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 E-P-S-D-T 3. 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, 1 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 2 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 3 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. 4