|Medicaid EPSDT for Children: What Services Can They Get?
Nancy E. Wright, Esq. Newright.firstname.lastname@example.org
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
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
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
HCBS (disabilities or chronic medical conditions)
Pediatric nursing facilities
Inpt psychiatric for under 21
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?
Dental care, including orthodontia
Wheelchairs (including customized)
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
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.