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Understanding Medicaid and EPSDT/Health Tracks for Children in North Dakota Sponsored by: US Dept of Health & Human Services / Centers for Medicare and.

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Presentation on theme: "Understanding Medicaid and EPSDT/Health Tracks for Children in North Dakota Sponsored by: US Dept of Health & Human Services / Centers for Medicare and."— Presentation transcript:

1 Understanding Medicaid and EPSDT/Health Tracks for Children in North Dakota Sponsored by: US Dept of Health & Human Services / Centers for Medicare and Medicaid Services – Grant # 11-P /8-01 & Department of Human Services/Medical Services Division /CSHS Family Voices of North Dakota Health Information and Education Center

2 What is Medicaid? Title XIX of the Social Security Act is a program which provides medical assistance for certain individuals and families with low incomes and resources

3 What is Medicaid? The program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the Federal and State governments to assist States in the provision of adequate medical care to eligible needy persons.

4 What is Medicaid? Physician carePhysician care Hospital careHospital care Skilled nursing careSkilled nursing care Family planningFamily planning DMEDME EPSDT services, including dental and care coordinationEPSDT services, including dental and care coordination Lab and X-rayLab and X-ray TransportationTransportation Prescription DrugsPrescription Drugs Vision CareVision Care

5 HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid mainly serves low-income families, while Medicare covers elderly and disabled people who receive Social Security, regardless of their income.

6 HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid also covers many services for low-income elderly and disabled people that Medicare does not pay for. Both programs are individual entitlements, which means that you qualify if you meet certain criteria.

7 HOW IS MEDICAID DIFFERENT FROM MEDICARE? Medicaid is a joint program with costs shared by both federal and state governments, while Medicare is paid for entirely by the federal government

8 Medicaid Funding Currently, the federal government will pick up more than 50% of the cost, but not more than 75%. North Dakota ’ s current federal match is 67.49%

9 Medicaid Funding In other words, for every $100,000 that the state budgets for Medicaid services, the Federal government also contributes $100,000 resulting in $200,000 available for services.

10 Medicaid Within broad national guidelines, which the Federal government provides …

11 Each State: 1.establishes its own eligibility standards; 2.determines the type, amount, duration, and scope of services; 3.sets the rate of payment for services; and 4.administers its own program.

12 Medicaid Thus, the Medicaid program varies considerably from State to State, as well as within each State over time.

13 However, Children Are Different! (Because of EPSDT/Health Tracks)

14 What Is EPSDT? Early and Periodic Screening, Diagnosis & Treatment or in North Dakota Health Tracks

15 Why is HEALTH TRACKS so Important? About HALF of all births in the U.S. are paid for by Medicaid.About HALF of all births in the U.S. are paid for by Medicaid. Over 22% of all children in the country under age 6 are covered by Medicaid.Over 22% of all children in the country under age 6 are covered by Medicaid. In % of American children 6 to 17 had no health care visits.In % of American children 6 to 17 had no health care visits. HEALTH TRACKS is designed to enhance primary care with emphasis on prevention, diagnosis and timely treatment.HEALTH TRACKS is designed to enhance primary care with emphasis on prevention, diagnosis and timely treatment.

16 What Is EPSDT? The federally mandated health care benefit package, administered in partnership with each state, for essentially ALL Medicaid enrolled children, ages birth through 20 years

17 What is HEALTH TRACKS? Early and Periodic Screening, Diagnosis & TreatmentEarly and Periodic Screening, Diagnosis & Treatment The federally mandated health care benefit package, administered in partnership with each state, for essentially ALL Medicaid enrolled children, ages birth through 20 years.The federally mandated health care benefit package, administered in partnership with each state, for essentially ALL Medicaid enrolled children, ages birth through 20 years.

18 What is HEALTH TRACKS? Medicaid is required to cover any medically necessary health care service listed in the Social Security Act, even if the service is not available to adults receiving Medicaid benefits. It emphasizes preventive care and complete early treatments. It does not include:Medicaid is required to cover any medically necessary health care service listed in the Social Security Act, even if the service is not available to adults receiving Medicaid benefits. It emphasizes preventive care and complete early treatments. It does not include: –Experimental treatments –Services or items not generally accepted as effective

19 Is EPSDT Different From Medicaid? Through EPSDT, each state’s Medicaid plan must provide to any EPSDT recipient any medically necessary health care service, even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

20 EPSDT/Health Tracks Coverage does not include: –Experimental treatments –Services or items not generally accepted as effective –Services for the caregiver’s convenience

21 The EPSDT Benefit Consists of: 1.Assuring availability and accessibility of required health care services and items;

22 Why is EPSDT so Important? More than HALF of all Medicaid enrollees across the country are children.More than HALF of all Medicaid enrollees across the country are children. EPSDT is designed to enhance primary care of children with emphasis on prevention, early diagnosis and timely treatment.EPSDT is designed to enhance primary care of children with emphasis on prevention, early diagnosis and timely treatment.

23 Why is EPSDT so Important? Children in ND who are enrolled in SCHIP or Healthy Steps are not entitled to the comprehensive benefits as offered through Medicaid via EPSDTChildren in ND who are enrolled in SCHIP or Healthy Steps are not entitled to the comprehensive benefits as offered through Medicaid via EPSDT

24 The EPSDT Benefit Consists of: Helping Medicaid clients and their parents or guardians effectively use these resources (through provider staff and EPSDT Coordinators).

25 EPSDT Staff FREE Resources for Families  Notify every enrolled family of the scope of EPSDT benefits and support services.

26 EPSDT Staff FREE Resources for Families  Guide families to appropriately use their Medicaid benefits with emphasis on education, prevention, diagnosis and timely treatment;

27 EPSDT Staff FREE Resources for Families  Maintain a Medicaid provider database for patient referrals, including dental care, vision care, hearing services, mental/behavioral health, and other services.

28 EPSDT Staff FREE Resources for Families Share extensive knowledge of Medicaid benefits and services, including those provided through HMOs;

29 EPSDT Staff FREE Resources for Providers  Assist families with Medicaid-enrolled children and youth to contact your offices to schedule appointments;

30 EPSDT Staff also……….  Assists providers in reducing the incidence of multiple appointments missed by Medicaid enrolled children and youth;

31 EPSDT Staff also……….  Identify and refer families to other community resources such as Early Intervention Services (Part C); housing; food banks; the Women, Infants and Children food program (WIC); Prenatal Plus; and Head Start.

32 Whom to contact Medical Services Division, North Dakota Department of Human Services Telephone:(701) Toll-free: or your County Social Services Office or your County Social Services Office

33 Who is Eligible for Health Tracks/EPSDT? Infants born to Medicaid-enrolled women, until the child’s first birthday.Infants born to Medicaid-enrolled women, until the child’s first birthday. Children from birth through age 5Children from birth through age 5 –If family income is below 133% FPL*

34 Who is Eligible for Health Tracks/EPSDT? Children from age 6 through age 18 at 100% FPLChildren from age 6 through age 18 at 100% FPL Children age 19 through 20 at 60% FPLChildren age 19 through 20 at 60% FPL Pregnant teenagers and womenPregnant teenagers and women –If family income is below 133% FPL *FPL stands for Federal Poverty Level. Levels change April 1st of every year. North Dakota Medicaid covers the following citizens and qualified non-citizens through age

35 And….  Children who would have been eligible for the now discontinued AFDC cash grant program, OR lost discontinued AFDC cash grant program, OR lost eligibility in that group due to increased wages or child eligibility in that group due to increased wages or child support, support,

36 And…. If family income is up to the state- established income If family income is up to the state- established income level level  Children who are in foster care, subsidized adoption under Title IV-E OR receive Supplemental Security Income (SSI) Title IV-E OR receive Supplemental Security Income (SSI)

37 Healthy Steps This is the State Child Health Insurance Plan or SCHIP

38 Healthy Steps Healthy Steps is health insurance coverage for low- income children (21 years of age and under and whose families earn <140% of FPL).

39 Healthy Steps Healthy Steps provides medical benefits including inpatient and outpatient hospital, physician, prescription drugs, dental and mental health care, of which some have a set benefit.

40 Medicaid eligibility Depending on the amount of net income, individuals may be eligible for full Medicaid benefits or may be responsible for a portion of their medical bills which is called their recipient liability. Children who are not eligible for full Medicaid benefits may be eligible for Healthy Steps. Medicaid looks at a family's total countable income and subtracts allowed expenses to establish net income. Some of the more common allowable expenses are: Taxes and other work related expensesTaxes and other work related expenses Health insurance premiumsHealth insurance premiums Dependent care expensesDependent care expenses Child support paid to a non household memberChild support paid to a non household member Other deductions may applyOther deductions may apply

41 Who Is Eligible for Medicaid? For Medicaid the following asset limits apply: Aged, Blind or Disabled: $3,000 for a one person household, $6,000 for two person household, plus $25 for each additional person in the household  There is no asset test for children and families

42 Who Is Eligible for Medicaid?  Children who are in foster care, subsidized adoption under Title IV-E OR receive Supplemental Security Income (SSI).

43 Who Is Eligible for Medicaid?  Children who have developmental delays AND need special community supports to remain at home (HCBS Waiver)

44 Who Is Eligible for EPSDT? Any child who is Medicaid- enrolled is eligible for EPSDT benefits up until their 21st birthday or as long as they have Medicaid eligibility.

45 Note: Non-citizens with appropriate documentation under any of the above categories may be eligible for Medicaid, but only for a limited period of time. These children are entitled to EPSDT.

46 Note: Undocumented Non-citizens under any of the above categories can be eligible for Medicaid, but receive only emergency care, which includes labor and delivery for pregnant women.

47 Please Note: ALWAYS refer people to submit an application even if they appear to be above the financial limits. If not eligible for Medicaid, the child may be eligible for Health Steps or the Caring Program

48 Home and Community Based Service Waivers Each waiver is built for a specific population Waivers must be passed by legislation Allows children at risk of institutionalization to stay in the community Some waivers, waive income limits, otherwise not be eligible for Medicaid A waiver for Medically fragile children is being developed at the current time for ND

49 Home and Community Based Service Waivers  Different waivers are administered by different agencies.  Medicaid's benefits are more inclusive than some private insurances  Provide case management, and other services (different waivers provide different services)

50 Home and Community Based Service Waivers  Eligibility criteria for all Medicaid Waivers requires qualifying for Long Term Care.  The individual must have functional needs (ADL’s)  Provide case management, and other services

51 Frequently Asked Questions Is EPSDT the form for a comprehensive well-child check-up (for children on Medicaid)?

52 No! It is all the benefits we’ve just talked about. It is all the benefits we’ve just talked about.

53 Frequently Asked Questions Isn’t EPSDT only for kids with severe disabilities?

54 No! The goal of EPSDT is early detection and treatment of problems for ALL children and youth enrolled in Medicaid.

55 Frequently Asked Questions Why not just call it Medicaid, instead of EPSDT?

56 EPSDT EPSDT implies the importance of Early and Periodic Screening, Diagnosis and Treatment in children. There are benefits in EPSDT that are not provided for in regular Medicaid. The most obvious is the EPSDT (periodic) screen.

57 Frequently Asked Questions What is an EPSDT screen?

58 Periodic Screen The EPSDT (periodic) screen is a comprehensive checkup. It is not necessarily a well-child checkup, because the doctor can do a comprehensive checkup sometimes when a child is ill. However, a comprehensive checkup is usually done at the time a well-child checkup schedule.

59 Periodic Screen In order for a comprehensive checkup to be counted as an EPSDT (periodic) screening, the checkup must include all of the components outlined for in EPSDT screening (i.e. mental health, vision, hearing, dental, developmental, laboratory screenings). If only some components are included, it should be considered an inter-periodic screen.

60 Frequently Asked Questions When might a letter of medical necessity be required?

61 Letter of Medical Necessity To justify extraordinary and expensive services, particularly those that require preauthorization. Services may not be for the convenience of the caregiver.

62 An Example of Medical Necessity: A child with mental retardation requires diapers at age 4 years because he is not yet toilet trained. (Justified as medically necessary because of his continued incontinence).

63 An Example of Medical Necessity: A prior authorization form is completed to include the diagnosis of mental retardation and incontinence as the reason requiring diapers at age 4 years.

64 Prior Authorization : Any prior authorization should include the following information: Any prior authorization should include the following information: A description of the child’s condition; A description of the proposed treatment plan; The effective date and estimated length of time treatment will be needed; The name and identification numbers of the child, ordering physician, PCP and the rendering provider; And The evaluation, diagnosis, prognosis, or any other clinical information necessary to establish medical necessity for the child.

65 An Example of Medical Necessity: Note: Since most children under age 3 require diapers, EPSDT will not covered the diapers until age 4 At that time the child’s continued incontinence is clearly due to his developmental delay. At that time the child’s continued incontinence is clearly due to his developmental delay.

66 An Example of Medical Necessity: A child with a cardiomyopathy requires a hospital bed in his home. (Justified as medically necessary because of his orthopnea).

67 An Example of Medical Necessity: These beds comes with a manual crank or an electric control to raise and lower the head of the bed. Services may not be for the convenience of the caregiver.

68 An Example of Medical Necessity: The mother, who has MS, would prefer an electric controlled bed. She has difficulty using the hand crank.

69 Services may not be for the convenience of the caregiver. The electric controlled bed may not be authorized because it is not medically necessary for the child.

70 Frequently Asked Questions How do children in North Dakota who don’t have health insurance get health care?

71 Frequently Asked Questions How do I contact an EPSDT Coordinator? Coordinator?

72 Who to Contact Local County Social Service Office Public Health Unit Or toll free to the ND State Office

73 EPSDT Screenings: The Foundation EPSDT requires Medicaid agencies to assess a child's health needs through initial and periodic examinations, and to assure that any health problems found are diagnosed and treated early, before they become more complex and their treatment more costly.

74 EPSDT Examinations EPSDT Examinations Medicaid enrolled children receive both comprehensive well-child exams (periodic screenings) AND any necessary visits in between (inter-periodic visits). Medicaid enrolled children receive both comprehensive well-child exams (periodic screenings) AND any necessary visits in between (inter-periodic visits).

75 EPSDT Screenings- The First Step EPSDT screenings are often called comprehensive “Well Child Check-Ups”. They are completed by the PCP or Public Health Unit. ** Make sure to check if your PCP is listed as a screener

76 EPSDT Screenings- The First Step Screenings should be provided at intervals established by state medical consultants.

77 Periodic Screening Schedule:  2 to 4 days after birth, if the newborn leaves the hospital less than 48 hours after delivery  by 1 month  2 months  4 months  6 months  9 months  12 months  15 months  18 months  once every year for ages 2 to 20

78 To be billed as a comprehensive screen, the following must be included:  Health history  Unclothed “head to toe” physical examination  Identification of all medical conditions and needs  Immunizations according to the ACIP schedule  Age appropriate laboratory tests  Health education including anticipatory guidance Continued….

79 To be billed as a comprehensive screen, the following must be included:  Developmental Assessment  Nutritional Assessment  Mental/Behavioral Health screening  Vision screening  Hearing screening  Oral inspection; send child to a dentist twice per year, starting no later than age one  Family planning services and adolescent maternity care  Treatment and referrals for any necessary services

80 With Particular Emphasis On: Appropriate immunizations in accordance with the ACIP schedule;Appropriate immunizations in accordance with the ACIP schedule; Laboratory test for lead toxicity at one AND two years old, OR any time up to age 6 if not previously tested;Laboratory test for lead toxicity at one AND two years old, OR any time up to age 6 if not previously tested; Mental/behavioral health screening and coordination;Mental/behavioral health screening and coordination; Vision Services – including corrective lens;Vision Services – including corrective lens; Hearing Services – including hearing aids;Hearing Services – including hearing aids; Dental Services – bi-annual exam by a dentist, including restoration of teeth and maintenance of dental health;Dental Services – bi-annual exam by a dentist, including restoration of teeth and maintenance of dental health; Health Education - including anticipatory guidance.Health Education - including anticipatory guidance.

81 Screening Results If the screening is normal, the PCP should:  assist the family in scheduling the next EPSDT screening  ensure that bi-annual dental exams occur (after age 1 year)

82 If the screening is abnormal, the PCP should:  Develop a treatment plan  Provide treatment, if appropriate  Refer to a provider for further evaluation or treatment, if necessary  Assist the family in scheduling the next EPSDT screening  Ensure that bi-annual dental exams occur (after age 1 year)

83 Inter-periodic Visits Any care that occurs outside the periodic screening schedule. (Includes partial screenings.)

84 Inter-periodic Visits For example: Treatment for an ear-ache or sore throat in the PCP’s office.

85 Inter-periodic Visits For example: Treatment of an ear infection and a delay in language prompts a referral from PCP’s office.

86 Inter-periodic Visits For example: Urgent care for a sports- related injury.

87 Inter-periodic Visits For example: To authorize the adjustment of a leg brace.

88 Questions

89 Family Voices of ND How to Contact the Health Information and Education Center PO Box 163, Edgeley ND


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