Early Periodic Screening, Diagnosis and Treatment (EPSDT) Virginia Department of Medical Assistance Services (DMAS) The Arc of Virginia Annual Convention August 11,

Website Tips dmasva.dmas.virginia.gov dmasva.dmas.virginia.gov Program informatio n on many programs, this points to Maternal and Child Health which houses EPSDT Find Provider Manuals and Memos at this link to the Medicaid Web Portal. 2

ntent_pgs/mch-home.aspx Find EPSDT forms here 3

Eligibility Criteria EPSDT services are available to Medicaid/FAMIS Plus enrollees under 21 years of age and FAMIS fee for service enrollees under the age of 19 EPSDT services are available to Medicaid/FAMIS Plus enrollees under 21 years of age and FAMIS fee for service enrollees under the age of 19 The individual must be enrolled in Medicaid/FAMIS Plus or FAMIS Fee for Service The individual must be enrolled in Medicaid/FAMIS Plus or FAMIS Fee for Service 4

What is EPSDT? What is EPSDT? Medicaid’s Early Periodic Screening Diagnosis and Treatment Program is the benefit plan for children under the age of 21 Medicaid’s Early Periodic Screening Diagnosis and Treatment Program is the benefit plan for children under the age of 21 Preventive care, traditional diagnostic and treatment services are the backbone of the program Preventive care, traditional diagnostic and treatment services are the backbone of the program There is no special application process for EPSDT. There is no special application process for EPSDT. Children are automatically eligible for EPSDT when enrolled in the Medicaid or FAMIS Fee-for-Service benefit plans Children are automatically eligible for EPSDT when enrolled in the Medicaid or FAMIS Fee-for-Service benefit plans 5

What is EPSDT? What is EPSDT? The requirement to “correct and ameliorate” health conditions is a unique feature of the EPSDT program. This requirement of the program is included in many of the services that DMAS provides for children The requirement to “correct and ameliorate” health conditions is a unique feature of the EPSDT program. This requirement of the program is included in many of the services that DMAS provides for children 6

Scope of Services Individualized health care, diagnostic services, and “treatment” as listed in the Federal Medicaid statute, must be provided when medically necessary to correct and ameliorate (improve) physical and mental conditions discovered during screening services whether or not included in the Medicaid state plan Individualized health care, diagnostic services, and “treatment” as listed in the Federal Medicaid statute, must be provided when medically necessary to correct and ameliorate (improve) physical and mental conditions discovered during screening services whether or not included in the Medicaid state plan The program does not cover services that are experimental or investigational The program does not cover services that are experimental or investigational 7

Safety Net Function EPSDT covers medically necessary treatments when: EPSDT covers medically necessary treatments when: Not available to certain disability groups Not available to certain disability groups Not covered by Medicaid/FAMIS Plus Not covered by Medicaid/FAMIS Plus Including FAMIS FFS which get Medicaid benefit Including FAMIS FFS which get Medicaid benefitExamples: Eating Disorders Treatment Eating Disorders Treatment Residential Substance Abuse Treatment Residential Substance Abuse Treatment Behavioral Treatments Behavioral Treatments 8

Specialized Services The following Services are covered only under EPSDT and require service authorization: The following Services are covered only under EPSDT and require service authorization: Hearing Aids Hearing Aids Medicaid/FAMIS MCO member = Request through MCO Medicaid/FAMIS MCO member = Request through MCO Assistive Technology Assistive Technology Medicaid MCO member = Request through MCO Medicaid MCO member = Request through MCO Available through DME benefit for FAMIS MCO member = Request through MCO Available through DME benefit for FAMIS MCO member = Request through MCO 9

Specialized Services In Home Behavioral Therapy In Home Behavioral Therapy Medicaid MCO member = Request services through EPSDT Medicaid MCO member = Request services through EPSDT FAMIS MCO = not covered service FAMIS MCO = not covered service Residential Behavioral Treatment Residential Behavioral Treatment Medicaid MCO member = Request services through EPSDT Medicaid MCO member = Request services through EPSDT Not available for FAMIS MCO member (Level C) Not available for FAMIS MCO member (Level C) Substance Abuse Residential Treatment Substance Abuse Residential Treatment Medicaid MCO member = Request services through EPSDT Medicaid MCO member = Request services through EPSDT Not available for FAMIS MCO member Not available for FAMIS MCO member 10

Specialized Services Personal Care Personal Care Medicaid MCO member = Request services through EPSDT Medicaid MCO member = Request services through EPSDT FAMIS MCO member = Not available for FAMIS MCO member FAMIS MCO member = Not available for FAMIS MCO member Private Duty Nursing Private Duty Nursing Medicaid/FAMIS MCO member = Request through MCO Medicaid/FAMIS MCO member = Request through MCO All EPSDT Specialized Services for FFS Medicaid/FAMIS Plus/FAMIS = request through EPSDT All EPSDT Specialized Services for FFS Medicaid/FAMIS Plus/FAMIS = request through EPSDT 11

What is Not Covered? Services must be deemed as medically necessary Services must be deemed as medically necessary Ex: Personal care would be medically necessary if a child meets the EPSDT personal care criteria Ex: Personal care would be medically necessary if a child meets the EPSDT personal care criteria Certain services are not covered by EPSDT due to Federal Limitations Certain services are not covered by EPSDT due to Federal Limitations Respite Care Respite Care Environmental Modifications Environmental Modifications Vocational Services Vocational Services Educational Services Educational Services 12

Specific Program Guidelines Please refer to the EPSDT Program manuals and fact sheets for more information about these services Click on Provider manuals and select specific manual from drop down menu. 13

Personal Care Assistance with activities of daily living (ADLs): Assistance with activities of daily living (ADLs): ADL categories: ADL categories: bathing eating/feeding dressingtoileting transferscontinence ambulation 14

Personal Care Health conditions cause limitations in performing three or more ADLs. Health conditions cause limitations in performing three or more ADLs. This is a great service for those on the waitlist for Medicaid waivers such as Intellectual Disability Waiver This is a great service for those on the waitlist for Medicaid waivers such as Intellectual Disability Waiver 15

EPSDT Nursing EPSDT nursing is private duty nursing deemed medically necessary by the attending physician EPSDT nursing is private duty nursing deemed medically necessary by the attending physician EPSDT nursing can provide for assessing and providing interventions, maintaining nursing care and communicating with the physician regarding changes in the individual's medical status EPSDT nursing can provide for assessing and providing interventions, maintaining nursing care and communicating with the physician regarding changes in the individual's medical status 16

EPSDT Nursing Medical Needs Require skilled intervention or medical monitoring from a medical professional in order to maintain physical health or to prevent imminent physical harm Require skilled intervention or medical monitoring from a medical professional in order to maintain physical health or to prevent imminent physical harm Have chronic nursing needs that are not intensive enough to meet eligibility for the Technology Assisted Waiver Have chronic nursing needs that are not intensive enough to meet eligibility for the Technology Assisted Waiver Needs are intermittent or the illness/injury related nursing is not covered by the Home Health Program Needs are intermittent or the illness/injury related nursing is not covered by the Home Health Program 17

Assistive Technology Specialized medical equipment, supplies, devices, controls, and appliances not available under the regular Medicaid program Enable members to increase their abilities to perform ADLs or to perceive, control, or communicate with the environment in which they live

Assistive Technology If member enrolled in Waiver which covers AT, must request coverage first through waiver If not covered, then may be requested through EPSDT (this process is done internally with the ID and DD waivers) Home/environmental modifications are not covered If AT is requested during school hours, documentation must be presented to EPSDT why school not covering under IDEA

Assistive Technology Request for services: Letter of medical necessity from the child's physician A DMAS-352 (Certificate of Medical Necessity) completed by the DME or AT provider and signed by the child's physician An itemized quote or invoice from the child's physician/AT provider Include warranty, repairs, servicing, time frame that AT may be needed

Audiology and Hearing Aids Digital and analog hearing aids are covered Digital and analog hearing aids are covered FM amplification systems are covered as necessary to aid language development FM amplification systems are covered as necessary to aid language development Cochlear implants are covered for all ages Cochlear implants are covered for all ages 21

Audiology and Hearing Aids Fact sheet /mch/mch-epsdt_ssi6.pdf Fact sheet /mch/mch-epsdt_ssi6.pdf Manual uals/ManualChapters/General/prm- EPSDT_Hear_Audio.pdf Manual uals/ManualChapters/General/prm- EPSDT_Hear_Audio.pdf 22

Behavioral Therapy Services EPSDT Behavioral Therapy allows reimbursement for treatment interventions related to developmental delays and/or health conditions which, if left untreated, would lead to significant long term impairments in adaptive functioning EPSDT Behavioral Therapy allows reimbursement for treatment interventions related to developmental delays and/or health conditions which, if left untreated, would lead to significant long term impairments in adaptive functioning Behavioral Treatment is available either in a primarily home based setting or in a residential treatment setting Behavioral Treatment is available either in a primarily home based setting or in a residential treatment setting 23

Service Goals Behavioral treatment services are intended to increase adaptive behaviors of the child Behavioral treatment services are intended to increase adaptive behaviors of the child Increasing communication skills and impulse control are main targets for these services Increasing communication skills and impulse control are main targets for these services Services should integrate other clinical and medical services with the behavioral treatment protocol to increase the enrollee’s adaptive functioning Services should integrate other clinical and medical services with the behavioral treatment protocol to increase the enrollee’s adaptive functioning 24

Treatment Coordination Services such as speech therapy, occupational therapy or psychiatric care must be coordinated with and integrated with the behavioral treatment plan Services such as speech therapy, occupational therapy or psychiatric care must be coordinated with and integrated with the behavioral treatment plan All services must be evidence based, measureable and medically necessary to specifically improve components of adaptive functioning All services must be evidence based, measureable and medically necessary to specifically improve components of adaptive functioning 25

Provider Participation Requirements (In Home) In Home Behavioral Treatment providers must be licensed to provide one of the following services: Intensive In-Home Services Intensive In-Home Services Outpatient Clinic Outpatient Clinic Day Treatment Day Treatment 26

EPSDT Inpatient Treatment 27

EPSDT Case Examples Conditions served through EPSDT: Severe Behavioral problems and health problems associated with: Severe Behavioral problems and health problems associated with: Autism Autism Brain Injury Brain Injury Eating Disorders Eating Disorders (when inpatient treatment is necessary) Chronic Illnesses that require inpatient treatment Chronic Illnesses that require inpatient treatment Substance Abuse Disorders Substance Abuse Disorders 28

How to Access Behavioral Treatment Services 29

Eligibility Criteria/Physician Referral The individual must have a medical need for behavioral treatment. The need for residential behavioral treatment must be identified by the child’s physician through an Inter-periodic/problem- focused visit or an EPSDT screening/well-child visit. The individual must have a medical need for behavioral treatment. The need for residential behavioral treatment must be identified by the child’s physician through an Inter-periodic/problem- focused visit or an EPSDT screening/well-child visit. 30

Managed Care Organization Enrollees DMAS contracted Managed Care Organizations (MCOs) are not required to provide coverage for behavioral treatment services DMAS contracted Managed Care Organizations (MCOs) are not required to provide coverage for behavioral treatment services Services (such as psych, OT, SLP, MD) other than those that are carved-out of the MCO contract should be coordinated as usual through the MCO in which the child is enrolled Services (such as psych, OT, SLP, MD) other than those that are carved-out of the MCO contract should be coordinated as usual through the MCO in which the child is enrolled 31

Managed Care Organization Enrollees Behavioral Treatment services for children who are enrolled in a Medicaid/FAMIS Plus MCOs are available to the member through DMAS and not the member’s MCO Behavioral Treatment services for children who are enrolled in a Medicaid/FAMIS Plus MCOs are available to the member through DMAS and not the member’s MCO FAMIS MCO members do not have Behavioral Treatment as covered service FAMIS MCO members do not have Behavioral Treatment as covered service 32

Approval Allowances DMAS will generally authorize 6 months for the initial service authorizations DMAS will generally authorize 6 months for the initial service authorizations Continuation of services will generally be authorized in 3 month increments Continuation of services will generally be authorized in 3 month increments Less time may be approved when DMAS must request specific clinical information to decide if continuation of treatment is effective or clinically necessary Less time may be approved when DMAS must request specific clinical information to decide if continuation of treatment is effective or clinically necessary 33

Where to Send Service Requests Requests for services may be faxed to: (804) Requests for services may be mailed to: DMAS Maternal and Child Health Division 600 E. Broad St., Ste 1300 Richmond VA,

Service Requests DMAS processes all typical requests within business days DMAS processes all typical requests within business days MCO’s use their own PA processes MCO’s use their own PA processes To find MCO contact numbers use this link: To find MCO contact numbers use this link: mcrguides/Chapter_8.pdf mcrguides/Chapter_8.pdf 35

EPSDT Contacts Brian Campbell, EPSDT Services Supervisor Brian Campbell, EPSDT Services Supervisor (804) Anne Young, EPSDT Nursing and Preauthorization Clinician Anne Young, EPSDT Nursing and Preauthorization Clinician (804) Shirlene Harris, EPSDT Preauthorization Shirlene Harris, EPSDT Preauthorization (804) Tabitha Taylor, MCH Program Analyst (804) Jeff Beard, MCH Program Analyst (804) Use the Web to find forms and more information! DMAS Portal: DMAS Portal: 36