“Securing Health Rights for Those in Need”

1. “Securing Health Rights for Those in Need” Children’s Services Under Medicaid: Ensuring EPSDT coverage & accountability On-line meeting: OH, MI, & WV November 14, 2008 Jane Perkins

2. About NHeLP • Non-profit public interest law firm working to increase access to quality health care on behalf of limited income individuals, including children, women, the elderly, and people with disabilities • Litigation & policy expertise includes: Medicaid; managed care; EPSDT; civil and disability rights; court access • www.healthlaw.org

3. Presentation overview • Medicaid Basics • Focus on EPSDT • Explain the benefit • Explore ways to assure EPSDT’s promise (government accountability)

4. Medicaid %*#)@ • “Byzantine construction” makes Medicaid “almost unintelligible to the uninitiated” • Medicaid Act is “an aggravated assault on the English language” • Medicaid “regulations so drawn they have created a Serbonian bog”

5. Medicaid Basics • “Cooperative federalism” • Shared funding: • OH: 62.14% MI: 60.27% WV: 73.73% (FY ’09) • Shared administration: • Federal: Centers for Medicare & Medicaid Services (CMS) • States: • OH Dep’t of Job & Fam. Serv. • MI Dep’t of Community Health • WV Department of Health & Human Resources • “Entitlement”

6. Medicaid Basics • Mandatory & optional eligibility groups, e.g. • children aged 6 to 19 with incomes < FPL • Mandatory & optional services

7. Why EPSDT? • Children are not little adults • Adolescents are not big children • Poor children are more likely to have: • Vision, hearing and speech problems • Untreated tooth decay • Elevated lead blood levels • Sickle cell disease • Behavioral Health problems • Asthma • And more . . .

8. EPSDT coverage • Mandatory Medicaid services for children and youth under age 21 • Covers more than one in four children in US • Covers more than one in three children in WV • Over 30% of all pediatrician visits

9. Medicaid EPSDT E = Early P= Periodic S = Screening D = Diagnosis T = Treatment

10. EPSDT in the States • OH: EPSDT = HealthChek • MI: EPSDT = EPSDT • WV: EPSDT = HealthCheck

11. A Word about WV Mountain Health Choices • Non-disabled, non-pregnant women & children • Member responsibility agreement: Enhanced benefits • No member responsibility agreement: Basic benefits, e.g. • Home health -- 25/year • PT -- 20/year • Weight management -- not covered • Rx – 4/month • Transportation – 10/year

12. A Word about WV Mountain Health Choices • 93% of children in Basic Plan (CCF, Aug. 2008) • EPSDT CANNOT BE IGNORED • EPSDT STILL APPLIES

13. A Word about Managed Care (OH, MI, WV) • State Medicaid agencies contract with at-risk health plans to provide Medicaid services • EPSDT CANNOT BE IGNORED • EPSDT STILL APPLIES

14. EPSDT Requirements— Medical, vision, hearing, dental screening Medical Screens • Health and developmental assessment • Unclothed physical exam • Immunizations • Lab tests, including lead blood tests • Health education and anticipatory guidance

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

16. EPSDT Requirements—Early and Periodic screening • Periodic Screens • Set according to age • Set by medical and dental experts • Different for medical, dental, hearing and vision • Interperiodic “as needed” Screens • States must provide or arrange for the provision of screening services in all cases there they are requested

17. Features of “E” & “P” • Medical screen = 5 components • Provider need not deliver all services • Up to date periodicity schedules • Bright Futures, 3d edition (www.aap.org) • No cost sharing • Appointment & transportation assistance • No prior authorization • Any encounter=Interperiodic screen*

18. Advocating for EPSDT Screening in West Virginia • Up-to-date periodicity schedules? • Age-appropriate screening forms? • OH, MI -- ? • WV form – up to date? part of EMR? Mental health form being used? • Limiting providers to all EPSDT services? • Adequate screening for developmental delay/substance abuse?

19. EPSDT Screening in West Virginia—what to look for • Periodicity Schedules AgeAAPWV <1 7 7 1-2 4 4 3-5 3 3 6-9 2 ? 10-14 3 ? 15-18 2 ? 19-20 1 ?

20. EPSDT Treatment Requirements • States must arrange (directly or through referral) for corrective treatment needed as a result of a screen • Federal scope of benefits • Federal definition of medical necessity

21. EPSDT Services—Federal Scope of Benefits All necessary treatment within 1396d(a) Mandatory servicesOptional Services Physician services Prescription drugs Laboratory/x-ray Dental services In-patient hospital Physical and other therapies Outpatient hospital Private duty nursing Nursing facility services Home health care* Home health care* Rehabilitation services EPSDT Personal care services Case management Transportation

22. EPSDT Services— Federal Definition of Medical Necessity Treatment and services “necessary … to correct or ameliorate physical and mental illnesses and conditions” • 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.”S. Rep. No. 404, 89th Congress, 1st Session

23. Advocating for the “T” • Diagnosed during an EPSDT screen? • On the list of covered services? • Medically necessary? • Not experimental? • No less costly, equally effective alternative available in the geographic area?

24. EPSDT – To get the “T” Request should include • Written justification from physician (e.g. Rx pad) & treatment team • Patient history • Diagnosis/prognosis • Medical justification • Description of benefits to fit into a Medicaid “box” • Incontinence supplies=home health • Basic living skills=home health, rehabilitation • Length of time service/treatment is needed • If appropriate: product information, photographs, comparable prices • Statement that request is under EPSDT to “correct or ameliorate” the child’s condition

25. EPSDT RequirementsOutreach and informing • States must inform Medicaid families & children about EPSDT • Informing must be effective • Oral and written • Translated • Targeted (e.g. pregnant teens, non-users) • Transportation and appointment assistance (prior to screen due date) • Coordinate with other entities

26. EPSDT Informing

27. EPSDT-Addressing Stubborn Barriers Monitoring • Annual reporting required—CMS Form 416 • Report by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, 19-20) • Children screened • Children referred for corrective treatment • Children receiving dental treatment • Children receiving lead blood testing

28. EPSDT – Addressing Stubborn Barriers Monitoring • State/managed care organizations must available: • Names, locations, qualifications of participating providers, non-English language spoken & whether accepting new Medicaid patients

29. EPSDT – Addressing Stubborn Barriers Monitoring • State/managed care organizations must available: • External independent quality reviews • Healthcare Effectiveness Information & Data Set (HEDIS) • Well child & adolescent visits • Treatment of children w/respiratory infections • Antidepressant medication management • OH, MI, WV – all use

30. EPSDT – Addressing Stubborn Barriers Monitoring National Health Law Program – Sunshine & Government Accountability Project Using-publicly available data to hold government payers accountable for spending taxpayer $$ on covered health services

31. EPSDT – Addressing Stubborn Barriers Complaints • Right to an administrative hearing • Right to go to court • NHeLP Health Activist Court Watch Project