EPSDT / HealthCheckMCO Provider Training

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

EPSDT 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 ServicesEPSDT mandates the following 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

CMS requires all states to perform blood lead tests on enrolled children at 12 and 24 months of age If lead screening is not previously documented, children should also be screened between 36 and 72

months Health education and anticipatory guidance

Vision screening Hearing screening Dental screening Other necessary health care

Diagnostic services, if needed for further evaluation Treatment (or referrals) to correct or improve health conditions

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.

Vision and Hearing Services

Vision Diagnosis and prescription for defects in vision including eyeglasses

Vision services must be provided according to district periodicity schedule

Hearing Diagnosis and prescription for defects in hearing including hearing aids

Hearing services must be provided according to district periodicity schedule

Dental Services

Oral screening must be part of every well-child physical exam, but should not be seen as a substitute for an exam by a dentist. (See periodicity schedule for initiation and interval for dental screenings)

Caregivers should be referred to an oral health provider within 6 months of the eruption of a child’s first tooth, and should be encouraged to take their child to a dentist every six (6) months.

For assistance in finding a dentist and scheduling an appointment, caregivers should be encouraged to call the Dental HelpLine at 1-866-758-6807.

Other Necessary Health Care

Provide for other necessary health care, diagnostic services, treatment to correct or ameliorate developmental defects, and referral for treatment of physical and mental/behavioral illness or conditions identified through screening services.

EPSDT in DC=HealthCheck

EPSDT incorporated into MCO contracts with expectations and penalties HealthCheck provides each Medicaid-enrolled child with a medical home in the District of

Columbia 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.

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 Program Keep VFC vaccines separate from private insurance vaccines

EPSDT Periodicity Schedule

DC has adopted AAP and AAPD periodicity schedules

NEED TO INSERT PERIODICITY SCHEDULENEED TO INSERT DENTAL PERIODCITIY SCHEDULENEED TO INSERT IMMUNIZATION SCHEDULE 0-6NEED TO INSERT IMMUNIZATION SCHEDULE 7-18NEED TO INSERT IMMUNIZATION SCHEDULE 19-65NEED TO INSERT CATCH-UP SCHEDULE

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 age 99382 Early Childhood – age 1 to 4 years 99383 Late Childhood – age 5 to 11 years 99384 Adolescent – age 12 to 17 years 99385 Age 18 to 22 years

• Established Patient 99391 Infant under 1 year of age 99392 Early Childhood – age 1 to 4 years 99393 Late Childhood – age 5 to 11 years 99394 Adolescent – age 12 to 17 years 99395 Age 18 to 22 years

EPSDT Billing • Immunization codes

– Administration of immunizations only• Codes 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

• 90718Tetanus 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 - Hemoglobin• 85014 - Hemocrit• 85018 - Hemoglobin• 83655 - Lead screen • 81000 - Urinalysis• 86580 – TB Test, Intradermal • 86585 - TB Test, Tine Test• 83718 – Cholesterol, HDL• 83719 – Cholesterol, Direct • 85660 - Sickle Cell• 99000-99001 – Specimen Handling

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 - BJ Wolf @ 202.495.7538

DC Department of Health Care Finance– EPSDT Coordinator- Colleen Sonosky @ 202.442.5913

Web Sites INCLUDE:

www.dchealthcheck.netwww.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