1. Kentucky Medicaid and EPSDT Stephanie Bates Branch Manager Disease and Case Management Kentucky Department for Medicaid Services

2. Administration of Medicaid Governed by Federal Regulations Services available to Medicaid recipients are outlined in a State Plan Amendment (SPA) The SPA is approved by the Center for Medicaid and Medicare Services (CMS)

3. Mandatory Medicaid Benefits Inpatient hospital services Outpatient hospital services EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services Nursing Facility Services Home health services Physician services Rural health clinic services Federally qualified health center services Laboratory and X-ray services Family planning services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Freestanding Birth Center services (when licensed or otherwise recognized by the state) Transportation to medical care Tobacco Cessation counseling for pregnant women

4. Optional Medicaid Benefits Prescription Drugs Clinic services Physical therapy Occupational therapy Speech, hearing and language disorder services Respiratory care services Other diagnostic, screening, preventive and rehabilitative services Podiatry services Optometry services Dental Services Dentures Prosthetics Eyeglasses Chiropractic services Other practitioner services

5. Optional Medicaid Benefits (cont.) Private duty nursing services Personal Care Hospice Case management Services for Individuals age 65 or Older in an Institution for Mental Disease (IMD) Services in an intermediate care facility for the developmentally disabled TB related services Inpatient psychiatric services for individuals under age 21 (Ordinarily states are responsible for the costs of IMDs; the federal Medicaid program specifically excludes reimbursement for residents of an IMD. The two exceptions are individuals over age 65 who receive this service, and younger individuals who receive the psych under 21 service. Individuals in either type of IMD who are between the ages of 22 and 64 may not receive Medicaid reimbursement.) Self-Directed Personal Assistance Services Other services approved by the Secretary

6. EPSDT Early and Periodic Screening, Diagnostic, and Treatment Services All optional Medicaid benefits are mandatory under the EPSDT benefit These benefits are for children ages 0-20 MUST BE MEDICALLY NECESSARY

7. Who decides if a service is medically necessary? Medically necessity is determined by using a nationally recognized process The provider who orders the service must document completely in order to demonstrate medical necessity Too much documentation is better than not enough

8. What isn’t covered under the EPSDT benefit? Respite care Environmental Educational Vocational Cosmetic Convenience Over-the-counter (OTC) items Room and board

9. EPSDT Screening Services Special Services

10. Screening Services Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests (including lead screening) Health education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention

11. Special Services The EPSDT benefit includes all medically necessary services that are included within the categories of mandatory and optional services listed in section 1905(a), regardless of whether the services are covered under the State Plan This means that any service a child (ages 0-20) needs should be covered if it is medically necessary

12. Kentucky Medicaid Managed Care Organizations Anthem BCBS Medicaid Aetna Better Health of Kentucky) Humana - CareSource Passport Health Plan WellCare of Kentucky All five MCOs are statewide

13. MCOs Can Help EPSDT Coordinators Case management Care coordination Disease management Patient education Provider education

14. EPSDT and Providers All providers can provide services under the EPSDT benefit as long as it’s in their scope of practice and is medically necessary Document, document, document when requesting a service that requires a prior authorization To provide services for Medicaid members, the provider must be a Medicaid provider

15. EPSDT and Parents The purpose of early and periodic screening is to identify problems early and correct them Parents have the power to ensure their children are up-to-date on their screenings.

16. Oversight The Department for Medicaid Services monitors EPSDT activity to ensure children are receiving the services they need MCOs report to DMS DMS reports to CMS The goal is improvement in overall health outcomes

17. Questions? Stephanie Bates Branch Manager: Disease and Case Management Branch Division of Program Quality & Outcomes Department for Medicaid Services 275 East Main Street 6C-C Frankfort, KY 40621 Stephanie.Bates@ky.gov 502-564-9444 ext. 2112