EPSDT and what it means to your child
What is EPSDT and why is it important?
EPSDT and your child's IEP
Parent consent requirements for schools to bill Medicaid for your child's services
What is EPSDT
EPSDT has to be the least-written about Federal program out there. The GAO's website (as of July 2, 2009) contains three references to it, the most recent from 2007. The Center for Medicaid and Medicare Services hasn't updated their page defining EPSDT for about that same length of time.
EPSDT grants any child receiving medicaid a civil right to every service a doctor says is medically necessary, under the economic supposition that money spent now is less money spent in the future.
In these times where state budgets are hurting, a May 29, 2009 letter written by Disability Rights California succinctly summarizes the states' dilemma: EPSDT is a federal entitlement, and as such the state cannot eliminate the services it pays for.
The state cannot eliminate the federal entitlement to EPSDT services unless it gives up all of its federal Medi-Cal matching funds
In 2004, a brochure was published by the US Department of Health and Human Services explaining to the parents of children with disabilities how EPSDT would help them. EPSDT - Supporting Children with Disabilities was published in September of 2004.
Flip to page 17 and you'll find the following rather extended quote:
A special case of how EPSDT covers medically necessary services occurs in the education system – where many children receive their services. Many children with special needs receive a wide variety of services through the public school system. They range from academic services, such as reading and math instruction, to more health-related services, such as physical therapy and personal care. Trying to figure out who is responsible for paying for which services can be very confusing. However, schools can (and many do) bill Medicaid for reimbursable services under EPSDT. Medical necessity is just as important here as it is outside the school system. According to the federal government, “Medicaid is the payer of first resort for medical services provided to children with disabilities pursuant to the Individuals with Disabilities Education Act (IDEA).”5 In other words, Medicaid eligible children with disabilities are entitled to receive medical services in the school setting, paid for by Medicaid, if two important requirements are satisfied. First, the school/school district must be a participating Medicaid provider. Second, the services must be written into the child’s IEP/IFSP, which automatically makes them considered medically necessary.
The point is that the Federal government appears to be saying that our children are entitled to everything that one of their service providers says is medically necessary. The list is extensive, and it's on page 14 of the brochure.
It's described in greater detail in The Social Security Act Section 1905(a).
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EPSDT and your child's IEP
All of your child's EPSDT services are supposed to be included in the IEP. In fact, if the school is providing services for your child, and your child is covered by Medicaid, then the school is actually required to go to Medicaid for payment before any other funding source.
According to a publication of the CMS that was just re-ratified in June 2009,
Section 1903(c) of the Act requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA.
The IDEA authorizes federal funding to states for medical services provided to children through a child’s Individualized Education Program (IEP), including children that are covered under Medicaid. In 1988, section 1903(c) of the Act was amended to permit Medicaid payment for medical services provided to Medicaid eligible children under IDEA and included in the child’s IEP.
Medicaid covers services included in an IEP under the following conditions:
• The services are medically necessary and included in a Medicaid covered category (speech therapy, physical therapy, etc.);
• All other federal and state Medicaid regulations are followed, including those for provider qualifications, comparability of services and the amount, duration and scope provisions;
• The services are included in the state’s plan or available under EPSDT; and
• The medical service must be provided to a Medicaid eligible student.
Here is a list of everything that is covered by EPSDT, copied from a 2004 brochure printed by CMS called "EPSDT - Supporting Children with Disabilities
Hospital Services
•
Ambulance to and from hospital/emergency room
•
Inpatient hospital care
•
Outpatient hospital care (day visits)
•
Emergency room visits
Physical Health Care
•
Physician/nurse practitioner services: routine check-ups, illness-
related visits
•
Dental visits: routine check-ups/cleanings (including accommodations
for children with special needs), fillings, preventive care
•
Vision care: eye exams, glasses, eye drops, scratch-proof lenses
•
Hearing care: hearing tests, hearing aides, cochlear implants
•
Immunizations: according to established schedule
•
Lab tests/x-ray services: including blood lead tests
•
Podiatry care: including orthotic inserts
Mental health
•
Psychiatrist visits
•
Mental health therapy/counseling
•
Substance abuse treatment
•
Inpatient psychiatric hospitalization
Medications and Pharmacy Supplies
•
Prescription drugs
•
Diapers
•
Special foods: diet supplements, thickeners, other foods found in a
store’s pharmacy section
Home/Community Services and Therapies
•
Private duty nurses: nursing care in the home or community for
children who require medical attention/services
•
Personal care/personal assistant services: assistance with nonmedical
services in the home, community or school, including feeding,
bathing/personal hygiene, transferring, following behavior plan
•
Physical therapy
•
Occupational therapy
•
Speech, hearing, and language therapy (includes audiology services)
•
Chiropractic services
•
Nutritional services/counseling
•
Some behavioral therapy: behavioral therapies for children with
autism are generally covered by EPSDT, although there is some
controversy about this
Supplies/Equipment
•
Durable medical equipment: wheelchairs, ankle/foot/leg braces,
monitors, catheters, oxygen equipment, nebulizers
•
Augmentative communication devices: communication aides,
optical headpointers, headsets
•
Diabetic supplies: insulin pumps, glucometers, syringes
•
Prostheses
Other services
•
Transportation: to and from doctors’ appointments, therapy visits
•
Case management
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Legal requirements for parental consent to state billing of Medicaid for your child's services
* DRAFT *
IDEA Requirements for Parental Consent In Order to Bill Medicaid for Special Education Costs September 18, 2009
The Individuals with Disabilities Act (IDEA) discusses parental consent in 34 CFR 300.9 and 34 CFR 300.154. IDEA defines “consent” in 34 CFR 300.9 as follows:
Consent means that—
(a) The parent has been fully informed of all information relevant to the activity for which consent is sought, in his or her native language, or through another mode of communication;
(b) The parent understands and agrees in writing to the carrying out of the activity for which his or her consent is sought, and the consent describes that activity and lists the records (if any) that will be released and to whom; and
(c)(1) The parent understands that the granting of consent is voluntary on the part of the parent and may be revoked at any time.
(2) If a parent revokes consent, that revocation is not retroactive (i.e., it does not negate an action that has occurred after the consent was given and before the consent was revoked).
(3) If the parent revokes consent in writing for their child’s receipt of special education services after the child is initially provided special education and related services, the public agency is not required to amend the child’s education records to remove any references to the child’s receipt of special education and related services because of the revocation of consent.
34 CFR 300.154(d)(2) sets forth two requirements in order for DOE to bill Medicaid (or another public insurance program) for special education services:
(d) Children with disabilities who are covered by public benefits or insurance.
(1) A public agency may use the Medicaid or other public benefits or insurance programs in which a child participates to provide or pay for services required under this part, as permitted under the public benefits or insurance program, except as provided in paragraph (d)(2) of this section.
(2) With regard to services required to provide FAPE to an eligible child under this part, the public agency—
(iv)(A) Must obtain parental consent, consistent with § 300.9, each time that access to public benefits or insurance is sought; and
(B) Notify parents that the parents’ refusal to allow access to their public benefits or insurance does not relieve the public agency of its responsibility to ensure that all required services are provided at no cost to the parents.
The Office of Special Education Programs (OSEP) of the U.S. Department of Education issued a Memorandum on May 3, 2007, to State Directors of Special Education, with its interpretation of 34 CFR 300.154(d)(2)(iv)(A):
“This consent may be obtained one time for the specific services, and duration of services identified in a child's individualized education program (IEP), and a local educational agency (LEA) would not be required to obtain a separate consent each time a Medicaid agency or other public insurer or public program is billed for the provision of required services.” [emphasis added]
“While this type of consent may be obtained at an IEP meeting, it could also be obtained at some point after the IEP is developed.”
If DOE wants to use the student’s Medicaid benefits to pay for additional hours of service, for example if the IEP is revised or extended, and/or DOE charges different amounts for the services and wants to access the Medicaid benefits for those costs, DOE must obtain parental consent which covers the additional amount of service or cost.
The IEP must state specific services for a specific period of time. The consent is valid for the period of time that particular IEP is in effect, without changes to the cost, type or duration of services.
These provisions are intended to ensure that parents are fully informed of DOE’s proposed access of their child’s benefits and to provide written parental consent prior to DOE’s access to the Medicaid benefits.
If parents give consent directly to Medicaid agency, DOE isn’t required to obtain a separate parental consent, if that consent meets the requirements of 34 CFR 300.9 and 300.154(d).
“LEA [DOE] must maintain a copy of the parental consent to both demonstrate its compliance under Part B of the IDEA and to ensure that it is available for the parent or child to review.”
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