MEDICAID – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

PURPOSE

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a comprehensive child-health program for all Medicaid-eligible children birth to 21 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.

CONTACT

SCOPE OF SERVICES

Terrie Fritz, L.S.W.-C.

OK Health Care Authority

4545 N Lincoln Blvd., Ste 124

Oklahoma City, OK 73105

(405) 522-7377

http://tinyurl.com/24mnpgq

Ms. Karen Hylton

OK Dept of Human Services

Sequoyah Memorial Office Bldg.

2400 Lincoln Blvd

Oklahoma City, OK 73105

(405) 521-3679

FAX: (405) 521-4158

MAILING ADDRESS

P. O. BOX 25352

Oklahoma City, OK 73125

http://tinyurl.com/23oj52v

See Appendix B for Department of Human Services County Offices.

ELIGIBILITY

• All children ages 0-21 years are eligible for Medicaid.

• The family income cannot exceed 185% of the federal poverty level. The financial criteria changes frequently, therefore, check at the local DHS office for eligbility.

• Individuals may also be eligible if they are on an In-Home Support Waiver or a Home and Community Based Waiver.

AT SERVICES PROVIDED/COVERED

• Assessments & Evaluations

• Fabrication of Devices

• Training for Consumer & Family

• Maintenance & Repairs

• Case Management

• Information & Referral

• Locating Alternate Funding

• Advocacy/Other

AT DEVICES PROVIDED/COVERED

Aids for Hearing Impaired
Medical Supplies *

Aids for Vision Impaired
Prosthetics/Orthotics †

Augmentative Communication
Seating/Positioning Equipment

Environmental Controls
Wheelchairs/Mobility Aids

Hospital Beds

* No Adult Diapers

† No Leg Braces

APPLICATION PROCESS

• 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.

APPEALS PROCESS

1. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.

2. 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.

3. 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.

4. 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.

5. 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

• assists 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.