Early Periodic
Screening, Diagnosis
and Treatment
(EPSDT)
Virginia Department of Medical Assistance
Services (DMAS)
The Arc of Virginia Annual Convention
August 11, 2011
1
Website Tips dmasva.dmas.virginia.gov
Program
informatio
n on many
programs,
this points
to
Maternal
and Child
Health
which
houses
EPSDT
Find Provider Manuals and Memos at this link to the Medicaid Web Portal.
2
http://dmasva.dmas.virginia.gov/Co
ntent_pgs/mch-home.aspx
Find EPSDT
forms here
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Eligibility Criteria

EPSDT services are available to
Medicaid/FAMIS Plus enrollees under 21 years
of age and FAMIS fee for service enrollees
under the age of 19

The individual must be enrolled in Medicaid/FAMIS
Plus or FAMIS Fee for Service
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What is EPSDT?




Medicaid’s Early Periodic Screening Diagnosis and
Treatment Program is the benefit plan for children
under the age of 21
Preventive care, traditional diagnostic and treatment
services are the backbone of the program
There is no special application process for EPSDT.
Children are automatically eligible for EPSDT when
enrolled in the Medicaid or FAMIS Fee-for-Service
benefit plans
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What is EPSDT?

The requirement to “correct and ameliorate”
health conditions is a unique feature of the
EPSDT program. This requirement of the
program is included in many of the services that
DMAS provides for children
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Scope of Services


Individualized health care, diagnostic services,
and “treatment” as listed in the Federal
Medicaid statute, must be provided when
medically necessary to correct and ameliorate
(improve) physical and mental conditions
discovered during screening services whether or
not included in the Medicaid state plan
The program does not cover services that are
experimental or investigational
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Safety Net Function

EPSDT covers medically necessary treatments
when:
Not available to certain disability groups
 Not covered by Medicaid/FAMIS Plus


Including FAMIS FFS which get Medicaid benefit
Examples:
 Eating Disorders Treatment
 Residential Substance Abuse Treatment
 Behavioral Treatments
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Specialized Services

The following Services are covered only under
EPSDT and require service authorization:

Hearing Aids


Medicaid/FAMIS MCO member = Request through
MCO
Assistive Technology
Medicaid MCO member = Request through MCO
 Available through DME benefit for FAMIS MCO
member = Request through MCO

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Specialized Services

In Home Behavioral Therapy
Medicaid MCO member = Request services through
EPSDT
 FAMIS MCO = not covered service


Residential Behavioral Treatment
Medicaid MCO member = Request services through
EPSDT
 Not available for FAMIS MCO member (Level C)


Substance Abuse Residential Treatment
Medicaid MCO member = Request services through
EPSDT
 Not available for FAMIS MCO member

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Specialized Services

Personal Care
Medicaid MCO member = Request services through
EPSDT
 FAMIS MCO member = Not available for FAMIS MCO
member


Private Duty Nursing


Medicaid/FAMIS MCO member = Request through
MCO
All EPSDT Specialized Services for FFS
Medicaid/FAMIS Plus/FAMIS = request through
EPSDT
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What is Not Covered?

Services must be deemed as medically necessary


Ex: Personal care would be medically necessary if a
child meets the EPSDT personal care criteria
Certain services are not covered by EPSDT due
to Federal Limitations
Respite Care
 Environmental Modifications
 Vocational Services
 Educational Services

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Specific Program
Guidelines
Please refer to the EPSDT Program
manuals and fact sheets for more
information about these services
www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual
Click on Provider manuals and select specific manual from drop
down menu.
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Personal Care


Assistance with activities of daily living (ADLs):
ADL categories:
bathing
dressing
transfers
ambulation
eating/feeding
toileting
continence
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Personal Care


Health conditions cause limitations in
performing three or more ADLs.
This is a great service for those on the waitlist
for Medicaid waivers such as Intellectual
Disability Waiver
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EPSDT Nursing


EPSDT nursing is private duty nursing deemed
medically necessary by the attending physician
EPSDT nursing can provide for assessing and
providing interventions, maintaining nursing
care and communicating with the physician
regarding changes in the individual's medical
status
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EPSDT Nursing Medical Needs
Require skilled intervention or medical monitoring
from a medical professional in order to maintain
physical health or to prevent imminent physical
harm
 Have chronic nursing needs that are not intensive
enough to meet eligibility for the Technology
Assisted Waiver
 Needs are intermittent or the illness/injury related
nursing is not covered by the Home Health Program

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Assistive Technology


Specialized medical equipment, supplies,
devices, controls, and appliances not available
under the regular Medicaid program
Enable members to increase their abilities to
perform ADLs or to perceive, control, or
communicate with the environment in which
they live
Assistive Technology

If member enrolled in Waiver which covers AT,
must request coverage first through waiver



If not covered, then may be requested through
EPSDT (this process is done internally with the ID
and DD waivers)
Home/environmental modifications are not
covered
If AT is requested during school hours,
documentation must be presented to EPSDT
why school not covering under IDEA
Assistive Technology
Request for services:



Letter of medical necessity from the child's physician
A DMAS-352 (Certificate of Medical Necessity)
completed by the DME or AT provider and signed by
the child's physician
An itemized quote or invoice from the child's
physician/AT provider
 Include warranty, repairs, servicing, time frame that
AT may be needed
Audiology and Hearing Aids



Digital and analog hearing aids are covered
FM amplification systems are covered as
necessary to aid language development
Cochlear implants are covered for all ages
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Audiology and Hearing Aids


Fact sheet
http://dmasva.dmas.virginia.gov/Content_atchs
/mch/mch-epsdt_ssi6.pdf
Manual
http://websrvr.dmas.virginia.gov/ProviderMan
uals/ManualChapters/General/prmEPSDT_Hear_Audio.pdf
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Behavioral Therapy Services


EPSDT Behavioral Therapy allows
reimbursement for treatment interventions
related to developmental delays and/or health
conditions which, if left untreated, would lead to
significant long term impairments in adaptive
functioning
Behavioral Treatment is available either in a
primarily home based setting or in a residential
treatment setting
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Service Goals



Behavioral treatment services are intended to
increase adaptive behaviors of the child
Increasing communication skills and impulse
control are main targets for these services
Services should integrate other clinical and
medical services with the behavioral treatment
protocol to increase the enrollee’s adaptive
functioning
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Treatment Coordination


Services such as speech therapy, occupational
therapy or psychiatric care must be coordinated
with and integrated with the behavioral
treatment plan
All services must be evidence based,
measureable and medically necessary to
specifically improve components of adaptive
functioning
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Provider Participation Requirements
(In Home)
In Home Behavioral Treatment providers must be
licensed to provide one of the following
services:
Intensive In-Home Services
 Outpatient Clinic
 Day Treatment

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EPSDT
Inpatient
Treatment
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EPSDT Case Examples

Conditions served through EPSDT:
Severe Behavioral problems and health problems
associated with:





Autism
Brain Injury
Eating Disorders
(when inpatient treatment is necessary)
Chronic Illnesses that require inpatient treatment
Substance Abuse Disorders
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How to Access
Behavioral Treatment Services
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Eligibility Criteria/Physician
Referral

The individual must have a medical need for
behavioral treatment. The need for residential
behavioral treatment must be identified by the
child’s physician through an Inter-periodic/problemfocused visit or an EPSDT screening/well-child
visit.
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Managed Care Organization
Enrollees


DMAS contracted Managed Care Organizations
(MCOs) are not required to provide coverage
for behavioral treatment services
Services (such as psych, OT, SLP, MD) other
than those that are carved-out of the MCO
contract should be coordinated as usual through
the MCO in which the child is enrolled
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Managed Care Organization
Enrollees


Behavioral Treatment services for children who
are enrolled in a Medicaid/FAMIS Plus MCOs
are available to the member through DMAS and
not the member’s MCO
FAMIS MCO members do not have Behavioral
Treatment as covered service
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Approval Allowances



DMAS will generally authorize 6 months for the
initial service authorizations
Continuation of services will generally be
authorized in 3 month increments
Less time may be approved when DMAS must
request specific clinical information to decide if
continuation of treatment is effective or
clinically necessary
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Where to Send Service Requests
Requests for services may be faxed to:
(804) 612-0043
Requests for services may be mailed to:
DMAS
Maternal and Child Health Division
600 E. Broad St., Ste 1300
Richmond VA, 23219
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Service Requests



DMAS processes all typical requests within 1015 business days
MCO’s use their own PA processes
To find MCO contact numbers use this link:
http://www.dmas.virginia.gov/downloads/
mcrguides/Chapter_8.pdf
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EPSDT Contacts

Brian Campbell, EPSDT Services
Supervisor

(804) 786-0342
brian.campbell@dmas.virginia.gov

Anne Young, EPSDT Nursing and
Preauthorization Clinician
(804) 371-2635
anne.young@dmas.virginia.gov

Shirlene Harris, EPSDT
Preauthorization
(804) 225-3124
shirlene.harris@dmas.virginia.gov
Tabitha Taylor, MCH Program
Analyst
(804) 225-3231
Tabitha.Taylor@dmas.virginia.gov

Jeff Beard, MCH Program Analyst
(804)371-7981
Jeff.Beard@dmas.virginia.gov
Use the Web to find forms
and more information!
http://dmasva.dmas.virginia.gov/
DMAS Portal:
www.virginiamedicaid.dmas.virginia.gov/wps/portal
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