Transcript Children’s Rights Under Medicaid EPSDT and How to Ensure

EPSDT: What Does It Mean For Your
Clients and How Can you Use It?
Florida Guardian ad Litem Training
Florida Legal Services
November 12, 2008
What is “EPSDT?”
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EPSDT is a comprehensive health benefit for
all Medicaid-eligible children and youth
under age 21.
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An “entitlement” program pursuant to 42 U.S.C. §
§ 1396(a)(43) & 1396d(r)(5). See also §
409.905(2), Fla. Stat.
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Includes both screening and treatment
Who is Eligible for EPSDT?
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ALL Children on Medicaid
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“Children in Care”
Children in low income families
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Children in home and community based waivers
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See Fla. Admin Code R. 65A-1.703(1)(a);(3); ESS Policy Manual Appendix A-7;
Fla. Stat. 409.903
See 1/10/01 Dear State Medicaid Director letter
Children on SSI
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Fla. Stat. 409.903(2)
Which “Children in Care”Are Eligible
to Receive Medicaid & EPSDT?
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All children in foster care who qualify for Title IV-E foster care payments
automatically qualify for Medicaid. See Fla. Admin. Code Rule 65A-1.703(1)(b);
ESS Public Assistance Policy Manual, Section 2050.000 at:
http://www.dcf.state.fl.us/publications/esspolicymanual/index.shtml & CF Operating
Procedure No. 175-71 available at:
http://www.dcf.state.fl.us./publications/policies.shtml
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Children in Emergency Shelter; See Fla. Admin. Code R. 65A-1.703(1)(b) & ESS
Policy Manual Section 2050.000
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Foster Care Youth (ages 16-18) in Independent Living Situations; See 409.1451(9),
Fla. Stat.
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Youth ages 18-20 who are exiting foster care and meet the requirements in s.
409.1451(5), Fla. Stat.
What Services Are Covered Under
EPSDT?
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Screening
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Regular periodic screens, including medical, vision, hearing
and dental
Treatment
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Any Medicaid covered services necessary to “correct or
ameliorate” a diagnosed physical or mental condition,
whether or not the state covers these services for adults.
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Don’t be mislead by Florida’s name for the EPSDT programthe “Child Health Check-Up Program.”
What are Medicaid Covered Services?
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All services (including both mandatory and optional services) listed in the
Medicaid statute, see at 42 U.S.C. §1396d(a). This includes, for example:
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Personal care services
Private duty nursing services
Dental services
Medical supplies and equipment
Speech, occupational & physical therapies
Inpatient psychiatric hospital services for persons under 21.
“other diagnostic, screening, preventive and rehabilitative services, including
medical or remedial services recommended for the maximum reduction of
physical or mental disability and restoration of an individual to the best possible
functional level.” 42 U.S.C. § 1396d(a)(13)
Medicaid Covered Services, cont.
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Note: When state service definitions and limitations
conflict with federal law, federal law supercedes
state law.
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Example: C.F. v. Department of Children & Families, 934
So. 2d 1,6 (Fla. App. 3 Dist. 2005)
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Holding that the hearing officer improperly interpreted the state
definition of “personal care” as limited to services provided in
the recipient’s home since federal Medicaid law authorizes
these services in locations outside of the home.
What Services is the State Likely to
Deny under EPSDT?
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“Habilitation” services
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Habilitation services incorporate elements of training, and
are for the purpose of developing the functional abilities of
persons with developmental disabilities;
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Under federal law, these services are available under a
Home and Community Based Medicaid Waiver;
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In Florida, these services are covered under the
Developmental Disabilities Home and Community Based
Services (DDHCBS) program administered by APD.
DDHCBS Waiver
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Unlike EPSDT services, these are not “entitlement” services
and there is a long waiting list for placement on this waiver;
However, under state law, (§ 393.065, Fla. Stat.) children in
foster care must be moved to the top of the waiting list for
DDHCBS services.
Further, many services under the DDHCBS program must be
available for children under the EPSDT program (e.g. personal
care, nursing, durable medical equipment);
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Advocacy Tip: If you have clients on the Waiver waiting list,
(1) make a request to the Area Medicaid office for any
services that should be covered under the EPSDT program;
(2) request a fair hearing if the services are denied or if you
do not get timely response.
How Do Advocates Avoid EPSDT
Exclusions?
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Make service requests to the Medicaid agency which “fit” under one or
more of the covered services listed at 42 U.S.C. 1396(d)(a).
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For example, a child with serious mental illness needs a bundle of services
referred to as “wrap-around” services in order to live in a home-based
setting. “Wrap-around” services are not listed as a covered service under
federal Medicaid law.
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However, various service needs can be fit within the benefits listed in §
1396d(a), and as interpreted by previous CMS statements.
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Examples: targeted case management, behavioral assessments, crisis
intervention team services, a behavioral aide to assist at home and
school, independent living skills training, counseling, psychology and
therapy services.
“Medical Necessity” & EPSDT
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Under Florida Medicaid rules, all services
must be “medically necessary” (MN) in order
for Medicaid to cover these services.
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See Fla. Admin. Code R. 59G- 1.010(166)for the
state MN definition.
The MN rule is incorporated into all Medicaid
provider handbooks used by providers to
determine the amount, duration and scope of
services that Medicaid will cover.
Medical Necessity &
Prior Service Authorization
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Some services must be “prior authorized” by
Medicaid or a third party vendor (e.g. Maximus, First
Health) before a health care professional initiates the
services or before the service will be covered.
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Third party reviewers apply the state’s medical
necessity definition to determine if services will be
authorized.
Florida’s “Medical Necessity”
Definition & Medicaid HMOs
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The MN definition is included in all AHCA
contracts with Medicaid HMO providers;
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It is the yardstick that HMOs use to determine the
need for services for all Medicaid recipients
including those 0-21.
Compare Federal & State
Medical Necessity Standards
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The federal EPSDT standard is much broader;
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Services necessary “to correct or ameliorate” a physical or
mental illness or condition are covered;
This standard includes “maintenance services” such as
personal care and in-home nursing services needed to keep
children with disabilities out of institutions.
The state medical necessity rule is more restrictive;
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Services must be “necessary to protect life, to prevent
significant illness or significant disability or to alleviate severe
pain”
The State’s Medical Necessity Rule Is
Unlawful As Applied to Children &
Youth (0-21)
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C.F. v. DCF, 934 So. 2d 1 (Fla. App. 3 Dist.
2005) holds that the state’s application of its
medical necessity rule to determine the level of
personal care services needed by a child
violates federal Medicaid EPSDT law.
Behavioral Health Care
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Child Welfare Prepaid Mental Health Plan: The state has
contracted prepaid mental health plans (PMHPs) with provide
mental health services to most children and adolescents up to
age 18 who have an open case for services as identified in the
HomeSafeNet database and are enrolled in MediPass.
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Children excluded from the plan: those in Medicaid HMOs,
Statewide Inpatient Psychiatric Programs (SIPP) and those
receiving behavioral health overlay services (BHOS).
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Non-covered services: residential treatment, prescriptions,
suitability assessments, drug or alcohol services.
Behavioral Health Care
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Lots of potential legal/advocacy issues:
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PMHP is applying Florida’s state definition of “medical
necessity” as part of its pre-authorization process. Is this
causing improper denials of services?
Is the pre-authorization process causing delays in the
provision of care?
Are recipients being properly notified of their appeal rights
when services are denied, suspended or terminated?
Is there an adequate supply of providers to meet the mental
health needs of foster care children?
Are dually diagnosed children (e.g., children with autism)
getting needed behavioral services?
Therapies
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In July 2007, AHCA agreed to contract with two
managed care companies to “manage” physical,
occupational, respiratory and speech therapy
services for Medicaid children under 21 who are not
enrolled in a Medicaid HMO.
The vendors will create a provider network of
therapists.
Therapists will be required to submit documentation
of the need for services and get prior authorization.
State Obligations Under EPSDT
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EPSDT services cannot be capped.
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Coverage limitations (e.g., limits on visits, monetary
limits), applied to adults cannot be applied to
recipients under 21.
There can be no waiting lists for EPSDT
services.
“Optional” services never made available to
adults must be available to recipients under
21 if necessary to “correct or ameliorate” a
physical or mental condition.
There can be no charge for EPSDT services.
State’s Obligations Under EPSDT
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Rule 65C-13.016, F.A.C. requires each district to
develop a health care plan “to ensure that initial and
on-going health services are provided to foster
children.
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The plan must include procedures to ensure that each child
gets an EPSDT screening within 72 hours after placement
in shelter status.
Needs identified “will be met through Medicaid services, to
the extent that services are covered and providers are
available.”
State Obligations Under EPSDT
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Under state rule, (65C-30.006, F.A.C.) the “services worker” (SW) must ensure that tasks
and services necessary to meet the child’s physical and mental health needs are
documented in the case plan;
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The SW must also ensure that there are referrals and follow-up for medical and mental
health care including:
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an EPSDT screening at the time of removal and according to the periodicity schedule.
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A referral within 7 days of removal for a comprehensive behavioral health assessment (CBHA) for
any child in “out of home care”
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Any assessments, evaluations and treatment necessary for physical and/or mental health
conditions.
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Mental health service needs identified in the CBHA must be implemented within 30 days or if not,
documented in the case file the reasons why. “The SW shall ensure that the services begin as soon
as possible.”
What Can Advocates Do When EPSDT
Services are Denied, Reduced,
Terminated or Delayed?
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Recipients have the right to notice and the opportunity for a fair
hearing 42 C.F.R. 431. 200 et seq.
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They also have the right to continued services if this is a
termination, reduction or suspension of an ongoing service
and an appeal is filed within 10 days of written notice.
For children, most service denials, reductions and terminations
are potentially subject to challenge because Medicaid (and
Medicaid HMOs) are still using the state’s overly restrictive
medical necessity definition.
A Road Map for Child Advocates
Seeking EPSDT Services
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Identify the services needed and “fit” the services into one of
Medicaid’s covered services under federal law;
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Make sure a treating professional has recently prescribed the
needed service and obtain copies of this documentation;
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Identify a health care professional, preferably the treating physician,
who can substantiate the need for the services through a letter and
ideally through testimony if a hearing is necessary;
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Write the AHCA area office and the managed care plan (if the child
is enrolled in one) requesting the services. If the child is in the
Waiver program, ask the waiver support coordinator to make this
request to the AHCA area office as well.
Questions for GALS
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Can GAL request a Medicaid fair hearing on
behalf of a child in care?
Do GALS need to seek orders from the
juvenile court authorizing them to file a
Medicaid appeal (hearing request) on behalf
of a child in care?
Can GALS sign HIPAA release?
Contact FLS for Assistance
Anne Swerlick – [email protected]
OR
– Miriam Harmatz – [email protected] (305)
573-0092 ext 206
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