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EPSDT: Early and Periodic Screening, Diagnosis and Treatment Program Presenter: Diana M. Straube National Assistive Technology Advocacy Project, Neighborhood Legal Services. Medicaid covers DME that:. can withstand repeated use are primarily and customarily used for medical purposes

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EPSDT: Early and Periodic Screening, Diagnosis and Treatment ProgramPresenter:Diana M. StraubeNational Assistive Technology Advocacy Project, Neighborhood Legal Services

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Medicaid covers DME that:

  • can withstand repeated use

  • are primarily and customarily used for medical purposes

  • are generally not useful in the absence of an illness or injury

  • usually not fitted, designed or fashioned for a particular individual’s use.

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Equipment may also be covered under

  • physical therapy

  • occupational therapy

  • speech pathology services

  • rehabilitation

  • prosthetics

  • orthotics, etc.

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Medical Necessity

Prevent, diagnose, correct or cure a condition that:

  • causes acute suffering

  • endangers life

  • results in illness or infirmity

  • interferes with the capacity for normal activity

  • threatens to cause a significant handicap

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  • comprehensive and preventative health care program for recipients under 21

  • early and periodic screening and diagnosis to ascertain physical or mental defects

  • such health care, treatment or other measures to correct or ameliorate defects and chronic conditions

  • broadens definition of medical necessity

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Medicaid must provide:

  • Outreach and informing

  • Screening

  • Diagnosis

  • Treatment

  • Adequate provider participation

  • Reporting

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EPSDT screenings (assessments) must include:

  • Gross and fine motor development

  • Communication skills or language development

  • Self-help or self-care skills

  • Social-emotional development

  • Ability to engage in social interaction

  • Cognitive skills, focusing on problem solving or reasoning

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As children age, assessments should include:

  • Visual-motor integration

  • Visual-spatial organization

  • Visual sequencing processing skills

  • Auditory sequential memory

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Assessments of adolescents should include:

  • Identification of potential learning disabilities

  • Peer relations

  • Psychological/psychiatric problems

  • Vocational skills

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Matter of J.P., NY FH # 3689971R

Sip-and-puff mechanism for wheelchair was necessary to:

  • maximize child’s opportunity for cognitive development

  • allow him to be more responsible for own self-care and safety

  • foster his learning capacity

  • foster his general ability to explore his environment “as is necessary for any child his age”

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Matter of John, NY FH # 4337314K

  • Medicaid denied prior approval for power wheelchair for young child, claiming child always had a caregiver present who could push him.

  • Decision rejected agency’s argument that continued reliance on caregivers to push him would be developmentally inappropriate for child.

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Following services are available if medically necessary:

  • computers, such as the Apple II Computer with printers, computer software

  • exercise equipment including exercise bikes, swing sets, and tricycles

  • communication devices such as the Dynavox

  • specialized eating utensils and other daily living aids

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