Epsdt specialized services the dmas safety net l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 64

EPSDT Specialized Services The DMAS “ Safety Net ” PowerPoint PPT Presentation


  • 458 Views
  • Uploaded on
  • Presentation posted in: General

EPSDT Specialized Services The DMAS “ Safety Net ”. Virginia Department of Medical Assistance Services (DMAS) Fall 2010. Medicaid/FAMIS Plus.

Download Presentation

EPSDT Specialized Services The DMAS “ Safety Net ”

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Epsdt specialized services the dmas safety net l.jpg

EPSDTSpecialized ServicesThe DMAS “Safety Net”

Virginia Department of Medical Assistance Services (DMAS)

Fall 2010


Medicaid famis plus l.jpg

Medicaid/FAMIS Plus

  • EPSDT is the benefit package for Medicaid/FAMIS Plus enrollees under 21 years of age. EPSDT is available to all FAMIS Plus enrollees under the age of 21 enrolled in Managed Care Organizations, MEDALLION, or Fee-for-Service (FFS) Medicaid.


Epsdt benefits in fee for service and mco programs l.jpg

EPSDT Benefits in Fee-for-Service and MCO Programs

  • The fundamental preventive services such as well child visits, vaccines, developmental, hearing and vision screenings should be the same and do not require prior authorization to the FAMIS PLUS members

  • The EPSDT benefit is the same in scope in the MCO network and the FFS network.

  • Each MCO is required to provide the same set of services

  • Operational processes may differ among the systems for accessing treatment services.

  • Some treatment services are “carved out” and are provided through the FFS system for all members


Famis mco benefits l.jpg

FAMIS MCO Benefits

  • Children who are eligible for the FAMIS program must enroll with a Managed Care Organization (MCO) when available in their area.

  • FAMIS members receive well child visits and a full scope of healthcare benefits, they are not eligible for certain EPSDT treatment services.

  • EX: Personal Care and Residential Treatment are not available to FAMIS members, the “correct and ameliorate” consideration is not required during clinical reviews for FAMIS MCO members


Famis ffs l.jpg

FAMIS FFS

  • FAMIS FFS is available only when there is no MCO available in their geographic area.

  • The EPSDT treatment benefit is available to FAMIS Fee-for-Service enrollees

  • FAMIS FFS members may not receive psychiatric Residential Treatment or services from a freestanding psychiatric facility


Website tips l.jpg

Website Tips

Find Provider Manuals and Memos Here

Program information on many programs, this points to Maternal and Child Health which houses EPSDT


Find manuals l.jpg

Find Manuals

Helpful Hint:

  • Chapter 2 is always

    • Provider requirements/enrollment criteria

  • Chapter 4 is always

    • Covered Services


What does medicaid cover l.jpg

What Does Medicaid Cover?

  • Medicaid offers a comprehensive array of service options for enrollees under the age of 21

  • Service packages can be designed to provide wrap around benefits tailored to the persons health and chronic care needs

  • It is best to review covered services according to the needs of the enrollee


Medicaid covered services examples l.jpg

Medicaid Covered ServicesExamples

Children with Special Health Care Needs

Durable Medical Equipment

Rehabilitation

Pharmacy

Long Term Care Waiver Services

EPSDT


Medicaid covered services examples10 l.jpg

Medicaid Covered ServicesExamples

  • Children with Substance Abuse and Behavioral Disorders

  • Psychiatric

  • Community Mental Health Rehabilitation

  • Hospital

  • Pharmacy

  • Children’s Mental Health Program

  • EPSDT


What is epsdt l.jpg

What is EPSDT?

  • Medicaid’s program for children up to the age of 21 with a preventive treatment approach

  • Diagnostic and screening services are the backbone of the program

  • The “correct and ameliorative” aspects of the program are included in many of the services that DMAS provides for children


What are epsdt services l.jpg

What are EPSDT Services?

EPSDT services include:

  • Screening/Well Child check-ups, lead testing and immunizations

  • Other treatment services to correct a medical condition, make it better, or prevent the child’s health status from worsening


Scope of services l.jpg

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 physical and mental conditions discovered during screening services whether or not included in the state plan

  • The program does not cover services that are experimental or investigational


Individualized clinical reviews l.jpg

Individualized Clinical Reviews

  • Treatment is considered for medical necessity in how that service may effectively treat/ameliorate the targeted health or mental health condition

    • Individualized clinical review must consider:

    • “That treatment, for that child, for that condition”

  • This process must be completed before any service is denied for children enrolled in FAMIS Plus/Medicaid


Safety net function l.jpg

Safety Net Function

  • EPSDT covers treatments that are:

    • Not available to certain disability groups

    • Not covered by Medicaid

      Examples:

    • Eating Disorders Treatment

    • Residential Substance Abuse Treatment

    • In Home Behavioral Treatments for children with DD/MR (not in a waiver)

    • ABA


Specialized services l.jpg

Specialized Services

  • The following Services are covered only under EPSDT

  • All Require pre authorization at DMAS

    • Hearing Aids

    • Inpatient Treatment

    • Specialized Residential Treatment

      • (MCO Exclusion, request services at KePRO/DMAS)

    • Substance Abuse Residential Treatment

      • (MCO Exclusion, request services at KePRO/DMAS)

    • Personal Care

      • (MCO Carve out, request services at DMAS)

    • Private Duty Nursing

    • Assistive Technology

    • Behavioral Treatment


What is not covered l.jpg

What is Not Covered?

  • Services must be deemed as medically necessary

    • Ex: Personal care would be medically necessary if a child meets the EPSDT personal care criteria

  • Certain services may not be covered by EPSDT

    • Respite

    • Environmental Modifications

    • Vocational

    • Educational


Slide18 l.jpg

Specific Program GuidelinesPlease refer to the EPSDT Program manuals and fact sheets for more information about these services


New program development l.jpg

New Program Development

  • Current policy development is geared toward a variety of treatment services in the “home” setting and in facilities

  • CMS calls this Behavioral Rehabilitation

  • The claims system has already been designed to handle new program developments


Http dmasva dmas virginia gov content pgs mch home aspx l.jpg

http://dmasva.dmas.virginia.gov/Content_pgs/mch-home.aspx

Find EPSDT forms Here

Find EPSDT Program Info Here


Assistive technology l.jpg

Assistive Technology


At coverage l.jpg

AT Coverage

  • Assistive Technology is a covered service in both the FFS and MCO networks

  • Some Waivers provide Assistive Technology


At definition l.jpg

AT Definition

  • Assistive Technology is defined as specialized medical equipment, supplies, devices, controls, and appliances not available under the Virginia State Plan for Medical Assistance.

  • Assistive Technology items directly enable individuals to increase their abilities to perform ADLs or to perceive, control, or communicate with the environment in which they live. Assistive Technology items are expected to be portable.


At items l.jpg

AT Items

  • Only Assistive Technology items that are determined to be medically necessary may be covered for reimbursement by DMAS. The following criteria must be satisfied through the submission of adequate and verifiable documentation satisfactory to DMAS.


At criteria l.jpg

AT Criteria

  • A reasonable and medically necessary part of a treatment plan;

  • Consistent with the recipient’s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the recipient;

  • Not furnished solely for the convenience of the family, attending physician, or other practitioner or supplier;

  • Consistent with generally accepted professional medical standards (i.e., not experimental or investigational); and

  • Provided at a safe, effective, and cost-effective level that is suitable for use by the enrollee.


At limitations l.jpg

AT Limitations

  • Assistive Technology must involve direct patient care

  • AT must be for the express purpose of diagnosing, treating or preventing (or minimizing the adverse effects of) illness, injury or other impairments to an individual’s physical or mental health.

  • AT Services that do not involve direct patient care or environmental services dealing exclusively with an individual’s surroundings rather than the individual are not covered.

  • Environmental Modifications are not covered


At paper trail l.jpg

AT Paper Trail

Medical documentation must provide DMAS with a clear understanding of the recipient’s needs.

  • The medical need for the requested Assistive Technology;

  • The diagnosis related to the reason for the Assistive Technology request;

  • The individual’s functional limitation and its relationship to the requested Assistive Technology item;

  • How the Assistive Technology item will treat the individual’s medical condition;

  • The quantity needed and the medical reason the requested amount is needed;

  • The frequency of use;

  • The estimated length of use of the item;


At paper trail continued l.jpg

AT Paper Trail (continued)

  • Any conjunctive treatment related to the use of the item;

  • How the needs were previously met identifying changes that have occurred which necessitate the Assistive Technology request;

  • Other alternatives tried or explored and a description of the success or failure of these alternatives;

  • How the Assistive Technology item is required in the individual’s home or community environment; and

  • The individual’s or caregiver’s ability, willingness, and motivation to use the Assistive Technology item.


Hearing audiology services l.jpg

Hearing/Audiology Services


Covered hearing services l.jpg

Covered Hearing Services

  • Analog and digital hearing aids are covered

  • FM amplification systems are covered as necessary to aid language development

  • Cochlear implants are covered for all ages

  • New Hearing Program

    • Began January 1, 2008

    • For more information refer to the DMAS Audiology and Hearing Aid manual


Personal care l.jpg

Personal Care


Personal care criteria l.jpg

Personal Care Criteria

  • ADL dependency in three areas is mandatory to require personal care

  • Care need is not solely due to normal developmental milestones


Personal care33 l.jpg

Personal Care

  • Developmentally appropriate Consumer-Directed and Agency-Directed Personal Care

  • EPSDT Personal Care provides care such as: dressing, eating, bathing, etc. .

  • Primary Target group: Waiver waitlists


Epsdt nursing l.jpg

EPSDT Nursing


Epsdt nursing coverage l.jpg

EPSDT Nursing Coverage

  • EPSDT Nursing is a covered service in both the FFS and MCO networks

  • Technology Assisted Waiver referrals may be made for some EPSDT nursing cases


Epsdt nursing definition l.jpg

EPSDT Nursing Definition

  • EPSDT nursing is medically necessary private duty nursing care.

  • EPSDT nursing differs from both skilled nursing and home health nursing because the nursing is provided continuously as opposed to the intermittent care provided under either skilled nursing or home health nursing services.


Nursing and waiver enrollees l.jpg

Nursing and Waiver Enrollees

  • If the enrollee’s waiver does not offer private duty nursing then EPSDT can provide nursing to the child to help manage chronic nursing care needs

  • If the child’s primary service need is nursing care then the EDCD waiver may not meet the child’s needs absent EPSDT coverage


Nursing and waiver enrollees38 l.jpg

Nursing and Waiver Enrollees

Waiver enrollees must use waiver services each month to keep their waiver eligibility

  • If in the EDCD waiver the child should use a waiver service on a regular basis

  • If waiver enrollees lose their waiver they may lose their Medicaid coverage


Nursing for individuals in managed care organizations l.jpg

Nursing for Individuals in Managed Care Organizations

  • MCO Addresses and Telephone Numbers can be found on the DMAS website at: http://www.dmas.virginia.gov/downloads/pdfs/mc-medicaid_MCO_Addr_Tel.pdf


Dmas nursing scores l.jpg

DMAS Nursing Scores

The levels of EPSDT nursing care are defined as:

A Score (1-6) points

Maximum nursing (Individual Consideration)

B Score (7-22) points

Maximum nursing 8 hrs / day

C Score (23-36) points

Maximum nursing 12 hrs / day

D Score (37-49) points

Maximum nursing 16 hrs / day

 E Score (50 or more) points

Maximum nursing (Individual Consideration)

(Usually Tech Waiver Eligible)


Paper trail l.jpg

Paper Trail

Provider Requests must contain the following:

  • EPSDT Medical Needs Assessment Form

  • Home Health Certification and Plan of Care (may use the CMS 485 or equivalent to meet documentation requirements) signed by the ordering physician

  • The Plan of Care must contain the enrollee Medicaid ID number, provider number, and documentation which reflects the nursing care as described in the Medical Needs Assessment (DMAS-62) form


Epsdt nursing contacts l.jpg

EPSDT Nursing Contacts

Anne Young, EPSDT Preauthorization Coordinator

(804) 371-2635

[email protected]

EPSDT Fax

(804) 612-0043


Infant medical formula nutritional supplements and medical foods l.jpg

Infant Medical Formula, Nutritional Supplements and Medical Foods


Background l.jpg

Background

Previously, if a Medicaid or FAMIS fee-for-service eligible recipient followed through a metabolic clinic had a need for non-routine formula they would receive that formula from the Virginia Department of Health (VDH) Pharmacy

Previously, DMAS providers could supply what the local office did not supply

NOW: All medically necessary amounts may be supplied by either the local WIC clinic or the DME provider


Epsdt and medical formula l.jpg

EPSDT and Medical Formula

  • The EPSDT program allows Medicaid programs to provide medically necessary formula and medical foods to EPSDT eligible children under the age of 21 based on medical necessity.


General information l.jpg

General Information

  • All Medical Formula is provided by

    • Local WIC offices (children under 5) or

    • DMAS enrolled Durable Medical Equipment provider

  • All medical formula and nutritional supplements are reimbursed through DMAS directly

  • MCO’s do not cover medical formula effective October, 2007


Epsdt behavioral treatment l.jpg

EPSDT Behavioral Treatment


Epsdt behavioral treatment48 l.jpg

EPSDT Behavioral Treatment

  • Behavioral treatment services are intended to improve the functional behaviors of the enrollee by integrating multi disciplinary clinical and medical services with the behavioral treatment protocol to increase the enrollee’s adaptive functioning and communicative abilities.


Behavioral treatment cont l.jpg

Behavioral Treatment (cont.)

  • Family training and counseling related to the implementation of the behavioral treatment is included as part of the service. The service goal is to ensure that the enrollee’s family is trained to successfully manage clinically designed behavioral modification strategies in the home setting. The family involvement in treatment is meant to increase the child’s adaptive functioning by training the family in effective methods of behavioral modification strategies.


Behavioral treatment medical necessity l.jpg

Behavioral Treatment Medical Necessity

  • The individual is eligible for behavioral treatment when all of the following are met:

    • The individual is medically stable and needs systematic behavioral treatment interventions to increase adaptive behavioral functioning and increase communication abilities. The individual requires treatment from one or more other disciplines to enhance and promote effective behavioral treatment

    • The individual’s treatment needs cannot be adequately met in the home setting unless family training effectively integrates the behavioral modification strategies that will be implemented so that successful treatment will include the family members and/or caregivers who are able to participate in the behavioral treatment process. The family members or caregivers must be willing and capable of learning and applying effective behavioral modification strategies.

    • It has been documented that the individual would not achieve a demonstrable clinical improvement using only traditional outpatient treatment modalities in a clinic setting;


Continuation of treatment l.jpg

Continuation of Treatment

To qualify for ongoing services the individual must have demonstrated difficulties in three of the following areas:

  • Demonstrates physical aggression, self abuse with significant frequency, duration and intensity;

  • Demonstrates significant pragmatic communication deficits;

  • Demonstrates disruptive behaviors such as tics, elopement, repetitive or ritualized behaviors with significant frequency, duration and intensity; or

  • Requires continued clinical oversight and services after being transitioned to the home from an out-of-home placement due to prior documented clinical and/or medical needs of the child.


Epsdt residential and inpatient treatment l.jpg

EPSDT Residentialand Inpatient Treatment


Residential behavioral treatment clinical necessity l.jpg

Residential Behavioral Treatment Clinical Necessity

  • The individual is eligible for residential behavioral treatment when all of the following are met:

    • The recipient is medically stable, but needs systematic treatment interventions to increase adaptive behavioral functioning and increase communication abilities;

    • The individual’s needs cannot be met in the home setting because the behavioral modification strategies that were attempted in the home setting were not successful or the family members or caregivers are not able to or not willing to participate in the behavioral treatment process.

    • It has been documented that the individual would not achieve a demonstrable clinical improvement if using similar treatment modalities in the home setting or within a less structured environment;

    • Demonstrates physical aggression, self abuse with significant frequency, duration and intensity;

  • Demonstrates significant pragmatic communication deficits;

  • Demonstrates disruptive behaviors such as tics, elopement, repetitive or ritualized behaviors with significant frequency, duration and intensity;


Residential treatment criteria cont l.jpg

Residential Treatment Criteria (cont.)

  • It has been documented that the individual would not achieve a demonstrable clinical improvement if using similar treatment modalities in the home setting or within a less structured environment;

  • Demonstrates physical aggression, self abuse with significant frequency, duration and intensity;

  • Demonstrates significant pragmatic communication deficits;

  • Demonstrates disruptive behaviors such as tics, elopement, repetitive or ritualized behaviors with significant frequency, duration and intensity;


  • Epsdt residential l.jpg

    EPSDT Residential

    • EPSDT will review requests that do not:

      • Meet standard RTC level A,B and C criteria

      • Do not benefit from RTC because a standard psychiatric treatment environment is not clinically appropriate to their condition


    Epsdt residential treatment examples l.jpg

    EPSDT Residential Treatment Examples

    Conditions served through EPSDT:

    • Severe Behavioral problems and health problems associated with:

      • Autism

      • Brain Injury

        * Substance Abuse Disorders (*SA RTC uses different “ASAM” placement criteria)


    Epsdt residential coverage l.jpg

    EPSDT Residential Coverage

    EPSDT Residential Treatment includes:

    • Behavioral Support Counselor,

    • Clinical Supervision related to his treatment plan

    • Case Management,

    • Treatment Team Activity


    Epsdt residential exclusions l.jpg

    EPSDT Residential Exclusions

    The provider may bill DMAS directly for services not included in the child’s IEP such as:

    • Individual adapted Psychotherapy

    • Occupational Therapy,

    • Speech and Language Therapy

    • Physical Therapy


    Epsdt inpatient treatment l.jpg

    EPSDT Inpatient Treatment

    • The EPSDT program provides inpatient services when the individual requires intensive treatment and also requires management of multiple health conditions that cannot be effectively managed in a less intensive treatment setting.

    • EPSDT inpatient services may be provided to treat a variety of complex health, mental health and neurological conditions that are generally prohibited as a primary reason for admission in the existing Medicaid state plan services.


    Inpatient settings may vary according to treatment needs l.jpg

    Inpatient Settings May Vary According to Treatment Needs

    • EPSDT inpatient services may be provided in inpatient settings based on the individual’s complex healthcare needs. Individuals must be medically unstable due to medical conditions that require inpatient services to manage, treat and stabilize the medical condition and facilitate a return to a lower level of care.


    Inpatient examples l.jpg

    Inpatient Examples

    • Some examples of conditions that may benefit from EPSDT inpatient treatment are:

    • eating disorders,

    • complex neurological conditions,

    • acquired brain injury and

    • other conditions with medical instability being the prime reason for admission.


    Ffs pre auth timeline l.jpg

    FFS Pre-Auth Timeline

    • DMAS processes all typical requests within 10 business days

    • MCO’s use their own PA processes

    • To find MCO contact numbers use this link:

    • http://www.dmas.virginia.gov/downloads/mcrguides/Chapter_8.pdf

      (804) 612-0043 EPSDT fax

      www.dmas.virginia.gov/ch-home.htm


    Epsdt contacts l.jpg

    EPSDT Contacts

    Shirlene Harris, EPSDT Preauthorization Coordinator

    (804) 225-3124

    [email protected]

    Anne Young, EPSDT Preauthorization Coordinator Nursing

    (804) 371-2635

    [email protected]

    Tabitha Taylor, EPSDT Assistive Technology, Hearing Aids and Personal Care Coordinator

    (804) 225-3231

    [email protected]

    (804) 225-3961 or (804) 612-0043

    EPSDT fax

    www.dmas.virginia.gov/ch-home.htm


    Slide64 l.jpg

    Thank You!

    EPSDT Services Supervisor

    Brian Campbell

    [email protected]


  • Login