Kentucky Medicaid and EPSDT

1
Kentucky Medicaid and EPSDT

• Stephanie Bates
• Branch Manager Disease and Case Management
• Kentucky Department for Medicaid Services

2
Administration of Medicaid

• Governed by Federal Regulations
• Services available to Medicaid recipients are
  outlined in a State Plan Amendment (SPA)
• The SPA is approved by the Center for Medicaid
  and Medicare Services (CMS)

3
Mandatory Medicaid Benefits

• Inpatient hospital services
• Outpatient hospital services
• EPSDT Early and Periodic Screening, Diagnostic,
  and Treatment Services
• Nursing Facility Services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Family planning services
• Nurse Midwife services
• Certified Pediatric and Family Nurse Practitioner
  services
• Freestanding Birth Center services (when licensed
  or otherwise recognized by the state)
• Transportation to medical care
• Tobacco Cessation counseling for pregnant women

4
Optional Medicaid Benefits

• Prescription Drugs
• Clinic services
• Physical therapy
• Occupational therapy
• Speech, hearing and language disorder services
• Respiratory care services
• Other diagnostic, screening, preventive and
  rehabilitative services
• Podiatry services
• Optometry services
• Dental Services
• Dentures
• Prosthetics
• Eyeglasses
• Chiropractic services
• Other practitioner services

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Optional Medicaid Benefits (cont.)

• Private duty nursing services
• Personal Care
• Hospice
• Case management
• Services for Individuals age 65 or Older in an
  Institution for Mental Disease (IMD)
• Services in an intermediate care facility for the
  developmentally disabled
• TB related services
• Inpatient psychiatric services for individuals
  under age 21 (Ordinarily states are responsible
  for the costs of IMDs the federal Medicaid
  program specifically excludes reimbursement for
  residents of an IMD. The two exceptions are
  individuals over age 65 who receive this service,
  and younger individuals who receive the psych
  under 21 service. Individuals in either type of
  IMD who are between the ages of 22 and 64 may not
  receive Medicaid reimbursement.)
• Self-Directed Personal Assistance Services
• Other services approved by the Secretary

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EPSDT

• Early and Periodic Screening, Diagnostic, and
  Treatment Services
• All optional Medicaid benefits are mandatory
  under the EPSDT benefit
• These benefits are for children ages 0-20
• MUST BE MEDICALLY NECESSARY

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Who decides if a service is medically necessary?

• Medically necessity is determined by using a
  nationally recognized process
• The provider who orders the service must document
  completely in order to demonstrate medical
  necessity
• Too much documentation is better than not enough

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What isnt covered under the EPSDT benefit?

• Respite care
• Environmental
• Educational
• Vocational
• Cosmetic
• Convenience
• Over-the-counter (OTC) items
• Room and board

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EPSDT

• Screening Services
• Special Services

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Screening Services

• Comprehensive health and developmental history
• Comprehensive unclothed physical exam
• Appropriate immunizations
• Laboratory tests (including lead screening)
• Health education (anticipatory guidance including
  child development, healthy lifestyles, and
  accident and disease prevention

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Special Services

• The EPSDT benefit includes all medically
  necessary services that are included within the
  categories of mandatory and optional services
  listed in section 1905(a), regardless of whether
  the services are covered under the State Plan
• This means that any service a child (ages 0-20)
  needs should be covered if it is medically
  necessary

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Kentucky MedicaidManaged Care Organizations

• Anthem BCBS Medicaid
• Aetna Better Health of Kentucky)
• Humana - CareSource
• Passport Health Plan
• WellCare of Kentucky
• All five MCOs are statewide

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MCOs Can Help

• EPSDT Coordinators
• Case management
• Care coordination
• Disease management
• Patient education
• Provider education

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EPSDT and Providers

• All providers can provide services under the
  EPSDT benefit as long as its in their scope of
  practice and is medically necessary
• Document, document, document when requesting a
  service that requires a prior authorization
• To provide services for Medicaid members, the
  provider must be a Medicaid provider

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EPSDT and Parents

• The purpose of early and periodic screening is to
  identify problems early and correct them
• Parents have the power to ensure their children
  are up-to-date on their screenings.

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Oversight

• The Department for Medicaid Services monitors
  EPSDT activity to ensure children are receiving
  the services they need
• MCOs report to DMS
• DMS reports to CMS
• The goal is improvement in overall health outcomes

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Questions?

• Stephanie Bates
• Branch Manager Disease and Case Management
  Branch
• Division of Program Quality Outcomes
• Department for Medicaid Services
• 275 East Main Street 6C-C
• Frankfort, KY 40621
• Stephanie.Bates_at_ky.gov
• 502-564-9444 ext. 2112