1 epsdt and the id waiver changes in preauthorization of children’s services virginia department...
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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
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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.
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EPSDT Eligibility• Children with Medicaid • Under the age of 21• Require “medically necessary”
supports
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“Medically necessary” means
needed to improve physical or mental health conditions.
Needs determined by ISP process.
EPSDT Eligibility
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Services available under both EPSDT and Waiver:
• Personal Care/Assistance
• Assistive Technology• Therapeutic
Consultation
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Personal Care under EPSDT
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EPSDT Personal Care
• “Personal Assistance” under ID Waiver
• Support with routine needs • “Medically necessary”
supervision
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• General Supervision unrelated to safety
• Respite• Support with employment
tasks• Assistance provided in other funded settings
EPSDT Personal Care is not:
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EPSDT Personal Care – Preauthorization
• DMAS -7 from MD, PA or RNP
• ID Waiver Personal Assistance ISARs
Annually!
Forward to assigned ODS PA Consultant prior to beginning
services
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EPSDT Personal Care/ID Waiver PA
• Back-up plans required• Same providers• Same services
• AD Personal Assistance • CD Personal Assistance
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Assessment: SIS
If no SIS, ODS-approved assessment tool or DMAS-99
Plan of care: PC ISP Plan for Support (Part V) orDMAS-7A with Personal
Preferences tool
EPSDT Personal Care/ID Waiver PA
Completed by:Completed by:Registered Nurse,Registered Nurse,Services Facilitator orServices Facilitator orProgram ManagerProgram Manager
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Personal Preferences Tool for use with the DMAS 7A
EPSDT Personal Care/ID Waiver PA
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EPSDT Personal Care
Provider Reviews• Written reviews every 6 months• Verbal reports for 3 and 9 month
reviews
Submit to SC!
If the PA provider is a DBHDS licensed provider, quarterly reviews are required.
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EPSDT Assistive Technology
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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
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EPSDT Assistive Technology
• Authorized up to 3 months
• No dollar limit per item/per year
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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
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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
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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
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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
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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
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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
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Therapeutic Consultation
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Therapeutic Consultation Specialty areas under the ID Waiver:
• Psychology• Behavioral consultation• Speech and language pathology• Occupational therapy• Physical therapy
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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)
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EPSDT TC – Preauthorization
• Letter or DMAS-355 from MD
• ID Waiver TC ISAR
Annually!
Forward to assigned ODS PA Consultant prior to beginning
services
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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.
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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
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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
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Don’t forget…
• Children become ineligible for EPSDT on their 21st birthday.
• PA, AT and TC will need to be authorized under the ID Waiver at that time
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Contacts
ODS Community Resource Consultantshttp://www.dbhds.virginia.gov/ODS-Contacts.htm
DMAS EPSDT Services SupervisorBrian [email protected]