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

“Securing Health Rights for Those in Need”

Children’s Services Under Medicaid:Ensuring EPSDT coverage & accountability

On-line meeting: OH, MI, & WV

November 14, 2008Jane Perkins

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

Presentation overview

• Medicaid Basics• Focus on EPSDT

– Explain the benefit– Explore ways to assure EPSDT’s promise (government

accountability)

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”

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”

Medicaid Basics

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

• Mandatory & optional services

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 . . .

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

Medicaid EPSDT

E = EarlyP= Periodic

S = ScreeningD = Diagnosis

T = Treatment

EPSDT in the States

• OH: EPSDT = HealthChek• MI: EPSDT = EPSDT• WV: EPSDT = HealthCheck

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

A Word about WV Mountain Health Choices

– 93% of children in Basic Plan (CCF, Aug. 2008)

– EPSDT CANNOT BE IGNORED– EPSDT STILL APPLIES

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

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

EPSDT Requirements— Medical, vision, hearing, dental screening

• Additional Required ScreensVision, including eyeglasses

Hearing, including hearing aids

Dental, including relief of pain, restoration of teeth and maintenance of dental health

EPSDT Requirements—Early and Periodic screening

• Periodic Screens Set according to age Set by medical and dental expertsDifferent 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

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*

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?

EPSDT Screening in West Virginia—what to look for

• Periodicity Schedules Age AAP WV<1 7 7 1-2 4 43-5 3 36-9 2 ?10-14 3 ?15-18 2 ?19-20 1 ?

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

EPSDT Services—Federal Scope of Benefits

All necessary treatment within 1396d(a)Mandatory services Optional 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

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

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?

• 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

EPSDT – To get the “T” Request should include

EPSDT RequirementsOutreach and informing

• States must inform Medicaid families & children about EPSDT• Informing must be effective

Oral and writtenTranslatedTargeted (e.g. pregnant teens, non-users)

• Transportation and appointment assistance (prior to screen due date)

• Coordinate with other entities

EPSDT Informing

Inform Families About:

Benefits of preventive care

Services availablethrough EPSDT

Transport & schedulingassistance

EPSDT-Addressing Stubborn BarriersMonitoring

• 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

EPSDT – Addressing Stubborn BarriersMonitoring

• State/managed care organizations must available:– Names, locations, qualifications of participating

providers, non-English language spoken & whether accepting new Medicaid patients

EPSDT – Addressing Stubborn BarriersMonitoring

• 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

EPSDT – Addressing Stubborn BarriersMonitoring

National Health Law Program –

Sunshine & Government Accountability Project

Using-publicly available data to hold government payers accountable for spending taxpayer $$ on covered health services

EPSDT – Addressing Stubborn BarriersComplaints

• Right to an administrative hearing• Right to go to court

– NHeLP Health Activist Court Watch Project