Medicaid - Child Health Program
Early and Periodic Screening, Diagnosis, and Treatment
Oklahoma Health Care Authority
The Child Health Program also referred to as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a comprehensive child health program for all Medicaid eligible children birth through 20 years of age. EPSDT is designed to ensure the availability of, and access to, required health care resources and help parents and guardians to effectively use those resources. Children receive a broad range of primary and preventative health services. Thus, states must cover regular and periodic exams for eligible children and provide any medically necessary services prescribed by the EPSDT screen, including AT devices and services, even if that service is not covered in the state plan for the regular Medicaid program.
OK Health Care Authority
2401 NW 23rd, Ste 1A
Oklahoma City, OK 73107
OK Dept of Human Services
Sequoyah Memorial Office Bldg.
2400 N Lincoln Blvd
Oklahoma City, OK 73105
FAX: (405) 521-4158
P.O. BOX 25352
Oklahoma City, OK 73125
See Appendix B for Department of Human Services County Offices.
- All children ages 0-20 years who are eligible for Medicaid;
- family income cannot exceed 185% of the federal poverty level;
- a resident of Oklahoma and meet citizenship or legal immigration status; and
- individuals may also be eligible if they are on an In-Home Support Waiver, a Home and Community-Based Waiver, or TEFRA.
AT SERVICES PROVIDED/COVERED
- Assessments & Evaluations
- Training for Consumer
- Maintenance & Repairs
- Case Management
AT DEVICES PROVIDED/COVERED
- Aids for Daily Living
- Aids for Hearing Impaired
- Mobility/Seating & Positioning
- Speech Communication
- Environmental Adaptations
- Apply for EPSDT under the SoonerCare program at the local DHS office (the same process as applying for Medicaid).
- Case management services for EPSDT are provided through the county DHS office.
- The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
- In order to file an appeal, the member files a LD-1 form within 20 days of the triggering event. The triggering event occurs at the time when the member knew or should have known of such condition or circumstance for appeal. The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form that arrangements will be made.
- If the LD-1 form is not received within 20 days of the triggering event or if the form is not completely filled out with all necessary documentation, OHCA sends the Appellant a letter stating the appeal will not be heard.
- Upon receipt of the member’s appeal, a fair hearing before the Administrative Law Judge (ALJ) will be scheduled. The member will be notified in writing of the date and time for this procedure. The member must appear at this hearing. The ALJ’s decision may be appealed to the CEO, which is a record review at which the parties do not appear.
- Member appeals are to be decided within 90 days from the date OHCA receives the member’s timely request for a fair hearing unless the member waives this requirement.
PIECES OF THE PUZZLE
- EPSDT is an important funding source for individuals who cannot afford private insurance. Medicaid payment is payment in full. Providers may not bill both the individual and Medicaid.
- EPSDT can offer expanded services to children ages 0-21 years that are not available to other Medicaid clients. These EPSDT services can include AT devices and services that have been and continue to be excluded in the state plan for the regular Medicaid program.
- Not all types of AT devices can be purchased under Medicaid. There must be a medical need, which must be clearly demonstrated on a case-by-case basis, for an AT device. “Medically necessary” service means medical, dental, behavioral, rehabilitative or other health care services which are:
- reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatment for conditions that cause suffering or pain, cause physical deformity or limitation in function, cause illness or infirmity, endanger life, or worsen a disability;
- provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s medical conditions;
- consistent with the diagnosis of the condition
- no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, efficiency and independence; and
- assisting the individual in achieving or maintaining maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual, and those functional capacities that are appropriate for individuals of the same age.
- The amount, duration, or scope of services to recipients may not be denied arbitrarily or reduced solely because of the diagnosis, type of illness, or condition. Appropriate limits may be placed on services based on medical necessity.
- According to OHCA, AT refers to those medically necessary devices used by an individual with a disability to enhance developmental skills, learning, and adaptation to the individual’s environment. These devices must be unique, customized or personalized to the specific individual. AT devices include, but are not limited to, cognitive and developmental aids and alternative augmentative and communication aids.
- All DME purchased with Oklahoma Medicaid funds becomes the property of the OHCA to be used by the recipient until no longer needed.
- Medicaid is the payor of last resort for equipment purchases. If an individual has health insurance, Medicaid only begins paying after the health insurance stops.
- Schools may be Medicaid providers and receive reimbursement for services that are provided under the IDEA if the school district contracts with OHCA.
- Due to parental income, some children with disabilities may not have been eligible for Medicaid prior to the age of 18, but may become income eligible for Medicaid and could receive services up to the age of 21.
- All DME purchased with Oklahoma Medicaid funds is the property of the OHCA to be used by the member until no longer needed.
- When the SoonerCare member no longer needs the valuable DME they may contact the Oklahoma Durable Medical Equipment Reuse Program (OKDMERP) so it can be refurbished, repaired if needed, and reassigned to another Oklahoman at no cost. Priority is given to SoonerCare members for the first 60 days. Call OKDMERP staff at 405-523-4810 or go to www.okabletech.okstate.edu for more details.