Transcript The Basics of Medicaid

A New Day for Medicaid
EPSDT 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
Overview
 Medicaid Basics
 EPSDT Basics
 EPSDT in NC
 Cases and tips
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%
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
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 – 108A70.9
NC regulations, 10A N.C.A.C. chs. 21-22
Policy manuals and medicaid managed care
contracts
Medicaid’s basic Structure
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Federal/state program
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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
General eligibility requirements
The “Four Doors”
• Citizenship or specified immigration status
• N.C. residence
• Limited Income
• Fit into a category
Financial Eligibility
• Income and resources – “methodologies”
• Disregards
• Long-term care rules – spousal protection
Mandatory v. Optional
• Eligibility – Mandatory and optional
• E.g, SSI = mandatory, Medically needy (“spend down”)
= optional
• Services – mandatory and optional
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
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
Services: Optional e.g.:
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Prescription drugs, prosthetic devices
Dental
Private duty nursing
Physical therapy
Rehabilitation (not habilitation)
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)
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

Medicaid Services
Prior authorization
Special rules for prescription drugs
 Provider obligations

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)
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

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

North Carolina
EPSDT = “Health Check”
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 . . .
EPSDT Requirements—
Medical, vision, hearing, dental screening
Medical Screens
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Health and developmental history
“Unclothed” physical exam
Immunizations
Lab tests, including lead blood tests at 12 &
24 mos.
Health education and anticipatory guidance
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To child and family
EPSDT Requirements—
Medical, vision, hearing, dental screening
Other Required Screens
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Vision, including eyeglasses
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Hearing, including hearing aids
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Dental, including “relief of pain, restoration of
teeth and maintenance of dental health”
EPSDT Requirements—
Early and Periodic screening
Periodic Screens
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Based on age
Set by medical and dental experts
Different for medical, dental, hearing and
vision
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

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.
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

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
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
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
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.
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
EPSDT Services-Request for treatment should include:
Doctor’s orders (e.g. on Rx pad)
Written justification from physician & treatment team
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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
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
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”
EPSDT Services—
Limitations
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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!
EPSDT Services—
Limitations
Out of state services will not be covered if
“medically necessary, similarly efficacious”
services are available in NC
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
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
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

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
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EPSDT—
Cost sharing
No cost sharing in N.C. for <21
EPSDT—
Providers
North Carolina must make available a
variety of qualified and willing individual
and group providers
EPSDT Requirements
Outreach 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
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
Related Services
Transportation and developmental,
corrective and other services that are
required to assist a child with a disability to
benefit from special education
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
Related services and EPSDT
Related services can be paid for by
Medicaid
Federal government cannot refuse to pay for
Medicaid services provided in school
Providers
In order for schools to bill for Medicaid
services provided through an IEP, the
school must be licensed as a Medicaid
provider.
EPSDT Requirements –
Reporting
CMS Form 416
Number of children:
provided screening services
 referred for corrective treatment
 receiving dental services

EPSDT Requirements –
Reporting
Participation goals
Developed and set by federal govt. each
year
States must report results in obtaining goals
on 416 form
EPSDT Requirements –
Reporting
Issues
Methodology – overcounting
 Provider compliance
 Since 1999, no uniform periodicity schedule
across different states

EPSDT–
Required for CAP recipients under 21
Cannot exceed cost cap in CAP/C, CAP/DA
Exceeding cost cap in CAP/MR-DD
requires prior approval
Children on waitlist for CAP should get
EPSDT services, if otherwise eligible for
Medicaid
CAP services can be provided in school
Cases
Antrican v. Odom
D.B. v. Blue Ridge Center
Salazar v. District of Columbia
S.D. v. Hood
Katie A. v. Belshe
Questions?