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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

Case ManagementHow to Use EPSDT Services for Children with Complex Health Needs

Virginia Department of Medical Assistance Services (DMAS)

October 6, 2009

what is epsdt
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
what are epsdt services
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
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
epsdt specialized services
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)
specialized services
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
medical necessity cont
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
dmas website how to s
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

how to choose a provider
How to Choose a Provider

Select category and location

got epsdt forms
Got EPSDT Forms?

Find EPSDT forms Here

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

covered hearing services
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
personal care15
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
personal care criteria
Personal Care Criteria
  • ADL dependency in three areas is mandatory to require personal care
  • Care need is not solely due to normal developmental milestones
epsdt nursing18
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.
epsdt nursing19
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.
epsdt nursing coverage
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 case examples
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
epsdt contacts
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

thank you
Thank You!

Brian Campbell, EPSDT Coordinator

(804) 786-0342

brian.campbell@dmas.virginia.gov