A New Day for Medicaid EPSDT and Service Appeals

1. A New Day for MedicaidEPSDT and Service Appeals Doug Sea, Legal Services of the Southern Piedmont Sarah Somers and Jane Perkins, National Health Law Program North Carolina Academy of Trial Lawyers Raleigh, NC October 23, 2007

2. Overview • Medicaid Basics • EPSDT Basics • EPSDT in NC • Cases and tips

3. Medicaid as Insurance Coverage Insurance for Americans below federal poverty limit • Medicaid: 40% • Employers: 15% • Individual or other private sources: 5.9% • Other public entities: 3.3% • Uninsured: 36%

4. Medicaid for children and youth • Covers 1/3 of all births • Covered over 28 million children in 2005 • Covers 30% of all pediatrician visits • 48% of Medicaid enrollees are children, who account for just 18% of its costs

5. EPSDT Citations Medicaid Act, 42 U.S.C. §§ 1396-1396v Medicaid Regulations, 42 C.F.R. part 430 CMS, State Medicaid Manual N.C. statute, N.C.G.S. §§ 108A-54 – 108A-70.9 NC regulations, 10A N.C.A.C. chs. 21-22 Policy manuals and medicaid managed care contracts

6. Medicaid’s basic Structure • Federal/state program • Dept. of Health and Human Services, Center for Medicare & Medicaid Services • “Single state agency” – N.C. Dept. of Health and Human Services, Division of Medical Assistance • Federal match of state expenditures – 64% • Entitlement • But note: Waivers

7. General eligibility requirementsThe “Four Doors” • Citizenship or specified immigration status • N.C. residence • Limited Income • Fit into a category

8. Financial Eligibility • Income and resources – “methodologies” • Disregards • Long-term care rules – spousal protection

9. Mandatory v. Optional • Eligibility – Mandatory and optional • E.g, SSI = mandatory, Medically needy (“spend down”) = optional • Services – mandatory and optional

10. Some optional categories covered by Medicaid in North Carolina • Children birth to age 5 under 200% of FPL (SCHIP) • Medically needy • Breast and cervical cancer • Special needs adoption

11. Services: Mandatory e.g.: • Physician services • Laboratory/x-ray services • Inpatient & outpatient hospital • Early and Periodic Screening, Diagnosis and Treatment • Family planning services and supplies • Certified nurse practitioner services • Home health care

12. Services: Optional e.g.: • Prescription drugs, prosthetic devices • Dental • Private duty nursing • Physical therapy • Rehabilitation (not habilitation)

13. Optional Services, e.g., cont’d • Intermediate care facility services for the mentally retarded • Case management • Personal care services • Other services designated by the Secretary of HHS (transportation)

14. Medicaid Services • “Amount, duration and scope” of service must be sufficient to achieve its purpose • No discrimination based on condition • Cost sharing • Provider participation • “Equal access” requirement • Medicaid is payment in full

15. Medicaid Services • Prior authorization • Special rules for prescription drugs • Provider obligations

16. Home and community-based waivers - Overview • Allows waiver of: statewideness, comparability, financial eligibility requirements • Goal: provide services to persons at home or community & end/avoid institutionalization • In N.C., Community Alternatives Program (CAP)

17. Home and community-based waiver: overview • For individuals at risk of institutionalization (e.g. NF, ICF-MR, hospital) • NC Waivers: • CAP/MR • CAP/C • CAP/AIDS • CAP/DA

18. EPSDT • Early and Periodic Screening, Diagnosis and Treatment • Must be covered for Medicaid-eligible children and youth up to age 21 • Reasons for EPSDT • Children are not little adults • Adolescents are not big children

19. North Carolina EPSDT = “Health Check”

20. Poor Children = Poor Health Poor children are more likely to have: • Vision, hearing and speech problems • Untreated tooth decay • Elevated lead blood levels • Behavioral health problems • Anemia, Asthma • And many more . . .

21. EPSDT Requirements—Medical, vision, hearing, dental screening Medical Screens • Health and developmental history • “Unclothed” physical exam • Immunizations • Lab tests, including lead blood tests at 12 & 24 mos. • Health education and anticipatory guidance • To child and family

22. EPSDT Requirements—Medical, vision, hearing, dental screening • Other Required Screens • Vision, including eyeglasses • Hearing, including hearing aids • Dental, including “relief of pain, restoration of teeth and maintenance of dental health”

23. EPSDT Requirements—Early and Periodic screening • Periodic Screens • Based on age • Set by medical and dental experts • Different for medical, dental, hearing and vision

24. EPSDT Screening • Interperiodic Screens • As medically necessary to detect problems • Any encounter by a health care professional w/in scope of practice (even if not participating in Medicaid), acc. CMS

25. EPSDT Requirements– Treatment All necessary treatment described in the federal Medicaid Act (42 U.S.C. sec. 1396d(a)) To “correct or ameliorate physical and mental illnesses and conditions,” even if the service is not covered under the state plan for adults.

26. EPSDT Requirements– Treatment • 42 U.S.C. § 1396a(a)(43) • must provide or arrange for the provision of screening services in all cases where requested • Must arrange for (directly or through referralto appropriate agencies/individuals) corrective treatment the need for which is disclosed by such screening services

27. EPSDT Services—Requirements • Prescription drugs • Dental services • Physical, occupational and speech therapies • Private duty nursing • Home health care • Rehabilitation services (not habilitation) • Personal care services • Case management • Transportation

28. EPSDT Services—Requirements • Does not have to be covered under state plan for adults to be covered under EPSDT • No set lists of covered services

29. Determining Medical Necessity Under EPSDT • “Necessary … to correct or ameliorate” • Deference to treating provider “…the physician is the key figure in determining utilization of health services . . . it is a physician who is to decide upon admission to a hospital, order tests, drugs and treatments and determine the length of stay.” U.S. Senate Report on passing Medicaid, 1965

30. Correct? Ameliorate? Correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

31. EPSDT Services—Requirements • Clinical coverage criteria do not necessarily apply • No cap on $$, numbers of hours or visits • No restriction on location for, e.g., personal care services

32. EPSDT Services-- Request for treatment should include: • Doctor’s orders (e.g. on Rx pad) • Written justification from physician & treatment team • Patient history • Diagnosis/prognosis • Medical justification • Description of benefits • Length of time service/treatment is needed • When appropriate: product information, photographs, comparable prices • Explanation of how service will “correct or ameliorate,” and its effectiveness and safety

33. EPSDT Services-- Prior Authorization • Any request for < 21 is an EPSDT request • No “magic words” • Submit documentation when clinical coverage criteria or policy not met • Case managers and LME personnel should never deny – requests go to DMA

34. EPSDT Services—Limitations • Equally effective, less costly alternative • not sufficient to cover a standard, lower cost service instead of a specialized service if not equally effective • Must be service listed in 1396d(a) • Not “experimental”

35. EPSDT Services—Limitations • Must be determined to be medical in nature. • Must be generally recognized as an accepted method of medical practice or treatment.* • Must not be experimental, investigational. • Must be safe. • Must be effective. *Potentially problematic!

36. EPSDT Services—Limitations • Out of state services will not be covered if “medically necessary, similarly efficacious” services are available in NC

37. EPSDT Service—Not listed in Medicaid Act • Fit service into a Medicaid box • Scope of services in federal regs Basic living skills=home health, rehabilitation Swimming class=physical therapy Crisis intervention=rehabilitation Maintenance service=private duty nursing Incontinence supplies=home health, durable medical equipment

38. EPSDT Service—Not listed in Medicaid Act • Habilitation – diagnosis of DD does not necessarily mean that a services is habilitative • E.g. dual diagnoses, behavioral disorders

39. EPSDT Service—Not listed in Medicaid Act • Acceptable, non-habilitative goals, e.g.: • Controlling behavior, improving social skills • Assistance with personal needs • Teaching coping skills and emotional control • Monitoring and safety • Improving fine motor skills

40. EPSDT Services—Experimental service?? • Investigate: • Discuss with provider • Look at medical literature • Look at other Medicaid programs • Look at Medicare, private insurers • Look at other countries

41. EPSDT— Cost sharing • No cost sharing in N.C. for <21

42. EPSDT— Providers • North Carolina must make available a variety of qualified and willing individual and group providers

43. EPSDT RequirementsOutreach and informing • Effective and aggressive • Oral and written • Translated • Targeted (e.g. pregnant teens, non-users) • Transportation and appointment assistance (prior to screen due date) • Coordinate with other entities

44. EPSDT and special education Individuals with Disabilities Education Act (IDEA) 20 U.S.C. § 1401 et. seq. • free, appropriate public education • qualifying children with disabilities • consists of special education and related services provided at public expense

45. Related Services • Transportation and developmental, corrective and other services that are required to assist a child with a disability to benefit from special education

46. Related Services include: • Speech-language pathology and audiology services • Psychological services • Physical and occupational therapy • Recreation, including therapeutic recreation • Social work and counseling services • Orientation and mobility services • Medical services for diagnostic and evaluation purposes only

47. Related services and EPSDT • Related services can be paid for by Medicaid • Federal government cannot refuse to pay for Medicaid services provided in school

48. Providers • In order for schools to bill for Medicaid services provided through an IEP, the school must be licensed as a Medicaid provider.

49. EPSDT Requirements –Reporting CMS Form 416 Number of children: provided screening services referred for corrective treatment receiving dental services

50. EPSDT Requirements –Reporting • Participation goals • Developed and set by federal govt. each year • States must report results in obtaining goals on 416 form