Medicaid epsdt for Children: What Services Can They Get?



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Medicaid EPSDT for Children: What Services Can They Get?






Nancy E. Wright, Esq. Newright.law@gmail.com

GAL Video Training 2015
1. Medicaid and Children

According to Medicaid Annual Child Enrollment Report, in 2013, over 37 million children were enrolled in Medicaid.

Florida had 2,119,324 children enrolled

Children account for about half of all Medicaid beneficiaries, but only 20 to 25% of the cost.


2. What is EPSDT?

EPDST has been required by the Medicaid Act since 1967. (Medicaid was implemented in 1965.)

EPSDT is not a single service, but a health benefit package for ALL Medicaid-eligible children under age 21.

The purpose is “to discover, as early as possible, the ills that handicap our children” and to provide “continuing follow up and treatment so that handicaps do not go neglected.” HRS Website

3. E-P-S-D-T
Early-Periodic-Screening-Diagnosis-Treatment
Identify early, starting at birth

Check health at periodic, age-appropriate intervals

Physical, mental, developmental, dental, hearing, vision and other tests

Tests to follow up when risk identified

Treating problems found
4. Medicaid Act

EPSDT is defined in 42 USC §1396d(r) to include:

Screening Services (comprehensive health and developmental history, physical exam, immunizations

Vision services, including eyeglasses

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

Hearing services, including hearing aids AND

“Such other necessary health care, diagnostic services, treatment,

and other measures described in subsection (a) of this section [which lists all Medicaid mandatory and optional services]

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.”
5. What does “ameliorate” mean?

To reduce, or to remove the bad effects of something (Macmillan Dictionary)

To make better or more tolerable (Merriam-Webster Dictionary)

6. Federal Medicaid Regulations

Under 42 CFR § 441.56, the State agency must:

Inform all eligible individuals and their families about EPSDT

Provide comprehensive screening for health/developmental assessments, vision, dental & hearing, if requested

Provide diagnosis & treatment

Keep records for accountability

Ensure timely EPSDT treatment, generally within an outer limit of six months after the request for screening services.


7. Florida’s “Child Health Check-Up”

Term Florida uses to describe the comprehensive, preventive screening service required by EPSDT.

Screening and provider requirements are set out in Florida’s Child Health Check-up Coverage and Limitations Handbook

For children not in Medicaid managed care, Child Health Check-Up coordinators are located in each AHCA Medicaid Area Office to assist with scheduling appointments and arranging transportation


8. EPSDT is a MANDATORY Medicaid Service

Required by the Medicaid Act

Must be available to all Medicaid recipients under age 21

Applies to managed care

EPSDT services can’t be capped

They must be timely provided

There can be no charge
9. What Medicaid Services are covered by EPSDT?

A. State Plan Medicaid Services 
(Not Exhaustive)



Mandatory

Inpatient & outpatient hospital

Physician & nurse practitioner services

Labs & x-rays

Prenatal care, nurse midwife & family planning

EPSDT for under 21

Rural health clinic

Fed Qualified Health Ctr

Nursing facility for over 21

Limited home health services

Transportation to medical care



Optional

HCBS (disabilities or chronic medical conditions)

Pediatric nursing facilities

Dental


Inpt psychiatric for under 21

ICF/DD


Prescription medication

Personal care services

Private duty nursing

PT, OT, S/LT, RT

Vision & dental services

Durable medical equipment


B. Medicaid Act Catch-All

“Medical Assistance” includes under 42 USC §1396d(a)(13):

“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.”

C. What can children get that adults don’t get?

Eyeglasses

Hearing aids

Dental care, including orthodontia

Immunizations

Wheelchairs (including customized)

Prosthetic devices

OT, PT, S/LT, RT beyond limits

Prescribed medical formula foods

Assistive communication devices

Personal care (including private duty nursing)

Certain behavioral services

Substance abuse treatment

D. EPSDT Applied

Incontinence supplies. Smith v. Benson, 703 F. Supp. 2d 1262 (S.D. Fla. 2009)

In-home behavioral supports for children with serious emotional disturbances. Rosie D. v. Patrick, 410 F. Supp.2d 18 (D. Mass. 2006)

Long term residential psychiatric treatment. Collins v. Hamilton, 349 F.3d 371 (7th Cir. 2003)

Organ transplants. Pittman v. FL HRS, 998 F.2d 887 (11th Cir. 1993

Early intervention day treatment. Pediatric Specialty Care, Inc. v. Ark. DHS, 293 F.3d 472 (8th Cir. 2002)

E. EPSDT Case Study:
ABA Services in Garrido v Dudek

Federal action under 42 USC §1983

AHCA handbook provided that Medicaid would not pay for community behavioral health services for treatment of autism.

Plaintiffs were children diagnosed with ASD and had ABA prescribed for treatment. They argued violation of EPSDT for failure to provide ABA.

The court held that AHCA’s determination that ABA is experimental was “arbitrary, capricious and unreasonable.” Upheld on appeal to 11th Circuit.

F. Special Services for Children

In the Medicaid Provider General Handbook:

Medicaid Special Services for Children

Prior authorization allowed for a medically necessary services that is not listed in a service-specific handbook.

Request is through AHCA Area Office
10. Medical Necessity
A. Medically Necessary

Applies to all services, in all Medicaid Programs

“Medical necessity” is defined by Florida Administrative Code Rule 59G-1.010(166)

Protect life, prevent illness or disability, alleviate pain

Consistent with diagnosis and not in excess of need

Not experimental

No less costly treatment

Not primarily for convenience of client or caregiver

B. Moore ex rel Moore v Reese
637 F. 3d 1220 (11th Cir. 2011)

State must provide all Medicaid services “when such services are medically necessary to correct or ameliorate” the illness or condition.

State may require “reasonable standards” “consistent with the objectives of” EPSDT.

State may adopt a medical necessity definition that places limits on the treating physician discretion, but the treating physician still has primary responsibility.



Medical assistance must be sufficient in amount, duration and scope to reasonably achieve its purpose.




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