EPSDT / HealthCheck

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• EPSDT / HealthCheck
• MCO Provider Training

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

Your participation counts! Dont forget to
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3

• Total number of DC Medicaid EPSDT eligible
  members (children under 21)
• 80,339
• Total number of DC Medicaid Primary Care
  Providers
• 354

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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

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Medicaid EPSDT Services Benefit

• 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

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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

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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

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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.

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Blood Lead Testing

• Childhood 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

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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 [phone]
  or 535-1394.

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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.

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Vision and Hearing Services

• Vision
• Diagnosis and prescription for defects in vision
  including eyeglasses
• Vision services must be provided according to
  DCs periodicity schedule
• Hearing
• Diagnosis and prescription for defects in hearing
  including hearing aids
• Hearing services must be provided according to
  DCs periodicity schedule

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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.
• 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 patients 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

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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.

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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.

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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

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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
  childs health issues become more complex and
  treatment more costly.

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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

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EPSDT Periodicity Schedule

• DC is based on AAP and AAPD periodicity
  schedules, with consultation.
• These are available at
• www.dchealthcheck.net/resources/healthcheck/period
  icity.html

• HealthCheck follows CDCs ACIP Recommended
  Childhood and Adolescent Immunization Schedules.
• These are available at
• www.dchealthcheck.net/resources/pediatric/immuniza
  tions.html

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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.

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

• 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

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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
• 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

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

• 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
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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.

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Access Standards Required by MCO Contracts
Type 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 Practitioners office Not to exceed 1 hour
Use of free interpreter services As needed during all appointments
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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 Practitioners office Not to exceed 1 hour
Use of free interpreter services As needed during all appointments
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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
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Resources

• Chartered Health Plan EPSDT Manager, Christina
  Bristol [phone]
• Unison Health Plan EPSDT Manager, Jenine
  Woodward [phone]
• Health Services for Children with Special Needs
  (HSCSN) EPSDT Manager,
• B.J. Wolf [phone]
• DC Department of Health Care Finance EPSDT
  Coordinator,
• Colleen Sonosky [phone]
• Web Sites
• INCLUDE
• www.dchealthcheck.net Provider Education Site
• www.aap.org
• www.aapd.org
• www.brightfutures.org
• www.chartered-health.com
• http//www.hscsn-net.org
• www.unisonhealthplan.com

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Provider Questions or Further Training Requests

• Chartered Health Plan Director of Provider
  Network
• Athena Cross-Edge [phone]
• 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 [phone]
• DC Department of Health Care Finance Manager,
  Office of Provider Services
• Laurie Rowe [phone]

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

Your participation counts! Dont forget to
REGISTER and RECEIVE CMEs!