EPSDT and the ID Waiver Changes in Preauthorization

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 1

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. 2

EPSDT Eligibility • Children with Medicaid • Under the age of 21 • Require “medically necessary” supports 3

EPSDT Eligibility “Medically necessary” means needed to improve physical or mental health conditions. Needs determined by ISP process. 4

Services available under both EPSDT and Waiver: • Personal Care/Assistance • Assistive Technology • Therapeutic Consultation 5

Personal Care under EPSDT 6

EPSDT Personal Care • “Personal Assistance” under ID Waiver • Support with routine needs • “Medically necessary” supervision 7

EPSDT Personal Care is not: • General Supervision unrelated to safety • Respite • Support with employment tasks • Assistance provided in other funded settings 8

EPSDT Personal Care – Preauthorization • DMAS -7 from MD, PA or RNP • ID Waiver Personal Assistance ISARs ! y l l a u n An Forward to assigned ODS PA Consultant prior to beginning services 9

EPSDT Personal Care/ID Waiver PA • Back-up plans required • Same providers • Same services • AD Personal Assistance • CD Personal Assistance 10

EPSDT Personal Care/ID Waiver PA Assessment: SIS If no SIS, ODS-approved assessment tool or DMAS-99 Plan of care: PC ISP Plan for Support (Part V) or DMAS-7 A with Personal Preferences tool Completed by: Registered Nurse, Services Facilitator or Program Manager 11

EPSDT Personal Care/ID Waiver PA Personal Preferences Tool for use with the DMAS 7 A 12

EPSDT Personal Care Provider Reviews • Written reviews every 6 months • Verbal reports for 3 and 9 month reviews If the PA provider is a DBHDS licensed provider, quarterly reviews are required. Submit to SC! 13

EPSDT Assistive Technology 14

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 15

EPSDT Assistive Technology • Authorized up to 3 months • No dollar limit per item/per year 16

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 17

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 18

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 19

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 20

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 21

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 22

Therapeutic Consultation 23

Therapeutic Consultation Specialty areas under the ID Waiver: • • • Psychology Behavioral consultation Speech and language pathology Occupational therapy Physical therapy 24

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) 25

EPSDT TC – Preauthorization ! y l l a nnu A • Letter or DMAS-355 from MD • ID Waiver TC ISAR Forward to assigned ODS PA Consultant prior to beginning services 26

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 27

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 28

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 29

Don’t forget… • Children become ineligible for EPSDT on their 21 st birthday. • PA, AT and TC will need to be authorized under the ID Waiver at that time I 30

Contacts ODS Community Resource Consultants http: //www. dbhds. virginia. gov/ODS-Contacts. htm DMAS EPSDT Services Supervisor Brian Campbell 804 -786 -0342 brian. campbell@dmas. virginia. gov 31