Current State of Health Coverage for Kids:
What you should know about the ACA, EPSDT,
and how to get pediatric patients the care they need
David Koeninger, J.D.
Managing Attorney, Advocates for Basic Legal Equality
L. Kate Mitchell, J.D.
Legal Director, Medical Legal Partnership for Children, ABLE
Kim Reno, MSW, LISW, Social Worker
Toledo Children’s Hospital, Pediatric Pulmonary and Cystic Fibrosis Care Center
Training Objectives
 Become familiar with recent
changes in health care coverage
options for children and families
 Understand how EPSDT ensures
medically necessary services to
children on Medicaid
 Identify tools to advocate for
healthcare coverage to children
under EPSDT
The ACA and Low-Income Children
 Many children already eligible thanks to CHIP
 Medicaid expansion affects mainly low-income adults up to
138% FPL.
 Many adults (over 138% FPL) will qualify for Advance Premium
Tax Credits (APTC) that will help them purchase insurance
through an exchange.
 But what income is counted?
Introducing Modified Adjusted Gross Income (MAGI)
 New method of counting income for health insurance purposes
 Essentially the same method used in the exchanges /
marketplaces now used in Medicaid programs for parents and
caretakers relatives, children, pregnant women, and newly
eligible adults under the expansion
 Not used for programs for seniors or the disabled.
MAGI
 Links tax status to eligibility for Medicaid and health
insurance subsidies
 Ends the “penalty” for receipt of child support
 Excludes unmarried partners from the income calculation –
unlike Food Assistance and other benefits
 Puts eligibility focus on the front of the Form 1040
http://www.irs.gov/pub/irs-pdf/f1040.pdf
MAGI (cont’d)
 Filing status becomes important: household determined by
dependents claimed on return
 Income counted is Adjusted Gross Income (AGI) from Line
37 on Form 1040, minus some exceptions: gifts and
inheritances, Veteran’s Benefits, scholarships/ work-study,
child support received.
 Hence, Modified Adjusted Gross Income, MAGI
 Social Security Benefits, but not SSI, are counted in MAGI
What If My Patient Doesn’t File a Return?
 “Ping!”
 Medicaid or the Exchange will “ping” the IRS system
to check income.
 If no information there, will use what patient reports,
subject to verification
 If receiving APTCs, must file a return for that year, and
if married, must file jointly.
What Changes?
 MAGI is intended to standardize and simplify, so, for MA
purposes, it gets rid of all deductions and disregards,
except a 5% across the board deduction for everyone.
 To account for loss of deductions, CHIP categories raised
to 156% and 206% FPL, plus the 5% across the board.
 No asset test, a lump sum received in one month is income
in that month and then no longer counts.
Winners and Losers
 Winners: Single parents receiving more than token child support
(current $50 deduction goes away because support is not counted);
 Winners: Veterans benefits not counted anymore
 Also, unmarried partners do not matter (not claimed on tax return)
 Losers: those with deductible child care expenses
 Losers: Step-parent income will now count (depending on tax filing),
when it did not before, in calculating income for CHIP purposes
Case Study I
 Jane is divorced. She has one child, Jill, who lives with her.
Jane works 20 hours per week at minimum wage ($7.85 per
hour in Ohio). Jane receives $500 per month in child support
from Joe, Jill’s biological father who claims her as a dependent
on his tax return.
 Is Jane eligible for Medicaid under Ohio’s Low-Income Families
(LIF) Medicaid category, which has an income eligibility limit of
90 percent of the Federal Poverty Level?
Case Study I
 Under old methodology:
 Jane’s family size is 2
 90% FPL for a family of 2 is $1180 per month
 Jane’s household income is $675.10 per month from work, plus
$500 in child support, totaling $1175.10
 Jane receives a standard $50 deduction in child support, and a
standard $90 earned income disregard, reducing her income to
$1035.10.
 Jane is eligible for Medicaid.
Under MAGI methodology:
 Jane’s family size is 1.
 90% FPL for a family of 1 is $876 per month; MAGI permits an
additional 5% FPL disregard, making the income limit 95% FPL
or $925 per month.
 Jane’s household income is $675.10 per month from work. The
$500 in child support she receives is not counted. No other
deductions or income disregards are applied.
 Jane is eligible for Medicaid.
Case Study II
 Jane is divorced. She has one child, Jill, who lives with her.
Jane works 30 hours per week at minimum wage ($7.85 per
hour in Ohio). Jane receives $100 per month in child support
from Joe, Jill’s biological father who claims her as a dependent
on his tax return.
 Is Jane eligible for Medicaid under Ohio’s Low-Income Families
(LIF) Medicaid category, which has an income eligibility limit of
90 percent of the Federal Poverty Level?
Case Study II
 Under old methodology:
 Jane’s family size is 2
 90% FPL for a family of 2 is $1180 per month
 Jane’s household income is $1012.65 per month from work,
plus $100 in child support, totaling $1112.65
 Jane receives a standard $50 deduction in child support, and a
standard $90 earned income disregard, reducing her income to
$972.65.
 Jane is eligible for Medicaid.
Under MAGI methodology:
 Jane’s family size is 1.
 90% FPL for a family of 1 is $876 per month; MAGI permits an
additional 5% FPL disregard, making the income limit 95% FPL
or $925 per month.
 Jane’s household income is $1012.65 per month from work.
The $100 in child support she receives is not counted. No
other deductions or income disregards are applied.
 Jane is not eligible for Medicaid. However, Jane should qualify
for Medicaid under the new expansion category.
Case Study III
 Jane is divorced and remarried. She has one child, Jill. Jane and
Jill live with Bob, Jane’s second husband and Jill’s stepfather.
Jane receives $500 per month in child support from Jill’s father,
Joe who claims Jill as a dependent on his tax return. Bob has
not adopted Jill. Jane works 30 hours per week at minimum
wage ($7.85 per hour in Ohio). Bob works 40 hours per week at
$13.75 per hour. Jane and Bob file a joint tax return.
 Is Jill eligible for Medicaid under Ohio’s CHiP category, which
has an income eligibility limit of 206 percent of the Federal
Poverty Level under the MAGI methodology?
Case Study III
 Under old methodology:
 Jill’s family size is 2 (Bob is excluded)
 200% FPL for a family of 2 is $2701 per month
 Jill’s household income is Jane’s monthly income of $1012.65,
minus the $90 earned income disregard, plus the $500 child
support, minus the $50 child support disregard. Jill’s countable
income is $1372.65.
 Jill is eligible for Medicaid.
Under MAGI methodology:
 Jill’s family size is 3 (Bob is included)
 Pursuant to the MAGI conversion, the income level is increased
from 200% FPL to 206% to account for the removal of income
disregards, plus the 5% FPL MAGI disregard, extends the
eligibility limit to 211% FPL for a family of 3, which is $3481 per
month.
 Jill’s household income is Jane’s monthly income of $1012.65
plus Bob’s monthly income of $2365 for a total of $3368. Child
support is not counted.
 Jill is eligible for Medicaid
Why Do We Care?
 Studies show that expanding public health insurance coverage
to parents benefits children in the form of increased
participation in Medicaid.
 See L. Dubay and G. Kenney, “Expanding Public Health
Insurance to Parents: Effects on Children’s Coverage under
Medicaid” 38 HEALTH SERVS. RES. 1283 (October 2003)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360947/
(last downloaded, May 16, 2014)
All Medicaid/CHIP kids get EPSDT
 Helping parents navigate the changes brought by the
implementation of MAGI in Medicaid and the exchanges may
lead to more children getting eligibility for Medicaid
 With Medicaid, for children, comes access to “such early and
periodic screening and diagnosis ... To ascertain...physical or
mental defects, and such health care, treatment, and other
measures to correct or ameliorate defects and chronic
conditions discovered thereby . . . .” 42 USC 1396d(a)(4)(B).
 Importantly, EPSDT requires that states provide all mandatory
and optional services “whether or not such services are
covered under the State plan.” 42 USC 1396d(r)(5)
What is EPSDT?
 EPSDT is Early and Periodic Screening, Diagnosis, and
Treatment
 If a child is under age 21 and on Medicaid, the child’s
Medicaid coverage is governed by federal EPSDT
standards
 In Ohio we call EPSDT Healthchek
Medicaid for Kids in Ohio: The Plans
 Ohio Medicaid (aka “fee-for-service” or “straight”)
 Child is BCMH eligible (Bureau for Children with Medical Handicaps)
 Child received Medicaid via a waiver
 Child has cystic fibrosis, hemophilia, or cancer
 Child dual eligible for Medicaid and Medicare
Medicaid for Kids in Ohio: The Plans
 Medicaid Managed Care Plans
 Buckeye Community Health Plan
 Care Source
 Molina Healthcare of Ohio
 Paramount Advantage
 United HealthCare Community Plan of Ohio
All Forms of Medicaid must follow EPSDT
 Coverage should be consistent throughout various plans
 Medicaid Managed Care Plans are bound by federal
Medicaid laws and EPSDT
 However, different plans can have different procedures
for preauthorization, different forms, etc.
WHY HEALTHCHEK/EPSDT IS IMPORTANT
 Promotes preventative healthcare
by providing for early and regular
medical and dental screenings.
 Provides medically necessary
healthcare to correct or ameliorate
a defect, physical or mental illness,
or a condition [health problem]
identified through a screening.
What’s covered?
 Early and Periodic screening services – well child visits
 Vision, dental and hearing screenings and services
 Other necessary health care identified via screening
 Rehabilitative services
 PT and OT
 In home nursing, personal care, specialized therapies
 Mental health and substance abuse treatment
 Transportation to medical appointments
 Medical and adaptive equipment
 Other medically necessary care
What does Medically Necessary Mean?
 To correct or ameliorate a
physical or mental illness or
condition.
 Must be medical in nature
 Must be recognized as an
accepted method of medical
practice or treatment
 Must not be experimental or
investigational
What does Ameliorate mean?
 To improve the child’s health in the best condition possible
 To compensate for a health problem
 To prevent a health problem from worsening
 To prevent the development of additional health problems
EPSDT FEATURES
 No Waiting List for EPSDT Services
 No Monetary Cap on the Total Cost of EPSDT services
 No Upper Limit on the Number of Hours under EPSDT
 No Limit on the Number of EPSDT Visits
 No Set List that Specifies When or What EPSDT Services or
Equipment May Be Covered
 No Co-payment or Other Cost to the Recipient
 Coverage for Services Not Listed in the State Medicaid Plan
How do I get services for my patient?
Using the Prior Authorization Process
 Some services, treatments, equipment, etc. must be approved
prior to being given to the patient
 Prior authorization submitted
 By Medicaid provider
 To Medicaid Managed Care Plan or Ohio Medicaid
 Must determine PA process of the Plan and follow that process
What do you do if a PA request is denied?
 Find out why?
 Need to try less expensive viable options?
 Need more documentation?
 Other options
 Peer to peer review
 Appeal to the plan
 Provide family with information about appeal
to plan and/or DJFS
Case Study IV
11 year old with Asthma
 Child controlled with Advair, physician changed med to
Flovent as step down therapy to manage with one
medication in July
 In August, child had an exacerbation, physician changed
Flovent to Qvar 80
 Child responded well, decreased to Qvar 40
 In November, child started having trouble, FEV1 56;
physician started Advair
Case Study IV
11 year old with Asthma
 Child controlled with Advair, physician changed med to Flovent
as step down therapy to manage with one medication in July
 In August, child had an exacerbation, physician changed
Flovent to Qvar 80
 Child responded well, decreased to Qvar 40
 In November, child started having trouble, FEV1 56; physician
started Advair
Case Study IV
 In December, child's FEV1 increased to 80
 In January, the drug formulary changed, Advair no longer preferred drug
 Pharmacy faxed the office the insurance information and need to prior
authorize the medication
 Faxed office notes, PFT results, dictated letters and history of failed
therapy as noted above, medication approved
 Office called pharmacy with approval number to fill the medication
What can you do?
Prior Authorization Tips and Insights
 Use appropriate forms, most can be found online: www.covermymeds.com
 Include pertinent, factual information to support the plan of treatment
 Make sure treatment plan diagnosis and ICD code support request
 Provide an explanation as to why a particular treatment is required as
opposed to another option
 Provide information about "treatment failure"
 Review drug formulary of insurance companies
 Provide documentation or medical records to support the request. For
example, culture results for an antibiotic
What to do if the PA process is not working?
 Follow the appeals process
 Document reasons for not following
established guidelines, offer current research
 Use strong language and hold individual
accountable for their denial. (what is your
name so that your denial can be documented
in the chart.)
 When needed use your resources
 MLP
 Research associates
Resources
 Toledo MLPC: mlpc.ablelaw.org
 United Way 211
 Legal Aid Line: (888) 534-1432
www.legalaidline.org
 National Center for MLP:
medical-legalpartnership.org
 Disability Rights Ohio:
www.disabilityrightsohio.org