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1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

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Presentation on theme: "1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office."— Presentation transcript:

1 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office of Developmental Services, in collaboration with Department of Medical Assistance Services, EPSDT

2 2 Centers for Medicaid and Medicare require eligible children to access EPSDT prior to Waiver for covered services. Beginning with annual ISP date January 1, 2011.

3 3 EPSDT Eligibility Children with Medicaid Under the age of 21 Require “medically necessary” supports

4 4 “Medically necessary” means needed to improve physical or mental health conditions. Needs determined by ISP process. EPSDT Eligibility

5 5 Services available under both EPSDT and Waiver: Personal Care/Assistance Assistive Technology Therapeutic Consultation

6 6 Personal Care under EPSDT

7 7 EPSDT Personal Care “Personal Assistance” under ID Waiver Support with routine needs “Medically necessary” supervision

8 8 General Supervision unrelated to safety Respite Support with employment tasks Assistance provided in other funded settings EPSDT Personal Care is not:

9 9 EPSDT Personal Care – Preauthorization DMAS -7 from MD, PA or RNP ID Waiver Personal Assistance ISARs Annually! Forward to assigned ODS PA Consultant prior to beginning services

10 10 EPSDT Personal Care/ID Waiver PA Back-up plans required Same providers Same services AD Personal Assistance CD Personal Assistance

11 11 Assessment: SIS If no SIS, ODS-approved assessment tool or DMAS-99 Plan of care: PC ISP Plan for Support (Part V) or DMAS-7A with Personal Preferences tool EPSDT Personal Care/ID Waiver PA Completed by: Registered Nurse, Services Facilitator or Program Manager

12 12 Personal Preferences Tool for use with the DMAS 7A EPSDT Personal Care/ID Waiver PA

13 13 EPSDT Personal Care Provider Reviews Written reviews every 6 months Verbal reports for 3 and 9 month reviews Submit to SC! If the PA provider is a DBHDS licensed provider, quarterly reviews are required.

14 14 EPSDT Assistive Technology

15 15 EPSDT Assistive Technology Specialized medical equipment, supplies, devices, controls and appliances not available under DME Increases independence or ability to perceive/communicate Portable Medically necessary

16 16 EPSDT Assistive Technology Authorized up to 3 months No dollar limit per item/per year

17 17 EPSDT AT -- Criteria Reasonable Included in the ISP Consistent with individual’s needs Not for the convenience of others In accord with medical standards Safe and cost effective

18 18 EPSDT AT -- Criteria Must directly support the child Must minimize the adverse effects of mental or physical condition Must be of direct benefit to the child rather than enhance surroundings Environmental modifications are not covered

19 19 Assistive Technology – under the ID Waiver AT items not “medically necessary” should be requested under the ID Waiver $ annual limit per calendar year for ID Waiver AT Can be used in combination with AT under EPSDT

20 20 EPSDT AT – Preauthorization Letter or DMAS-355 from MD Written recommendation from professional ID Waiver AT ISAR Documentation to confirm need Forward to assigned ODS PA Consultant prior to beginning services

21 21 Assistive Technology Documentation must confirm: Formal diagnosis related to need Limitations/changes resulting in need for AT How AT will be of benefit Reason for quantity /quality How often AT will be used How long AT will be needed

22 22 Assistive Technology Documentation must confirm: Other supportive therapies tried/previous efforts to meet needs Successes/failures How item is necessary at home/community Individual/family interest in using the item

23 23 Therapeutic Consultation

24 24 Therapeutic Consultation Specialty areas under the ID Waiver: Psychology Behavioral consultation Speech and language pathology Occupational therapy Physical therapy

25 25 Therapeutic Consultation EPSDT provides therapy and consultation when of medical benefit Need documented in the PC ISP Supports described in the TC Plan for Supports (Part V)

26 26 EPSDT TC – Preauthorization Letter or DMAS-355 from MD ID Waiver TC ISAR Annually! Forward to assigned ODS PA Consultant prior to beginning services

27 27 Don’t forget… Beginning January 1, 2011: All children newly enrolling in Waiver, needing PA, AT or TC, will have these services authorized under EPSDT. I

28 28 Don’t forget… Beginning January 1, 2011: PA, TC and AT received by children in the ID Waiver must be authorized under EPSDT with the child’s next annual ISP. I

29 29 Don’t forget… That a child must receive at least one Waiver service to remain in the Waiver. If the child’s supports can be provided under EPSDT alone, the Waiver services will need to be terminated and the slot reassigned. I

30 30 Don’t forget… Children become ineligible for EPSDT on their 21st birthday. PA, AT and TC will need to be authorized under the ID Waiver at that time I

31 31 Contacts ODS Community Resource Consultants DMAS EPSDT Services Supervisor Brian Campbell


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