EPSDT / HealthCheckMCO Provider Training

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Total number of DC Medicaid EPSDT eligible members (children under 21):

80,339

Total number of DC Medicaid Primary Care Providers:

354

Medicaid EPSDT Services Benefit

Medicaid is a joint federal-state partnership program administered by the Centers for Medicare & Medicaid Services (CMS).

Congress enacted the Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) services benefit as part of the federal Medicaid Program. • Defined the benefit in 1967 and expanded it in 1989

Medicaid EPSDT Services BenefitEPSDT entitles all Medicaid enrolled children (birth – 21 years) to a comprehensive benefit package which includes screenings, preventive health care, and medically necessary diagnosis and treatment

• Assures availability and accessibility of required health resources

• Helps Medicaid beneficiaries and their caregivers effectively use these resources

EPSDT Services

EPSDT mandates the following Early and Periodic preventive health services:

Screening services Comprehensive health and developmental history (physical, mental, and developmental) Comprehensive unclothed physical exam Appropriate immunizations (per ACIP) Laboratory tests, including mandatory lead screening Vision screening Hearing screening Dental screening Other necessary health care cont. next slide

EPSDT Services, cont. EPSDT mandates the following preventive health services:

Diagnostic services, if needed for further evaluation. If screenings indicate need for further evaluation, diagnostic services must be provided. Referrals should be made without delay, including follow-up to ensure that a diagnostic evaluation is received. If you have difficulty finding information on where to refer, call the Office of the Ombudsman 877-685-6391.

Treatment (or referrals) to correct or improve health conditions. All Medicaid-enrolled children should receive comprehensive EPSDT treatment services, including:

developmental services, eyeglasses, hearing aids, orthodontia, wheelchairs and prosthetic devices, occupational and physical therapy, prescribed medical formula and nutritional supplements, assistive communication devices, personal care, therapeutic behavioral services (TBS), behavioral rehabilitation, home health, speech therapy, and substance abuse treatment. For for the full scope of services covered under HealthCheck, see Medicaid's EPSDT Scope of Benefits

Health Education

Required component of screening services – includes anticipatory guidance

Health education and counseling to both parents and children is required– Assist in understanding age-appropriate developmental issues– Provide information on benefits of healthy lifestyles and practices, including

regular dental care– Accident and disease prevention

Additional Health Education resources, including anticipatory guidance cards, can be found in the Resource section at www.dchealthcheck.net.

Blood Lead TestingChildhood lead poisoning is the most common environmental disease in children younger than 6 years of age in the United States.

Lead testing and prompt intervention in early childhood help reduce the risk of learning disabilities, attention deficits, hyperactivity, and behavioral disorders caused by elevated lead levels.

Only a small percentage of children in the District are documented to be receiving blood lead tests at the appropriate intervals. In response to this, the District is committed to improving this percentage.

cont. next slide

Blood Lead Testing, cont.

Lead screening periodicity and guidelines can be summarized on the next slide.

For more information, contact the DC Lead Poisoning Prevention Division at (202) 535-2634 or 535-1394.

Blood Lead Testing, cont.All children covered under Medicaid should receive 2 blood lead tests.

District law requires all Medicaid-enrolled children receive a lead test at least twice: first between ages 9 and 14 months, and a second time between ages 22 and 26 months. This also complies with federal law that requires tests at 12 and 24 months for all children covered under Medicaid.

In addition, if there is no documentation of previous lead screening, federal law requires that all Medicaid-eligible children between the ages of 36 and 72 months of age also receive a screening blood lead test.

All other children 36-72 months require a test unless assessed as low lead risk. Lead level of concern: greater than or equal to 10 ug/dL.

Vision and Hearing Services

Vision Diagnosis and prescription for defects in vision including eyeglasses

Vision services must be provided according to DC’s periodicity schedule

HearingDiagnosis and prescription for defects in hearing including hearing aids

Hearing services must be provided according to DC’s periodicity schedule

Dental ServicesOral screening must be part of every well-child physical exam, but should not be seen as a substitute for an exam by a dentist.

An oral assessment should be done by the primary care physician/pediatrician up to age 3. Every Medicaid-enrolled infant should receive an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age that includes: (1) assessing the patient’s risk of developing oral disease using the AAPD Caries-risk assessment tool; (2) providing education on infant oral health; and (3) evaluating and optimizing fluoride exposure.

All Medicaid-enrolled children should be referred to a dentist for the establishment of a dental home within 6 months after the first tooth erupts, or 12 months of age (whichever comes first). Providers should encourage families to take their child to a dentist every 6 months. cont. next slide

Dental Services, cont.The oral assessment done by the primary care physician/pediatrician should not be in place to a visit to a dentist, and should include the importance of oral care and a referral to a dentist.

For assistance in finding a dentist and scheduling an appointment, caregivers should be encouraged to call the Dental Helpline: 866-758-6807.

Other Necessary Health Care

Provide for other necessary health care, diagnostic services, treatment, and other measures (as described further in the Medicaid statute) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered by the State plan.

To learn more about services covered under HealthCheck/EPSDT, see www.dchealthcheck.net.

EPSDT in DC = HealthCheck EPSDT incorporated into MCO contracts with expectations and penalties

HealthCheck provides each Medicaid-enrolled child with a medical home in DC

Additional HealthCheck goals are to:

– Improve knowledge of the external review of DC's Medicaid managed care program

– Help satisfy the requirements of the Salazar court mandates –Target goal of 80% EPSDT Compliance

• Required reporting and documentation of HealthCheck services

2009 EPSDT Compliance Ratio for DC: 68%

Why is EPSDT/HealthCheck Important?

Collaboration: CMS, state Medicaid agencies, and EPSDT providers have a shared obligation to ensure comprehensive pediatric preventive care for eligible children and teens, and to support their families in accessing the health services available through EPSDT.

Scheduling: Develop an approved schedule of preventive health visits at regular intervals that meet reasonable standards of medical practice, including intervals for vision, hearing, and dental screening services. See www.dchealthcheck.net for the most up-to-date schedules of services.

Screening: Assess child health needs through initial and periodic examinations and evaluations

Diagnose and Treat: Identify health problems for early diagnosis and treatment – before the child’s health issues become more complex and treatment more costly.

Tools Required for EPSDT/HealthCheck Visit

• Blood pressure cuffs (size appropriate)• Eye vision screening tool available • Audiometer• Thermometer• Scales appropriate for age to measure weight• Device/tool to measure height

• Ophthalmoscope• Otoscope• Exam table with paper• Percussion hammer • Stethoscope• Exam gown for older children

Providers will make available to patients health educational materials:• Educational materials evident• Education materials available in languages appropriate for patient population• Explanation of EPSDT services provider orally and in writing to patients

All provider who immunize children shall participate in the Vaccines for Children ProgramKeep VFC vaccines separate from private insurance vaccines

EPSDT Periodicity ScheduleDC is based on AAP and AAPD periodicity schedules, with consultation….

These are available at:www.dchealthcheck.net/resources/healthcheck/periodicity.html

HealthCheck follows CDC’s ACIP Recommended Childhood and Adolescent Immunization Schedules.

These are available at:www.dchealthcheck.net/resources/pediatric/immunizations.html

EPSDT Billing Office Visit Codes

The following office visit codes are used to bill for EPSDT visits and are age specific. There are also different codes to distinguish between new and established patients.

Managed Care Organizations and DHCF use the data submitted on claims to evaluate and monitor EPSDT care in the District, so it is especially important that the claims are complete and accurate.

EPSDT Billing New Patient

99381 Infant under 1 year of age99382 Early Childhood – age 1 to 4 years99383 Late Childhood – age 5 to 11 years99384 Adolescent – age 12 to 17 years99385 Age 18 to 22 years

Established Patient99391 Infant under 1 year of age99392 Early Childhood – age 1 to 4 years99393 Late Childhood – age 5 to 11 years99394 Adolescent – age 12 to 17 years99395 Age 18 to 22 years

Billing Codes are online at www.dchealthcheck.net/training/documentation/codes.html

EPSDT Billing Immunization codesAdministration of immunizations onlyCodes for administration 90465-90474

Codes for vaccine rejected 90476-90749

90700 Diphtheria, Tetanus Toxoids and Acellular Pertussis vaccine (DTap)

90701 Diphtheria, Tetanus Toxoids and Pertussis vaccine (DTP)

90702 Diphtheria and Tetanus Toxoids

90703 Tetanus Toxoid

90707 Measles, Mumps and Rubella virus vaccine, live (MMR)

90712 Poliovirus vaccine, live, oral (any type)

90716 Varicella (chicken pox) vaccine

90718 Tetanus and Diphtheria Toxoids absorbed, for adult use (Td)

90720 Diphtheria, Tetanus Toxoids and Pertussis (DTP) and Hemophilus Infuluenza B (HIB) vaccine

90744 Immunization, active, Hepatitis B vaccine; newborn to 11 years

EPSDT Billing

Lab codes

85013 Hemoglobin85014 Hemocrit85018 Hemoglobin83655 Lead screen 81000 Urinalysis86580 TB Test, Intradermal

86585 TB Test, Tine Test83718 Cholesterol, HDL83719 Cholesterol, Direct 85660 Sickle Cell99000-99001 Specimen Handling

Billing Codes are online at www.dchealthcheck.net/training/documentation/codes.html

EPSDT Billing

Provide well care during sick visit. Both visit codes can be billed using modifier 25 with the regular office visit.

For example: 99213 with a modifier 25 and 99391.

Access Standards Required by MCO ContractsType of Appointment Standard

Emergency care [life threatening] Immediately at the nearest facility

Urgent care or Sick Care Appointments w/PCP Within 24 hours of request

Urgent Care with a Specialist Within 48 hours of referral

Routine Appointments [including Health Check and IDEA appointments]

Within 30 days of request

Initial Appointments for pregnant women or persons needing family planning

Within 10 days of request

Routine Physical Examination Within 30 days of request

Waiting Time in Practitioner’s office Not to exceed 1 hour

Use of free interpreter services As needed during all appointments

Behavioral Health Access Standards

Type of Appointment Standard

Behavioral Health Emergency care [life threatening]

Immediately at the nearest facility

Behavioral Health Telephone Crisis Triage Within 15 minutes over the telephone

Psychiatric Intervention or face-to-face Assessment Within 90 minutes of completion of telephone assessment [when needed] and available on a 24 hours basis 7 days a

week

Treatment for non-life threatening emergency Treated as emergency care

Routine Behavioral Health Appointments Within 10 days of request

Waiting Time in Practitioner’s office Not to exceed 1 hour

Use of free interpreter services As needed during all appointments

Access to After Hours Care

Type of Appointment Standard

Emergency Care Call 911 and/pr go to the nearest facility immediately

Urgent non-medical emergency where care is needed before business hours

Provide a telephone number for the covering practitioner

Urgent non-medical emergency where care is not needed until business hours

Advise member to call during business hours

ResourcesChartered Health Plan – EPSDT Manager, Christina Bristol (202) 216-2317Unison Health Plan – EPSDT Manager, Jenine Woodward (202) 218-7884

Health Services for Children with Special Needs (HSCSN) – EPSDT Manager, B.J. Wolf (202) 495-7538

DC Department of Health Care Finance – EPSDT Coordinator, Colleen Sonosky (202) 442-5913

Web Sites INCLUDE:

www.dchealthcheck.net Provider Education Sitewww.aap.org

www.aapd.orgwww.brightfutures.org

www.chartered-health.comhttp://www.hscsn-net.org

www.unisonhealthplan.com

Provider Questions or Further Training Requests

Chartered Health Plan – Director of Provider Network

Athena Cross-Edge (202) 552-3748

Health Services for Children with Special Needs – Director of Provider Services Terri Hunt (202) 495-7587

Unison Health Plan – Director of Provider Network Management

Marci Jones (202) 218-7880

DC Department of Health Care Finance – Manager, Office of Provider Services

Laurie Rowe (202) 698-2044

Complete the extended training and resources available at www.dchealthcheck.net

Your participation counts!

Don’t forget to REGISTER and RECEIVE CMEs!