1. 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

2. 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

3. 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.

4. 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 . . .

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

6. 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

7. 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”

8. EPSDT Requirements— Early and Periodic screening
Periodic Screens
Based on age
Set by medical and dental experts
Different for medical, dental, hearing and vision

9. EPSDT Screening Periodicity Schedules:
AAP –
AMA Guidelines for Adolescent Preventive Services-
Bright Futures-
AAPD –
ADA –

10. EPSDT Screening
Interperiodic Screens

11. 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.

12. 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

13. 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

14. 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.

15. 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

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

17. 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

18. 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

19. 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

20. 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”

21. 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

22. 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

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

24. 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

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

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

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

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

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

30. Quiz Time!