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

Medicaid in Brief • States create their own unique programs • Each State develops and operates a State plan outlining 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

State Administered/Federal Oversight • Requirement for the designation or establishment of 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

Medicaid Eligibility • Individuals must be in a “group” covered by the State’s Medicaid program • Some groups are mandatory, others are optional

State/Federal Partnership & the Medicaid State Plan • 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 operated per the requirements of Title XIX of the Social Security Act and other official issuances • Developed and amended collaboratively with CMS

State Plan Requirements • 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 or condition

Key State Plan Requirements: Sufficiency • “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: Statewideness • “. . .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: Comparability • 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: Freedom of Choice • “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

Additional State Plan Requirements • 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 of care principles

State Plan Amendments • 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

Medicaid Benefits in the Regular State Plan • • MANDATORY OPTIONAL – Inpatient hospital services ‐ Prescription Drugs – ‐ Outpatient hospital services Clinic services – ‐ EPSDT: Early and Periodic Screening, Therapies – PT/OT/Speech/Audiology ‐ Respiratory care services Diagnostic, and Treatment services – ‐ Podiatry services Nursing Facility services – ‐ Optometry services Home Health services – ‐ Dental Services & Dentures Physician services ‐ – Prosthetics Rural Health Clinic services ‐ Eyeglasses – Federally Qualified Health Center services ‐ Other Licensed Practitioner services – Laboratory and X-ray services ‐ Private Duty Nursing services – Family Planning services ‐ Personal Care Services – Nurse Midwife services ‐ Hospice – Certified Pediatric and Family Nurse ‐ Case Management & Targeted Case Practitioner services Management – Freestanding Birth Center services (when ‐ TB related services licensed or otherwise recognized by the ‐ State Plan HCBS - 1915(i) state) ‐ Community First Choice Option - 1915(k) – Transportation to medical care ‐ Inpatient Psychiatric Services for Individuals – Tobacco Cessation counseling for pregnant under age 21 (required per EPSDT) women

EPSDT • 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 of 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 Required Services • 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 others under the state plan) 16

EPSDT • 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 17

EPSDT Medical Necessity • 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 on a case by case basis • Providers’ recommendations should be considered in making the determination 18

EPSDT State requirements • 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 19

EPSDT • 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 20

EPSDT Additional Resources • 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 21

Services to Treat Autism Spectrum Disorder • Longstanding policy on Medicaid coverage of habilitative services • Habilitative services not coverable under the rehabilitative benefit (must restore function) • CMS released an Information Bulletin on July 7, 2014, addressing coverage options for treatment services for ASD 22

Services to Treat Autism Spectrum Disorder • Information Bulletin laid out several benefit categories where treatment services for ASD could be covered: – Preventive – Other licensed practitioners – Therapy services (PT, OT, ST) 23

Services to Treat Autism Spectrum Disorder • 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 24

Home and Community Based Services for Children with Disabilities 25