EPSDT Specialized Services The DMAS “ Safety Net ”

1. EPSDTSpecialized ServicesThe DMAS “Safety Net” Virginia Department of Medical Assistance Services (DMAS) Fall 2010

2. Medicaid/FAMIS Plus • EPSDT is the benefit package for Medicaid/FAMIS Plus enrollees under 21 years of age. EPSDT is available to all FAMIS Plus enrollees under the age of 21 enrolled in Managed Care Organizations, MEDALLION, or Fee-for-Service (FFS) Medicaid.

3. EPSDT Benefits in Fee-for-Service and MCO Programs • The fundamental preventive services such as well child visits, vaccines, developmental, hearing and vision screenings should be the same and do not require prior authorization to the FAMIS PLUS members • The EPSDT benefit is the same in scope in the MCO network and the FFS network. • Each MCO is required to provide the same set of services • Operational processes may differ among the systems for accessing treatment services. • Some treatment services are “carved out” and are provided through the FFS system for all members

4. FAMIS MCO Benefits • Children who are eligible for the FAMIS program must enroll with a Managed Care Organization (MCO) when available in their area. • FAMIS members receive well child visits and a full scope of healthcare benefits, they are not eligible for certain EPSDT treatment services. • EX: Personal Care and Residential Treatment are not available to FAMIS members, the “correct and ameliorate” consideration is not required during clinical reviews for FAMIS MCO members

5. FAMIS FFS • FAMIS FFS is available only when there is no MCO available in their geographic area. • The EPSDT treatment benefit is available to FAMIS Fee-for-Service enrollees • FAMIS FFS members may not receive psychiatric Residential Treatment or services from a freestanding psychiatric facility

6. Website Tips Find Provider Manuals and Memos Here Program information on many programs, this points to Maternal and Child Health which houses EPSDT

7. Find Manuals Helpful Hint: • Chapter 2 is always • Provider requirements/enrollment criteria • Chapter 4 is always • Covered Services

8. What Does Medicaid Cover? • Medicaid offers a comprehensive array of service options for enrollees under the age of 21 • Service packages can be designed to provide wrap around benefits tailored to the persons health and chronic care needs • It is best to review covered services according to the needs of the enrollee

9. Medicaid Covered ServicesExamples Children with Special Health Care Needs Durable Medical Equipment Rehabilitation Pharmacy Long Term Care Waiver Services EPSDT

10. Medicaid Covered ServicesExamples • Children with Substance Abuse and Behavioral Disorders • Psychiatric • Community Mental Health Rehabilitation • Hospital • Pharmacy • Children’s Mental Health Program • EPSDT

11. What is EPSDT? • Medicaid’s program for children up to the age of 21 with a preventive treatment approach • Diagnostic and screening services are the backbone of the program • The “correct and ameliorative” aspects of the program are included in many of the services that DMAS provides for children

12. 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

13. 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

14. Individualized Clinical Reviews • Treatment is considered for medical necessity in how that service may effectively treat/ameliorate the targeted health or mental health condition • Individualized clinical review must consider: • “That treatment, for that child, for that condition” • This process must be completed before any service is denied for children enrolled in FAMIS Plus/Medicaid

15. Safety Net Function • EPSDT covers treatments that are: • Not available to certain disability groups • Not covered by Medicaid Examples: • Eating Disorders Treatment • Residential Substance Abuse Treatment • In Home Behavioral Treatments for children with DD/MR (not in a waiver) • ABA

16. Specialized Services • The following Services are covered only under EPSDT • All Require pre authorization at DMAS • Hearing Aids • Inpatient Treatment • Specialized Residential Treatment • (MCO Exclusion, request services at KePRO/DMAS) • Substance Abuse Residential Treatment • (MCO Exclusion, request services at KePRO/DMAS) • Personal Care • (MCO Carve out, request services at DMAS) • Private Duty Nursing • Assistive Technology • Behavioral Treatment

17. What is Not Covered? • Services must be deemed as medically necessary • Ex: Personal care would be medically necessary if a child meets the EPSDT personal care criteria • Certain services may not be covered by EPSDT • Respite • Environmental Modifications • Vocational • Educational

18. Specific Program GuidelinesPlease refer to the EPSDT Program manuals and fact sheets for more information about these services

19. New Program Development • Current policy development is geared toward a variety of treatment services in the “home” setting and in facilities • CMS calls this Behavioral Rehabilitation • The claims system has already been designed to handle new program developments

20. http://dmasva.dmas.virginia.gov/Content_pgs/mch-home.aspx Find EPSDT forms Here Find EPSDT Program Info Here

21. Assistive Technology

22. AT Coverage • Assistive Technology is a covered service in both the FFS and MCO networks • Some Waivers provide Assistive Technology

23. AT Definition • Assistive Technology is defined as specialized medical equipment, supplies, devices, controls, and appliances not available under the Virginia State Plan for Medical Assistance. • Assistive Technology items directly enable individuals to increase their abilities to perform ADLs or to perceive, control, or communicate with the environment in which they live. Assistive Technology items are expected to be portable.

24. AT Items • Only Assistive Technology items that are determined to be medically necessary may be covered for reimbursement by DMAS. The following criteria must be satisfied through the submission of adequate and verifiable documentation satisfactory to DMAS.

25. AT Criteria • A reasonable and medically necessary part of a treatment plan; • Consistent with the recipient’s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the recipient; • Not furnished solely for the convenience of the family, attending physician, or other practitioner or supplier; • Consistent with generally accepted professional medical standards (i.e., not experimental or investigational); and • Provided at a safe, effective, and cost-effective level that is suitable for use by the enrollee.

26. AT Limitations • Assistive Technology must involve direct patient care • AT must be for the express purpose of diagnosing, treating or preventing (or minimizing the adverse effects of) illness, injury or other impairments to an individual’s physical or mental health. • AT Services that do not involve direct patient care or environmental services dealing exclusively with an individual’s surroundings rather than the individual are not covered. • Environmental Modifications are not covered

27. AT Paper Trail Medical documentation must provide DMAS with a clear understanding of the recipient’s needs. • The medical need for the requested Assistive Technology; • The diagnosis related to the reason for the Assistive Technology request; • The individual’s functional limitation and its relationship to the requested Assistive Technology item; • How the Assistive Technology item will treat the individual’s medical condition; • The quantity needed and the medical reason the requested amount is needed; • The frequency of use; • The estimated length of use of the item;

28. AT Paper Trail (continued) • Any conjunctive treatment related to the use of the item; • How the needs were previously met identifying changes that have occurred which necessitate the Assistive Technology request; • Other alternatives tried or explored and a description of the success or failure of these alternatives; • How the Assistive Technology item is required in the individual’s home or community environment; and • The individual’s or caregiver’s ability, willingness, and motivation to use the Assistive Technology item.

29. Hearing/Audiology Services

30. Covered Hearing Services • Analog and digital hearing aids are covered • FM amplification systems are covered as necessary to aid language development • Cochlear implants are covered for all ages • New Hearing Program • Began January 1, 2008 • For more information refer to the DMAS Audiology and Hearing Aid manual

31. Personal Care

32. Personal Care Criteria • ADL dependency in three areas is mandatory to require personal care • Care need is not solely due to normal developmental milestones

33. Personal Care • Developmentally appropriate Consumer-Directed and Agency-Directed Personal Care • EPSDT Personal Care provides care such as: dressing, eating, bathing, etc. . • Primary Target group: Waiver waitlists

34. EPSDT Nursing

35. EPSDT Nursing Coverage • EPSDT Nursing is a covered service in both the FFS and MCO networks • Technology Assisted Waiver referrals may be made for some EPSDT nursing cases

36. EPSDT Nursing Definition • EPSDT nursing is medically necessary private duty nursing care. • EPSDT nursing differs from both skilled nursing and home health nursing because the nursing is provided continuously as opposed to the intermittent care provided under either skilled nursing or home health nursing services.

37. Nursing and Waiver Enrollees • If the enrollee’s waiver does not offer private duty nursing then EPSDT can provide nursing to the child to help manage chronic nursing care needs • If the child’s primary service need is nursing care then the EDCD waiver may not meet the child’s needs absent EPSDT coverage

38. Nursing and Waiver Enrollees Waiver enrollees must use waiver services each month to keep their waiver eligibility • If in the EDCD waiver the child should use a waiver service on a regular basis • If waiver enrollees lose their waiver they may lose their Medicaid coverage

39. Nursing for Individuals in Managed Care Organizations • MCO Addresses and Telephone Numbers can be found on the DMAS website at: http://www.dmas.virginia.gov/downloads/pdfs/mc-medicaid_MCO_Addr_Tel.pdf

40. DMAS Nursing Scores The levels of EPSDT nursing care are defined as: A Score (1-6) points Maximum nursing (Individual Consideration) B Score (7-22) points Maximum nursing 8 hrs / day C Score (23-36) points Maximum nursing 12 hrs / day D Score (37-49) points Maximum nursing 16 hrs / day  E Score (50 or more) points Maximum nursing (Individual Consideration) (Usually Tech Waiver Eligible)

41. Paper Trail Provider Requests must contain the following: • EPSDT Medical Needs Assessment Form • Home Health Certification and Plan of Care (may use the CMS 485 or equivalent to meet documentation requirements) signed by the ordering physician • The Plan of Care must contain the enrollee Medicaid ID number, provider number, and documentation which reflects the nursing care as described in the Medical Needs Assessment (DMAS-62) form

42. EPSDT Nursing Contacts Anne Young, EPSDT Preauthorization Coordinator (804) 371-2635 anne.young@dmas.virginia.gov EPSDT Fax (804) 612-0043

43. Infant Medical Formula, Nutritional Supplements and Medical Foods

44. Background Previously, if a Medicaid or FAMIS fee-for-service eligible recipient followed through a metabolic clinic had a need for non-routine formula they would receive that formula from the Virginia Department of Health (VDH) Pharmacy Previously, DMAS providers could supply what the local office did not supply NOW: All medically necessary amounts may be supplied by either the local WIC clinic or the DME provider

45. EPSDT and Medical Formula • The EPSDT program allows Medicaid programs to provide medically necessary formula and medical foods to EPSDT eligible children under the age of 21 based on medical necessity.

46. General Information • All Medical Formula is provided by • Local WIC offices (children under 5) or • DMAS enrolled Durable Medical Equipment provider • All medical formula and nutritional supplements are reimbursed through DMAS directly • MCO’s do not cover medical formula effective October, 2007

47. EPSDT Behavioral Treatment

48. EPSDT Behavioral Treatment • Behavioral treatment services are intended to improve the functional behaviors of the enrollee by integrating multi disciplinary clinical and medical services with the behavioral treatment protocol to increase the enrollee’s adaptive functioning and communicative abilities.

49. Behavioral Treatment (cont.) • Family training and counseling related to the implementation of the behavioral treatment is included as part of the service. The service goal is to ensure that the enrollee’s family is trained to successfully manage clinically designed behavioral modification strategies in the home setting. The family involvement in treatment is meant to increase the child’s adaptive functioning by training the family in effective methods of behavioral modification strategies.

50. Behavioral Treatment Medical Necessity • The individual is eligible for behavioral treatment when all of the following are met: • The individual is medically stable and needs systematic behavioral treatment interventions to increase adaptive behavioral functioning and increase communication abilities. The individual requires treatment from one or more other disciplines to enhance and promote effective behavioral treatment • The individual’s treatment needs cannot be adequately met in the home setting unless family training effectively integrates the behavioral modification strategies that will be implemented so that successful treatment will include the family members and/or caregivers who are able to participate in the behavioral treatment process. The family members or caregivers must be willing and capable of learning and applying effective behavioral modification strategies. • It has been documented that the individual would not achieve a demonstrable clinical improvement using only traditional outpatient treatment modalities in a clinic setting;