Presentation on theme: "EPSDT / HealthCheck MCO Provider Training. Total number of DC Medicaid EPSDT eligible members (children under 21): 80,339 Total number of DC Medicaid."— Presentation transcript:
EPSDT / HealthCheck MCO Provider Training
Total number of DC Medicaid EPSDT eligible members (children under 21): 80,339 Total number of DC Medicaid Primary Care Providers: 354
Medicaid EPSDT Services Benefit Medicaid is a joint federal-state partnership program administered by the Centers for Medicare & Medicaid Services (CMS). Congress enacted the Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) services benefit as part of the federal Medicaid Program. Defined the benefit in 1967 and expanded it in 1989 EPSDT entitles all Medicaid enrolled children (birth – 21 years) to a comprehensive benefit package which includes screenings, preventive health care, and medically necessary diagnosis and treatment Assures availability and accessibility of required health resources Helps Medicaid beneficiaries and their caregivers effectively use these resources
EPSDT Services EPSDT mandates the following preventive health services: Screening services Comprehensive health and developmental history (physical, mental, and developmental) Comprehensive unclothed physical exam Appropriate immunizations (per ACIP) Laboratory tests, including mandatory lead screening CMS requires all states to perform blood lead tests on enrolled children at 12 and 24 months of age If lead screening is not previously documented, children should also be screened between 36 and 72 months Health education and anticipatory guidance Vision screening Hearing screening Dental screening Other necessary health care Diagnostic services, if needed for further evaluation Treatment (or referrals) to correct or improve health conditions
Health Education Required component of screening services – includes anticipatory guidance Health education and counseling to both parents and children is required Assist in understanding age-appropriate developmental issues Provide information on benefits of healthy lifestyles and practices, including regular dental care Accident and disease prevention Additional Health Education resources, including anticipatory guidance cards, can be found in the Resource section at
Vision and Hearing Services Vision Diagnosis and prescription for defects in vision including eyeglasses Vision services must be provided according to district periodicity schedule Hearing Diagnosis and prescription for defects in hearing including hearing aids Hearing services must be provided according to district periodicity schedule
Dental Services Oral screening must be part of every well-child physical exam, but should not be seen as a substitute for an exam by a dentist. (See periodicity schedule for initiation and interval for dental screenings) Caregivers should be referred to an oral health provider within 6 months of the eruption of a child’s first tooth, and should be encouraged to take their child to a dentist every six (6) months. For assistance in finding a dentist and scheduling an appointment, caregivers should be encouraged to call the Dental HelpLine at
Other Necessary Health Care Provide for other necessary health care, diagnostic services, treatment to correct or ameliorate developmental defects, and referral for treatment of physical and mental/behavioral illness or conditions identified through screening services.
EPSDT in DC=HealthCheck EPSDT incorporated into MCO contracts with expectations and penalties HealthCheck provides each Medicaid-enrolled child with a medical home in the District of Columbiamedical home Additional HealthCheck goals are to: – Improve knowledge of the external review of DC's Medicaid managed care program – Help satisfy the requirements of the Salazar court mandates –Target goal of 80% EPSDT ComplianceSalazar court mandates Required reporting and documentation of HealthCheck services 2009 EPSDT Compliance Ratio for DC: 68%
Why is EPSDT/HealthCheck Important? Collaboration: CMS, state Medicaid agencies, and EPSDT providers have a shared obligation to ensure comprehensive pediatric preventive care for eligible children and teens, and to support their families in accessing the health services available through EPSDT. Scheduling: Develop an approved schedule of preventive health visits at regular intervals that meet reasonable standards of medical practice, including intervals for vision, hearing, and dental screening services. Screening: Assess child health needs through initial and periodic examinations and evaluations Diagnose and Treat: Identify health problems for early diagnosis and treatment – before the child’s health issues become more complex and treatment more costly.
Tools Required for EPSDT/HealthCheck Visit Blood pressure cuffs (size appropriate) Eye vision screening tool available Audiometer Thermometer Scales appropriate for age to measure weight Device/tool to measure height Ophthalmoscope Otoscope Exam table with paper Percussion hammer Stethoscope Exam gown for older children Providers will make available to patients health educational materials: Educational materials evident Education materials available in languages appropriate for patient population Explanation of EPSDT services provider orally and in writing to patients All provider who immunize children shall participate in the Vaccines for Children Program Keep VFC vaccines separate from private insurance vaccines
EPSDT Periodicity Schedule DC has adopted AAP and AAPD periodicity schedules NEED TO INSERT PERIODICITY SCHEDULE NEED TO INSERT DENTAL PERIODCITIY SCHEDULE NEED TO INSERT IMMUNIZATION SCHEDULE 0-6 NEED TO INSERT IMMUNIZATION SCHEDULE 7-18 NEED TO INSERT IMMUNIZATION SCHEDULE NEED TO INSERT CATCH-UP SCHEDULE
EPSDT Billing Office Visit Codes The following office visit codes are used to bill for EPSDT visits and are age specific. There are also different codes to distinguish between new and established patients. Managed Care Organizations and DHCF use the data submitted on claims to evaluate and monitor EPSDT care in the District, so it is especially important that the claims are complete and accurate.
EPSDT Billing New Patient Infant under 1 year of age Early Childhood – age 1 to 4 years Late Childhood – age 5 to 11 years Adolescent – age 12 to 17 years Age 18 to 22 years Established Patient Infant under 1 year of age Early Childhood – age 1 to 4 years Late Childhood – age 5 to 11 years Adolescent – age 12 to 17 years Age 18 to 22 years
EPSDT Billing Immunization codes – Administration of immunizations only Codes for administration Codes for vaccine rejected Diphtheria, Tetanus Toxoids and Acellular Pertussis vaccine (DTap) Diphtheria, Tetanus Toxoids and Pertussis vaccine (DTP) Diphtheria and Tetanus Toxoids Tetanus Toxoid Measles, Mumps and Rubella virus vaccine, live (MMR) Poliovirus vaccine, live, oral (any type) Varicella (chicken pox) vaccine 90718Tetanus and Diphtheria Toxoids absorbed, for adult use (Td) Diphtheria, Tetanus Toxoids and Pertussis (DTP) and Hemophilus Infuluenza B (HIB) vaccine Immunization, active, Hepatitis B vaccine; newborn to 11 years
EPSDT Billing Lab codes Hemoglobin Hemocrit Hemoglobin Lead screen Urinalysis – TB Test, Intradermal TB Test, Tine Test – Cholesterol, HDL – Cholesterol, Direct Sickle Cell – Specimen Handling
EPSDT Billing Provide well care during sick visit. Both visit codes can be billed using modifier 25 with the regular office visit. – For example: with a modifier 25 and
Access Standards Required by MCO Contracts Type of AppointmentStandard Emergency care [life threatening]Immediately at the nearest facility Urgent care or Sick Care Appointments w/PCPWithin 24 hours of request Urgent Care with a SpecialistWithin 48 hours of referral Routine Appointments [including Health Check and IDEA appointments] Within 30 days of request Initial Appointments for pregnant women or persons needing family planning Within 10 days of request Routine Physical ExaminationWithin 30 days of request Waiting Time in Practitioner’s officeNot to exceed 1 hour Use of free interpreter servicesAs needed during all appointments
Behavioral Health Access Standards Type of AppointmentStandard Behavioral Health Emergency care [life threatening] Immediately at the nearest facility Behavioral Health Telephone Crisis TriageWithin 15 minutes over the telephone Psychiatric Intervention or face-to-face AssessmentWithin 90 minutes of completion of telephone assessment [when needed] and available on a 24 hours basis 7 days a week Treatment for non-life threatening emergencyTreated as emergency care Routine Behavioral Health AppointmentsWithin 10 days of request Waiting Time in Practitioner’s officeNot to exceed 1 hour Use of free interpreter servicesAs needed during all appointments
Access to After Hours Care Type of AppointmentStandard Emergency CareCall 911 and/pr go to the nearest facility immediately Urgent non-medical emergency where care is needed before business hours Provide a telephone number for the covering practitioner Urgent non-medical emergency where care is not needed until business hours Advise member to call during business hours
Resources Chartered Health Plan – EPSDT Manager - Christina Unison Health Plan – EPSDT Manager – Jenine Health Services for Children with Special Needs (HSCSN) – EPSDT Manager - BJ DC Department of Health Care Finance– EPSDT Coordinator- Colleen Web Sites INCLUDE:
Provider Questions or Further Training Requests Chartered Health Plan – Director of Provider Network Athena Health Services for Children with Special Needs – Director of Provider Services Terri Unison Health Plan – Director of Provider Network Management Marci DC Department of Health Care Finance—Manager, Office of Provider Services Laurie