EPSDT and the Providers Role

1. EPSDT and the Providers Role Presented by Care Connection for Children A program of CHKD Fall 2009

2. What is EPSDTEarly, Periodic, Screening, Diagnosis and Treatment • A program of Medicaid that provides medically necessary health care services to correct or improve physical and mental health conditions for children and youth , enrolled in Medicaid (FAMIS Plus), under the age of 21

3. Goals of EPSDT • Diagnose health and developmental concerns early • Treat before problems become more complex • Assure treatment is medically justified

4. Lead Testing Policy Reimbursement for Developmental, Hearing and Vision Screening using standardized screening tools DMAS Approved Developmental Screening Tools Memo Date: 3/24/2006 Memo Date 8/23/2007 Memo Date 2/10/2009 EPSDT Traditional Services Recent Policy Improvements

5. How does it work? • Periodic screenings are provided by physicians or nurse practitioners based on the AAP and Bright Futures periodicty schedule • Problem focused assessments that can occur because of illness or change in condition • Screenings can be requested by caregiver, or professionals working with the child/youth

6. Components of a screening • Comprehensive, unclothed exam • Medical History • Developmental screening • Lab services( MANDATORY lead test 12 and 24 months) • Immunizations • Dental referral • Anticipatory Guidance and counseling • Referrals for medically necessary treatment • Documentation of the above

7. EPSDT Treatment Services • Provider orders services or makes referrals based on medical need identified in screening • Treatments that are experimental or investigational are not covered Examples: • EPSDT covers ”specialized services” not routinely covered through VA Medicaid Examples: Assistive technology, personal care, private duty nursing, hearing aids, medical formulas and supplements, residential TX services

8. How to initiate Specialized Treatment services? • Identify a need for a specific medically necessary Medicaid covered service during a health screening • Identify the treatment or service medically necessary to correct the medical condition, make it better, or prevent the child’s health status from worsening

9. What does the PCP do next? • Complete the DMAS-355 EPSDT Specialized Services Treatment Referral Information Form • Fax the completed form to DMAS/Maternal and Child Health Division Fax: (804)225-3961 • DMAS will notify you of additional requirements needed

10. EPSDT and Early Intervention • DMAS will unveil a brand new Early Intervention program beginning October 1, 2009 • The new model will reimburse for natural environment treatment • EI Services will be covered by Managed Care Organizations and DMAS Fee For Service providers • MCO integration with Early Intervention reimbursement is rare among Medicaid programs • MD Administered Developmental Screening tools such as the Ages and Stages will eventually be used by local EI programs to more efficiently determine eligibility for EI • Universal Referral form was created to allow EI agencies and MD practices to communicate within FERPA and HIPAA laws

11. EPSDT and Medical Home Coding • DMAS reimburses for a wide variety of services • Reimbursement for Medical Home services to manage complex health conditions is available through Virginia’s Medicaid program • Refer to the attached handout for examples of DMAS covered Medical Home CPT codes

12. Contacts Brian Campbell, EPSDT Services Supervisor (804) 786-0342 brian.campbell@dmas.virginia.gov Shirlene Harris, EPSDT Preauthorization Coordinator (804) 225-3124 shirlene.harris@dmas.virginia.gov Anne Young, EPSDT Preauthorization Coordinator Nursing (804) 371-2635 anne.young@dmas.virginia.gov EPSDT fax (804) 612-0043 or (804) 225- 3961 Email epsdt@dmas.virginia.gov www.dmas.virginia.gov/ch-home.htm