatment team – Patient history
– Diagnosis/prognosis
– Medical justification
– Description of benefits to fit into a Medicaid “box”• Incontinence supplies=home health• Basic living skills=home health, rehabilitation
• Length of time service/treatment is needed • If appropriate: product information, photographs, comparable prices• Statement that request is under EPSDT to “correct or ameliorate”
the child’s condition
EPSDT – To get the “T” Request should include
EPSDT RequirementsOutreach and informing
• States must inform Medicaid families & children about EPSDT• Informing must be effective
Oral and writtenTranslatedTargeted (e.g. pregnant teens, non-users)
• Transportation and appointment assistance (prior to screen due date)
• Coordinate with other entities
EPSDT Informing
Inform Families About:
Benefits of preventive care
Services availablethrough EPSDT
Transport & schedulingassistance
EPSDT-Addressing Stubborn BarriersMonitoring
• Annual reporting required—CMS Form 416• Report by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, 19-20)
– Children screened– Children referred for corrective treatment– Children receiving dental treatment– Children receiving lead blood testing
EPSDT – Addressing Stubborn BarriersMonitoring
• State/managed care organizations must available:– Names, locations, qualifications of participating
providers, non-English language spoken & whether accepting new Medicaid patients
EPSDT – Addressing Stubborn BarriersMonitoring
• State/managed care organizations must available:– External independent quality reviews– Healthcare Effectiveness Information & Data Set
(HEDIS)– Well child & adolescent visits– Treatment of children w/respiratory infections– Antidepressant medication management
» OH, MI, WV – all use
EPSDT – Addressing Stubborn BarriersMonitoring
National Health Law Program –
Sunshine & Government Accountability Project
Using-publicly available data to hold government payers accountable for spending taxpayer $$ on covered health services