+ All Categories
Home > Documents > 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department...

1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department...

Date post: 19-Jan-2016
Category:
Upload: yvette-beeching
View: 215 times
Download: 0 times
Share this document with a friend
Popular Tags:
31
1 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
Transcript
Page 1: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

1

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

Page 2: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

2

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.

Page 3: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

3

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

supports

Page 4: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

4

“Medically necessary” means

needed to improve physical or mental health conditions.

Needs determined by ISP process.

EPSDT Eligibility

Page 5: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

5

Services available under both EPSDT and Waiver:

• Personal Care/Assistance

• Assistive Technology• Therapeutic

Consultation

Page 6: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

6

Personal Care under EPSDT

Page 7: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

7

EPSDT Personal Care

• “Personal Assistance” under ID Waiver

• Support with routine needs • “Medically necessary”

supervision

Page 8: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

8

• General Supervision unrelated to safety

• Respite• Support with employment

tasks• Assistance provided in other funded settings

EPSDT Personal Care is not:

Page 9: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

9

EPSDT Personal Care – Preauthorization

• DMAS -7 from MD, PA or RNP

• ID Waiver Personal Assistance ISARs

Annually!

Forward to assigned ODS PA Consultant prior to beginning

services

Page 10: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

10

EPSDT Personal Care/ID Waiver PA

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

• AD Personal Assistance • CD Personal Assistance

Page 11: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

11

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

Page 12: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

12

Personal Preferences Tool for use with the DMAS 7A

EPSDT Personal Care/ID Waiver PA

Page 13: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

13

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.

Page 14: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

14

EPSDT Assistive Technology

Page 15: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

15

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

Page 16: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

16

EPSDT Assistive Technology

• Authorized up to 3 months

• No dollar limit per item/per year

Page 17: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

17

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

Page 18: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

18

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

Page 19: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

19

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

Page 20: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

20

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

Page 21: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

21

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

Page 22: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

22

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

Page 23: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

23

Therapeutic Consultation

Page 24: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

24

Therapeutic Consultation Specialty areas under the ID Waiver:

• Psychology• Behavioral consultation• Speech and language pathology• Occupational therapy• Physical therapy

Page 25: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

25

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)

Page 26: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

26

EPSDT TC – Preauthorization

• Letter or DMAS-355 from MD

• ID Waiver TC ISAR

Annually!

Forward to assigned ODS PA Consultant prior to beginning

services

Page 27: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

27

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.

I

Page 28: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

28

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

Page 29: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

29

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

Page 30: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

30

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

I

Page 31: 1 EPSDT and the ID Waiver Changes in Preauthorization of Children’s Services Virginia Department of Behavioral Health & Developmental Services, Office.

31

Contacts

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

DMAS EPSDT Services SupervisorBrian [email protected]


Recommended