Early Periodic Screening, Diagnosis and Treatment (EPSDT) Sarah Somers and Jamie Brooks National Health Law Program “Train the Trainer” North Carolina Council on Developmental Disabilities

EPSDT Early and Periodic Screening, Diagnosis and Treatment Must be covered for Medicaid-eligible children and youth up to age 21 Reasons for EPSDT Children are not little adults Adolescents are not big children

EPSDT is . . . “Health Check” in North Carolina In North Carolina, preventive health care visits for children are known as Health Check Health Check is designed to prevent your children from becoming ill and suffering medical difficulties by detecting problems early. Under Health Check, Medicaid is required to cover most of the treatments your children need to stay health.

Poor Children = Poor Health 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 Anemia Asthma And many more . . .

EPSDT Citations Medicaid Act Medicaid Regulations CMS, State Medicaid Manual N.C. statute, regulations, policy manuals Medicaid managed care contracts

EPSDT Requirements— Medical, vision, hearing, dental screening Medical Screens Health and developmental history “Unclothed” physical exam Immunizations Lab tests, including lead blood tests Health education

EPSDT Requirements— Medical, vision, hearing, dental screening Other Required Screens Vision, 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 Based on age Set by medical and dental experts Different for medical, dental, hearing and vision

EPSDT Screening Periodicity Schedules: AAP – www.aap.org AMA Guidelines for Adolescent Preventive Services- www.ama-assn.org/ Bright Futures- www.brightfutures.org AAPD – www.aapd.org ADA – www.ada.org

EPSDT Screening Interperiodic Screens

EPSDT Requirements– Treatment All necessary treatment described in the federal Medicaid Act (42 U.S.C. sec. 1396d(a)) To “correct or ameliorate physical and mental illnesses and conditions,” even if the service is not covered under the state plan.

EPSDT Services— Requirements Prescription drugs Dental services Physical, occupational and speech therapies Private duty nursing Home health care Rehabilitation services Personal care services Case management Transportation Psychological services

Determining Medical Necessity Under EPSDT “Necessary … to correct or ameliorate” 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.” U.S. Senate Report on passing Medicaid, 1965

Correct? Ameliorate? correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

EPSDT Services-- Request for treatment should include: Doctor’s orders (e.g. on Rx pad) Written justification from physician & treatment team Patient history Diagnosis/prognosis Medical justification Description of benefits Length of time service/treatment is needed When appropriate: product information, photographs, comparable prices Statement that request is under EPSDT to “correct or ameliorate” the child’s condition

EPSDT Services— Limitations Equally effective, less costly alternative Must be service listed in 1396d(a) Not “experimental”

EPSDT Service— Not listed in Medicaid Act Fit service into a Medicaid box Basic living skills=home health, rehabilitation Swimming class=physical therapy Crisis intervention=rehabilitation Maintenance service=private duty nursing Incontinence supplies=home health, durable medical equipment

EPSDT Services— Experimental service?? Investigate: Discuss with provider Look at medical literature Look at other Medicaid programs Look at Medicare, private insurers Look at other countries

EPSDT Cost sharing No cost sharing in N.C. Federal option, except for children in mandatory coverage categories or with family income under 100 percent of FPL (Deficit Reduction Act) No cost sharing for “preventive” services

Reminders about EPSDT services Necessary treatment to “correct or ameliorate” listed in Medicaid Act Individualized determination of need Broad base of qualified providers Utilization controls consistent with EPSDT “preventive thrust”

EPSDT Requirements Outreach and informing Effective and aggressive Oral and written Translated Targeted (e.g. pregnant teens, non-users) Transportation and appointment assistance (prior to screen due date) Coordinate with other entities

EPSDT and special education Individuals with Disabilities Education Act (IDEA) 20 U.S.C. § 1401 et. seq. free, appropriate public education qualifying children with disabilities consists of special education and related services provided at public expense

Related Services Transportation and developmental, corrective and other services that are required to assist a child with a disability to benefit from special education

Related Services include: Speech-language pathology and audiology services Psychological services Physical and occupational therapy Recreation, including therapeutic recreation Social work and counseling services Orientation and mobility services Medical services for diagnostic and evaluation purposes only

Related services and EPSDT Related services can be paid for by Medicaid Federal government cannot refuse to pay for Medicaid services provided in school

Providers In order for schools to bill for Medicaid services provided through an IEP, the school must be licensed as a Medicaid provider

EPSDT Requirements – Reporting CMS Form 416 Number of children: provided screening services referred for corrective treatment receiving dental services

EPSDT Requirements – Reporting Participation goals Developed and set by federal govt. each year States must report results in obtaining goals on 416 form

EPSDT Requirements – Reporting Issues Methodology – overcounting Provider compliance Since 1999, no uniform periodicity schedule across different states

Quiz Time!