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,
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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
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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
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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.
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