New mexico 090409 epsdt (medicaid for children) and waiver programs



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NEW MEXICO 090409

EPSDT (MEDICAID FOR CHILDREN) AND WAIVER PROGRAMS

TIP SHEET



What is EPSDT?

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are those services available to children under the age of 21 who are covered by the New Mexico Medicaid State Plan. EPSDT services include preventive check-ups, diagnostic tests and direct services, such as therapies and personal care services. The Medicaid State Plan also includes a range of mental health services. Any child/youth receiving services through a waiver program is also eligible to receive EPSDT services through the Medicaid state plan. For more information visit the website:


www.hsd.state.nm.us/mad/keepingkidshealthy.html

How does someone access EPSDT services?

Most Medicaid recipients are required to select a Salud! Managed Care Organization (MCO). EPSDT services are provided through the person’s Salud! MCO or Fee For Service (FFS). Persons selecting an MCO may choose Presbyterian, Lovelace, Molina or Blue Salud. Native American Medicaid recipients receive Medicaid coverage on a Fee For Service (FFS) basis, unless the recipient chooses to “opt-in” to Salud! Under opt-in, the Native American Medicaid recipient actively chooses to sign up with a Salud! MCO. If a child has special healthcare needs, it may be beneficial to select a Salud! MCO, as care coordination is only available through the MCOs and not through FFS. For more details visit: www.hsd.state.nm.us/mad/naoptin.html

EPSDT services must be ordered by a doctor or primary care provider (PCP) and be medically necessary. Often a prior authorization from the MCO or FFS is required before a service can be provided.

What about Respite Care and Personal Care Services?

Respite services are available through the waiver programs but not through EPSDT or the MCOs. Sometimes it is difficult to distinguish between Respite and Personal Care, which is covered by EPSDT/Medicaid. Respite is for the primary purpose of relieving the child’s caregiver and is therefore not covered by EPSDT. Personal Care is covered because it is focused on the child’s needs and is not intended to relieve the primary caregiver. Personal Care is provided for children through EPSDT, but must be prescribed as medically necessary by a doctor or PCP.



Remember:

  • For children under age 21 who are on a waiver program, all home healthcare services (therapies, private duty nursing, personal care services and home health aides) are provided by EPSDT through the MCO’s or FFS. These services are not paid through the waiver programs.

  • MCO Care Coordination can be requested by the family or the child’s doctor/ PCP. If a person is having problems navigating the health care system, they should contact their MCO.

  • To apply for NM Medicaid, contact a local Income Support Division (ISD) office. To find a local ISD office, look in the phone book in the State Government listings or go to the website: www.hsd.state.nm.us/isd/fieldoffices.html

  • Mental health services can be accessed through Optum Health care.

For additional disability related information or resources contact:

Center for Development and Disability Information Network

1-800-552-8195 or 505-272-8549

Download Tip Sheets at http://cdd.unm.edu/InfoNet/publications

The content of this document does not necessarily reflect the position or policy of the EPSDT program and no official endorsement should be inferred.

EPSDT Services:

  • Physical, Speech and Occupational therapy

  • Private Duty Nursing (RN,LPN)

  • Home Health Aide

  • Personal Care
    Services (PCS)

  • Care Coordination

Fee for Service

(505) 827-3113



MCO Organizations:

Presbyterian

Member Services

1-888-977-2333

Intake Coordinator

1-866-672-1242

Waiver Nurse

Care Coordinator

505-281-9718 www.phs.org/healthplan/


hpsalud.shtml


Molina

Customer Service

1-800-377-9594

Intake Coordinator

1-800-344-9594 xt. 181120

www.molinahealthcare.com

Lovelace

Customer Care

1-877-894-4783

Salud!


Case Management Intake Coordinator

1-877-894-4783

xt. 26660

505-816-6660



www.lovelacehealthplan.com
Blue Cross/Blue Shield – Blue Salud

1-800-835-8699


Optum Health

1-866-660-7185






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