Medicaid Services and Part C

1. MedicaidServices and Part C April 26, 2006 Early Intervention Conference Hotel Roanoke

2. Relationship between MCH services EPSDT BabyCare Schools FAMIS Family Planning Waiver Collaboration with VDH, DSS and DMHMRSAS Part C Head Start WIC Lead Vaccines for Children Resource Mothers Overview of Maternal and Child Health Services • MCH Division changes

3. Definitions of Benefit Plans • FAMIS 133% < 200% FPL • MCO (no MCO? = Fee for Service) • FAMIS for children under 19 • Medicaid < 133% FPL • FAMIS Plus = Children’s Medicaid (under age 19) • MCO vs Fee For Service

4. Medicaid and FAMIS Get detailed information service criteria and limitations via the internet at… www.dmas.virginia.gov www.famis.org

5. FY 2005

6. Early and Periodic Screening, Diagnosis, and Treatment Services(EPSDT)

7. What is EPSDT? • A Medicaid program for children up to the age of 21 with a preventive treatment approach • Diagnosis or screening services are the backbone of the program • EPSDT criteria must be considered within existing state plan service reviews • Referrals for treatment services occur during well child or other as needed screenings

8. Who is Eligible for EPSDT? • Children under the age of 21 who receive Medicaid through Medicaid/FAMIS Plus, or a MCO are eligible to receive the full scope of Medicaid/EPSDT services • FAMIS children who are not enrolled with a Managed Care Organization • MCO enrolled FAMIS children receive Well Child services through their MCO but are not eligible for the full scope of EPSDT

9. MCO and EPSDT • MCO’s have responsibility to provide EPSDT diagnostic and treatment services according to Federal Criteria American Academy of Pediatrics (AAP) guidelines

10. 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

11. EPSDT Required Services All children should receive these services • Preventive screenings • Preventive Laboratory Services • Developmental/Behavioral Assessment • Lead testing at 12 and 24 months • Immunizations • Referral to a dentist at age 3

12. EPSDT Screenings

13. EPSDT Screenings • EPSDT screenings must: • Be regularly scheduled according to AAP/Bright Futures Guidelines (refer to periodicity chart for detail) • Contain certain elements to be considered an EPSDT screening

14. EPSDT Screening Types There are 4 types of EPSDT screenings • Medical • Dental • Vision • Hearing

15. EPSDT Screeners • Physician • Certified Nurse Practitioner

16. Types of Screenings • AAP recommended screenings: • These are typical “well child care” • They are conducted according to the DMAS periodicity schedule

17. Types of Screenings • Inter-periodic or partial screenings: • These are intermittent physician encounters or “sick visits” • Problem-focused screening

18. Screening and Treatment • Periodic, Inter-periodic or partial screenings may be used to document the need for EPSDT treatment • Any caregiver or professional who comes in contact with the EPSDT enrollee may request an inter-periodic screening

19. Mandated Screening Elements • A Comprehensive health and developmental history (including assessment of both physical and mental health development); • A comprehensive unclothed physical exam; • Age appropriate (if needed) immunizations scheduled according to the: Advisory Committee on Immunization Practices (ACIP) guidelines: http://www.cdc.gov/nip/recs/child-schedule.htm

20. More Screening Elements 4. Laboratory tests (including lead blood level assessment at 12 and 24 or when new patient with unknown history up to 72 months or as appropriate for age and risk factors); AND 5. Health Education- Anticipatory Guidance and problem focused guidance and counseling.

21. EPSDT Periodicity Schedule • States must provide screenings at intervals which meet reasonable standards of medical and dental practice, for pediatric vaccines • Virginia uses the American Academy of Pediatrics (AAP) guidelines to develop its EPSDT periodicity schedule

22. Screening and Long Term Care • Referrals should be made to agencies who help with accessing Long Term Care/Community Based Waiver Programs • More information accessing waiver services may be found by calling the DMAS Long Term Care Division at • 804-786-1465

23. Possible Referrals to Programs • Mental Health Services • Specialized Therapies/Rehabilitative Services to manage developmental disabilities • EPSDT Nursing, Personal Care, • Medical and adaptive equipment • Residential Treatment, facility and hospital services • Other medically necessary care

24. The EPSDT Difference • Mandatory Lead Testing is the exception where EPSDT screenings exceed Well Child Care • The EPSDT difference is in the scope of EPSDT treatment

25. Lead Testing Requirements • The Centers for Medicare and Medicaid Services (CMS) requires that all Medicaid enrolled children receive a blood lead test at 12 months and 24 months of age.

26. Lead Testing Requirements • Children enrolled in Medicaid between the ages of 24 months and 72 months of age must also receive a blood lead test if they have not been previously screened for lead poisoning or if the current medical record is insufficient to prove that a lead test has been performed on the child

27. Lead Testing Requirements • Testing may be performed by venipuncture or capillary blood sample. Filter paper methods are also acceptable. • Confirm elevated capillary blood lead levels ≥10 μg/dL. • A second capillary sample for confirmation is allowable if performed within 12 weeks (84 days) of the original capillary sample. • A venous sample is considered “confirmed”. A venous sample is required for an environmental investigation at levels above 15 μg/dL.

28. Active Lead Testing Laboratories • Environmental investigations are a service offered by Medicaid through Lead Safe Virginia. Environmental Investigations are reimbursed to DMAS enrolled health departments.Medicaid funds are not available for testing of environmental substances such as water, paint or soil. Please consult with your local health department or contact Lead-Safe Virginia to see if your patient qualifies for a risk assessment

29. DMAS Enrolled Labs • MCO enrolled providers will use the labs as designated in their provider contracts • DMAS labs who currently provide pediatric lead testing can be found on the DMAS website www.dmas.virginia.gov by contacting the provider help-line and by email at epsdt@virginia.gov

30. Lead Safe Virginia • Lead-Safe Virginia provides clinical guidance • Free Medical "hotline" at 866-767-5323 (866-SOS-LEAD). • The hotline is within the University of Virginia and it is available 24 hours a day seven days a week.

31. DMAS Birthday Cards • DMAS/EPSDT birthday cards include lead testing requirements for children under the age of 6 and information about upcoming well child appointments. • The cards are sent to all Medicaid- eligible recipients, including those in Managed Care Organization • Follow up notices go to the providers to remind them that a test is required

32. Bright Futures • Developed in conjunction with CMS, AAP, and HRSA to promote EPSDT • More information and family guidance is provided at www.brightfutures.org • Bright futures materials mirror the AAP guidelines

33. Tools for Families • Tools for practices • Tools for social workers • A tool for Medicaid programs

34. Bright Futures Bright Futures guidelines address the new health risks that threaten children and families today. Bright futures discusses chronic conditions such as: • asthma, • obesity and • complications of early sexual activity.

35. Bright Futures Bright futures discusses healthcare issues that affect many Medicaid families such as: • poverty and limited access to health care, • prenatal risks and low birth-weight babies, • nutrition and school performance, substandard housing and lead poisoning.

36. Bright Futures Web Based Training Module http://www.vahealth.org/brightfutures/

37. Bright Futures Virginia • http://www.vahealth.org/brightfutures/ • The web course is divided into six segments, and can be completed in about seven hours. • One section teaches participants how to apply Bright Futures Guidelines to their practices and is particularly helpful for those who serve high-risk families

38. Bright Futures Virginia • Other segments include an overview of Bright Futures, developmental assessments, medical assessment, immunization and screening, and tools to help put Bright Futures into practice

39. Take 5

40. 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 • Must be services that are considered eithermandated or optional services by CMS

41. EPSDT Treatment • If a health condition is discovered during an EPSDT screening the physician will refer the individual for evaluation to recommend treatment for the condition. • When these services are included in the Virginia State Plan, they are considered treatment services • When these services are not services that are included in the Virginia State Plan, they are considered specialized services

42. MCO and EPSDT • MCOs provide EPSDT treatment services through their provider network • Certain Medicaid services such as Community Mental Health Rehabilitation and Personal Care are accessed directly through DMAS upon referral from the MCO enrolled physician

43. Medical Necessity • All services must be deemed medically necessary to correct or ameliorate a health or mental health conditions • Determined on a case-by-case basis according to EPSDT criteria

44. EPSDTSpecialized Services • Periodic, Inter-periodic or partial screenings may be used to document the need for EPSDT treatment • Any caregiver or professional who comes in contact with the EPSDT enrollee may request an inter-periodic screening

45. Inpatient Hospital Services Emergency Hospital Services Outpatient Hospital Services Nursing Facility Care Rural Health Clinic Services Federally Qualified Health Center Clinic Services Lab and X-Ray Services Physician Services Home Health Services EPSDT Family Planning Nurse-Midwife Services Transportation Medicare Premiums (Part A) - Hospital; (Part B) - Supplemental Ins. For Categorically Needy Federally MandatedMedicaid Services

46. Other Clinic Services Skilled Nursing Facility Services for Individuals under 21 years of age Podiatrist Services Optometrist Services Clinical Psychologist Services Certified Pediatric Nurse and Family Nurse Practitioner Services Home Health: PT, OT, and Speech Therapy Dental Services for Persons under 21 Physical Therapy & Related Services Prescribed Drugs Case Management Services Prosthetics Mental Health Services Mental Health Clinic Services Hospice Services Medicare Part B Premiums for the Medically Needy PACE Optional Medicaid Services

47. Accessing Specialized Services (cont.) • EPSDT requests for state plan services will be rejected and referred to the existing Medicaid program • Service denials in other programs should be appealed as appropriate • EPSDT is not always an option for service or waiver denials

48. Is it on The List? • All EPSDT or other treatment services provided through Medicaid must be defined in the • Social Security Act 1905 (a) • The Social Security Act defines which services that states may offer through their Medicaid program

49. Specialized Services • The following Services are not covered under the State Plan and are covered only under EPSDT • Substance Abuse Treatment Services • Hearing Aids • Assistive Technology • Personal Care • Private Duty Nursing

50. Accessing Specialized Services Fax Specialized Services requests to EPSDT Coordinator @ (804)786-5799 EPSDT Requests must contain the following: • Request form (DMAS-412 or 351) • Letter of Medical need (DMAS-352 or 353) • Evaluation from specialist (discipline specific) • Treatment plan (from relevant provider) • Description of service requested and why established programs do not meet this need