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

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EPSDTSpecialized ServicesThe DMAS “Safety Net”

Virginia Department of Medical Assistance Services (DMAS)

Fall 2010

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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.

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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

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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

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  • 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

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Website Tips

Find Provider Manuals and Memos Here

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

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Find Manuals

Helpful Hint:

  • Chapter 2 is always

    • Provider requirements/enrollment criteria

  • Chapter 4 is always

    • Covered Services

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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

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Medicaid Covered ServicesExamples

Children with Special Health Care Needs

Durable Medical Equipment



Long Term Care Waiver Services


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Medicaid Covered ServicesExamples

  • Children with Substance Abuse and Behavioral Disorders

  • Psychiatric

  • Community Mental Health Rehabilitation

  • Hospital

  • Pharmacy

  • Children’s Mental Health Program


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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

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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

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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

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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

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Safety Net Function

  • EPSDT covers treatments that are:

    • Not available to certain disability groups

    • Not covered by Medicaid


    • Eating Disorders Treatment

    • Residential Substance Abuse Treatment

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

    • ABA

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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

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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

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

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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

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Find EPSDT forms Here

Find EPSDT Program Info Here

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AT Coverage

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

  • Some Waivers provide Assistive Technology

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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.

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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.

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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.

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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

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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;

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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.

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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

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Personal Care Criteria

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

  • Care need is not solely due to normal developmental milestones

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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

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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

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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.

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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

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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

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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

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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)

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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

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EPSDT Nursing Contacts

Anne Young, EPSDT Preauthorization Coordinator

(804) 371-2635

[email protected]


(804) 612-0043

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Background Foods

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

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EPSDT and Medical Formula Foods

  • 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.

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General Information Foods

  • 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

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EPSDT FoodsBehavioral Treatment

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EPSDT Behavioral Treatment Foods

  • 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.

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Behavioral Treatment (cont.) Foods

  • 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.

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Behavioral Treatment FoodsMedical 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;

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Continuation of Treatment Foods

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.

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EPSDT Residential Foodsand Inpatient Treatment

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Residential Behavioral Treatment Clinical Necessity Foods

  • 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;

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Residential Treatment Criteria (cont.) Foods

  • 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;

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    EPSDT Residential Foods

    • 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

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    EPSDT Residential Treatment Examples Foods

    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)

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    EPSDT Residential Coverage Foods

    EPSDT Residential Treatment includes:

    • Behavioral Support Counselor,

    • Clinical Supervision related to his treatment plan

    • Case Management,

    • Treatment Team Activity

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    EPSDT Residential Exclusions Foods

    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

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    EPSDT Inpatient Treatment Foods

    • 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.

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    Inpatient Settings May Vary According to Treatment Needs Foods

    • 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.

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    Inpatient Examples Foods

    • 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.

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    FFS Pre-Auth Timeline Foods

    • 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


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    EPSDT Contacts Foods

    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


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    Thank You! Foods

    EPSDT Services Supervisor

    Brian Campbell

    [email protected]