Understanding Medicaid and EPSDT/Health Tracks for Children in
North Dakota Sponsored by: US Dept of Health & Human Services /
Centers for Medicare and Medicaid Services Grant # 11-P- 92506/8-01
& Department of Human Services/Medical Services Division /CSHS
Family Voices of North Dakota Health Information and Education
Center Slide 2 What is Medicaid? Title XIX of the Social Security
Act is a program which provides medical assistance for certain
individuals and families with low incomes and resources Slide 3
What is Medicaid? The program, known as Medicaid, became law in
1965 as a jointly funded cooperative venture between the Federal
and State governments to assist States in the provision of adequate
medical care to eligible needy persons. Slide 4 What is Medicaid?
Physician carePhysician care Hospital careHospital care Skilled
nursing careSkilled nursing care Family planningFamily planning
DMEDME EPSDT services, including dental and care coordinationEPSDT
services, including dental and care coordination Lab and X-rayLab
and X-ray TransportationTransportation Prescription
DrugsPrescription Drugs Vision CareVision Care Slide 5 HOW IS
MEDICAID DIFFERENT FROM MEDICARE? Medicaid mainly serves low-income
families, while Medicare covers elderly and disabled people who
receive Social Security, regardless of their income. Slide 6 HOW IS
MEDICAID DIFFERENT FROM MEDICARE? Medicaid also covers many
services for low-income elderly and disabled people that Medicare
does not pay for. Both programs are individual entitlements, which
means that you qualify if you meet certain criteria. Slide 7 HOW IS
MEDICAID DIFFERENT FROM MEDICARE? Medicaid is a joint program with
costs shared by both federal and state governments, while Medicare
is paid for entirely by the federal government Slide 8 Medicaid
Funding Currently, the federal government will pick up more than
50% of the cost, but not more than 75%. North Dakota s current
federal match is 67.49% Slide 9 Medicaid Funding In other words,
for every $100,000 that the state budgets for Medicaid services,
the Federal government also contributes $100,000 resulting in
$200,000 available for services. Slide 10 Medicaid Within broad
national guidelines, which the Federal government provides Slide 11
Each State: 1.establishes its own eligibility standards;
2.determines the type, amount, duration, and scope of services;
3.sets the rate of payment for services; and 4.administers its own
program. Slide 12 Medicaid Thus, the Medicaid program varies
considerably from State to State, as well as within each State over
time. Slide 13 However, Children Are Different! (Because of
EPSDT/Health Tracks) Slide 14 What Is EPSDT? Early and Periodic
Screening, Diagnosis & Treatment or in North Dakota Health
Tracks Slide 15 Why is HEALTH TRACKS so Important? About HALF of
all births in the U.S. are paid for by Medicaid.About HALF of all
births in the U.S. are paid for by Medicaid. Over 22% of all
children in the country under age 6 are covered by Medicaid.Over
22% of all children in the country under age 6 are covered by
Medicaid. In 1999 16 % of American children 6 to 17 had no health
care visits.In 1999 16 % of American children 6 to 17 had no health
care visits. HEALTH TRACKS is designed to enhance primary care with
emphasis on prevention, diagnosis and timely treatment.HEALTH
TRACKS is designed to enhance primary care with emphasis on
prevention, diagnosis and timely treatment. Slide 16 What Is EPSDT?
The federally mandated health care benefit package, administered in
partnership with each state, for essentially ALL Medicaid enrolled
children, ages birth through 20 years Slide 17 What is HEALTH
TRACKS? Early and Periodic Screening, Diagnosis &
TreatmentEarly and Periodic Screening, Diagnosis & Treatment
The federally mandated health care benefit package, administered in
partnership with each state, for essentially ALL Medicaid enrolled
children, ages birth through 20 years.The federally mandated health
care benefit package, administered in partnership with each state,
for essentially ALL Medicaid enrolled children, ages birth through
20 years. Slide 18 What is HEALTH TRACKS? Medicaid is required to
cover any medically necessary health care service listed in the
Social Security Act, even if the service is not available to adults
receiving Medicaid benefits. It emphasizes preventive care and
complete early treatments. It does not include:Medicaid is required
to cover any medically necessary health care service listed in the
Social Security Act, even if the service is not available to adults
receiving Medicaid benefits. It emphasizes preventive care and
complete early treatments. It does not include: Experimental
treatments Services or items not generally accepted as effective
Slide 19 Is EPSDT Different From Medicaid? Through EPSDT, each
states Medicaid plan must provide to any EPSDT recipient any
medically necessary health care service, even if the service is not
available under the State's Medicaid plan to the rest of the
Medicaid population. Slide 20 EPSDT/Health Tracks Coverage does not
include: Experimental treatments Services or items not generally
accepted as effective Services for the caregivers convenience Slide
21 The EPSDT Benefit Consists of: 1.Assuring availability and
accessibility of required health care services and items; Slide 22
Why is EPSDT so Important? More than HALF of all Medicaid enrollees
across the country are children.More than HALF of all Medicaid
enrollees across the country are children. EPSDT is designed to
enhance primary care of children with emphasis on prevention, early
diagnosis and timely treatment.EPSDT is designed to enhance primary
care of children with emphasis on prevention, early diagnosis and
timely treatment. Slide 23 Why is EPSDT so Important? Children in
ND who are enrolled in SCHIP or Healthy Steps are not entitled to
the comprehensive benefits as offered through Medicaid via
EPSDTChildren in ND who are enrolled in SCHIP or Healthy Steps are
not entitled to the comprehensive benefits as offered through
Medicaid via EPSDT Slide 24 The EPSDT Benefit Consists of: Helping
Medicaid clients and their parents or guardians effectively use
these resources (through provider staff and EPSDT Coordinators).
Slide 25 EPSDT Staff FREE Resources for Families Notify every
enrolled family of the scope of EPSDT benefits and support
services. Slide 26 EPSDT Staff FREE Resources for Families Guide
families to appropriately use their Medicaid benefits with emphasis
on education, prevention, diagnosis and timely treatment; Slide 27
EPSDT Staff FREE Resources for Families Maintain a Medicaid
provider database for patient referrals, including dental care,
vision care, hearing services, mental/behavioral health, and other
services. Slide 28 EPSDT Staff FREE Resources for Families Share
extensive knowledge of Medicaid benefits and services, including
those provided through HMOs; Slide 29 EPSDT Staff FREE Resources
for Providers Assist families with Medicaid-enrolled children and
youth to contact your offices to schedule appointments; Slide 30
EPSDT Staff also. Assists providers in reducing the incidence of
multiple appointments missed by Medicaid enrolled children and
youth; Slide 31 EPSDT Staff also. Identify and refer families to
other community resources such as Early Intervention Services (Part
C); housing; food banks; the Women, Infants and Children food
program (WIC); Prenatal Plus; and Head Start. Slide 32 Whom to
contact Medical Services Division, North Dakota Department of Human
Services Telephone:(701) 328- 2321 Toll-free: 1-800-755-2604 or
your County Social Services Office or your County Social Services
Office Slide 33 Who is Eligible for Health Tracks/EPSDT? Infants
born to Medicaid-enrolled women, until the childs first
birthday.Infants born to Medicaid-enrolled women, until the childs
first birthday. Children from birth through age 5Children from
birth through age 5 If family income is below 133% FPL* Slide 34
Who is Eligible for Health Tracks/EPSDT? Children from age 6
through age 18 at 100% FPLChildren from age 6 through age 18 at
100% FPL Children age 19 through 20 at 60% FPLChildren age 19
through 20 at 60% FPL Pregnant teenagers and womenPregnant
teenagers and women If family income is below 133% FPL *FPL stands
for Federal Poverty Level. Levels change April 1st of every year.
North Dakota Medicaid covers the following citizens and qualified
non-citizens through age Slide 35 And. Children who would have been
eligible for the now discontinued AFDC cash grant program, OR lost
discontinued AFDC cash grant program, OR lost eligibility in that
group due to increased wages or child eligibility in that group due
to increased wages or child support, support, Slide 36 And. If
family income is up to the state- established income If family
income is up to the state- established income level level Children
who are in foster care, subsidized adoption under Title IV-E OR
receive Supplemental Security Income (SSI) Title IV-E OR receive
Supplemental Security Income (SSI) Slide 37 Healthy Steps This is
the State Child Health Insurance Plan or SCHIP Slide 38 Healthy
Steps Healthy Steps is health insurance coverage for low- income
children (21 years of age and under and whose families earn
