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EPSDT and the ID Waiver Changes in

Preauthorization of Children’s Services

Virginia Department of Behavioral Health & Developmental Services, Office of Developmental

Services, in collaboration with Department of Medical

Assistance Services, EPSDT

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Centers for Medicaid and Medicare

require eligible children to access EPSDT prior to Waiver for covered services.

Beginning with annual ISP date January 1, 2011.

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EPSDT Eligibility• Children with Medicaid • Under the age of 21• Require “medically necessary”

supports

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“Medically necessary” means needed to improve physical

or mental health conditions.

Needs determined by ISP process.

EPSDT Eligibility

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Services available under both EPSDT and Waiver:

•Personal Care/Assistance•Assistive Technology•Therapeutic

Consultation

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Personal Care under EPSDT

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EPSDT Personal Care

• “Personal Assistance” under ID Waiver

• Support with routine needs • “Medically necessary”

supervision

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• General Supervision unrelated to safety

• Respite• Support with employment

tasks• Assistance provided in other funded settings

EPSDT Personal Care is not:

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EPSDT Personal Care – Preauthorization

• Letter or DMAS-355 from MD

• DMAS -7 from MD, PA or RNP

• ID Waiver Personal Assistance ISARs

Annually!

Forward to assigned ODS PA Consultant prior to beginning

services

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EPSDT Personal Care/ID Waiver PA

• Back-up plans required• Same providers• Same services

• AD Personal Assistance • CD Personal Assistance

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Assessment: SIS

If no SIS, ODS-approved assessment tool or DMAS-99

Plan of care: PC ISP Plan for Support (Part V) orDMAS-7A with Personal Preferences tool

EPSDT Personal Care/ID Waiver PA

Completed by:Completed by:Registered Nurse,Registered Nurse,Services Facilitator orServices Facilitator orProgram ManagerProgram Manager

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Personal Preferences Tool for use with the DMAS 7A

EPSDT Personal Care/ID Waiver PA

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EPSDT Personal Care

Provider Reviews• Written reviews every 6 months• Verbal reports for 3 and 9 month

reviews

Submit to SC!

If the PA provider is a DBHDS licensed provider, quarterly reviews are required.

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EPSDT Assistive Technology

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EPSDT Assistive Technology

• Specialized medical equipment, supplies, devices, controls and appliances not available under DME

• Increases independence or ability to perceive/communicate

• Portable• Medically necessary

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EPSDT Assistive Technology

• Authorized up to 3 months• No dollar limit per item/per year

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EPSDT AT -- Criteria

• Reasonable• Included in the ISP• Consistent with individual’s needs• Not for the convenience of others• In accord with medical standards• Safe and cost effective

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EPSDT AT -- Criteria

• Must directly support the child• Must minimize the adverse effects of

mental or physical condition• Must be of direct benefit to the child

rather than enhance surroundings• Environmental modifications are not

covered

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Assistive Technology –

under the ID Waiver• AT items not “medically

necessary” should be requested under the ID Waiver

• $5000.00 annual limit per calendar year for ID Waiver AT

• Can be used in combination with AT under EPSDT

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EPSDT AT – Preauthorization

• Letter or DMAS-355 from MD

• Written recommendation from professional

• ID Waiver AT ISAR • Documentation to

confirm need

Forward to assigned ODS PA Consultant prior to beginning

services

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Assistive Technology

Documentation must confirm:

• Formal diagnosis related to need• Limitations/changes resulting in need for AT• How AT will be of benefit• Reason for quantity /quality• How often AT will be used• How long AT will be needed

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Assistive Technology

Documentation must confirm:

• Other supportive therapies tried/previous efforts to meet needs

• Successes/failures• How item is necessary at home/community• Individual/family interest in using the item

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Therapeutic Consultation

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Therapeutic Consultation Specialty areas under the ID Waiver:

• Psychology• Behavioral consultation• Therapeutic recreation• Speech and language pathology• Occupational therapy• Physical therapy• Rehabilitation engineering

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Therapeutic Consultation

• EPSDT provides therapy and consultation when of medical benefit

• Need documented in the PC ISP

• Supports described in the TC Plan for Supports (Part V)

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EPSDT TC – Preauthorization

• Letter or DMAS-355 from MD

• ID Waiver TC ISAR

Annually!

Forward to assigned ODS PA Consultant prior to beginning

services

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Don’t forget…Beginning January 1,

2011: • All children newly enrolling in

Waiver, needing PA, AT or TC, will have these services authorized under EPSDT.

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Don’t forget…Beginning January 1,

2011: • PA, TC and AT received by

children in the ID Waiver must be authorized under EPSDT with the child’s next annual ISP. I

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Don’t forget…

• That a child must receive at least one Waiver service to remain in the Waiver.

• If the child’s supports can be provided under EPSDT alone, the Waiver services will need to be terminated and the slot reassigned.I

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Don’t forget…• Children become ineligible for

EPSDT on their 21st birthday.

• PA, AT and TC will need to be authorized under the ID Waiver at that time

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Contacts

ODS Community Resource Consultantshttp://www.dbhds.virginia.gov/ODS-Contacts.htm

DMAS EPSDT Services SupervisorBrian Campbell804-786-0342brian.campbell@dmas.virginia.gov