“Securing Health Rights for Those in Need” Children’s Services Under Medicaid: Ensuring EPSDT coverage & accountability On-line meeting: OH, MI, & WV November 14, 2008 Jane Perkins

About NHeLP Non-profit public interest law firm working to increase access to quality health care on behalf of limited income individuals, including children, women, the elderly, and people with disabilities Litigation & policy expertise includes: Medicaid; managed care; EPSDT; civil and disability rights; court access

Presentation overview Medicaid Basics Focus on EPSDT – Explain the benefit – Explore ways to assure EPSDT’s promise (government accountability)

Medicaid “Byzantine construction” makes Medicaid “almost unintelligible to the uninitiated” Medicaid Act is “an aggravated assault on the English language” Medicaid “regulations so drawn they have created a Serbonian bog”

Medicaid Basics “Cooperative federalism” –Shared funding: OH: 62.14%MI: 60.27%WV: 73.73% (FY ’09) –Shared administration: Federal: Centers for Medicare & Medicaid Services (CMS) States: –OH Dep’t of Job & Fam. Serv. –MI Dep’t of Community Health –WV Department of Health & Human Resources “Entitlement”

Medicaid Basics Mandatory & optional eligibility groups, e.g. – children aged 6 to 19 with incomes < FPL Mandatory & optional services

Why EPSDT? Children are not little adults Adolescents are not big children Poor children are more likely to have: Vision, hearing and speech problems Untreated tooth decay Elevated lead blood levels Sickle cell disease Behavioral Health problems Asthma And more...

EPSDT coverage Mandatory Medicaid services for children and youth under age 21 –Covers more than one in four children in US Covers more than one in three children in WV –Over 30% of all pediatrician visits

Medicaid EPSDT E = Early P= Periodic S = Screening D = Diagnosis T = Treatment

EPSDT in the States OH:EPSDT = HealthChek MI:EPSDT = EPSDT WV:EPSDT = HealthCheck

A Word about WV Mountain Health Choices Non-disabled, non-pregnant women & children Member responsibility agreement: Enhanced benefits No member responsibility agreement: Basic benefits, e.g. –Home health -- 25/year –PT -- 20/year –Weight management -- not covered –Rx – 4/month –Transportation – 10/year

A Word about WV Mountain Health Choices –93% of children in Basic Plan (CCF, Aug. 2008) – EPSDT CANNOT BE IGNORED – EPSDT STILL APPLIES

A Word about Managed Care (OH, MI, WV) –State Medicaid agencies contract with at-risk health plans to provide Medicaid services – EPSDT CANNOT BE IGNORED – EPSDT STILL APPLIES

EPSDT Requirements— Medical, vision, hearing, dental screening Medical Screens  Health and developmental assessment  Unclothed physical exam  Immunizations  Lab tests, including lead blood tests  Health education and anticipatory guidance

EPSDT Requirements— Medical, vision, hearing, dental screening Additional Required Screens  Vision, including eyeglasses  Hearing, including hearing aids  Dental, including relief of pain, restoration of teeth and maintenance of dental health

EPSDT Requirements— Early and Periodic screening Periodic Screens  Set according to age  Set by medical and dental experts  Different for medical, dental, hearing and vision Interperiodic “as needed” Screens States must provide or arrange for the provision of screening services in all cases there they are requested

Features of “E” & “P” Medical screen = 5 components Provider need not deliver all services Up to date periodicity schedules – Bright Futures, 3d edition ( No cost sharing Appointment & transportation assistance No prior authorization Any encounter=Interperiodic screen*

Advocating for EPSDT Screening in West Virginia Up-to-date periodicity schedules? Age-appropriate screening forms? – OH, MI -- ? – WV form – up to date? part of EMR? Mental health form being used? Limiting providers to all EPSDT services? Adequate screening for developmental delay/substance abuse?

EPSDT Screening in West Virginia— what to look for Periodicity Schedules AgeAAPWV < ? ? ? ?

EPSDT Treatment Requirements States must arrange (directly or through referral) for corrective treatment needed as a result of a screen – Federal scope of benefits – Federal definition of medical necessity

EPSDT Services— Federal Scope of Benefits All necessary treatment within 1396d(a) Mandatory services Optional Services Physician servicesPrescription drugs Laboratory/x-ray Dental services In-patient hospital Physical and other therapies Outpatient hospital Private duty nursing Nursing facility services Home health care* Home health care*Rehabilitation services EPSDTPersonal care services Case management Transportation

EPSDT Services— Federal Definition of Medical Necessity Treatment and services “necessary … to correct or ameliorate physical and mental illnesses and conditions” Deference to treating provider “…the physician is the key figure in determining utilization of health services... it is a physician who is to decide upon admission to a hospital, order tests, drugs and treatments and determine the length of stay.”S. Rep. No. 404, 89 th Congress, 1 st Session

Advocating for the “T” Diagnosed during an EPSDT screen? On the list of covered services? Medically necessary? Not experimental? No less costly, equally effective alternative available in the geographic area?

Written justification from physician (e.g. Rx pad) & treatment team –Patient history –Diagnosis/prognosis –Medical justification –Description of benefits to fit into a Medicaid “box” Incontinence supplies=home health Basic living skills=home health, rehabilitation Length of time service/treatment is needed If appropriate: product information, photographs, comparable prices Statement that request is under EPSDT to “correct or ameliorate” the child’s condition EPSDT – To get the “T” Request should include

EPSDT Requirements Outreach and informing States must inform Medicaid families & children about EPSDT Informing must be effective  Oral and written  Translated  Targeted (e.g. pregnant teens, non-users) Transportation and appointment assistance (prior to screen due date) Coordinate with other entities

EPSDT Informing Inform Families About: Benefits of preventive care Services available through EPSDT Transport & scheduling assistance

EPSDT-Addressing Stubborn Barriers Monitoring Annual reporting required—CMS Form 416 Report by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, 19-20) – Children screened – Children referred for corrective treatment – Children receiving dental treatment – Children receiving lead blood testing

EPSDT – Addressing Stubborn Barriers Monitoring State/managed care organizations must available: – Names, locations, qualifications of participating providers, non-English language spoken & whether accepting new Medicaid patients

EPSDT – Addressing Stubborn Barriers Monitoring State/managed care organizations must available: –External independent quality reviews –Healthcare Effectiveness Information & Data Set (HEDIS) –Well child & adolescent visits –Treatment of children w/respiratory infections –Antidepressant medication management »OH, MI, WV – all use

EPSDT – Addressing Stubborn Barriers Monitoring National Health Law Program – Sunshine & Government Accountability Project Using-publicly available data to hold government payers accountable for spending taxpayer $$ on covered health services

EPSDT – Addressing Stubborn Barriers Complaints Right to an administrative hearing Right to go to court –NHeLP Health Activist Court Watch Project