Early and Periodic Screening, Diagnosis, and Treatment EPSDT Services

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Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Services

• Virginia Department of Medical Assistance
  Services (DMAS)
• epsdt_at_dmas.virginia.gov

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Topics

• EPSDT 101
• Federal Mandates
• Whats new with EPSDT at DMAS?

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EPSDT 101
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What is EPSDT?

• A Medicaid program for children up to the age of
  21
• EPSDT is healthcare with a preventive approach
• Screening services are the backbone
• of the program

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EPSDT Goals

• Assuring that health concerns are diagnosed as
  early as possible
• Assuring that treatment is provided before
  problems become more complex
• Assuring that medically justified services are
  provided to treat or correct identified problems.

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What are EPSDT Services?

• EPSDT Services Include
• Screening/Well Child check-ups,
• Diagnosis and Treatment services to correct a
  medical condition, make it better, or prevent the
  childs health status from worsening

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EPSDT Screenings

• EPSDT Screenings must contain these
• 5 Elements
• Comprehensive health and developmental history
• Comprehensive physical exam,
• Laboratory tests/Lead testing at 12 and 24 months
• Age Appropriate Immunizations
• Anticipatory Guidance/Health counseling

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EPSDTScreenings

• Inter periodic screenings are outpatient
  physician encounters or sick visits
• The visit is a problem-focused screening
• Inter-periodic or partial screenings may be used
  to document the need for EPSDT treatment

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Diagnosis and Treatment

• Individualized health care, diagnostic services,
  and treatment as listed in the Federal Medicaid
  statute, must be provided when medically
  necessary to correct and ameliorate physical and
  mental conditions discovered during screening
  services whether or not included in the state
  plan
• The program does not cover services that are
  experimental or investigational

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Diagnosis and Treatment

• All services must be deemed medically necessary
  to correct or ameliorate a health or mental
  health conditions
• Certain services may not be covered by EPSDT
• Respite
• Environmental Modifications
• Vocational
• Educational

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Diagnosis and Treatment

• When services for children are reviewed in any
  state plan service EPSDT program criteria must be
  considered to determine medical necessity
• EPSDT is the philosophy in childrens Medicaid
• Childrens services should always have the EPSDT
  federal correct or ameliorate criteria applied
  to service approval decisions

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Federal EPSDT Mandates
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Federal Mandates

• If states want to provide Medicaid, then they
  must provide EPSDT
• EPSDT programs must include
• Transportation, referral assistance
• Care Coordination
• Notifications to recipients who have not utilized
  services

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Federal Mandates

• CFR Sec. 441.57 Discretionary services.
• Under the EPSDT program, the agency may provide
  for any other medical or remedial care specified
  in part 440 of this subchapter, even if the
  agency does not otherwise provide for these
  services to other recipients or provides for them
  in a lesser amount, duration, or scope.

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Federal Mandates

• That means
• Correct or Ameliorate with EPSDT treatment
• Individualized medical review, as defined in the
  CMS issued state Medicaid manual, to determine
  medical necessity
• States may have treatment limits, but those
  limits cannot interfere with treatment when the
  medical need is determined in a screening
• States cannot arbitrarily deny or reduce the
  amount, duration or scope of a service solely
  because of the diagnosis, type of illness, or
  condition

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Federal Mandates

• Other necessary healthcare
• August 1992 memo from HCFA/CMS states
• that treatment for maintenance of a health
  condition is covered by the OBRA 89 legislation
• All EPSDT law applies to mental and physical
  health treatment

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416 Comparisons
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Whats New with DMAS EPSDT?
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What is New in DMAS EPSDT

• Developing program guidelines
• Personal care
• Substance Abuse Treatment
• EPSDT Nursing
• Physician EPSDT screening procedures

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What is New in DMAS EPSDT

• Physician focus groups will identify direct
  practice perspectives on EPSDT
• Website design in progress for parent and
  provider tools and service awareness
• VDH is completing the Bright Futures Web Based
  Training Module
• Created and implemented by VDH with DMAS input
• Collaboration with VDH and DMHMRSAS for increased
  service quality and outreach
• Integrated mental health screening and treatment
  initiatives with VDH DMAS and DMHMRSAS
  collaborating for effective treatment

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What is New in DMAS EPSDT

• Statewide case management training in maternal
  and child health services
• Case manager focus groups to evaluate program
  changes
• Evaluate communication processes with physician
  focus groups

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EPSDT Contacts

• Brian Campbell, EPSDT Coordinator
• [phone]
• Email epsdt_at_dmas.virginia.gov
• Information also may be found on the DMAS website
  at www.dmas.virginia.gov

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Thank you!