EPSDT: Early and Periodic Screening, Diagnosis and Treatment Program Marge Gustas,Paralegal Neighborhood Legal Services, Inc. 237 Main Street, Ste. 400 Buffalo, NY14203 (716) 847-0655 extension256 email@example.com fax: 847-0227 attention, Marge Gustas
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
Equipment May Also Be Covered Under: • physical therapy • occupational therapy • speech pathology services • rehabilitation • prosthetics • orthotics, etc.
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
EPSDT: • comprehensive and preventative health care program for recipients under age 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
Medicaid Must Provide: • outreach and informing • screening • diagnosis • treatment • adequate provider participation • reporting
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
As Children Age, Assessments Should Include: • Visual-motor integration • Visual-spatial organization • Visual sequencing processing skills • Auditory sequential memory
Assessments of Adolescents Should Include: • Identification of potential learning disabilities • Peer relations • Psychological/psychiatric problems • Vocational skills
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”
Matter of John, NY FH # 4337314K • Medicaid denies 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
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
Medicaid Managed Care Section 1115 Waiver of the Social Security Act • “Must show that cost of the demonstration project is no more expensive, or less expensive, than the provision of traditional Medicaid fee-for-service programs.” • The “New York Partnership Plan” uses MCO’s to provide services to current recipients and expand services to others who would be without.
The Managed Care Organization and the Medicaid Recipient • Can restrict the Medicaid recipient to using only its doctors; • Must identify, define and specify the amount, duration and scope of the services it offers; • Must provide services in the same amount, duration and scope as services provided to fee for service Medicaid recipients, • Cannot deny the Medicaid recipient’s request pursuant to a membership contract.
All requests for devices should be reviewed in the same manner as Medicaid fee for service recipients • Does it meet the definition of DME? • Does it meet the definition of a prosthetic or an orthotic? • Is the device a therapeutic adjunct? • Does the device fit under the EPSDT guidelines for children under age 21? • Does it meet the Medicaid requirements for prior approval?
All Denials Can be Appealed • The MCO can request that you follow its grievance procedure before requesting a New York State fair hearing; • Some MCO’s allow you to go straight to the state fair hearing, • Strictly adhered to all time lines on the notices.
Grievance #1 Client needs a power wheelchair for activities of daily living outside the home. His MCO denies his request stating that his contract provides only for equipment that is suitable for use in the home. • Client does not have a membership contract with the MCO; • Medicaid’s definitions of DME does not include the language “suitable for use in the home.”, • Medicaid prior approval does not rely upon the “suitable for use in the home” language to determine medical need.
Grievance #2 Small child with CP needs an adapted feeding chair. His school has decided to make the feeding chair for him because of certain physical aspects of his condition. His MCO denied the request stating that “these items would not be covered under your child’s current coverage with us.” • This again refers to a contract between the MCO and the recipient; • Medicaid pays for custom made equipment; • Medicaid also pays for the pre-designed feeding chairs; • The request meets both EPSDT services and the prior approval criteria.
Grievance #3 An autistic child request a weighted vest fro her MCO. She was denied because the device “is not listed on the New York State Approved List of Durable Medical Equipment”. Coverage is based on the New York State approved list. • New York State is not allowed to have an exclusionary list; • The MCO did not review the request pursuant to EPSDT; • The MCO did not review the request pursuant to Medicaid prior approval criteria.