EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services

1. EPSDT and the ID WaiverChanges in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office of Developmental Services, in collaboration with Department of Medical Assistance Services, EPSDT

2. Centers for Medicaid and Medicare require eligible children to access EPSDT prior to Waiver for covered services. Beginning with annual ISP date January 1, 2011.

3. EPSDT Eligibility • Children with Medicaid • Under the age of 21 • Require “medically necessary” supports

4. “Medically necessary” means needed to improve physical or mental health conditions. Needs determined by ISP process. EPSDT Eligibility

5. Services available under both EPSDT and Waiver: • Personal Care/Assistance • Assistive Technology • Therapeutic Consultation

6. Personal Care under EPSDT

7. EPSDT Personal Care • “Personal Assistance” under ID Waiver • Support with routine needs • “Medically necessary” supervision

8. EPSDT Personal Care is not: • General Supervision unrelated to safety • Respite • Support with employment tasks • Assistance provided in other funded settings

9. EPSDT Personal Care – Preauthorization • DMAS -7 from MD, PA or RNP • ID Waiver Personal Assistance ISARs Annually! Forward to assigned ODS PA Consultant prior to beginning services

10. EPSDT PersonalCare/ID Waiver PA • Back-up plans required • Same providers • Same services • AD Personal Assistance • CD Personal Assistance

11. EPSDT PersonalCare/ID Waiver PA Assessment: SIS If no SIS, ODS-approved assessment tool or DMAS-99 Plan of care: PC ISP Plan for Support (Part V) or DMAS-7A with Personal Preferences tool Completed by: Registered Nurse, Services Facilitator or Program Manager

12. EPSDT PersonalCare/ID Waiver PA Personal Preferences Tool for use with the DMAS 7A

13. EPSDT Personal Care Provider Reviews • Written reviews every 6 months • Verbal reports for 3 and 9 month reviews If the PA provider is a DBHDS licensed provider, quarterly reviews are required. Submit to SC!

14. EPSDT Assistive Technology

15. EPSDT Assistive Technology • Specialized medical equipment, supplies, devices, controls and appliances not available under DME • Increases independence or ability to perceive/communicate • Portable • Medically necessary

16. EPSDT Assistive Technology • Authorized up to 3 months • No dollarlimit per item/per year

17. EPSDT AT -- Criteria • Reasonable • Included in the ISP • Consistent with individual’s needs • Not for the convenience of others • In accord with medical standards • Safe and cost effective

18. EPSDT AT -- Criteria • Must directly support the child • Must minimize the adverse effects of mental or physical condition • Must be of direct benefit to the child rather than enhance surroundings • Environmental modifications are not covered

19. Assistive Technology –under the ID Waiver • AT items not “medically necessary” should be requested under the ID Waiver • $5000.00 annual limit per calendar year for ID Waiver AT • Can be used in combination with AT under EPSDT

20. EPSDT AT – Preauthorization • Letter or DMAS-355 from MD • Written recommendation from professional • ID Waiver AT ISAR • Documentation to confirm need Forward to assigned ODS PA Consultant prior to beginning services

21. Assistive Technology Documentation must confirm: • Formal diagnosis related to need • Limitations/changes resulting in need for AT • How AT will be of benefit • Reason for quantity /quality • How often AT will be used • How long AT will be needed

22. Assistive Technology Documentation must confirm: • Other supportive therapies tried/previous efforts to meet needs • Successes/failures • How item is necessary at home/community • Individual/family interest in using the item

23. Therapeutic Consultation

24. Therapeutic ConsultationSpecialty areas under the ID Waiver: • Psychology • Behavioral consultation • Speech and language pathology • Occupational therapy • Physical therapy

25. Therapeutic Consultation • EPSDT provides therapy and consultation when of medical benefit • Need documented in the PC ISP • Supports described in the TC Plan for Supports (Part V)

26. EPSDT TC – Preauthorization • Letter or DMAS-355 from MD • ID Waiver TC ISAR Annually! Forward to assigned ODS PA Consultant prior to beginning services

27. Don’t forget…Beginning January 1, 2011: • All children newly enrolling in Waiver, needing PA, AT or TC, will have these services authorized under EPSDT. I

28. Don’t forget…Beginning January 1, 2011: • PA, TC and AT received by children in the ID Waiver must be authorized under EPSDT with the child’s next annual ISP. I

29. Don’t forget… • That a child must receive at least one Waiver service to remain in the Waiver. • If the child’s supports can be provided under EPSDT alone, the Waiver services will need to be terminated and the slot reassigned. I

30. Don’t forget… • Children become ineligible for EPSDT on their 21st birthday. • PA, AT and TC will need to be authorized under the ID Waiver at that time I

31. Contacts ODS Community Resource Consultants http://www.dbhds.virginia.gov/ODS-Contacts.htm DMAS EPSDT Services Supervisor Brian Campbell 804-786-0342 brian.campbell@dmas.virginia.gov