Source: https://www.scribd.com/document/14645322/How-EPSDT-is-supposed-to-help-your-child
Timestamp: 2017-05-29 22:19:16
Document Index: 665957033

Matched Legal Cases: ['art 1', 'art 1', 'art 2', 'art 2', 'art 3', 'art 3', 'art 4', 'art 5', 'art 5', 'art 5', 'art 6', 'art 7', 'art 7', 'art, 10', 'art, 10', 'art, 10', 'art, 10', 'art, 10', 'art 440']

How EPSDT is supposed to help your child | Supplemental Security Income | State Children's Health Insurance Program
ScribdExploreEXPLORE BY INTERESTSCareer & MoneyBusiness Biography & HistoryEntrepreneurshipLeadership & MentoringMoney ManagementTime ManagementPersonal GrowthHappinessPsychologyRelationships & ParentingReligion & SpiritualitySelf-ImprovementPolitics & Current AffairsPoliticsSocietyScience & TechScienceTechHealth & FitnessFitnessNutritionSportsWellnessLifestyleArts & LanguagesFashion & BeautyFood & WineHome & GardenTravelEntertainmentCelebrity Biography & MemoirPop CultureBiographies & HistoryBiography & MemoirHistoryFictionChildren’s & YAClassic LiteratureContemporary FictionHistorical FictionLGBTQ FictionMystery, Thriller & CrimeRomanceScience Fiction & FantasyBROWSE BY CONTENT TYPEBooksAudiobooksNews & MagazinesSheet MusicUploadSign inJoinOptionsJoinSign InUploadHow EPSDT is supposed to help your childUploaded by Disability MomSupplemental Security IncomeState Children's Health Insurance ProgramMedicaidHealth Maintenance OrganizationService Industries0.0 (0)DownloadEmbedDescription: This pamphlet was published under the auspices of the US Department of Health and Human Services. It's designed to tell parents how to use the rights their children have under EPSDT in order to sec...View MoreThis pamphlet was published under the auspices of the US Department of Health and Human Services. It's designed to tell parents how to use the rights their children have under EPSDT in order to secure the services their children need. It even includes instructions on getting EPSDT written into your child's IEP.Copyright: Attribution Non-Commercial (BY-NC)Download as PDF, TXT or read online from ScribdFlag for inappropriate contentEPSDT: Supporting Children with DisabilitiesNATIONAL CENTER FOR FAMILY SUPPORT AT HUMAN SERVICES RESEARCH INSTITUTE
EPSDT: Supporting Children with Disabilities
NATIONAL CENTER FOR FAMILY SUPPORT AT HUMAN SERVICES RESEARCH INSTITUTE
Written by: Sarah Knipper National Center for Family Support Human Services Research Institute 8100 SW Nyberg Road, Suite 205 Tualatin, OR 97062 503-885-1436 (phone) 503-885-1536 (fax) www.familysupport-hsri.org
Prepared for: Administration on Developmental Disabilities Administration for Children and Families U.S. Department of Health and Human Services Mail Stop: HHH 300-F 370 L’Enfant Promenade, S.W. Washington, D.C. 20447
What is Medicaid? ..............................................................................................................2 What is EPSDT? ..................................................................................................................2 What Do Those Letters Stand for Anyway?.......................................................................3 How are EPSDT Services Delivered?.................................................................................7 What are the Requirements for EPSDT Services? ...........................................................8 Treatments must be medically necessary...................................................................8 Treatments must fit within a Medicaid coverable service..........................................9 Treatment must come from a Medicaid provider .................................................... 14 EPSDT Names .................................................................................................................. 15 Limits on EPSDT Services ............................................................................................... 17 Who is Eligible for EPSDT? .............................................................................................. 18 Standard Medicaid..................................................................................................... 19 State Children’s Health Insurance Program............................................................. 20 Medicaid/SCHIP Program Names ............................................................................. 22 Obtaining Medicaid Eligibility and Other Questions ...................................................... 25 SSI ............................................................................................................................... 25 TEFRA .......................................................................................................................... 28 Home and Community Based Services Waiver ........................................................ 30 Medicaid and Immigration .............................................................................................. 33 U.S.-Born Children with Immigrant Parents.............................................................. 33 What if I’m Denied? Grievances and Appeals .............................................................. 34 Managed Care ............................................................................................................ 35 Fair Hearing Process .................................................................................................. 35 Other Grievance Resources....................................................................................... 36 What’s Next? .................................................................................................................... 37 Appendix A Michigan Age Periodicity Scale Appendix B Additional Resources
If you have a child with a disability, getting adequate health care can be a very big challenge. However, for families eligible for Medicaid, there is a full children’s health care benefit package called EPSDT. EPSDT stands for Early Periodic Screening, Diagnosis, and Treatment, and is a part of every state’s required Medicaid package1. EPSDT can be a very powerful tool in assisting children with developmental and other disabilities and their families to access the important services they need. If you have a child with a disability, work with families, or are an advocate, this booklet has been written for you. It is very important that you know what EPSDT is, who is eligible for it, what it offers, and how to access its services. This booklet will provide much of the information you need and will also guide you to resources in your own state. Through EPSDT, federal Medicaid law requires each state to provide a wide range of medically necessary services for eligible children. Compared to the majority of private health insurance plans, EPSDT provides a more robust and complete benefit package. Because EPSDT is complicated, it is often misunderstood and not used to its full potential. However, if you are well-informed, EPSDT can help you to obtain a wide range of benefits for your child, including physical and occupational therapy, personal care attendants, communication aides, and many other critical services.
Q: What does EPSDT mean for my family? A: EPSDT can provide your child with many important services such as speech pathology, physical therapy, dental care, wheelchairs, personal care aide, medical equipment, and more.
We hope that this booklet will help you better understand EPSDT and Medicaid in general. It can also serve as a springboard for you and other advocates to become more knowledgeable about your state’s specific policies. We’ll talk about eligibility, the EPSDT process, available services, and typical areas of confusion. Every state differs in how it administers and delivers EPSDT. It is important that you first have a general understanding of the program to become fully educated about EPSDT in your own state.
Oregon is an exception to this rule. The Oregon Health Plan (Oregon’s Medicaid program) provides many of the same services covered under EPSDT, but is not required to provide all possible services in the same way as other states.
To understand what EPSDT is, you need to know a little bit about Medicaid. Medicaid is a program that provides health care coverage for people with low incomes, disabilities, and certain other groups that cannot afford traditional health care. Each state has its own Medicaid program which is overseen by the federal government. For every dollar that states put toward Medicaid, they will receive at least one dollar from the federal government (the average state receives $1.14 in federal money for every state dollar). In order to participate in Medicaid and receive federal money, there is a list of required benefits that all states must offer to all of its Medicaid recipients. These required benefits include immunizations, lab/x-ray services, hospitalization, and doctor visits. Other benefits, such as prescription drugs and personal care attendants, are optional, and states can choose to provide them if they wish. EPSDT is one of the required benefits that a state must provide through its Medicaid program. Eligibility for Medicaid is not limited to “welfare” recipients. Families with moderate incomes can be eligible for Medicaid in some circumstances. The amount of income a family can have and still qualify for Medicaid varies by state. We’ll provide more detailed information about eligibility later.
According to the Centers for Medicaid and Medicare Services (the federal agency in charge of Medicaid), EPSDT is based on two principles: 1. Assuring that health care services are available and accessible; and 2. Assisting eligible children and youth to get the health care services they need. Federal law requires that each state’s EPSDT program provide a variety of health care services and preventive check-ups to ensure that children receive the treatment they need to maintain and/or improve their health. States must inform all Medicaid beneficiaries that EPSDT services are available to them. They must also reach out to families who are potentially eligible and follow up to make sure that services are being provided.
Under EPSDT, eligible children and youth are entitled to regular check-ups, and full physical and mental health care from birth up to age 21.2 Now that you have an overview of EPSDT and Medicaid, let’s look at the details of the program. In order to understand it more fully, we’re going to first talk about the structure and benefits of EPSDT, and then move on to eligibility.
What Do Those Letters Stand for Anyway?
E P S = Early Periodic Screening The first three letters of EPSDT refer to the fact that eligible children are entitled to regular, comprehensive assessments of their health, or Early Periodic Screenings. These assessments (or “screenings”) must include check-ups in four areas: physical health, dental health, vision, and hearing. The purpose of these screenings is to: find any problems or conditions as early as possible so that they may be treated; and ensure that children receive necessary health care on a routine basis (e.g., immunizations, ongoing monitoring of existing conditions). Screenings address normal developmental concerns as well as signs of illness or a change in health. Your child does not have to be sick in order to be screened. Screenings also allow the rest of the process (diagnosis and treatment) to continue and be paid for by Medicaid. There are three types of screenings that a state must provide. The first kind is called an initial screen. This is a check-up that must be provided when a child enters the Medicaid program. The second type of screen is called a periodic screen (well child check-up), and should occur at regular intervals (e.g., babies get six hearing and vision screenings in the first 12 months).
Fact! Did you know… Your child can have an EPSDT screening because of: Illness Normal development issues A change in his or her disability/condition
In some states, children are only covered up to their 18th, 19th, or 20th birthday. EPSDT: Supporting Children with Disabilities Page 3
By law, periodic screenings are required to include certain procedures over time, although each state can set its own timetable (“periodicity schedule”) for the screenings and their components. Listed below are all the pieces required as part of a state’s screening process. Most states use the schedule recommended by the American Academy of Pediatrics. The procedures and intervals are identical to those recommended for all children. As an example, a copy of the schedule used by Michigan’s EPSDT program is shown in Appendix A.
Required Components of the Screening Process
1. Total health/developmental history (including a complete assessment
of physical and mental health)
2. Complete physical exam 3. Immunizations 4. Lab tests, including tests for lead toxicity in blood 5. Health education/counseling 6. Eye exams/other vision tests 7. Dental services (including check ups, cleanings, and preventive work) 8. Hearing services (including diagnosis and treatment, hearing aids)
The third type of screen is often the most useful for many families and is called an interperiodic screen. This is a check-up or assessment that can happen at any time outside of a regularly scheduled visit. If a child shows signs of illness or a change in his/her condition, a visit to that child’s doctor can count as an interperiodic screen. You can trigger an interperiodic screen by scheduling a doctor’s appointment for your child.
Fact! Did you know… Parents can initiate the EPSDT process by requesting a doctor’s appointment for their child. This visit can count as an interperiodic screen.
Q: What counts as an interperiodic screen? A: A doctor’s visit because of illness or change in condition or an encounter with any Medicaid health professional (school nurse, physical therapist, etc.). Q: Is an official referral needed for an interperiodic screen? A: No, the referral can be made by the child, his/her parents, or any professional in or out of the health care system.
Figure 1 below gives a summary of each type of screen, and shows how all three screens fit together. Children should be screened throughout childhood, starting with an initial screen and continuing on with regular check-ups and/or screens triggered by an immediate need or illness.
Figure 1. EPSDT Screening Process
Initial Screen First check-up, either at birth or when child enters Medicaid program
Periodic Screen Regular check-up that happens according to a schedule set by the state (e.g., yearly physical)
Interperiodic Screen Check-up that can happen at any time because of illness or a change in condition
D T = Diagnosis and Treatment Diagnosis and treatment are the “meat” of EPSDT and are triggered by screenings. Once a child is seen by his/her physician or provider and a screen reveals a problem, a diagnosis is made and an appropriate treatment can be provided. Any illness or condition that is discovered during a screen must be treated and covered by EPSDT. Conditions do not have to be “new” to be treated. By law, states must cover “necessary health care, diagnostic services, treatment and other measures…to correct or ameliorate defects and physical and mental illnesses and conditions.”3 This means that states cannot refuse to provide services based on whether or not they will “cure” a condition. If a treatment maintains a child’s current condition or makes it easier for a child to live with that condition, in general it must be covered by EPSDT. For example, a child with mental retardation can receive speech therapy under EPSDT to keep from losing any current function. Once a diagnosis has been made (or confirmed, if the condition is not new), the provider can either treat the condition, or refer the child to another provider for appropriate treatment.
Fact! Did you know… Your child cannot be denied treatment under EPSDT because of a “pre-existing condition.” All disabilities and illnesses must be treated!
The five pieces of EPSDT are designed to ensure that all eligible children have access to a full range of health care services, from prevention to identification and diagnosis all the way through treatment. The law is very clear that eligible children are entitled to this care, and that states have an obligation to make sure children are consistently screened and treated as part of this entitlement. Pictured below in Figure 2 is a graphical summary of how each piece of the EPSDT process fits together.
42 USC S 1396(r)(5) EPSDT: Supporting Children with Disabilities
Figure 2. Summary of the EPSDT Process
EPS D
Periodic screen Regular checkup Initial screen First checkup Interperiodic screen Other visit to doctor/provider Provider makes diagnosis Treatment is provided
How are EPSDT Services Delivered?
In general, states have two ways of delivering Medicaid benefits, including EPSDT. In a fee-for-service system, physicians and other providers are paid directly by the state to provide Medicaid services. If your child is in a fee-forservice region/state, his or her provider will probably be able to provide treatment without having to get prior authorization from the state. In this type of system, you select a primary care physician for your child and the physician works with you in accessing the services your child needs. In a Medicaid managed care system, the state pays a Health Maintenance Organization (HMO) or other managed health plan to provide and manage health care benefits. In managed care plans, your child’s doctor might have to get prior authorization (i.e., permission to treat and get paid) from the HMO before providing treatment. However, Medicaid HMOs still must meet all EPSDT guidelines and cover all appropriate treatments under EPSDT. Families who live in less populated areas or who are trying to obtain specialized services for their child may be told that their HMO doesn’t have a provider for that service/treatment. But there is no difference between what children in managed care and those in fee-for-service are entitled to under EPSDT. Later, we will discuss grievances and appeals in the event you run into problems getting services.
EPSDT: Supporting Children with Disabilities Page 7
What are the Requirements for EPSDT Services?
EPSDT law has certain requirements that must be met in order for a service or treatment to be administered. For a treatment to be covered by EPSDT, it must: 1. Be medically necessary; 2. Fit within a recognized Medicaid service category; and 3. Be prescribed and provided by a Medicaid physician/provider (i.e., one who has an agreement with the state). 1. Treatments Must be Medically Necessary States only pay for services under EPSDT that are medically necessary. An unofficial definition of medical necessity is the decision by a health care or other related professional that a person’s condition requires that a recognized service, intervention, or course of treatment be provided in order to address or improve the condition. There is, however, some gray area surrounding how this definition translates into specific situations. It can sometimes be difficult to convince the state Medicaid agency or managed care company that a service is actually medically necessary. However, deciding that a service is medically necessary should mainly be left to your child’s treating provider (primary care physician, physical therapist, speech pathologist, or other provider). States have the right to review a provider’s decision, and it is not uncommon for providers and Medicaid agencies/HMOs to disagree on what is medically necessary. However, several courts have found that states must defer to the doctor’s opinion in treating patients4.
Fact! Did you know… For adults in Medicaid, states are only required to cover a limited list of services (called “mandatory” services). They may also choose to offer additional benefits (called “optional” services). But for children, ALL Medicaid services are mandatory. Under EPSDT, states must offer coverage of all Medicaid service categories to children.
Weaver v. Reagen, 886 F .2d 194 (8th Cir. 1989) Hilburn by Hilburn v. Maher, 795 F .2d 252 (2nd Cir. 1986) Lewis v. Callahan, 125 F .3d 1436 (11th Cir. 1997) EPSDT: Supporting Children with Disabilities
You may have been told by your insurance plan that “pre-existing conditions” are not covered, or may only be covered for certain services. It is important to know that under EPSDT, all pre-existing conditions must be fully treated and cared for.
Q: My son’s doctor agrees that he needs a personal care attendant but my Medicaid HMO says that it doesn’t cover that service. Is that true? A: Personal care services are a required part of EPSDT, as long as they are prescribed as medically necessary by a provider. Since personal care is an “optional service” under basic Medicaid requirements, your state might not normally cover it for its adult Medicaid population. However, EPSDT requires that states cover both mandatory and optional services for children. Therefore, the HMO is required by law to cover it.
2. Treatments Must Fit within a Medicaid Coverable Service States must provide a comprehensive set of services under EPSDT, many of which are of great importance to children with disabilities. Services covered by EPSDT fall into broad categories such as inpatient/hospital care, transportation, mental health, prescription drugs and supplies, and routine primary care. Medicaid also covers other services not relevant to this booklet, including ICF/MR, nursing facility services, prenatal care, nurse midwife services, and hospice care. EPSDT services include (but are not limited to) the following services in Chart 1.
Chart 1. Services Covered by EPSDT Hospital Services Ambulance to and from hospital/emergency room Inpatient hospital care Outpatient hospital care (day visits) Emergency room visits Physical Health Care Physician/nurse practitioner services: routine check-ups, illnessrelated visits Dental visits: routine check-ups/cleanings (including accommodations for children with special needs), fillings, preventive care Vision care: eye exams, glasses, eye drops, scratch-proof lenses Hearing care: hearing tests, hearing aides, cochlear implants Immunizations: according to established schedule Lab tests/x-ray services: including blood lead tests Podiatry care: including orthotic inserts Mental health Psychiatrist visits Mental health therapy/counseling Substance abuse treatment Inpatient psychiatric hospitalization Medications and Pharmacy Supplies Prescription drugs Diapers Special foods: diet supplements, thickeners, other foods found in a store’s pharmacy section
Home/Community Services and Therapies Private duty nurses: nursing care in the home or community for children who require medical attention/services Personal care/personal assistant services: assistance with nonmedical services in the home, community or school, including feeding, bathing/personal hygiene, transferring, following behavior plan Physical therapy Occupational therapy Speech, hearing, and language therapy (includes audiology services) Chiropractic services Nutritional services/counseling Some behavioral therapy: behavioral therapies for children with autism are generally covered by EPSDT, although there is some controversy about this Supplies/Equipment Durable medical equipment: wheelchairs, ankle/foot/leg braces, monitors, catheters, oxygen equipment, nebulizers Augmentative communication devices: communication aides, optical headpointers, headsets Diabetic supplies: insulin pumps, glucometers, syringes Prostheses Other services Transportation: to and from doctors’ appointments, therapy visits Case management
While EPSDT offers a very comprehensive set of benefits, there are certain services that it will not cover. Services not covered by EPSDT are listed in Chart 2. Chart 2. Services Not Covered by EPSDT Respite care Sometimes it is difficult to distinguish between respite care and personal care (which IS covered). Respite care, though, is for the primary purpose of relieving the child’s caregiver and is therefore not covered under EPSDT/Medicaid. Personal care is covered because it is focused on the child’s needs and is not intended to replace the primary caregiver. Habilitation services Habilitation services are those services which help individuals acquire and/or improve social skills and basic living/adaptive skills (such as dressing, feeding, cooking). They are intended to help people reach their highest level of functioning and are not covered by EPSDT. Sometimes the line between habilitation and rehabilitation (covered by EPSDT) is not clear, and there may be disagreement over which category a service falls into. Habilitation services may be provided through a home and community-based waiver program. Targeted case management Targeted case management differs from case management in that it can deal with resources and services outside of Medicaid. Under targeted case management, states can conduct assessment, care planning, referrals, and monitoring of services for Medicaid beneficiaries. Unlike other Medicaid benefits, states do not have to provide this service to children under EPSDT (although some children might receive it based on their geographic location or disability). Treatment for another family member EPSDT is a child-centered program. While family members may be included in treatment insofar as they are needed (e.g., mental health family therapy that addresses how familial alcoholism is affecting the child, or parental training to administer an IV), the treatment must not be for the parent’s sole benefit (e.g., respite care).
Medical Necessity and Educational Services A special case of how EPSDT covers medically necessary services occurs in the education system – where many children receive their services. Many children with special needs receive a wide variety of services through the public school system. They range from academic services, such as reading and math instruction, to more health-related services, such as physical therapy and personal care. Trying to figure out who is responsible for paying for which services can be very confusing. However, schools can (and many do) bill Medicaid for reimbursable services under EPSDT. Medical necessity is just as important here as it is outside the school system. According to the federal government, “Medicaid is the payer of first resort for medical services provided to children with disabilities pursuant to the Individuals with Disabilities Education Act (IDEA).”5 In other words, Medicaideligible children with disabilities are entitled to receive medical services in the school setting, paid for by Medicaid, if two important requirements are satisfied. First, the school/school district must be a participating Medicaid provider. Second, the services must be written into the child’s IEP/IFSP, which automatically makes them considered medically necessary.
Q: My child’s school says he cannot get physcial therapy services at school because that is a medical service and not the school’s responsibility. What can I do about this? A: If physical therapy is a service that your child needs, it should go into his IEP. If the school says it cannnot pay for physical therapy, find out if it is able to accept Medicaid payments. Medicaid can pay for physical therapy for your child at school if he is Medicaid-eligible, and it is part of his IEP. If your school is not a Medicaid provider, let them know they can be. For more information on this, see “Medicaid and School Health: A Technical Assistance Guide”, available at http://cms.hhs.gov/medicaid/schools/scbintro.asp.
Letter to State Medicaid Directors from Sally Richardson, HCFA Director, May 21, 1999. Available on-line at: http://cms.hhs.gov/states/letters/smd52199.asp. EPSDT: Supporting Children with Disabilities Page 13
If your child is not yet school-aged, EPSDT can also serve an important function for early intervention (EI) services. Children younger than five who are considered at risk for developmental or other delays are often enrolled in a Head Start or other early intervention program. Medicaid/EPSDT often pays for many of the early intervention services that children receive, such as developmental assessments, case management, and nutritional services. The relationship between EPSDT and EI programs is very important because any problem or issue that is detected in an EI program is treatable through EPSDT. For example, if your child's developmental assessment shows that her motor skills are delayed, she is entitled to physical therapy services to address that delay under EPSDT. 3. Treatment Must Come from a Medicaid Provider In order for an EPSDT service to be paid for by Medicaid, the service provider must be an enrolled Medicaid provider. Be sure to check with your physician, therapist, or provider/provider agency to make sure he or she accepts Medicaid. Beyond fulfilling these three basic requirements of getting EPSDT treatment, there are other steps you and your provider can take to assure your child receives EPSDT services in a timely fashion. Dealing with different providers and Medicaid in an effort to obtain services quickly can be challenging. It may help you to know what a provider will need in order for Medicaid (and any managed care company involved) to successfully provide services under EPSDT.
Fact! Did you know… In the Medicaid world, the term “provider” can be used to mean a doctor, therapist, personal care assistant, or any other person who provides services that are paid for by Medicaid.
In order to make the process as smooth as possible, it is recommended that the following documentation accompany every health care provider’s request for EPSDT services6: 1. Physician’s order for services 2. Letter of medical necessity written by the physician or provider, which includes: a. Patient history, b. Diagnosis and prognosis, c. Description of recommended services and explanation of why they’re medically necessary, d. What the benefit to the patient will be, and e. Recommended length of time for the services.
Q: My child’s provider says she doesn’t know about EPSDT. What do I tell her? A: In many states, EPSDT goes by another name, such as “Health Check” in Wyoming or “Healthy Kids” in Illinois. Also, it is often misunderstood to be only a wellchild check-up program, able to provide immunizations, physicals, and basic health care for small children. Ask your provider to check with the provider relations department of Medicaid for more information.
EPSDT Names
To make EPSDT a more user-friendly and marketable program, some states have created special names for their EPSDT programs such as KIDMED or Health Check. In some states, there are even separate names for the “EPS” part (check-ups and preventive care) and the “DT” part (diagnosis and treatment). Sometimes, these names incorrectly imply that EPSDT is tied only to early intervention and preventive care, and isn’t about treatment. Even if your state describes its version of EPSDT in terms of check-ups and services for young children, know that every EPSDT program is obligated to screen and treat all Medicaid-eligible children. Chart 3 lists names that you might hear used in your state to refer to EPSDT.
O’Connell, M and Watson, S. Medicaid and EPSDT. March, 2001. http://www.nls.org/conf/epsdt.htm EPSDT: Supporting Children with Disabilities Page 15
Chart 3. EPSDT Names
State Alaska, Arizona, Arkansas, Colorado, Delaware, District of Columbia, Florida, Hawaii, Kentucky, Maryland, Massachusetts, Michigan, Mississippi, Montana, New Jersey, Oklahoma, Rhode Island, South Carolina, Virginia, Vermont Alabama California Connecticut Georgia, Idaho, Nebraska, North Carolina, Wisconsin, West Virginia, Wyoming Iowa Illinois, Nevada, Washington Indiana Kansas Lousiana Maine Minnesota Missouri New Hampshire New Mexico New York North Dakota Ohio Oregon7 Pennsylvania South Dakota Tennessee Texas Utah EPSDT Name
Well Child Check-Up CHDP (Child Health & Disability Prevention) EPSDT/Husky A Health Check Care for Kids Healthy Kids Health Watch KAN Be Healthy KIDMED HealthWorks C&TC (Child and Teen Checkups) HCY (Healthy Children & Youth) EPSDT/CHAP (Children’s Health Assurance Program) EPSDT/Tot-to-Teen Health Checks CTHP (Child Teen Health Program) Health Tracks HealthChek MediCheck Children’s Checkup Healthy Kids Klub Caring for Kids Texas Health Steps CHEC (Child Health Evaluation & Care)
MediCheck is only the screening and referral part of EPSDT in Oregon. As mentioned earlier, Oregon has a unique Medicaid plan that does not require it to offer all medically necessary services under EPSDT. EPSDT: Supporting Children with Disabilities
Limits on EPSDT Services
States are allowed to place certain limits on EPSDT services related to medical necessity, length/duration of treatment, and how economical it is. Medical Necessity As previously stated, all EPSDT services/treatments are limited to those that are medically necessary to the child’s health. Remember, though, that this treatment does not have to be necessary to cure or improve your child’s condition, but needs only maintain his/her current level of health. “Tentative” Limits States are also allowed to put “tentative” limits on EPSDT treatment. However, states must also have an efficient, well-publicized process to allow children and families to receive services beyond this limit. For example, states can have a “tentative” limit of 20 outpatient mental health visits per year. But if a psychiatrist decides that it is medically necessary for a child with severe depression to have weekly visits, there must be an efficient process for the psychiatrist and family to get that approved. States may not place hard and fast limits on services that are medically necessary. Most Economical Mode A state can limit treatment settings and types to a less expensive or more economic setting/type of service (e.g. using medical equipment or medications that have a “generic” manufacturer rather than a brand name). However, if there is a shortage of treatment/service of a more economical mode, the more expensive version must be provided. Also, children and families must still have a sufficient choice of providers for the treatment.
Remember… Medical necessity is the decision by a health care or other related professional that a person’s condition requires that a recognized service, intervention or course of treatment be provided in order to address or improve the condition.
Who is eligible for EPSDT?
Sometimes people think that EPSDT has its own special set of eligibility criteria, but it does not. EPSDT is a required part of every state Medicaid plan and therefore has the exact same eligibility standards as Medicaid. Every child with a Medicaid card is eligible to receive services under EPSDT. There are two main pathways to obtain Medicaid eligibility for a child. One pathway revolves around your household’s income. If it is under the limit set by the state, your children will qualify for Medicaid (regardless of whether they have a disability). The second pathway is dependent on the severity of a child’s disability and can also be affected by your family’s income. No matter how a child becomes eligible, though, the same set of EPSDT benefits are available. The most common paths to EPSDT/Medicaid eligibility are: Standard Medicaid State Children’s Health Insurance Program (SCHIP) Overall Income Eligibility and the Federal Poverty Level This explanation of eligibility based on household income will require that you understand a little bit about the Federal Poverty Level (FPL). The FPL is a set of income guidelines issued by the federal government each year. FPL guidelines are loosely based on consumer prices, and account for family size. The FPL is used to set income eligibility for many different public programs such as Medicaid, Head Start, food stamps, and Home Energy Assistance. You will see the FPL mentioned several times in explaining both Standard Medicaid and
Fact! Did you know… No matter how a child becomes eligible for Medicaid (SCHIP, waiver, SSI, TEFRA, or standard Medicaid), that child is also always eligible for EPSDT. There is no separate application or eligibility process.
SCHIP. The table below shows how gross monthly income translates into FPL guidelines for 2004 for all states and DC except Alaska and Hawaii.8
Chart 4. 2004 Federal Poverty Level Guidelines
Family size 2 3 4 5 6 7
Monthly income as percentage of Federal Poverty Level 100% $1,041 $1,306 $1,571 $1,836 $2,101 $2,366 133% $1,388 $1,741 $2,094 $2,448 $2,801 $3,154 150% $1,561 $1,959 $2,356 $2,754 $3,151 $3,549 185% $1,926 $2,416 $2,906 $3,396 $3,887 $4,377 200% $2,082 $2,612 $3,142 $3,672 $4,202 $4,732 300% $3,123 $3,918 $4,713 $5,508 $6,303 $7,098
Standard Medicaid Medicaid is a healthcare program for families and individuals with disabilities and/or low incomes. Under Medicaid, states must provide a basic benefits package to everyone who is eligible to participate. The program is run and paid for jointly by the states and the federal government. For low income children, eligibility for Medicaid is based on comparing the family’s income to the Federal Poverty Level (FPL). Under federal law, states are required to provide Medicaid to: Children birth through age 5 with household incomes up to 133% FPL; and Children ages 6 to 18 in households with incomes up to 100% FPL. These are the minimum requirements. Many states have adopted higher household income standards for Medicaid eligibility. On pages 23 and 24, Chart 5 shows specific eligibility standards for each state.
Alaska and Hawaii have higher FPL’s than the other states. To get the FPL for Alaska, multiply the monthly income amount in the chart by 1.25. To get the FPL for Hawaii, multiple the income amount by 1.15. EPSDT: Supporting Children with Disabilities Page 19
State Children’s Health Insurance Program (SCHIP) While Medicaid covers many of the lowest income children and families in our society, it does not cover many who still cannot afford traditional insurance. To permit states to cover children at higher income levels than Medicaid, Congress enacted the State Children’s Health Insurance Plan (SCHIP) legislation in 1997. Just as with Medicaid, states commit to spending their own dollars which are then “matched” by federal funds. Under SCHIP, states choose one of three options: expand their existing Medicaid program, design a separate SCHIP program, or combine the two approaches. Figure 3 shows the breakdown of types of SCHIP programs by state.
Figure 3. State SCHIP Options
SCHIP Status Medicaid Expansion Separate SCHIP Combination
Medicaid Expansion Programs States that decide to expand their existing Medicaid programs are required to provide the same Medicaid benefit package to new children under SCHIP. Since EPSDT is a required part of every Medicaid package, this means states that select this option extend Medicaid and EPSDT to a broader population of low-income children. Fourteen states and the District of Columbia currently operate SCHIP programs that are purely an expansion of the regular Medicaid package. Separate SCHIP Programs Separate SCHIP programs are more flexible in their design – these programs do not have to offer the entire Medicaid benefit package. Instead, states that elect this option offer a benefit package that meets a comprehensive set of criteria. In general, states with separate SCHIP programs provide some services that are a part of EPSDT, but have stricter limits on the types and amount of services that are allowed. For example, a state might only provide eight hours of personal care services (dressing, personal hygiene, behavioral aid, etc.) per month to SCHIP children, as opposed to having to cover all medically necessary personal care services for children in standard Medicaid. Sixteen states currently operate these more limited, separate SCHIP programs. Medicaid/SCHIP Combination Programs Finally, twenty states chose to combine the two strategies and provide some expanded coverage through the Medicaid plan, as well as additional coverage in a separate SCHIP plan. For instance, a state might expand Medicaid eligibility to children ages 0 – 5 up to 200% of the poverty level, but then have a separate SCHIP program for children 6 – 18 up to 200% of the poverty level.
Fact! Did you know… In some states, children in SCHIP are also eligible for EPSDT. If your state’s SCHIP program is a Medicaid expansion, EPSDT is available to all SCHIP children.
SCHIP/Medicaid Eligibility Examples Example 1 Eve and Mark Gilbert have three children, ages seven months, three, and six years. They live on the outskirts of Atlanta and have a household income of $27,000. Since this puts them at about 122% of the FPL, their two younger children are eligible for standard Medicaid and EPSDT. Example 2 James is a single father with two children, ages six and eleven. They live in Baton Rouge, Louisiana and have a household income of $31,000. For a family of three, this puts them at 198% of the FPL. It is too high to qualify for standard Medicaid, but it does make both children eligible for SCHIP. Since Louisiana has extended the Medicaid benefit package to SCHIP children, they are also eligible for EPSDT.
Medicaid/SCHIP Program Names When navigating the Medicaid/SCHIP system, be aware that your state may have one or more names for either Medicaid and/or SCHIP. These names can reflect different benefit packages, eligibility levels, and/or whether co-payments are required. For example, Arkansas operates ARKIDS A and ARKIDS B. ARKIDS A is the name of the basic Medicaid program, which covers the EPSDT benefit package and does not have any co-payments for enrolled families. ARKIDS B is the separate SCHIP program for families with higher incomes. It does require co-payments, and does not cover EPSDT as a benefit package (although it does cover many of the same services with some limits). Although they both are considered “Medicaid programs”, only ARKIDS A actually provides EPSDT. ARKIDS B offers many services that are also provided under EPSDT, but the entire scope of services is much more limited. It is not essential that you understand every intricate detail of the complicated maze of Medicaid/SCHIP eligibility, but it is important to know up to what point your state provides the Medicaid benefits package (and therefore, EPSDT). As you can see in Chart 5, household income limits vary considerably from state to state. In Vermont, children in a four person household can have an income as high as $56,556 can qualify. But in Virginia, financial eligibility for a family with four people could be no higher than $25,128.
Page 22 EPSDT: Supporting Children with Disabilities
Chart 5. EPSDT Eligibility through Medicaid/SCHIP9
Household income is no more than (% of FPL) State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maryland Maine Massachusetts Michigan Child less than 1 year old 133% 175% 140% 133% 200% 133% 185% 200% 133% 200% 185% 200% 150% 200% 150% 200% 150% 150% 200% 185% 200% 150% 185% Child 1-5 years old 133% 175% 133% 133% 133% 133% 185% 200% 133% 200% 10 133% 200% 150% 133% 150% 133% 133% 150% 200% 185% 200% 150% 150% Child 6–18 years old 100% 175% 100% 100% 100% 100% 185% 200% 100% 100% 100% 200% 150% 133% 150% 133% 100% 150% 200% 185% 200% 150% 150%
These limits are current as of December 2003. In Florida, eligibility for children ages 1-4 is 200%, and for age 5 is 133%.
Household income is no more than (% of FPL) State Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin12 Wyoming
Child less than 1 year old 280%11 133% 300% 133% 185% 133% 300% 185% 235% 200% 185% 133% 200% 185% none 185% 250% 185% 200% 185% 185% 133% 300% 133% 250% 133% 185% 133%
Child 1-5 years old 275% 133% 300% 133% 185% 133% 185% 133% 235% 133% 133% 133% 200% 185% none 133% 250% 150% 200% 133% 133% 133% 300% 133% 250% 100% 185% 133%
Child 6–18 years old 275% 100% 300% 100% 185% 100% 185% 133% 235% 133% 100% 100% 200% 185% none 100% 250% 150% 200% 100% 100% 100% 300% 133% 250% 100% 185% 100%
In Minnesota, eligibility for children under 2 is 280% FPL, and 275% for ages 2-5. Once on Medicaid, families may remain until household income exceeds 200% FPL.
Obtaining Medicaid Eligibility and Other Questions
Obtaining Medicaid eligibility via the “household income” pathway requires filling out an application. Exactly where to go to obtain and submit an application varies from state to state. The federal department of Health and Human Services has a centralized list of state eligibility and application procedures at www.insurekidsnow.gov. There you can get detailed information on how to submit a Medicaid application. Many states have expanded their Medicaid programs so that uninsured children can access health care benefits and services. Even if your family already has health care coverage, it still may make sense to obtain Medicaid for a child with a disability. Usually, Medicaid offers a wider range of services and benefits than your private health insurance plan may offer. If you have health insurance and your child qualifies for Medicaid, the state will seek payment from your health insurance first. If it does not cover the bill, then Medicaid will pay for the service. For children enrolled in standard Medicaid, there is no “premium” or copayment for any services. States are only permitted to charge co-payments or premiums for children in an SCHIP program (whether it is an expansion, separate, or combination plan). There are three paths to Medicaid eligibility based on a child’s income/disability: SSI TEFRA Home and Community Based Waivers SSI SSI, which stands for Supplemental Security Income, provides a monthly stipend to individuals who have a severe disability and who meet certain income and resource (property, assets, etc.) restrictions. Children under age 18 who are SSI recipients qualify for both Medicaid and the SSI program. Some states automatically enroll SSI recipients in Medicaid. In others, children have to go through a separate enrollment process. Eligibility for SSI hinges on a) the nature and severity of a child’s disability and b) in the case of children, the
financial situation of the family. To meet the Social Security Administration’s (SSA) disability definition, your child must have a physical or mental condition that: Results in severe functional limitations (see list of conditions at www.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm) Is expected to last at least 12 months or result in death When a family applies for SSI, the federal government gathers information from anyone that the parent lists as having relevant input about the child’s disability and the effects that the disability has on the child’s life. Parents should list as many people as possible, including physicians, school personnel/teachers, other family members, therapists, etc. Obtaining SSI also hinges on financial eligibility tests. In deciding financial eligibility for children and youth up to age 18, SSA looks at the family’s income and resources (assets)13. SSA employs a process called deeming to assign a portion of the family’s income to the child. The amount assigned to the child is then compared to the Federal Benefit Rate (FBR); in 2004, the FBR is $564. If the amount of income deemed available to the child is less than the FBR, the child is financially eligible for SSI. The deeming process is complicated. The calculations depend on the type of income the household receives, whether there are other children (with or without disabilities) in the household, and whether it is a single or two-parent household. As a result, it is not possible to provide a simple “rule of thumb” concerning the amount of household income that permits a child to qualify financially for SSI. We provide two simplified examples to illustrate the income deeming process.
After age 18, SSA only looks at the person’s own income – not the family’s – in determining financial eligibility for SSI. EPSDT: Supporting Children with Disabilities
SSI Eligibility Examples Example 1 Marco is a bright ten year-old with spina bifida who lives in San Diego with his parents and two younger sisters. His mother, Susana, stays at home to take care of Marco and his sisters; his father, Ricardo, earns $40,000 per year as the assistant manager of an office supply store. Based on their earned income for a two-parent family and the number of non-disabled children in the household (2), the SSA deems $476 of monthly income to Marco. This means that the family is eligible for a monthly SSI check of about $88. In addition, Marco is eligible to receive Medicaid. Example 2 Fifteen year-old Leah lives with her mom and younger brother in a small town in northern Wisconsin. Leah has Down Syndrome and is a freshman at her local high school where she is enrolled in a special education class with other students with cognitive disabilities. Leah's mother, Kristin, earns $9.25/hour as a classroom aide. Based on the family's earned income for a single parent family and having one non-disabled child in the household, the SSA deems $34 of monthly income to Leah. This means that the family is eligible for a monthly SSI check of approximately $530. Leah is also eligible for Wisconsin's Medicaid program.
In addition to household income, SSA also looks at household resources (for example, money in a savings account). Certain resources, including a family’s home, are not counted toward this amount. There is a process for deeming some resources to the child. As long as the amount deemed available to the child is less than $2,000, the child can qualify for SSI. Even if families are doubtful as to their child’s financial eligibility, they are advised to apply, and in some cases, reapply. SSI cases are often turned down the first time only to be accepted after reapplication. A self-screening tool (not an application) is available online to help you assess whether your child might be eligible for SSI. It can be found at www.best.ssa.gov. To apply for SSI, call the Social Security Administration at 1-800-772-1213.
It is not uncommon that a child might qualify for Medicaid under both “standard” Medicaid and through SSI. If the child qualifies for SSI, then there will also be a benefit payment made in addition to Medicaid services. If the child does not qualify for SSI because of household income and your state does not offer the other paths described below, then it may be possible to obtain Medicaid based on household income, depending on your state. TEFRA (otherwise known as the Katie Beckett option) Eligibility for standard Medicaid and SCHIP are based on household income levels. Some states allow children whose household incomes cause them to be ineligible for SSI to still qualify for Medicaid (and therefore, EPSDT). States have the option of offering Medicaid eligibility to children with severe disabilities who do not qualify for SSI because of household income. This option is called TEFRA (for the Tax Equity and Fiscal Responsibility Act of 1982), or the “Katie Beckett” option. This provision was named for a girl with severe disabilities whose parents petitioned President Reagan in the early 1980’s to pay for their daughter’s health care to be provided at home under Medicaid. It is sometimes mistakenly referred to as a waiver. However, this is not correct – TEFRA/Katie Beckett is a Medicaid eligibility option that does not require special permissions in the same way as a waiver (see discussion of Home and Community Based waivers later).
Fact! Did you know… Even if your family income is too high for your child to qualify for Medicaid or SCHIP, there are other ways that he/she could receive EPSDT benefits. If your state participates in TEFRA, it can ignore parental income when figuring out Medicaid eligibility for a child. Even if your state doesn’t have TEFRA, your child still might qualify through a Medicaid Home and Community Based Waiver.
Under TEFRA, states can choose to ignore parental income when determining Medicaid eligibility. This allows children with severe disabilities who do not receive SSI to receive the full range of Medicaid services at home. Before Katie Beckett, children whose families made too much money to qualify for Medicaid
would have to place their child in a hospital or institution in order to be eligible for Medicaid14. In order to be considered eligible for Katie Beckett, a child must have a disability; be under the age of 21; require a level of care given in hospitals, nursing facilities, or ICF/MR; need care that is medically appropriate to be provided in the home; and receive care whose estimated cost does not exceed what it would be in a residential facility.
TEFRA/Katie Beckett Example Ashley is a fourteen year-old girl who lives at home with her mom in Charleston, South Carolina. Ashley has a Traumatic Brain Injury (TBI) as a result of a car accident several years ago that requires a high level of constant care. Ashley’s mom makes about $2,800 per month (about 269% FPL) which is too much for Ashley to qualify for South Carolina’s Medicaid program. But Ashley’s health care needs are too much for her mom to afford. Because South Carolina has TEFRA, it can look only at Ashley’s income when determining her Medicaid eligibility. Since she doesn’t have any income, she is eligible for Medicaid, and can live at home and receive private duty nursing, personal care, and the other services that she needs.
States sometimes have differences as to what qualifies as an eligible disability, but typically eligible disabilities include cerebral palsy, serious emotional disturbance, and Down Syndrome with severe cognitive/behavioral impairments. The table below shows the states that offer TEFRA for children with disabilities.
When a child is placed in an institution, a family’s income is not considered when determining Medicaid eligibility. EPSDT: Supporting Children with Disabilities Page 29
Chart 6. TEFRA States Alaska Arkansas Delaware District of Columbia Georgia Idaho Maine Massachusetts Michigan Minnesota Mississippi Nevada New Hampshire Rhode Island South Carolina South Dakota Vermont Wisconsin West Virginia
Because the TEFRA/Katie Beckett option permits ignoring family income altogether, it is a very powerful tool for providing access to EPSDT for children with severe disabilities. Home and Community Based Services Waivers Only a little more than one-third of states have the TEFRA/Katie Beckett option. Other states have decided not to use the option because they are concerned with how much it might cost. Another way that states can make children with severe disabilities eligible for Medicaid who do not qualify for SSI is to serve them in a Home and Community-Based Services (HCBS) waiver program. Under a waiver program, a state can ignore household income in offering services to children with severe disabilities. The difference is that, in a waiver program, a state can limit the number of people served. (Using the TEFRA option means that a state must provide Medicaid to all children who qualify.) States use HCBS waivers to provide certain services in a home or community setting to people who would otherwise need care in an institutional setting (hospital, nursing facility, or ICF/MR). Children who are covered under HCBS waivers are entitled to the normal set of Medicaid services, including EPSDT. Waivers can also provide services above and beyond what is allowable under
EPSDT. For instance, respite care or environmental/home modifications may be available under an HCBS waiver, although these are not permitted under EPSDT. Some states have HCBS waiver programs that target only children with disabilities. These include Louisiana, Nebraska, Oklahoma and Wyoming, among others. In other states, waiver programs serve people with developmental and/or other disabilities of all ages. In total, 47 states operate HCBS waivers for people with disabilities that include services for children. For family-friendly information about HCBS waivers (and other Medicaid information), visit: www.geocities.com/HotSprings/Villa/1029/medicaid.html. Relationship between TEFRA and HCBS Waivers For children with disabilities, the idea behind HCBS waivers is very similar to that of TEFRA. However, some very important differences exist. States who choose TEFRA must offer it to anyone who meets the eligibility criteria. However, HCBS waivers allow them to cap their enrollment and impose additional eligibility limits (e.g., children with autism, those who live in a certain part of the state). Both TEFRA and HCBS waivers provide EPSDT, but the entire benefit package under a waiver is often more generous than that under TEFRA. See Chart 7 on the following page for a comparison of TEFRA and HCBS waivers Waiver Services for Children with Autism Earlier, we mentioned that behavioral therapies for children with autism are generally covered by EPSDT, but that some controversy does exist over whether or not these types of services are truly allowable under EPSDT. In order to provide an additional set of services for this population, several states have designed waivers to better serve children with autism, either through a specific autism waiver or a developmental disabilities waiver that includes services for people with autism. States that have utilized one of these options include Indiana, Maryland, Maine, Minnesota, Missouri, and Wisconsin.
Chart 7. TEFRA and HCBS Comparison TEFRA What is it? A regular Medicaid option that states can choose without getting “special permission” from the federal government. It allows states to cover children under Medicaid without considering their parents’ income. In states that have chosen TEFRA, any child under 21 is eligible who: - has a disability - requires ongoing care that is normally provided in a hospital, nursing facility or ICF/MR - meets the cost test (estimated cost of care in the home cannot be more than the cost of care in an institution) States cannot “cap” the number of children who enter the program. Anyone who meets the criteria is eligible. What are the benefits? Standard Medicaid benefit package, including EPSDT HCBS Waivers A way that states can extend Medicaid coverage in a targeted way to certain groups of people. Waivers are distinct from a state’s regular Medicaid program, and require separate approval from the federal government. States have flexibility in setting their own eligibility requirements, depending on the purpose of the waiver. Recipients must: - require ongoing care that is normally provided in a hospital, nursing facility or ICF/MR - meet the cost test specified in the waiver program (varies by waiver) States are allowed to cap the program at a certain number of recipients. Other eligibility often depends on having a specific disability (e.g. mental illness). Standard Medicaid benefit package, including EPSDT Other services may be included (home modifications, respite care, disability-specific services)
Medicaid and Immigration
So far, we’ve discussed EPSDT eligibility in terms of income and level of disability. Medicaid does have certain rules, though, around eligibility for immigrants and their children. While not the focus of this booklet, we do want to briefly outline the Medicaid eligibility rules around immigration. For more detailed information on this topic, see the Families USA explanation at www.familiesusa.org/site/DocServer/immigrants.pdf?docid=365. When Congress enacted welfare reform with Temporary Assistance for Needy Families (TANF) in 1996, it also made it more difficult for non-United States citizens to access many public aid programs, including Medicaid. Many of the current eligibility rules, therefore, revolve around the date that TANF went into effect in 1996. Assuming all other eligibility guidelines are met, legal immigrants are eligible for SCHIP or Medicaid if they arrived in the U.S. before August 22, 1996.15
Fact! Did you know… Children who were born in the U.S. but whose parents are non-citizens can still be eligible for Medicaid/EPSDT.
However, for those legal immigrants who arrived on or after August 22, 1996, Medicaid cannot be provided for five years from the date of their entry. There is an exception for refugees who have been granted asylum, who can be eligible for Medicaid/SCHIP. There are also other exceptions for adults which we don’t discuss here, but can be found at the National Immigration Law Center site (www.nilc.org/immspbs/health/index.htm). U.S.-Born Children with Immigrant Parents Children born in the U.S. whose parents are not citizens are still eligible for EPSDT if they meet the regular eligibility requirements. For families in this situation, though, there might be some concern about what kinds of information might be collected during the eligibility determination process.
All states except Wyoming have elected to extend eligibility for standard Medicaid. For SCHIP, all states are required to allow immigrants entering before August 22, 1996 to apply. EPSDT: Supporting Children with Disabilities Page 33
Non-citizen parents who apply on behalf of their children should know the following: Medicaid does not share any information provided by applicants with the INS (although this is not necessarily true for other public aid programs such as food stamps). Parents are NOT required to provide documentation of their citizen status when applying for Medicaid for their children. Parents do NOT have to provide their own social security number if applying for their child. Parents WILL need to provide a social security number for their child when completing a Medicaid application.
What if I’m Denied? Grievances and Appeals
Problems and complaints can come up when you have to deal with health insurance coverage, especially if your child has specialized health care needs. These could include billing issues, trouble finding an appropriate provider/doctor, or communication issues. Or a service might be denied that you feel is very important for your child. It’s important to understand the proper procedure to follow in the case of a denial or other complaint. There are a few informal steps you can take before getting into a formal complaint process. If you have general questions or concerns, the first place to start is with your child’s primary care physician (PCP) or other health care provider (physical therapist, counselor, etc.). If you’ve spoken to your PCP and are still not satisfied, you may want to contact your HMO (or state Medicaid agency if you’re not in managed care). To do this, call the toll-free number in your member handbook and be specific about why you are dissatisfied. The solution may be very easy to implement. If these informal approaches are not successful, you can move into a formal grievance process. How this process works depends on whether your child is in a managed care or fee-for-service plan.
Managed Care If your child is enrolled in a managed care plan, your HMO must have an official internal grievance process that outlines the steps you need to follow to file a complaint, the timelines involved, and the responsibilities of the HMO throughout the process. You can use this process either to file a general complaint, or to appeal a denial of services. To get information on your plan’s process: You can call your HMO directly by using the member services phone number listed in your handbook; or If your child has had a service denied, you will receive written notification of the HMO’s internal process at the time you receive the denial. This internal process will generally involve you detailing your complaint in writing and sending it to your HMO. They will then have a certain number of days to review your complaint and make a decision about what the outcome will be. Fair Hearing Process If you are not satisfied with the result of your HMO’s internal grievance process, or if your child is enrolled in a fee-for-service plan, you can take your complaint/appeal through a fair hearing process. Federal law requires that all Medicaid participants have access to a fair hearing process to protect services being cut, reduced, or denied. Components of the fair hearing process include: A written letter from the Medicaid agency/HMO notifying you if it is going to deny, reduce, or cut a service. This is in addition to any telephone or other notification you receive. For service reductions/cuts, the letter must arrive at least 10 days before the change takes place. For denials of new services, the letter must arrive within 30 days of when prior authorization for the service was requested. If the written denial is not sent within 30 days, the request for prior authorization is automatically approved by default. The letter must include instructions on how to appeal the denial/service change.
EPSDT: Supporting Children with Disabilities Page 35
While you are appealing a reduction or cut in services, those services must continue until the appeal has been resolved. To appeal the denial, you must respond to the Medicaid agency in writing (usually within 30 days of receiving the written denial). This will trigger an administrative hearing, at which both you and the Medicaid agency can present your arguments. These hearings generally do not involve lawyers or other counsel. For more information on appealing Medicaid decisions, please see www.protectionandadvocacy.com/grievfst.htm. Otologic Reimbursement Management also maintains a consumer-friendly page about appealing Medicaid denials for cochlear implants, which also pertains to other services. You can find this at www.cochlearimplant.org/sys-tmpl/medicaidappeals/. Other Grievance Resources Your state might also have a program to assist people with Medicaid complaints – this is sometimes called an ombudsman. Your state Protection and Advocacy (P&A) organization is a good source of information on what additional grievance resources are available to you. You can locate your P&A at www.nls.com/paatstat.htm.
EPSDT Example Samuel is a 9-year old boy with severe cerebral palsy. Due to his disability, he receives SSI and therefore is eligible for Medicaid. Samuel receives several services through EPSDT in a variety of settings. His motorized wheelchair, eyeglasses, and communication board are all covered by EPSDT. In addition, Samuel has a bus assistant to aid him in getting to and from school each day. Samuel’s school is a participating Medicaid provider, and so many of the services on his IEP are covered by EPSDT. These include two hours per week of speech and language therapy, three hours per week of physical therapy, and an aide that he shares with one other child to assist in normal daily activities. Samuel also receives 8 hours of personal care per week in his home that is provided by direct care staff from a local service provider.
This booklet has now given you the basic tools to being a more effective advocate for your child around EPSDT. You have been introduced to the many ways it can support your child’s needs, the important pathways to Medicaid/EPSDT eligibility, the potential pitfalls and issues that you may encounter, and some possible solutions. Having this foundation is an important first step. We’ve presented you with lots of information that will be much more useful to you once you know what your state’s specific policies and procedures are. While we have included some state-specific information around eligibility, it’s up to you to become even more familiar with how your state handles EPSDT. To assist you further, we’ve included a list of resources that may be useful (see Appendix B). Some of the links listed provide information on EPSDT that applies to all states, while others are resources for specific state policies. If your state is not listed, you can call the EPSDT coordinator listed in the first link. As you learn more about your state’s EPSDT program, you will not only be a better advocate for your child, but can also become a great resource for other parents of children with special needs.
Appendix A Michigan Age Periodicity Schedule
Michigan Age Periodicity Scale
Infancy Age By 1 mo. History Immunization Review Initial/Interval Measurements Blood pressure Head circumference Height and weight Sensory Screening Hearing Vision Development Assessment Inspections Dental inspection Physical exam Procedures Anticipatory guidance Blood lead High risk Low risk Hematocrit or Hemoglobin Interpretive Conference Nutritional Assessment Sickle Cell (1st visit) Tuberculin (TB) test High risk Low risk Urine test ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
2 mo 4 mo 6 mo 9 mo 12 mo 15 mo
18 mo 24 mo 3 yr 4 yr
● = to be performed = test high-risk children = at least EPSDT: Supportingperformed during the indicated time period one test must be Children with Disabilities
Late Childhood Age History Immunization Review Initial/Interval Measurements Blood pressure Head circumference Height and weight Sensory Screening Hearing Vision Development Assessment Inspections Dental inspection Physical exam Procedures Anticipatory guidance Blood lead High risk Low risk Hematocrit or Hemoglobin Interpretive Conference Nutritional Assessment Sickle Cell (1st visit) Tuberculin (TB) test High risk Low risk Urine test ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
5 yr 6 yr 8 yr 10 yr 12 yr 14 yr
16 yr 18 yr 20+ yr
● = to be performed = test high risk children = at least one test must be performed during the indicated time period
List of State EPSDT Coordinators www.bmcc.org/Headstart/EPSDT/appendix-b.htm Children’s Health Matters: State Profiles of Children’s Medicaid Programs http://www.childrenshealthmatters.org/stateprofiles/ Family Voices Alphabet Soup Guide for Children with Special Health Care Needs http://www.familyvoices.org/Information/definitions.htm Accessing Parent Groups for Parents of Special Needs Children www.nichcy.org/pubs/parent/pa10txt.htm New Visions: A Parent’s Guide to Understanding Developmental Assessment http://www.zerotothree.org/visions.html Links and Resources for Families of Young Children with Disabilities www.uvm.edu/~cdci/pedilinks/obstetricians/resdisability.htm
Arkansas Arkansas EPSDT Information (Upper Arkansas Area Council of Governments) www.uaacog.com/epsdt.htm Using EPSDT to get Durable Medical Equipment in Arkansas www.arkansas-ican.org/txt/dme_brochure.htm Alabama Alabama Medicaid Information www.medicaid.state.al.us/ABOUT/index.htm
Alaska Guide to Medicaid www.hss.state.ak.us/dhcs/PDF/2000version.pdf
Arkansas Medicaid Benefits (ARKids) www.arkidsfirst.com/bene.htm Arkansas Letter to Providers on how to Prescribe EPSDT Treatment http://www.medicaid.state.ar.us/provider/amprcd/searcharea/Officia lNotices/DMS-02-W-6.pdf
California Health Consumer Alliance – Resources for Advocates www.healthconsumer.org/advocates.html
Connecticut Husky Health Benefits www.huskyhealth.com/benefits.htm Connecticut Health Policy Project: Husky Info www.cthealthpolicy.org/husky/default.htm
Idaho Guide to Medical Assistance www2.state.id.us/dhw/medicaid/what_is_medicaid_english.pdf
Indiana Guide to Hoosier Healthwise (Medicaid for Kids/Families) www.state.in.us/fssa/hoosier_healthwise/whatis.html Guide to Indiana Waivers (including autism waiver) www.iidc.indiana.edu/irca/ServArticles/waivers.html
Iowa EPSDT Care for Kids Newsletter Home www.medicine.uiowa.edu/uhs/EPSDT/index.cfm
Kansas Guide to EPSDT (KAN Be Healthy) https://www.kmap-stateks.us/Public/Kan%20Be%20Healthy%20Main.asp
Maine Guide to EPSDT www.state.me.us/dhs/bfi/mainecare/Early%20and%20Periodic%20S creening%20Diagnosis%20and%20Treatment.htm
Family Networks Mental Health Guide to Maryland EPSDT/Medicaid family-networks.org/epsdt.cfm Maryland Autism Waiver www.mdlcbalto.org/pdfs/autismguide10-02.pdf
Michigan Council for Maternal and Child Health EPSDT page www.mcmch.org/epsdt.htm
Montana EPSDT Provider Rules http://www.dphhs.state.mt.us/legal_section/montana_administrative _register/adoption_notices/37_276.pdf
List of North Dakota Health Tracks Screening Sites www.health.state.nd.us/ndhd/prevent/mch/hlthtrck.htm
Pennsylvania Children’s Checkup (EPSDT) Program www.dpw.state.pa.us/omap/recinf/omapepsdtchild.asp
South Dakota Health Kids Klub Screening Schedule www.state.sd.us/social/medical/Recipient/KidsKlub/Looks.htm
TennCare EPSDT page www.state.tn.us/tenncare/CaringforKids.html
Guide to Texas Health Steps (EPSDT) http://thsteps.org/index.htm Texas Medicaid Appeals Information www.hhsc.state.tx.us/HCF/med_apls/MedAppl_home.html
Utah CHEC Information health.utah.gov/medicaid/html/chec.html
Parent to Parent of Vermont EPSDT Guide www.partoparvt.org/SixWays.html
A Guide to Medicaid Managed Care and EPSDT (HealthCheck) www.legalaction.org/gmed1.htm
Documents Similar To How EPSDT is supposed to help your childSkip carouselEPSDT From a Parents' StandpointRuleSocial SecurityJoe D. Romero and Virginia Romero v. Patricia Harris, Secretary of Health, Education & Welfare, 675 F.2d 1100, 10th Cir. (1982)Proposed RuleCalley Votessample_Initial_Report.docSocial SecurityProposed Rule4 25 12 Feinwachs TestimonyELAINE CLARK RAYMOND GIANGRASSO TONY GONZALES JOHNNY L. Heather Man MONELL WHITE Individually on Behalf of Themselves and on Behalf of All Similarly Situated MvA Just Other People 100319 Clark Opinion2010ZZ 00000 R001115 OPM Acting Secretary Sisco TMY006 Philippine Health Care Providers v CIRState Premium TaxTexas Transition Plan Narrative 4 16 12NoticeAAPS News March 1971 - Stopping Nixon's HMOsImpact summary of 40 Kentucky counties without hospitalsImpact summary of 80 Kentucky counties with hospitals14s5Kaiser Report Hcbs Waivers 1209Trends Aswer 225 Big Effects ObamacareMedicare Appeal Form Cms20027Insurance AssignmentHOUSE HEARING, 113TH CONGRESS - OBAMACARE IMPLEMENTATION PROBLEMSICO FAQcopy of kr-insurance comparison chart (2)NoticeConsumer Notice HMODocuments About Supplemental Security IncomeSkip carouselMeasuring Social ProtectionCity Limits Magazine, August/September 1996 IssueSSISullivan v. Zebley, 493 U.S. 521 (1990)HOUSE HEARING, 111TH CONGRESS - ELIMINATING THE SOCIAL SECURITY DISABILITY BACKLOGMedicaid Expansion for Employed Persons With DisabilitiesDuke-Energy-Carolinas,-LLC-Residential-ServiceMaintaining and Strengthening Supplemental Security Income for Children with DisabilitiesDuke-Energy-Carolinas,-LLC-Residential-Service6173_1975-1979Asset Limits Are a Barrier to Economic Security and Mobility61977_2005-2009Duke-Energy-Carolinas,-LLC-Residential-ServiceDuke-Energy-Carolinas,-LLC-Residential-ServiceCalifano v. Torres, 435 U.S. 1 (1978)Schweiker v. Wilson, 450 U.S. 221 (1981)Woodlee v. Barnhart, 10th Cir. (2005)Smith v. Barnhart, 10th Cir. (2006)Puente v. Chater, 10th Cir. (1997)Valdez v. Barnhart, 10th Cir. (2006)Maynard v. Barnhart, 10th Cir. (2007)Lane v. Colvin, 10th Cir. (2016)Klitz v. Barnhart, 10th Cir. (2006)Lisa L. Cooper v. Commissioner of Social Security, 11th Cir. (2013)Scott v. Commissioner of Social Security, 11th Cir. (2011)Robert Cain v. Otis R. Bowen, Secretary of Health and Human Services, 846 F.2d 698, 11th Cir. (1988)Donnell Mitchell v. Commissioner, Social Security Administration, 11th Cir. (2014)Ruth Friedman v. Stephen Berger, Individually and as Commissioner of the New York State Department of Social Services, 547 F.2d 724, 2d Cir. (1976)Milagros Chaluisan v. Commissioner Social Security, 3rd Cir. (2012)Brad Nichols v. Comm Social Security, 3rd Cir. (2010)More From Disability MomSkip carouselMedicaid Coverage for Children on the Austism SpectrumPNRs Faxed 042312S2009 to 2011 Medicaid Membership in for-profitsDHS Technical Guidance Appeals_srg_06222011HelleinWellcareComplaintpdfJune 2009 and Nov 2010 Corporate Results Sheet146 Company Comparisons Annual6 Company Comparisons AnnualQexa Prior Notification Request Form FillableChanges to Medicaid's 1915(i) Option for Home- And Community-Based Care1915i HCBS Fact Sheet 2010Florida recovers $27 million in Medicaid fraud settlement – Vital Signs Health Blog – Orlando SentinelSummary of Fl Over Payments to Amerigroup WellcareHMOs Dispute $34M in State Fines - Sun SentinelCrowell & Moring Managed Care Lawsuit Watch - September 2008Taxpayers Against Fraud False Claims Acts Up to 120810OIG 2011 Medicare/Medicaid Fraud Fighting PlanApril 30 2010 Fed Register Cms 42cfr Part 440 Incl EpsdtDecember 2010 Court Order WellCareHealthPlansInc-1October 2010 Urban Institute Report on Uninsured KidsDec 2009 Progress of Enrolling in MedicaidUrban Institute July 2010 PPACA Affect Children42cfr 440.345 EPSDT RequirementJulie Prescription for Extension Tubes 100109Letter for Out of State TravelSample doctor letter for out of state specialist treatmentLetter of medical necessity for skilled nursingLetter of medical necessity for various therapiesKoh Letters for Hannah Nursing Therapies Trainer 1