A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents

Transcript

1 A Guide for States : EPSDT - Coverage in the Medicaid Benefit for Children and Adolescents KTAYLORG ©ISTOCKPHOTO | Early an d Periodic Screening, Diagnostic and Treatment (EPSDT) 2014 JUNE - http://www.medicaid.gov/Medicaid- CHIP- Program -Information/By Available at -and- Treatment.html Topics/Benefits/Early -and- Periodic -Screening -Diagnostic

2 EPSDT: A Guide for States Table of Contents Introduction ... 1 I. Periodic and Interperiodic Screenings II. ... 4 Diagnostic Services ... 8 III. ... 9 IV. The Scope of EPSDT Treatment Services A. Scope of Services ... 9 Cover ing a Range of Treatment Services to Meet a Child’s Needs ... 10 B. a. Mental Health and Substance Use Services ... 10 ... 12 b. Personal Care Services c. Oral Health and Dental Services ... 13 Vision and Hearing Services ... 15 d. e. Other Services ... 16 C. Enabl ing Services ... 16 ... 16 a. Transportation Services b. ... 17 Language Access and Culturally Appropriate Services Settings and Locations for Services D. ... 19 a. Services Provided Out of State ... 19 b. Services Provided in Schools ... 20 c. Most Integrated Setting Appropriate ... 21 V. Permissible Limitations on Coverage of EPSDT Services ... 23 Individual Medical Necessity ... 23 A. B. Prio r Authorization ... 24 Exp erimental Treatments ... 24 C. D. Cost -Effective Alternatives ... 25 ... 26 Services Available Under Other Federal Authorities VI. A. Home and Community Based Services Waivers ... 26 B. Alternative Benefit Plans ... 27 27 C. Role of Maternal and Child Health Services ... i

3 EPSDT: A Guide for States Access to S ... 28 VII. ervices Access to Providers A. ... 28 B. Managed Care ... 29 C. Timeliness ... 32 VIII. Notice and Hearing Requirements ... 33 IX. Conclusion ... 35 What You Need to Know About EPSDT ... 36 X. ... 37 XI. Resources CMS Resources ... 37 Adolescent Health ... 37 Oral Health ... 37 Mental Health ... 37 Screening Services ... 37 Accessibil ity ... 37 Other Federal Resources ... 38 Other Resources ... 38 Produced in collaboration with the National Health Law Program under subcontract to NORC at the University of Chicago www.NORC.org ii

4 EPSDT: A Guide for States INTRODUCTION I. program ’s benefit for children and adolescents is known as Early The Medicaid and Periodic Screening, Diagnostic and Treatment services, or EPSDT. EPSDT provides prevention , diagnostic, and treatment services a comprehensive array of for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act) . The EPSDT benefit is more that children robust than the Medicaid benefit for adults and is designed to assure receive early detection and care, health problems are averted or diagnosed so that and treated as early as possible. T he goal of EPSDT is to assure that individual children get 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’s goal is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. States share responsibility for implementing the benefit , along with the Centers (CMS) & Medicaid Services . States have an affirmative obligation for Medicare to make sure that Medicaid -eligible children and their families are aware of 1 EPSDT and have access to required screening s and necessary treatment services. also have broad flexibility to determine how to best ensure such services States either administer the benefit outright (through fee are provided . In gen eral, they for service arrangements) or provide oversight to private entities with whom they entities ). State s have contracted to administer the benefit (e.g., managed care children to must arrange (directly or through delegations or contracts) for receive the physical, mental, vision, hearing, and dental services they need to treat health problems and conditions. Through the EPSDT benefit, children’s health is they become advanced and treatment problems should be addressed before more difficult and costly. 1 CMS, State Medicaid Manual §§ 5010, 5121, 5310 (requiring states to “[a]ssure that hea lth problems found are diagnosed and treated early, before they become more complex and their treatment more costly,. . . that informing methods are effective, . . . [and] that services covered under Medicaid are available.”) 1

5 EPSDT: A Guide for States EPSDT entitles enrolled infants, children and adolescents to any treatment or proc edure that fits within any of the categories of Medicaid -covered services listed in Section 1905(a) of the Act if that treatment or service is necessary to 2 “correct or ameliorate” defects and physical and mental illnesses or conditions. , This includes physician, nurse practitioner and hospital services; physical speech , and occupational therap ies; home health services, including /language medical equipment, supplies, and appliances; treatment for mental health and substance use disorder s; treatment for vision, hearing and dental diseases and disorders, and much more. This broad coverage requirement result s in a comprehensive, high-quality health benefit for children under age 21 enrolled in Medicaid . Children’s health problems should be addressed before they become advanced and treatment is more difficult and costly. certain data about their delivery of services under report annually to CMS States 3 the EPSDT benefit. The reporting is made on the 416 . CMS and CMS Form use this data to monitor performance. states EPSDT This guide is intended to help states, health care providers and others to so that they may understand the scope of services that are covered under EPSDT provide the best possible c hild and adolescent health realize EPSDT’s goals and benefit through their Medicaid programs. While it does not establish new EPSDT policy, this guide serves the important purpose of compiling into a single document various EPSDT policy guidances that CMS has issued over the years. This outlines : guide EPSDT’s screening requirements, including when interperiodic screening should be provided; S cope of services covered under EPSDT ; EPSDT’s requirements governing dental, vision, and hearing services; P ermissible limitations on service coverage under EPSDT; 2 Section 1905(r)(5) of the S ocial Security Act. 3 Sections 1902(a)(43)(D) and 2108(e) of the Social Security Act; CMS, State Medicaid Manual § 2700.4. 2

6 EPSDT: A Guide for States S tates’ responsibilities to assure access to EPSDT services and providers; plans to provide the best states as they work with managed care A ssist ance to child health benefit possible; and Notice and appeal procedures required when services are denied, reduced or terminated . 3

7 EPSDT: A Guide for States PERIODIC AND INTERPE II. RIODIC SCREENINGS EPSDT covers regular screening services (check -ups) for infants, children and designed to identify health and developmenta adolescents. These screenings are l issues as early as possible. States have the responsibility to ensure that all eligible children (and their families) are informed of both the availability of screening services, and that a formal request for an EPSDT screening service is not required . States must provide or arrange for screening services both at established times and on an as- needed basis. Covered screen ing service s are medical, mental health, vision, hearing and dental. M edical screen ings has five components: nd developmental history that assesses for both Comprehensive health a ;4 physical and mental health, as well as for substance use disorders Comprehensive, unclothed physical examination; Appropriate immunizations , in accordance with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices ; Laboratory testing (including blood lead screening for age and appropriate risk factors); 5 and Health education and a nticipatory guid ance for both the child and caregiver .6 a periodicity schedule for each type of Under the Act, states must establish screening service : medical, vision, hearing, and dental. The periodicity schedules services should be provided and will be set the frequency by which certain 7 . covered The schedules are not prescribed by federal law, but should be based tates are on current standards of pediatric medical and dental practice, and s required to consult with recognized medical and dental organizations involved in child health care to assist in developing their periodicity schedules. One commonly used source is Bright Futures (deve loped by the American Academy , which , for example, suggest s that developmental screenings be of Pediatrics) s 9 months, 18 months, and 30 months. conducted when children are age The American Academy of Pediatric Dentistry (AAPD) has published a recommended periodicity schedule for dental services for children and adolescents. States should review their EPSDT periodicity schedules regularly to keep them up to date. 4 CMS issued an Informational Bulletin on March 27, 2013 , discussing Prevention and Early Identification of Mental Health and Substance Use Conditions in Children and informing states about resources available to help them meet the needs of children under EPSDT. 5 CMS issued guidance on June 22, 2012 to align blood lead screening for Medicaid children with recommendations of the Centers for Disease Control and Prevention (CDC). After providing data emonstrates that universal screening is not the most effective approach to identifying that d childhood exposure to lead, a state may request to implement a targeted lead screening plan rather than continue universal screening of all Medicaid -eligible children ag es 1 and 2. 6 Section 1905(r)(1)(B) of the Social Security Act. 7 42 C.F.R. § 441.58; CMS, State Medicaid Manual §§ 5110, 5140. 4

8 EPSDT: A Guide for States ates should review their EPSDT St periodicity schedules regularly to keep them up to date. EPSDT als “interperiodic ” screening o requires coverage of medically necessary state’s periodicity schedule . Coverage for such screenings is outside of the required based on an indication of a medical need to diagnose an illness or condition that was not present at the regularly scheduled screening or to determine if there has been a change in a previously diagnosed illness or services. condition that requires additional The determination of whether a is necessary may be made screening service outside of the periodicity schedule by the child’s physician or dentist, or by a health, developmental, or educational professional who comes into contact with a child outs ide of the formal health care system . This includes, for example, personnel working for s tate early intervention or special education programs, Head Start, and the Special Supplemental Nutrition Program for Women, Infants, and Children. A state may not lim it the number of medically necessary screenings a child receives and may ing s. ” screen not require prior authorization for either periodic or “ interperiodic Example of Screenings Beyond Those Required by the Periodicity Schedule A child receives a regularly scheduled periodic vision screening at age 5 at which no problem is detected. According to the state’s periodicity schedule, his next vision screening is due at age 7. At age 6, the school nurse recommends to the child’s parent that the child see an optometrist because a teacher suspects a vision problem. Even though the next scheduled vision screening is not due until the age of 7, the child would be entitled to receive a timely “interperiodic” screening to determine if there is a vision problem for which treatment is needed . The screening should not be delayed if there is a concern the child may have a vision problem. Source: NPRM, 58 Fed. Reg. 51288, 51290, 51291 (Oct. 1, 1993) Screening services provide the crucial link to necessary covered treatment, as EPSDT requires states to “arrang [e] for . . . corrective treatment ,” either directly , for any or through referral to appropriate providers or licensed practitioners 8 a screen ing . illness or condition detected by Th e affirmative obligation to connect children with necessary treatment makes EPSDT different from 9 Medicaid for adults. It is a crucial component of a quality child health benefit. 8 Section 1902(a)(43)(C) of the Social Security Act . 9 CMS, State Medicaid Manual § 5124.B. 5

9 EPSDT: A Guide for States The affirmative obligation to connect children with necessary treatment makes EPSDT different from Medicaid for adults. ified provider operating within the scope of his or her practice, as Any qual need not be defined by s tate law, can provide a screen ing service. The screening conducted by a Medicaid provider in order to trigger EPSDT coverage for follow up diagnostic services and medically necessary treatment by a qualified Medicaid provider. A screening service provided before a child enrolls in Medicaid is sufficient to trigger EPSDT coverage, after enro llment, for follow -up diagnostic services and necessary treatment. The family or beneficiary need not formally request an EPSDT screening in order to receive the benefits of EPSDT. Rather, any visit or contact with a qualified medical professional is suffi cient to satisfy EPSDT’s screening requirement, and states should consider a beneficiary who is receiving services to be participating in EPSDT, whether the beneficiary 10 requested screening services directly from the state or the health care provider. Any qualified provider operating within the scope of his or her practice, as defined by state law, can provide a screening service. services and should be establish their own fee schedules for screening States using Health Insurance Portability and Accountability Act (HIPAA) compliant billing codes. States may develop a bundled payment rate to pay for the physical health screening components under one billing code. States may also recognize ing separately. For example, one state pays each component of the EPSDT screen for the visit itself with one code and pays separately for each individual screening service delivered during the visit. This payment methodology not only encourages providers to perform every component of an EPSDT well- child visit, it also provides the state, through claims, information as to whether the physician actually met the elements of the EPSDT guidelines set out in the periodicity 10 CMS, State Medicaid Manual § 5310; HCFA, Title XIX State Agency Letter No. 91 -33 (April 3, 1991). 6

10 EPSDT: A Guide for States schedules. States may encourage providers to perform all five components of the EPSDT screening but may not exclude providers who perform only partial screenings from being reimbursed for the parts they do provide. Professional guidelines ( e.g. , Bright Futures) recommend that physicians include an oral health screen ing as part of the well -child visit at specified ages. In addition, states are permitted to include dental or oral health screening as a may be EPSDT service. These screening services, which separately covered performed by dental professionals or by medical professionals according to state scop e of practice rules, can take place in community or group settings as well as in clinics or medical and dental offices. Such screenings can be helpful in identifying children with unmet dental care needs so they can be referred to a added to the Two new procedure codes were dental professional for treatment. in 2012 to facilitate Code on Dental Procedures and Nomenclature (CDT) payment for oral health screenings and assessments: CDT 0190 and CDT 0191. In 2012, two new procedure codes were added to facilitate payment for oral health screenings and assessments: CDT 0190 and 0191. Vision and hearing screening services must also be provided. States should consult with ophthalmologists and optometrists to determine what procedures should be used during a vision screening and to establish the criteria for referral . For hearing screenings, appropriate procedures for for a diagnostic examination screening and methods of administering them can be obtained from audiologists 11 or from state health or education departments. 11 CMS, State Medicaid Manual § 5123.2.F. 7

11 EPSDT: A Guide for States III. DIAGNOSTIC SERVICES EPSDT covers medically necessary diagnostic services. When a screening examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnosis without delay. A child’s diagnosis may be performed by a physician, dentist or other practitioner qualified to evaluate and diagnose health problems at locations , including practitioners’ offices, maternal and child health (MCH) facilities, abilitation centers, and hospital outpatient community health centers, reh departments an outpatient basis . However, . Diagnosis can generally be made on inpatient services are covered when necessary to complete a diagnosis. When a screening examination indicates the need for further evaluation of a child’s health, the child should be referred for diagnosis without delay . 8

12 EPSDT: A Guide for States THE SCOPE OF EPSDT TREATMENT SERVICES IV. A. Scope of Services The Act provide s for coverage of that are all medically necessary services included within the categories of mandatory and optional services listed in section 1905(a), regardless of whether such se rvices are covered under the State Plan . These include physician and hospital services nursing, , private duty personal care services, home health and medi cal equipment and supplies, rehabilitative services, and vision, hearing, and dental services. Covered EPSDT services also include “any other medical care, and any other type of remedial care 12 recognized under S tate law, specified by the Secretary .” The role of states is to make sure the full range of EPSDT services is available as well as to assure that th ose services so as families of enrolled children are aware of and have access to to meet the individual child’s needs. T states to of services enables he broad scope design a child health benefit to meet the individual needs of the children served has the potential to result in by its Medicaid program—a benefit design that . As discussed in the next better care and healthier children at a lower overall cost section : while children enrolled in Medicaid are entitled to a broad scope of treatment services, no such service is covered under Medicaid unless medically necessary for that particular child . The Act provides for coverage of all medically necessary services that are included within the categories of mandatory and optional services listed in section 1905(a), regardless of whether such services are covered under the State Plan . 12 Section 1905(a)(29) of the Social Security Act. 9

13 EPSDT: A Guide for States has been determined to be medically If a service, supply or equipment that listed as covered (for adults) in a State Medicaid Plan, necessary for a child is not the child as long as the state will nonetheless need to provide it to the service or supply could be covered under the State Plan , that is, as long as it is included within the categories of mandatory and optional services listed in section 1905(a). In such circumstances , the state would need to develop a payment methodology for the service, supply or equipment, including the possibility that to be made using a single- payment may need -state service agreement with an in provider or an out-of- . state provider who will accept Medicaid payment A service need not cure a condition in order to be covered under EPSDT. Services that maintain or improve the child’s curr ent health condition are also covered in EPSDT because they “ameliorate” a condition. Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems. Services are covered when they prevent a condition from worsening or prevent development of additional health problems. The common definition of “ameliorate” is to “make more tolerable.” Thus, services such as physical and occupational therapy are covered when they have an urpose. This is particularly important for children ameliorative, maintenance p with disabilities, because such services can prevent conditions from worsening, reduce pain, and avert the development of more costly illnesses and conditions. Other, less common examples include items of durable medical equipment, such as decubitus cushions , bed rails and augmentative communication devices. Such services are a crucial component of a good, comprehensive child -focused health benefit. B. Covering a Range of T reatment Services to Meet a Child’s Needs As noted above, EPSDT cover s physical and mental health and substance use disorder services, regardless of whether these services are provided under the State Plan and regardless of any restrictions that states may impose on coverage could for adult services , as long as those services be covered under the State Plan . This section provides some examples of EPSDT’s broad scope of services, focusing on mental health and substance use services , personal care services, oral health and dental services, and vision and hearing services . a. Mental Health and Substance Use Services Treatment for mental health and substance use issues and conditions is available under a number of Medicaid service categories, including hospital and clinic services, physician services, and services provided by a licensed professional such as a psychologist. States should also make use of rehabilitative services. dren’s treatment needs, they While rehabilitative services can meet a range of chil 10

14 EPSDT: A Guide for States can be particularly critica l for children with mental health and substance use issues. Rehabilitative services are defined to include: any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an 13 individual to the best possible functional level. ve services need not Like other services covered under EPSDT, rehabilitati actually cure a disability or completely restore an individual to a previous are covered when they ameliorate a functional level. Rather, such services physical or mental disability, as discussed above. Moreover, determinations of whethe r a service is rehabilitative must take into consideration that a child may not have attained the ability to perform certain functions. That is, a child’s rehabilitative services plan of care should reflect goals appropriate for the child’s development al s tage. Rehabilitative services are particularly critical for children health and substance with mental use issues. Dependi ng on the interventions that the individual child needs, s ervices that can be covered as rehabilitative services include: Community -based crisis services, such as mobile crisis teams, and intensive outpatient services; Individualized mental health and substance use treatment services , including in non-traditional settings such as a school, a workplace or at home; Medication management; Counseling and therapy, including to eliminate psychological barriers that would impede development of community living skills; and Rehabilitative equipment, for instance daily living aids . With respect to the provision of rehabilitative services, including those noted above, CMS requires more specificity of providers and services due to the wide spectrum of rehabilitative services coverable under the broad definition . CMS 13 Section 1905(a)(13) of the Social Security Act; 42 C.F.R. § 440.130(d). 11

15 EPSDT: A Guide for States ir State Plan the services, with would expect a state to include in the and providers their qualifications, as well as a reimbursement methodology for each service it provides. CMS is available to provide technical assistance to states that are covering a service for children that has not otherwise been identified in the ir State Plan. A number of based services home and community- , including those that can be provided through EPSDT, have proven to significantly enhance positive outcomes for children and youth. These include intensive care coordination (“wraparound”), intensive in- home services, and mobile crisis response and stabilization. CMS has issued detailed guidance encouraging states to include screening, assessments, and treatments focusing on children who have been victims of complex trauma. EPSDT can be a crucial tool in addressing the profound needs of this population, including chil dren who are involved in the child welfare system. b. Personal Care Services EPSDT requires coverage of medically necessary personal care services, which : are f urnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility . . . or institution for mental disease, that are (A ) authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State), otherwise authorized for the individual in accordance with a service plan approved by the S tate; ( B) provided by an individual who is qualified to provide such services and is not a member of the individual’s family; and (C ) furnished in 14 a home or . . . in other location. Personal care services provide a range of assistance with performing activities of daily living, such as dressing, eating, bathing, transferring, and toileting; and and managing instrumental activities of daily living , such as preparing meals 15 medications. While it is optional for states to provide personal care services for adults in locations other than the home, this is not the case for a child. U nder EPSDT , personal care services are to be provided , for example, in a school or group home i f necessary to “correct or ameliorate” a condition. The determination of whether a child needs personal care services must be based ividual needs and provided in accordance with a plan of upon the child’s ind treatment or servic e plan . Under regular State Plan Medicaid, no Medicaid payments are available for personal care services provided by the child’s legally 14 Section 1905(a)(24) of the Social Security Act; 42 C.F.R. § 440.167 . 15 § 4480. CMS, State Medicaid Manual 12

16 EPSDT: A Guide for States 16 he determination of whether a child needs In addition, t responsible relatives. personal care services must be based up on the child’s individual needs and a consideration of family resources that are actually —not hypothetically— available. c. Oral Health and Dental Services 17 in the EPSDT benefit include: Dental services required Dental care needed for relief of pain, infection, restoration of teeth, and maintenance of dental health (provided at as early an age as necessary); and Emergency, preventive, and therapeutic services for dental disease that, if left untreated, may become acute dental problems or cause irreversible damage to the teeth or supporting structures. 18 19 In addition, medically necessary oral health and dental services, including those identified during an oral screening or a dental exam, are covered for children. -eligible children to the extent States must provide orthodontic services to EPSDT necessary to prevent disease and promote oral health, and restore oral structures 20 to health and function. Orthodontic services for cosmetic purposes are not covered . Once a child reaches the age specified by the state in its pediatric dental 21 periodicity schedule, typically age one, a direct dental referral is required. The referral must be for an encounter with a dentist or with another dental professional, such as a dental hygienist, working under the supervi sion of a 22 dentist. Dental supervision includes the entire range, for example, direct, indirect, general, public health and collaborative practice arrangements. 16 42 C.F.R. § 440.167. 17 Information on CMS efforts working with states to improve access to oral health services for children enrolled in Medicaid and CHIP can be found in CMS, Improving Access to and Utilization of Oral Health Services for Children in Medicaid and CHIP Programs: CMS Oral Health Strategy (April 11, 2011). Approaches states can use to improve the delivery of dental and oral health services to children in Medicaid and CHIP can be found in Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents and in Improving Oral Health Care Delivery in Medicaid and CHIP: A Toolkit for States . All of these documents are available at -Program http://www.medicaid.gov/Medicaid -CHIP -Topics/Benefits/Dental- -Information/By Care.html . 18 CMS, State Medicaid Manual § 5124.B.2.b . 19 State Medicaid Manual § 2700.4 (Form 416 Instructions, Note for Line 12 Data). Dental CMS, services are those performed by or under the supervision of a dentist. Oral health services are those performed by other licensed providers not working under the supervision of a dentist, for example, a physician or nurse , or by a dental professional operating without a supervisory relationship to a dentist (e.g., an independent practice dental hygienist ). 20 CMS, State Medicaid Manual § 5124.B.2.b 21 42 C.F.R. § 441.56(b)( vi). 22 G. § 5123.2. CMS, State Medicaid Manual 13

17 EPSDT: A Guide for States Current clinical guidelines recommend that a child have a first dental visit when the first tooth erupts or by age one. Dent al care must be provided at intervals indicated in the pediatric dental periodicity schedule adopted by the state after consultation with a recognized 23 dental organization involved in child health care. Current clinical guidelines recommend that a child have a first dental visit when the first tooth erupts or by age one, whichever occurs first. Dental care that is deemed medically necessary for an individual child is covered even when the frequency is greater than 24 specified in the periodicity schedule. For example, a child determined by a qualified provider to be at moderate or high risk for developing early childhood caries could be covered to receive dental exams and preventive treatments more frequently than the twice -yearly periodicity schedule recommended by the AAPD. As determined by dental practice acts in individual states, there is a wide range of dental professionals who can work under the supervision of a dentist, for example, dental hygienists, dental therapists, dental health aide therapists, dental hygienists in advanced practice, advanced practice dental therapists, dental assistants, and community dental health coordinat ors . Some state practice acts permit specified dental professionals to work without dentist supervision in . Such provisions can help ensure access to dental care as certain circumstances well as promote an integrated . As with medical care, health care delivery system any qualified provider operating within the scope of his or her practice, as defined by s tate law, can provide a dental or oral health service to a Medicaid enrollee. To qualify for federal matching funds, State Plans must list all provider types that will be permitted to bill for dental or oral health services. However, rendering providers (providers who actually serve the patient) need not be separately enumerated in the State Plan. with dental care can help Better i ntegration of primary medical care identify children at risk for tooth decay at the youngest age possible, offer evidence- based preventive care, such as fluoride varnish and oral health education, and refer children to a dent al professional for a complete check -up and any needed treatment . T hree oral health risk assessment CDT billing codes can support this 23 Section 1905(r) (3) of the Social Security Act ; CMS, State Medicaid Manual § 5110. 24 CMS, State Medicaid Manual § 5110. 14

18 EPSDT: A Guide for States , such as that approach, potentially preventing the need for costly treatment provided in an operating room. State Medicaid and CHIP programs can use risk assessment codes to h elp children access services based on their individual levels of risk, instead of assuming that all children need the same level of intervention. AAPD guidelines encourage providers to customize care plans based on an assessment of each isk assessment resources child’s individual risk for developing dental disease. R are available for providers, including an assessment tool from AAPD that includes a caries- risk assessmen t form, clinical guidelines and treatment protocols. In addition to dental providers, states may reimburse primary care medical providers for conducting oral health risk assessments, providing oral health education to parents and children, applying preventive measures such as fluoride varnish, and making referrals to dental professionals . The CMCS oral health strategy guide, Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents , provides additional information on oral health and EPSDT. d. Vision and Hearing Services Vision and hearing services are an essential component of the EPSDT ben efit. can lead to other problems, including interference with Hearing impairments normal language development in young children. They can also delay a child’s social, emotional, and academic development. Vision problems can be evidence of serious, degenera tive conditions , and can also lead to delays in learning and social development. EPSDT requires that vision and hearing services be provided at intervals that meet reasonable standards as determined in consultation with medical experts, and at other inter vals, as medically necessary, to determine the existence of a suspected illness or condition. At a minimum, vision services must include diagnosis and treatment for defects in vision, including eyeglasses. Glasses to replace those that are lost, broken, or stolen also must be covered. Hearing services must include, at a minimum, diagnosis and treatment for defects in 25 hearing, including hearing aids. In addition, i f hear ing and vision problems are detected through screening, medically necessary services th at are coverable under section 1905(a) must be covered. This includes not only physician and clinic services, but services from licensed professionals such as ophthalmologists, and equipment such as augmentative communication devices and cochlear implants. 25 Sections 1905(r)(2) and (4) of the Social Security Act. 15

19 EPSDT: A Guide for States e. Other Services for children under Medicaid when medically Examples of other services covered (and for which a federal match is available) include, but are not limited necessary 26 ; to, case management services (including targeted case management) incontinence supplies; organ transplants and any related services; a specially adapted car seat that is needed by a child because of a medical problem or condition; and nutritional supplements. Physicians and other providers use medical terminology, not Medicaid terms or legal terms, when recommending or prescribing medical services and treatments. If a requested service or treatment is not listed by name in Medicaid’s list of services, it should nonetheless be provided if the service or item is determine d to be medically necessary and coverable under the list of services at section 1905(a). In general, states are encouraged to include in their S tate Plans a range of provider types and settings likely to be sufficient to meet the needs of enrollees. Noneth eless, t here may be cases in which the type of provider that is . In such an instance, the state in Medicaid needed is not already participating could meet the EPSDT requirement by, for example, entering into a single - service agreement with the needed provi der. When providers use medical terminology instead of Medicaid or legal terms to recommend medical ly necessary services, the recommended services coverable should be covered if under section 1905(a). C. Enabling Services a. Transportation Services In order to promote access to needed preventive, diagnostic and treatment services, states must offer appointment scheduling assistance and are required to assure necessary transportation, to and from medical appointments, for children 26 Social Security Act; 42 C.F.R. §§ 440.169, 441.18. Section 1905(a)(19) of the 16

20 EPSDT: A Guide for States 27 This includes covering the costs of an ambulance, taxi, . enrolled in Medicaid bus, or other carrier. It can also include reimbursing for mileage. As with other services covered through EPSDT, states may cover the least expensive means of transportation if it is actually available, accessible, and appropriate. For example, the public transportation public transportation can be covered instead of a taxi if is physically accessible for a particular beneficiary and takes a reasonable amount of time. In addition, “related travel e xpenses” are covered if medically 28 necessary, including meals and lodging for a child and necessary attendant. Some states have addressed the transportation requirement by offering non- emergency transportation through brokers who coordinate transportation through administrative managers who act as gatekeepers for services, or transportation services. Transportation may also be included in managed care If a state chooses not to include transportation services in their contracts. managed care contracts, or o therwise to contract out administration of the service, the state must administer the service itself. No matter the type of arrangement, it is important to remember that the s tate has ultimate responsibility for ensuring the provision of transportation services. b. Language Access and Culturally Appropriate Services Many Medicaid -enrolled children live in families where English is not spoken at home. State Medicaid agencies and their contractors should inform eligible individuals about the EPSDT benefit with a combination of written and oral methods “using clear and nontechnical language” and “effec tively informing 29 those individuals who . . . cannot read or understand the English language.” State Medicaid agencies and Medicaid managed care plans , as recipients of federal funds, also have responsibilities to assure that covered services are delivered to children without a language barrier. They are required take “reasonable steps” to assure that in dividuals who are limited English proficient 30 have meaningful access to Medicaid services. This may include providing interpreter services, including at medical appointments, depending on factors such as the number of limited English proficien t individuals served by the 31 program. 27 Section 1905(a)(29) of the Social Security Act; 42 C.F.R. §§ 440.170, 441.62. 28 42 C.F.R. § 440.170(a). 29 42 C.F.R. § 441.56(a); CMS, State Medicaid Manual §§ 5121.A, 5121.C. 30 42 U.S.C. § 2000d (Title VI of the Civil Rights Act); Affordable Care Act § 1557; . CMS Dear State Medicaid Director (Aug. 31, 2000) 31 Department of Health & Human Services, Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, 68 Fed. Reg. 47311 (August 8, 2003). 17

21 EPSDT: A Guide for States (a) services, all Though interpreter services are not classified as mandatory 1905 providers who receive federal funds from HHS for the provision of Medicaid to make language services are obligated , under Title VI of the Civil Rights Act, limited English proficiency. services available to those with Though interpreters are not Medicaid qualified providers, their services may be reimbursed when billed by a qualified provider rendering a Medicaid covered service. e not required to (but may) reimburse providers for the cost of language States ar services. States may consider the cost of language services to be included in the regular rate of reimbursement for the underlying direct service. In those cases, Medicaid providers are obligated to provide language services to those with and to bear the costs for doing so. Alternatively, limited English proficiency states may allow providers to bill specifically for interpreter services. States have cost of interpretation services, either as medical the option to claim for the - 32 assistance related expenditures or as administration. Claiming Federal Matching Funds f or Interpreter Services. Interpreters are not owever Medicaid qualified providers. H , their services may be reimbursed when billed by a qualified provider rendering a Medicaid covered service. Interpreters may not be paid separately. As of February 2009, oral interpreter services can be claimed using billing code T-1013 along with the CPT code used for the medical encounter. States can also raise reimbursement rates to recognize additional service costs, including interpreter costs, but must do so for services rendered by all providers in the class. With the enactment of the Children’s Health Insurance Program Reauthorization Act in 2009, s tates were given the option to claim a higher federal matching rate (75% under Medicaid) for translation and interpretation services that are claimed as administration and are related to the enrollment, retention and use of services und er Medicaid and CHIP by children 33 of families for whom English is not their primary language. Otherwise, longstanding CMS policy permits reimbursement at the standard 50% federal 32 CMS , Dear State Medicaid Director (July 1, 2010) ; CMS, CMCS In formational Bulletin: Recent Developments in Medicaid (April 26, 2011) . 33 Section 1903(a)(2)(E) of the Social Security Act. 18

22 EPSDT: A Guide for States matching rate for translation and interpretation activities that are claimed as an administrative expense, so long as they are not included and paid for as part of 34 the reimbursement rate for direct services. State Medicaid programs, managed care entities, and Medicaid - participating health care providers should all be culturally competent . The HHS Office for Civil Rights and the Department of Justice have provided guidance for recipients of federal funds on expectations of how to provide 35 language services. State Medicaid programs, managed care entities, and Medicaid -participating health care providers should all be culturally competent. This means they need to recognize and understand the cultural beliefs and health practices of the families and children they serv e, and use that knowledge to implement policies and inform practic es that support quality interventions and good health outcomes for ongoing. The children. Given changing demographics, this process is DHHS offers numerous resources, including: Office of Minority Health Center for Linguistic and Cultural Competence in Health Care ; Think Cultural Health ; ; A Physician’s Practical Guide to Culturally Competent Care iate T he National Standards for Culturally and Linguistically Appropr Services in Health and Health Care (the National CLAS Standards) ; and The National CLAS Standards’ implementation guide, A Blueprint for Advancing and Sustaining CLAS Policy and Practice . D. Settings and Locations for Services Provided Out of S tate a. Services States may need to rely upon out-of- state services if necessary covered services are not available local ly, or if a Medicaid beneficiary is out of state at the time a need for medical services arises. States are required to pay for services provided 34 CMS, Dear State Medicaid Director (August 31, 2000). 35 ; U.S. Department of Justice, Executive Order 13166. Id 19

23 EPSDT: A Guide for States to the same extent services furnished in in another state -state would be paid for if: state services are required because of an emergency; The out-of- The child’s health would be endangered if she or he were required to travel to t heir home state; The state determines that the needed services are more readily available in the other state; or It is a general practice of the locality to use the services of an out -of- state 36 provider, for example, in areas that border another state. state providers gives Including out-of- states the opportunity to expand the range 37 and accessibility of Medicaid services that are available to their enrollees . Provided in b. Services Schools Services provided in schools can play an important role in the health care of adolescents and children. Whether implemented for children with special needs under the Individuals with Disabilities Education Act (IDEA) or through school- based or linked health clinics, school- centered programs may be able to provide medical extended care efficiently and and dental effectively while avoiding . absences from school In order for Medicaid to reimburse for health services provided in the schools, the services must be included among those listed in section 1905(a) of the Act and included in the S tate Plan , or be available under the EPSDT benefit . There is no benefit category in the Medicaid statute titled “school health services” or “early intervention services.” Therefore a state must describe its school health services in terms of the specific section 1905(a) services which will be provided. In a ddition, there must be a provider agreement in place between the state school must Medicaid agency and the provider billing for the service ; and the -specific requirements regarding service agree to comply with Medicaid 38 documentation and claims submission. States are encouraged to promote relationships between school -based providers and managed care plans. Services provided in schools can play an important role in the health care of adolescents and children. 36 Section 1902(a)(16) of the Social Security Act; 42 C. F.R. § 431.52. 37 HCFA, Dear State Medicaid Director (July 25, 2000). 38 42 C.F.R. § 431.107. 20

24 EPSDT: A Guide for States to provide medical, vision, and Schools are particularly appropriate places hearing screenings; vaccinations; some dental care; and behavioral health services. The Individuals with Disabilities Education Act (IDEA) requires that ve available a free appropriate public every child with a disability ha education that includes special education and related services. Part B of IDEA requires the development and implementation of an individualized education program (IEP) that addresses the unique needs of each child with a disability ages 3 through 39 21. A ch ild’s IEP identifies the special education and related services needed by that child . Medicaid covered services included in the IEP may be provided in, and reimbursed to, schools . Part C of IDEA covers early intervention services, which are developmental services designed to meet a child’s developmental needs in physical, cognitive, communication, adaptive, and social and emotional development, for children from birth to age 3. These services are provided pursuant to an Individualized Family Service Plan (IFSP). Examples of IDEA services that can be covered by Medicaid for a Medicaid eligible child include physical therapy, occupational therapy, personal care, and 40 services for children with speech, hearing and language disorders. c. Most Integra ted Setting Appropriate Title II of the Americans with Disabilities Act (ADA) prohibits discrimination on the basis of disability in public programs, including Medicaid. In Olmstead v. the Supreme Court held that unjustified institutionalization of M edicaid L.C., beneficiaries violate states must cover services in the Accordingly, s the ADA. community, rather than in an institution, when the need for community services can be reasonably accommodated and providing services in the community will lly alter not fundamenta the s tate’s Medicaid program. Community - based care is a best practice for supporting children with disabilities and chronic conditions . CMS has long encouraged states to provide services in home and community settings, particularly for children, not only because of Olmstead, but because community- based care is considered a best practice for supporting children with 39 While EPSDT covers children only through age 20 (up to the 21st birthday), the IDEA covers children through age 21 (up to the 22 nd birthday). 40 -covered services provided in schools can be found in the Additional information about Medicaid . CMS, Medicaid School Based Administrative Claiming Guide (2003) 21

25 EPSDT: A Guide for States disabilities and chronic conditions. In addition, it is generally more cost- 41 effective. EPSDT provides states with many options for covering physical and mental health services in the community. The EPSDT benefit requires coverage of medically necessary personal care, private duty nursing, physical, occu pationa l and speech -language therapy. And, as discussed below , optional services home and community based services waivers can further provided through state’s efforts to provide services in the community . advance the 41 HCFA, Dear State Medicaid Director, Olmstead Update Nos. 2 and 3 (July 25, 2000), No. 5 Joint CMCS and Dear State Medicaid Director (January 10, 2001); CMS, (May 20, 2010); CMS, SAMHSA Informational Bulletin: Coverage of Behavioral Health Services for Children, Youth, . and You ng Adults with Significant Mental Health Conditions (May 7, 2013) 22

26 EPSDT: A Guide for States PERMISSIBLE LIMITATI E OF V. ONS ON COVERAG EPSDT SERVICES A. Individual Medical Necessity Services that fit within the scope of coverage under EPSDT must be provided to a child only if n ecessary to correct or ameliorate the individual child’s physical or mental condition, i.e., only if “medically necessary .” The determination of whether a service is medically necessary for an individual child must be made on a case- by-case basis, taking into account the particular needs of the chil d. T he state (or the managed care entity should consider the as delegated by the state) child’s long- term needs, not just what is required to address the immediate situation. The state should also consider all aspects of a child’s needs, including nutritional, social development, and mental health and substance use disorders. States are permitted (but not required) to set parameters that apply to the determination of medical necessity in individual cases, but those parameters may not contradict or be more restrictive than the federal statutory requirement. As covered and occupational therapy are discussed above, services such as physical when they have an ameliorative, maintenance purpose . D etermination of whether a service is medically necessary - case must be made on a case- by basis, taking into account a particular child ’s needs. are individualized, flat limits or hard limits ical necessity decisions med Because ary constraints are not consistent with EPSDT based on a monetary cap or budget 42 . requirements States may adopt a definition of medical necessity that places tentative limits on services pending an individualized determination by the s tate, or that limits a treating provider’s discretion, as a utilization control, but additional services must be provided if determined to be medically necessary for 42 HCFA, Regional Transmittal Notice (Region IV) (Sept. 18, 1990); Memorandum from Rozann Abato, Acting Director, HCFA, to Associate Regional Administrator, Atlanta (Sept. 5, 1990); Memoran dum from Christine Nye, HCFA Medicaid Director, to Regional Administrator Region -42) (1991). VIII (FME 23

27 EPSDT: A Guide for States 43 For example, a state may place in its State Plan a while an individual child. number of physical therapy limit of a certain for individuals age visits per year 21 and older, such a “hard” limit could not be applied to children. A state could impose a “so a certain number of physical therapy visits annually for ft” limit of children, but if it were to be determined in an individual child’s case, upon review, that additional physical therapy services were medically necessary to correct or ameliorate a diagno sed condition, those services would have to be covered . While t he treating health care provider has a responsibility for determining or recommending that a particular covered service is needed to correct or ameliorate 44 the child’s condition, both the state and a child’s treating provider play a role in ing whether a service is medically necessary . If there is a disagreement determin between the treating provider and the s tate’s expert as to whether a service is medically necessary for a particular child, the state is responsible for making a decision, for the individual child, based on the evidence. That decision may be appealed by the child (or the child’s family) under the state’s Medicaid fair hearing procedures, as described in S ection VII I below. B. Prior Authorization States may impose utilization controls to safeguard against unnecessary use of care and services. For example, a state may establish tentative limits on the ion treatment service a child can receive and require prior authorizat amount of a 45 for coverage of medically necessary services above those limits. Prior authorization must be conducted on a case- by-case basis, evaluating each child’s needs individually . Importantly, prior authorization procedures may not delay delivery of needed treatment services and must be consistent with the “preventive 46 thrust” of EPSDT. As such, prior authorization may not be required for any EPSDT screening services. In addition, medical management techniques used for mental health and substance use disorders should comply with the Mental Health Parity and Addiction Equity Act. C. Experimental Treatments EPSDT does not require coverage of treatments, services , or items that are experimental or investigational . Such services and items may, however, be state’s discretion if covered at the it is determined that the treatment or item 47 would be effective to address the child’s condition. Federal Neither the Medicaid statute nor the regulations define what constitutes an experimental 43 42 C.F.R. §§ 440.230(c), (d); HCFA Dear State Medicaid Director (May 26, 1993). 44 Sections 1905(a) and (r) of the Social Security Act. 45 Id . 46 H.R. Re p. No. 101-247 at 399, reprinted in U.S.C.C.A.N. 1906, 2125. 47 §§ 4385.C.1, 5122.F. CMS, State Medicaid Manual 24

28 EPSDT: A Guide for States The state’ s determination of whether a service is experimental must be treatment. 48 reasonable and should be based on the latest scientific information available. Medicare guidance on whether a service is experimental or investigational is not 49 determinative of the issue and may not be relevant to the pediatric population. D. Cost- Effective Alternatives A state may not deny medically necessary treatment to a child based on cost alone, but may consider the relative cost effectiveness of alternatives as part of the prior authorization process . Also , a state need not make services available in every possible setting as long as the services are reasonably available through the where the service is actually offered . States may cover services in the settings mode as long as the less expensive service is equally effective most cost effective 50 51 and actually available. The child’s quality of life must also be considered. In addition, the ADA and the Olmstead decision require states to provide services in the most integrated setting appropriate to a child’s needs, as long as doing so See above, Section IV.D. Thus, tate’s program. does not fundamentally alter the s if an institutional setting is less costly than providing services in a home or y nevertheless require that the community, the ADA’s integration mandate ma 52 services be provided in the community. A state may not deny medically necessary treatment based on cost alone, but may consider the relative cost effectiveness of alternatives as part of the prior authorization process. 48 Memorandum from S. Richardson to State Medicaid Directors (April 17, 1995). 49 17, 1995). Memorandum from S. Richardson to State Medicaid Directors (April 50 Olmstead Update No. 4 (January 10, 2001); Letter from CMS, Dear State Medicaid Director, Rozann Abato, Acting Director, Medicaid Bureau, to State Medicaid Directors (May 26, 1993). 51 Id . 52 28 C.F.R. § 35.130(d) ; CMS, Dear State Medicaid Direct or, Olmstead Update No. 4 (January 10, 2001); DOJ, Statement of the Department of Justice on Enforcement of the Integration Mandate of . (June 22, 2011) Title II of the ADA and Olmstead v. L.C. 25

29 EPSDT: A Guide for States SERVICES AVAILABLE UNDER OTHER FEDERAL VI. AUTHORITIES A. Home and Community Based Services Waivers A state Medicaid program may offer services through home and community based services (HCBS) waiver programs. Such programs allow states to provide HCBS to individuals who would otherwise need long- term care in a nursing facility, intermediate care facilit y, or hospital. Waiver programs provide for coverage of services that are not otherwise available through the Medicaid program (including EPSDT) because they do not fit into one of the categories es, respite services, or listed in section 1905(a). This includes habilitative servic These other services approved by CMS that can help prevent institutionalization. programs are sometimes called 1915(c) waivers after the section of the Social 53 Security Act that authorizes them. ed in an HCBS waiver program are also Children under age 21 who are enroll entitled to all EPSDT screening, diagnostic, and treatment services. Because HCBS waivers can provide services not otherwise covered under Medicaid, waivers and EPSDT can be used together to provide a comprehensive ben efit for children with disabilities who would otherwise need the level of care provided in . Thi s enable an institutional setting s those children to remain in their homes and communities while receiving medically necessary services and supports. The iver services essentially “wrap -around” the EPSDT benefit. If a child HCBS wa enrolled in Medicaid is on a waiting list for HCBS waiver services, EPSDT requirements apply and necessary services that fit into the categories listed in 54 1905(a) must be covered. Ch ildren who are enrolled in an HCBS waiver program are also entitled to all EPSDT services. (j) (self- to children under section 1915 also choose to offer services States may directed personal assistance services), section 1915(k) (home and community- based attendant services and support) and section 1945 (coordinated care in 53 Section 1915(c) of the Social Security Act. 54 -B (Jan. 10, 2001). CMS, Dear State Medicaid Director, Olmstead Update No. 4, Att. 4 26

30 EPSDT: A Guide for States health homes for individuals with chronic conditions). Like services provided pursuant to a 1915(c) waiver, these services are not subject to EPSDT coverage provisions , but are instead available to supplement EPSDT services. B. Alternative Benefit Plans States must assure access to services available under the EPSDT benefit for all EPSDT -eligible children under age 21 enrolled in Alternative Benefit Plans 55 (formerly known as benchmark plans and benchmark- equivalent plans). C. Role of Maternal and Child Health Services Federal rules require state Medicaid agencies and Title V Maternal and Child Health (MCH) agencies and grantees to collaborate to assure better access to and receipt of the full range of screening, diagnostic, and treatment services covered 56 under EPSDT. Title V is administered by the Health Resources and Services Administration. Many state Medicaid agencies have entered into written agreements with their sister MCH programs and collaborate on improving access to EPSDT services in order to improve child health status. Among other things, cooperating MCH agencies can provide outreach, screening, diagnostic or treatment services, health education and counseling, case management and other assistance in achieving a comprehensive and effective child health benefit. MCH programs can also help Medicaid programs to enlist providers who can help ctual deliver a broad array of services. In addition, they can inform potential and a 57 Medicaid recipients about EPSDT and refer them to necessary services. CMS are crucial partner s in the encourages such collaborations as MCH programs , well -integrated child health benefit. creation and delivery of a high quality Many state Medicai d agencies have written agreements with their states’ MCH programs and collaborate to improv e access to EPSDT services . 55 42 C.F.R. § 440.345. 56 42 U .S.C. §§ 705(a)(5)(F), 709(a)(2); 42 C.F.R. § 441.61(c). 57 CMS, State Medicaid Manual § 5230. 27

31 EPSDT: A Guide for States ACCESS TO SERVICES VII. Access to Providers A. Access to covered services is of course a critical component of delivering an appropriate health benefit to children. Accordingly, a number of Medicaid and provisions are intended to assure EPSDT that children have access to an adequate number and range of pediatric providers. For example, s tates are required to “make available a variety of individual and group providers qualified and willing 58 to provide” services to children . States must also “take advantage of all 59 resources available” to provide a “broad base” of providers who treat children.” Some states may find it necessary to recruit new providers to meet children’s 60 needs. In the event a child needs a treatment that is not coverable under the categories listed in section 1905(a), states are to provide referral assista nce that includes giving the family or beneficiary the names, addresses, and telephone numbers of providers who have expressed a willingness to furnish uncovered 61 services at little or no expense to the family. S tates are required to make available a variety of providers who are qualified and willing to treat EPSDT children. ld is entitled to receive Medicaid services from any provider qualified to A chi provide the service and willing to furnish it, unless CMS has decided that this 62 “freedom of choice” requirement will not apply . Most states have received permission from CMS to provide some services to some children through managed care arrang that restrict the free choice of provider . ements An appropriate level of reimbursement can be critical to ensuring adequate 63 access to providers. While the statute provides states with broad authority to set provider payment rates, it requires that payments to providers must be consistent with efficiency, economy, and quality care and be sufficient to enlist enough 58 42 C.F.R. § 441.61. 59 CMS, State Medicaid Manual § 5220. 60 Id. 61 42 C.F.R. § 441.61(a). 62 Sections 1902(a)(23) and 1932(a) of the Social Security Act; 42 C.F.R. § 431.51(b). 63 (Jan 18, 2001). HCFA, Dear State Medicaid Director 28

32 EPSDT: A Guide for States at least to providers that care and services are available to Medicaid beneficiaries the general population in the geographic the extent that they are available to 64 area. Federal regulations provide that a Medicaid provider must agree to accept, as 65 full, the Medicaid payment for a covered service or item. payment in This may not bill a Medicaid beneficiary for the difference means that a provider between the provider’s charge and the Medicaid payment “balance (called bill ing” ). The payment in full requirement also prohibits Medicaid providers from billing beneficiaries for missed appointments. States may need to monitor compliance with this requirement. Section 1905(a) list s coverable Medicaid services and some provider types. means by which a s tate may cover a service by a provider There are at least two type that is not specified in section 1905(a). Section 1905(a)(6) permits s tates to cover “medical care, or any other type of remedial care recognized under S tate law, furnished by licensed practitioners within the scope of their practice as defined by S tate law.” Thus, a state may cover services performed by a class of providers (such as licensed dieticians) when the service they provide is not specifi ed in section 1905(a) as long as the service is determined medically necessary for a child. Alternatively, a provider’s services can be covered as a component of a section 1 905(a) service. For example, in the case of a licensed social worker, the services could be provided through a federally qualified health center or a clinic, both of which 1905(a). are recognized providers under section The process for covering a provider for a service not specified in section 1905(a) varies depending on how the state intends to provide the service. B. Managed Care EPSDT benefits must be available to all children covered by Medicaid . As such, children enrolled in managed care plans , prepaid inpatient health plans, prepaid ambulatory health plans , primary care case management systems (collectively referred to as managed care entities ) are entitled to the same EPSDT benefits Proper they would have in a fee for service Medicaid delivery system. ly implemented, managed care can enhance and promote EPSDT’s goals of ensuring that care is provided in a coordinated way and with an emphasis on prevention. States are responsible for assuring that the full EPSDT benefit is available to all Medicaid child ren in the state, even if the state contracts with a managed care entity to deliver some or all of the services available under EPSDT . The state’s 64 Section 1902(a)( 30)(A) of the Social Security Act; Medicaid Program: Methods for Assuring Access to Covered Medicaid Services , 76 Fed. Reg. 26,342 (May 11, 2011) (proposed regulations). 65 42 C.F.R. § 447.15. 29

33 EPSDT: A Guide for States managed care entit ies should be drafted with sufficient precision contracts with responsibilities with respect to children are delineated. so that the clearly entity’s A contract can provide that the managed care entities will be responsible for providing services under the EPSDT benefit to the same degree that the services are covered by the state. Or, i f certain responsibilities are carved out of the managed care contract, those carve-outs must be explicit, and the s tate will retain out services are provided to the responsibility for ensuring that those carved- enrolled children. For example, the state ma y ‘carve out’ dental services from the managed care contract; nonetheless, the state must assure that children receive (through either those services fee for service or a specialized dental plan). Managed care entities may not l use a definition of medica that is necessity for children more restrictive than the state’s definition . Managed care entities may for children not use a definition of medical necessity that is more restrictive than the state’s definition . One way to ensure this is for the s tate to include its definition of medical necessity in the entity’s contract . definitions and medical necessity States should review managed care entities’ ascertain criteria to is requirement . As a further step to whether they meet th consisten and proper implementation of provide for cy across the delivery system the children’s benefit package, it is the state ’s responsibility to educate its verify contracted managed care entities about EPSDT requirements, as well as to med about EPSDT requirements through that managed care providers are infor trainings and provider manuals. Further, states are responsible for ensuring that managed care entities fulfill their contractual responsibilities to inform all 66 families of the services available under EPSDT and how to access them. Information made available to enrollees, usually included in a member handbook, will should clearly explain which EPSDT services the managed care entity provide and how any EPSDT services not within the scope of the contract can be accessed by enrollees. M anaged care entities must make available to all enrolled children the entire scope of services included in the EPSDT benefit that is within 67 their contract with the state . 66 Sections 1902(a)(5) and (a)(43) of the Social Security Act. 67 42 C.F.R. § 438.210(a)(4). 30

34 EPSDT: A Guide for States demonstrate to Managed care entities must the state that they have adequate provider capacity in the plan to serve enrolled children, including an appropriate range of pediatric and specialty services; access to primary and preventive care; 68 and a sufficient number, mix and geographic distribution of providers. anaged care Monitoring m ’ compliance with EPSDT requirements is entities essential; a strong oversight framework ensures that states are meeting their 69 responsibilities to children as well as Federal monitoring requirements. There are several methods of exercising effective oversight in managed care systems. First, managed care organizations (MCOs) or prepaid states contracting with inpatient health plans (PIHPs) are statutorily required to draft, implement, and 70 maintain a managed care quality strategy. Th e quality strategy is intended to provide a blueprint for states in assessing and improving the quality of care 71 provided to managed care enrollees. By means of this strategy, states can monitor and evaluate managed care entities’ compliance with quali ty initiatives , track their performance on specified performance measures, and require them to design, implement and report the results of performance improvement projects . of MCOs external quality review Second, states are also required to ensure that 72 performed by unbiased, external entit and PHIPs are ies. tates can In this way, s determine whether managed care entities are reporting accurate performance outcomes data and whether they are in compliance with state contract provisions. tates can engage in an ongoing review of grievances and appeals related Third, s to children’s services, as well as monitoring complaints filed with the state’s enrollee and provider hotlines (if the state operates such hotlines). States could also require reports and perform data analysis of managed care entities’ encounter data to detect underutilization of services by children. 73 In addition, all states are required to complete and file the F orm 416 each year. This reports the number of children receiving health screening services, dental and oral health services, and referr als for corrective treatment, as well as the state’s rates of meeting EPSDT participation goals. 68 42 C.F.R. § 438.206. 69 42 C.F.R. § 438.240. 70 Section 1932(c)(1) of the Social Security Act; 42 C.F.R. §§ 438.202, 438.204. 71 42 C.F.R. § 438.202. 72 Section 1932(c)(2) of the Social Security Act; 42 C.F.R. § 438.350. 73 of the Social Security Act . Section 1902 (a)(43)(D) 31

35 EPSDT: A Guide for States C. Timeliness Services under the EPSDT benefit, like all Medicaid services, must be provided 74 wit h “reasonable promptness.” The s tate must set standards to ensure that EPSDT services are provided consistent with reasonable standards of medical and dental practice. The s tate must also ensure that services are initi ated within a reasonable period of time. What is reasonable depends on the nature of the service and the needs of the individual child. Because states have the obligation to “arrang[e] for . . . corrective treatment” either directly or through referral to oviders does not automatically relieve a state of appropriate providers, a lack of pr its obligation to ensure that services are provided in a timely manner. For example, as noted above, it may be necessary to cover services provided out of state. Services under the EPSDT benefit, like al l Medicaid services, must be provided with reasonable promptness. 74 Section 1902(a)(8) of the Social Security Act. 32

36 EPSDT: A Guide for States NOTICE AND HEARING R VIII. EQUIREMENTS Children under age 21, like all other people enrolled in Medicaid, have the right f a state or managed care to notice and an opportunity for a hearing. I take s entity an “action” – to deny, terminate, suspend, or reduce a requested treatment or service , it must give the beneficiary written notice of the action and of their right to a hearing (a pre-termination hearing, in instances where servic es are reduced 75 or terminated), including When instructions on how to request a hearing. services are being terminated or reduced, the notice must be sent at least ten days 76 effective date of the action. Under exceptional circumstances, the before the noti ce must be mailed no later than the day of the action, such as when the beneficiary’s physician prescribes a change in treatment or the beneficiary has 77 been admitted to an institution and is no longer eligible. The notice must contain a statement of the i ntended action, the specific reasons and legal support and an explanation of the individual’s hearing rights, rights to for the action, 78 representation and to continued benefits. If a state or managed care entity takes an action to deny, suspend, or reduce a terminate, requested treatment or service, it must give the beneficiary written notice of the action and of their right to a hearing. The beneficiary is entitled to a hearing before the state Medicaid agency, or, if a state’s hearing process provides for it, an evidentiary hearing at the local level (for example at a county department of social services) with a right of appeal to 79 the s tate agency. The hearing must be conducted at a reasonable time, date, and place by an impartial hearing officia l. A beneficiary must be allowed to present his or her case to an impartial decision maker and present evidence and 75 Section 1902(a)(3) of the Social Security Act; Goldberg v. Kelly , 397 U.S. 254 (1970). 76 42 C.F.R. § 431.211. 77 42 C.F.R. § 431.213. 78 42 C.F.R. §§ 431.206, 431.210. 79 42 C.F.R. § 431.205(b). 33

37 EPSDT: A Guide for States 80 is also entitled to have representation, including witnesses. The beneficiary 81 legal counsel, a relative, or a friend. Before the hearing, beneficiaries must have the case file and all documents that will be used at the the right to examine 82 hearing. When a service is terminated or reduced, if the beneficiary requests a hearing within ten days of receiving notice of the termination or reduct ion, the beneficiary has the right to continued coverage of services pending a hearing 83 decision. This is sometimes called “aid paid pending.” Once the agency issues a final decision, the beneficiary generally has the right to appeal that decision to state court. Managed care enrollees must have access to in -plan grievance and appeal 84 dition to the state fair hearing system. Managed care plans processes, in ad must provide enrollees written notices that explain the action, the reason for the action, and the procedures for using the in- plan grievance and state fair hearing processes, including rights to continued benefits . Managed care plans must resolve complaints in a timely manner, including within three working days whe n ious ly jeopardize the the enrollee or provider indicates that delay could ser 85 enrollee’s life, health or ability to attain, maintain , or retain maximum function. The state can require enrollees to exhaust the plan’s internal grievance process before obtaining a state fair hearing . 86 The state agency must issue and publicize its hearing decisions. In addition, the public must have access to all fair hearing decisions, subject to regulatory requirements providing for safeguarding of confidential personal and health 87 information. 80 42 C.F.R. §§ 431.240, 431.242. 81 42 C.F.R. § 431.206(b)(3). 82 42 C.F.R. § 431.242. 83 42 C .F.R. § 431.230. 84 42 C.F.R. § 438. 402. 85 42 C.F.R. § 438.408. 86 42 C.F.R. § 431.206(a). 87 42 C.F.R. § 431.244(g). 34

38 EPSDT: A Guide for States IX. CONCLUSION The goal of EPSDT is to assure that all Medicaid -enrolled children under age 21 receive the health care they need . EPSDT covers not only medically necessary treatment to correct or ameliorate identified conditions, but also preventive, and maintenance services. In addition, EPSDT covers age -appropriate medical, dental, vision and hearing screening services at specified times, and when health . problems arise or are suspected The broad scope of EPSDT provides states with the tools necessary to offer a comprehensive, high-quality health benefit. To fully realize EPSDT’s potential, however, attention is needed on issues affecting access to services, including supply of providers, the presence of managed care, linguistic and disability access, and transportation . CMS is available to help states address these issues to ensure that EPSDT coverage meets the needs of children under age 21 who depend on Medicaid for their health care. 35

39 EPSDT: A Guide for States W ABOUT EPSDT X. WHAT YOU NEED TO KNO E ARLY: Assessing and identifying problems early Children covered by Medicaid are more likely to be born with low birth weights, have poor health, have developmental delays or learning disorders, or have medical conditions (e.g., asthma) requiring ongoing use of prescription drugs. Medicaid helps these children and adolescents receive quality health care. EPSDT is a key part of Medicaid for children and adolescents. EPSDT emphasizes preventive and comprehensive care. Prevention can help ensure the early identification, diagnosis, and treatment of conditions before they become more complex and costly to tr eat. It is important that children and adolescents enrolled in Medicaid receive all recommended preventive services and any medical treatment needed to promote healthy growth and development. PERIODIC : Checking children’s health at age -appropriate interval s As they grow, infants, children and adolescents should see their health care providers regularly. Each state develops its own “periodicity schedule” showing the check -ups recommended at each age. These are often based on the American Academy of Pediatrics’ Bright Futures guidelines : Recommendations for Preventive Pediatric Health Care . Bright Futures helps doctors and fami lies understand the types of care that infants, children and adolescents - should get and when they should get it. The goal of Bright Futures is to help health care providers offer prevention based, family -focused, and developmentally -oriented care for all children and adolescents. Children and adolescents are also entitled to receive additional check -ups when a condition or problem is suspected. SCREENING : Providing physical, mental, developmental, dental, hearing, vision and other screening tests to detect potential problems All infants, children and adolescents should receive regular well -child check -ups of their physical and mental health, -up includes: growth, development, and nutritional status. A well -child check ■ A comprehensive health and developmental history, including both physical and mental health development assessments; ■ Physical exam; ■ Age -appropriate immunizations; ■ Vision and hearing tests; ■ Dental exam; ■ Laboratory tests, including blood lead level assessments at certain ages; and ■ Health education , including anticipatory guidance. DIAGNOSTIC : Performing diagnostic tests to follow up when a health risk is identified -child check- up or other visit to a health care professional shows that a child or adolescent might have a When a well ollow up diagnostic testing and evaluations must be provided under EPSDT. Diagnosis of mental health problem, f health, substance use, vision, hearing and dental problems is included. Also included are any necessary referrals so that the child or adolescent receives all needed treatment. TREATMENT : Correct, reduce or control health problems found EPSDT covers health care, treatment and other measures necessary to correct or ameliorate the child or adolescent’s physical or mental conditions found by a screening or a diagnostic procedure. In general, States must ensure the provision of, and pay for, any treatment that is considered “medically necessary” for the child or adolescent. This includes treatment for any vision and hearing problems, including eyeglasses and he aring aids. For children’s oral health, coverage includes regular preventive dental care and treatment to relieve pain and infections, restore teeth, and maintain dental health. Some orthodontia is also covered. 36

40 EPSDT: A Guide for States XI. RESOURCES CMS Resources CMS, ■ State Medicaid Manual §§ 2700.4 and 5010-5360 ■ CMS, Early and Periodic Screening Diagnostic and Treatment Resources Adolescent Health CMS, Paving the Road to Good Health: Strategies for Increasing Medicaid ■ Adolescent Well -Care Visits (Feb. 2014) Oral Health CMS, ■ Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents (September 2013) Improving Access to and Utilization of Oral Health Services for Children ■ CMS, in Medicaid and CHIP Programs, CMS Oral Health Strategy (April 11, 2011) CMS, CMCS Informational Bulletin, CMS Oral Health Initiative and Other ■ Dental Related Issues (April 18, 2013) Improving Oral Health Care Delivery in Medicaid and CHIP: A Toolkit for ■ (February 2014) States Mental Health Bulletin, Prevention and Early Identification of ■ l CMS, CMCS Informationa (March 27, 2013) Mental Health and Substance Use Conditions Joint CMCS and SAMHSA Informational Bulletin, Coverage of Behavioral ■ CMS, Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions (May 7, 2013) Screening Services CMS , Guide for States Interested in Transitioning to Targeted Blood Lead ■ Screening for Medicaid -eligible Children (May 2012) Accessibility CMS, ■ CMCS Informational Bulletin (April 26, 2011) (federal funding for interpretation and translation services) ■ CMS, Dear State Medicaid Director (Aug. 31, 2000) (Limited English Proficiency) ■ CMS, Dear State Medicaid Director, Olmstead Update No. 4 , Att. 4- B EPSDT (Jan. 10, 2001) (May 2003) ■ CMS, Medicaid School -Ba sed Administrative Claiming Guide 37

41 EPSDT: A Guide for States Other Federal Resources CDC, Vaccine Recommendations of the ACIP ■ EPSDT & Title V Collaboration to Improve Child Health ■ HRSA, Health Resources and Services Administration EPSDT website ■ ■ HHS Office of Minority Health's Think Cultural Health: Advancing Health Equity at Every Point of Contact ■ HHS Office of Minority Health’s A Physician’s Practical Guide to Culturally Competent Care ■ Culturally Competent Nursing Care: A HHS Office of Minority Health’s Cornerstone of Caring ■ HHS Office of Minority Health’s Cultural Compete ncy Curriculum for Disaster Preparedness and Crisis Response ■ HHS Office of Minority Health’s Cultural Competency Program for Oral Health Professionals ■ HHS Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care ( the National CLAS Standards ) HHS Office of Minority Health’s A Blueprint for Advancing and Sustaining ■ CLAS Policy Practice (The Blueprint) and Other Resources American Academy of Pediatrics, Bright Futures (2014) ■ ■ American Academy of Pediatrics, Bright Futures Recommendations for Pediatric Preventive Care (2014) ■ American Academy of Pediatric Dentistry, Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (2013) ■ Association of Maternal and Child Health Programs, Standards for Systems of Care for Children and Youth with Special Health Care Needs (March 2014) George Washington University, Health Information & The Law, ■ Understanding the Interaction Between EPSDT and Federal Health Information Privacy and Confidentiality Laws (2013) ■ National Academy of State Health Policy, Managing the “T” in EPSDT Services (2010) ■ National Academy of State Health Policy, Resources to Improve Medicaid for Children and Adolescents ■ National Health Law Program, Toward a Healthy Future: Medicaid EPSDT Services for Poor Children and Youth National Health Law Program, Annotated Federal Documents ■ 38

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