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Case Management How to Use EPSDT Services for Children with Complex Health Needs

Case Management How to Use EPSDT Services for Children with Complex Health Needs Virginia Department of Medical Assistance Services (DMAS) October 6, 2009 What is EPSDT? Medicaid ’ s program for children up to the age of 21 with a preventive treatment approach

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Case Management How to Use EPSDT Services for Children with Complex Health Needs

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  1. Case ManagementHow to Use EPSDT Services for Children with Complex Health Needs Virginia Department of Medical Assistance Services (DMAS) October 6, 2009

  2. 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

  3. 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

  4. 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

  5. EPSDTSpecialized Services • These services serve as a “Safety Net” • Specialized Services are those which are not part of the approved Medicaid mandatory or optional services (defined in US code 1396d)

  6. Specialized Services • The following Services are covered only under EPSDT • All Require pre authorization at DMAS • Hearing Aids • Specialized and Substance Abuse Residential Treatment • (MCO Exclusion, request services at KePRO/DMAS) • Personal Care • (MCO Carve out, request services at DMAS) • Private Duty Nursing

  7. Medical Necessity (cont.) • The medical justification for a service must accompany the request for EPSDT treatment services. • Certain services may not be covered by EPSDT • Respite • Environmental Modifications • Vocational • Educational

  8. DMAS Website How To’s Program information on many programs, this points to Maternal and Child Health which houses Schools, BabyCare and EPSDT Find Provider Manuals and Memos Here

  9. How to Choose a Provider Select category and location

  10. Got EPSDT Forms? Find EPSDT forms Here www.dmas.virginia.gov/ch-home.htm#EPSDT

  11. Specific Program Guidelines

  12. Hearing/Audiology Services

  13. 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

  14. Personal Care

  15. 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

  16. Personal Care Criteria • ADL dependency in three areas is mandatory to require personal care • Care need is not solely due to normal developmental milestones

  17. EPSDT Nursing

  18. EPSDT Nursing • EPSDT nursing is 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.

  19. EPSDT Nursing Persons who are eligible for nursing services are individuals who: • Require the skilled intervention or medical monitoring from a medical professional in order to maintain physical health or to prevent imminent physical harm.

  20. 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

  21. EPSDT Residential and Facility Based Care

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

  23. EPSDT Contacts Shirlene Harris, EPSDT Preauthorization Coordinator (804) 225-3124 shirlene.harris@dmas.virginia.gov Anne Young, EPSDT Nursing (804) 371-2635 anne.young@dmas.virginia.gov (804) 225-3961EPSDT fax Email epsdt@dmas.virginia.gov www.dmas.virginia.gov/ch-home.htm

  24. Thank You! Brian Campbell, EPSDT Coordinator (804) 786-0342 brian.campbell@dmas.virginia.gov

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