Children with Disabilities Medicaid 101, EPSDT and Services to Treat - - PowerPoint PPT Presentation

Medicaid Services for Children with Disabilities

Medicaid 101, EPSDT and Services to Treat Autism Spectrum Disorder

Jean Close, Technical Director Cindy Ruff Division of Benefits and Coverage Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services, CMS NAME Conference October 6, 2015

Medicaid Program Background

• Section 1902(a)(10)(A) of the Social Security Act

(the Act) provides “for making medical assistance available…”

• Implementing legislation

– Title XIX of the Social Security Act

• Partnership between Federal and State

governments

• State administered program
• Policies & programs vary from State to State

• States create their own unique programs
• Each State develops and operates a State plan
• utlining the nature and scope of services; the

State Plan and any amendments must be approved by CMS

• Medicaid mandates some eligibility groups and

services

• States choose optional eligibility groups and

services, payment levels, providers

Medicaid in Brief

• Requirement for the designation or establishment
• f a single State agency responsible for the

administration of the State plan.

• State Medicaid Agencies—

– Establish eligibility standards – Determine the services available and the amount, duration and scope – Determine the delivery system for services – Set payment rates for services; and – Administer the day-to-day operations

State Administered/Federal Oversight

• Individuals must be in a “group” covered by the

State’s Medicaid program

• Some groups are mandatory, others are optional

Medicaid Eligibility

• The Medicaid State Plan

―is a comprehensive written statement ―describes the nature & scope of the Medicaid program; and ―contains assurances that the program will be

• perated per the requirements of Title XIX of the

Social Security Act and other official issuances

• Developed and amended collaboratively with

CMS

State/Federal Partnership & the Medicaid State Plan

• States must follow the rules in the Social Security

Act, Federal regulations, the State Medicaid Manual, and policies issued by CMS

• States must specify the services to be covered

and the “amount, duration, and scope” of each covered service

• States may not place limits on services or

deny/reduce coverage due to a particular illness

• r condition

State Plan Requirements

• “Each service must be sufficient in amount, duration, and

scope to reasonably achieve its purpose.”

• 42 CFR 440.230(b)
• Amount, duration, and scope:

―How much ―How long ―To what extent

• Adequate to achieve purpose of service
• Cannot be reduced based on diagnosis, type of illness, or

condition of patient

Key State Plan Requirements: Sufficiency

• “. . .The plan will be in operation statewide

through a system of local offices, under equitable standards for assistance and administration that are mandatory throughout the State. . .”

• Statewideness - Available throughout state to

extent feasible, reasonable, and practical

Key State Plan Requirements: Statewideness

• Services available to any categorically needy

recipient are not less in amount, duration, and scope than those services available to a medically needy recipient; services are equal for any individual within an eligibility group.

‐ Same amount, duration, and scope within categorically needy and medically needy groups ‐ Exceptions: services provided only to individuals eligible for EPSDT benefit; pregnant women

Key State Plan Requirements: Comparability

• “any individual eligible for medical assistance…

may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required… who undertakes to provide him such services.”

— Beneficiaries must have a choice of qualified providers — And any willing and qualified provider must be allowed to participate in Medicaid program

Key State Plan Requirements: Freedom of Choice

• Provider qualifications- Provider qualifications

established by the State are reasonably related to the Medicaid service(s) furnished

• Payment for services (4.19-B pages)-

Reimbursement methodologies must include methods/procedures to assure payments are consistent with economy, efficiency, and quality

• f care principles

Additional State Plan Requirements

• Submission of a State Plan Amendment (SPA) is

necessary to make any changes in coverage or reimbursement for services.

• Why change the state plan?

—Mandated legislative changes (State/federal) —Change in eligibility group or resource standards or covered service(s) —Change/addition of managed care services —Implementation of optional services —Change in payment methodology

State Plan Amendments

• OPTIONAL

‐ Prescription Drugs ‐ Clinic services ‐ Therapies – PT/OT/Speech/Audiology ‐ Respiratory care services ‐ Podiatry services ‐ Optometry services ‐ Dental Services & Dentures ‐ Prosthetics ‐ Eyeglasses ‐ Other Licensed Practitioner services ‐ Private Duty Nursing services ‐ Personal Care Services ‐ Hospice ‐ Case Management & Targeted Case Management ‐ TB related services ‐ State Plan HCBS - 1915(i) ‐ Community First Choice Option - 1915(k) ‐ Inpatient Psychiatric Services for Individuals under age 21 (required per EPSDT)

Medicaid Benefits in the Regular State Plan

• MANDATORY

– Inpatient hospital services – Outpatient hospital services – EPSDT: Early and Periodic Screening, Diagnostic, and Treatment services – Nursing Facility services – Home Health services – Physician services – Rural Health Clinic services – Federally Qualified Health Center services – Laboratory and X-ray services – Family Planning services – Nurse Midwife services – Certified Pediatric and Family Nurse Practitioner services – Freestanding Birth Center services (when licensed or otherwise recognized by the state) – Transportation to medical care – Tobacco Cessation counseling for pregnant women

• Early and Periodic Screening, Diagnostic

and Treatment Benefit

• EPSDT is the Medicaid program’s

comprehensive preventive health benefit for children and adolescents under the age

• f 21 – mandatory provision of 1905(a)

services

• The goal of EPSDT is to ensure that children

receive the health care they need when they need it – the right care to the right child at the right time in the right setting

EPSDT

• Screening services
• Vision Services (including glasses)
• Dental Services
• Hearing Services (including hearing

aids)

• Any other medically necessary,

Medicaid coverable service under 1905(a) (regardless if it is offered to

• thers under the state plan)

EPSDT Required Services

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• Periodicity schedules (screening)

– States must develop a periodicity schedule that meets reasonable standards of medical and/or dental practice; or may adopt a nationally recognized schedule (AAP/Bright Futures)

• Interperiodic Screenings

EPSDT

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• Section 1905(r)(5) requires that any

medically necessary Medicaid coverable 1905(a) service be provided to an EPSDT eligible based on medical necessity.

• States determine medical necessity
• n a case by case basis
• Providers’ recommendations should

be considered in making the determination

EPSDT Medical Necessity

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• Inform all eligible beneficiaries (or

families) about the EPSDT benefit

• Ensure access is available for all

necessary services:

– Provide or arrange for screening services – Treatment services – Annual reporting to CMS

EPSDT State requirements

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• Maintenance services are required
• Services may vary by state for

experimental or investigational services/treatment

• Aging out – once an individual turns

21 – EPSDT eligibility ceases

EPSDT

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• http://www.medicaid.gov/medicaid-chip-

program-information/by- topics/benefits/early-and-periodic- screening-diagnostic-and-treatment.html

• http://www.medicaid.gov/medicaid-chip-

program-information/by- topics/benefits/downloads/epsdt_coverage _guide.pdf

EPSDT Additional Resources

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• Longstanding policy on Medicaid

coverage of habilitative services

• Habilitative services not coverable

under the rehabilitative benefit (must restore function)

• CMS released an Information Bulletin
• n July 7, 2014, addressing coverage
• ptions for treatment services for

ASD

Services to Treat Autism Spectrum Disorder

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• Information Bulletin laid out several

benefit categories where treatment services for ASD could be covered:

– Preventive – Other licensed practitioners – Therapy services (PT, OT, ST)

Services to Treat Autism Spectrum Disorder

23

• CIB also specified that for EPSDT

eligibles, services to treat ASD must be provided through the Medicaid state plan

• Home and Community Based Services

Waivers (1915 (c)) will need to be revised to ensure that all children have access to needed services

• Several states have approved state plans;

also working with states with 1915(c) waiver programs to move appropriate services to state plan

Services to Treat Autism Spectrum Disorder

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Home and Community Based Services for Children with Disabilities

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Home and Community Based Services (HCBS)

• 1915(c) HCBS Waiver Programs:
• 1915(i) HCBS State Plan Option
• 1915 (j) Self-directed Personal Care
• 1915(k) Community First Choice

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Person-Centered Service Planning

• Driven by the individual and includes people chosen by the

individual

• Reflects cultural considerations/uses plain language
• Includes strategies for solving disagreement
• Offers choices to the individual regarding services and

supports the individual receives and from whom

• Conducted to reflect what is important to the individual
• Includes risk factors and plans to minimize them
• Is signed by all individuals and providers responsible for its

implementation

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• HCBS Website –

http://www.medicaid.gov/HCBS

– Final HCBS regulation – Fact Sheets

• General overview
• HCBS settings
• 1915(c) - Changes to HCBS Waiver Program
• 1915(i) - Key Provisions or HCBS State Plan

Option

• Mailbox to send additional questions:

hcbs@cms.hhs.gov

HCBS Resources

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CMCS and SAMHSA Informational Bulletin

Encourages the integrated use of trauma-focused screening, functional assessments, and evidence-based practices to improve child well-being. http://www.medicaid.gov/Feder al-Policy- Guidance/Downloads/SMD-13- 05-07.pdf

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Number of Eligible but Uninsured Children 2008-2013 in the US (in Millions)

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Source: Forthcoming analysis of the Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2008 to 2013.

Jean Close Jean.close@cms.hhs.gov 410-786-2804 Cindy Ruff Cynthia.ruff@cms.hhs.gov 410-786-5916

Questions?