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Strengthening the Medical Home through Utilization of EPSDT Manjusha P. Kulkarni Staff Attorney Child Health Policy Research Symposium The California Endowment March 2, 2009 “Securing Health Rights for Those in Need” Coverage under Medicaid • Medicaid is the primary health care safety net program for low-income individuals • Covers 55 million Americans, including approximately 30 million kids • Offers comprehensive health care coverage, including hospital stays, physician office visits, and EPSDT • Entitlement program found in Title XIX of Social Security Act History of Medicaid and EPSDT • Medicaid was created in 1965 as part of President Johnson’s “Great Society” programs • Interest in improving access to pediatric health care rose from gov’t study that 50% rejection rate of military draftees was due to untreated physical and mental conditions • 1967 Amendments added the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, expanded Medicaid’s role to include promoting childhood growth and development Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program • “Program within a program” • Covers children and youth up to age 21 • Two key characteristics: – Expansive definition of “medical necessity” to ensure that each child’s specific medical needs are met at the appropriate level – Comprehensive screenings include medical, hearing, dental and vision screens • More generous than private health plans EPSDT’s Definition of “Medical Necessity” Definition of “medical necessity”: Any “necessary health care, diagnostic services, treatment and other measures… to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan” 42 U.S.C. § 1396d(r)(5) EPSDT Screening Components • Medical Screening components: – – – – Unclothed physical exam Comprehensive health & developmental history Appropriate immunizations Laboratory tests • Including lead, TB, genetic conditions as appropriate – Health education – Nutritional assessment EPSDT Screening Components • • • • Hearing Screens Vision Screens Dental Screens Mental Health Assessment More comprehensive than private managed care plans’ “well-baby” or “well-child” visits EPSDT Obligations • State is required to inform beneficiaries of EPSDT and how to obtain services • State must assist with scheduling appointments and transportation • Screenings must be periodic (follow Guidelines of the American Academy of Pediatrics) • Must include interperiodic screens when appropriate Obtaining EPSDT Services in California • In California, EPSDT service provision is compartmentalized: • Screening services under Child Health and Disability Prevention (CHDP) Program • Diagnosis and treatment services that are in State Medicaid Plan (and also provided to adults) under Medi-Cal • Diagnosis and treatment services not in State Medicaid Plan under EPSDT Supplemental Services • Managed Care overlay for all three Medical home framework in EPSDT • Comprehensive screening, diagnosis and treatment • Guaranteed access to specialized services, including physical therapy, occupational therapy, speech therapy, etc. • Provides payment for some services offered in a school setting and nontraditional setting EPSDT within the Medical Home Framework • Family centered care • Geographically, linguistically and culturally accessible care • Primary care focused, including growth and development screenings, health and nutrition counseling • Interaction with early intervention and early childhood education programs Questions? Los Angeles Office: (310) 204-6010 www.healthlaw.org Manjusha P. Kulkarni [email protected]