Child Health and Disability Prevention (CHDP) Program

Transcription

1 CHDP Summary Child Health and Disability Prevention (CHDP) Program This fact sheet will provide an overview of California s Child Health and Disability Prevention Program (CHDP). 1 The fact sheet will consider program structure, eligibility, coverage, outreach, and access to the program. Finally, the fact sheet will give suggestions of ways in which advocates can work to improve the program. CHDP is a California program to provide early screening, preventive care, and early treatment of childhood and other illnesses or disabilities. How does CHDP work together with EPSDT? To understand the CHDP program, one must also understand the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. 2 EPSDT is a program required in every state for all Medicaid (called Medi-Cal in California) beneficiaries up to age 21. Under EPSDT, children receive periodic screenings including physicals and visual, hearing, and dental screenings. 3 If a child is found to have a medical condition, Medicaid pays for services and treatments to correct or ameliorate the condition. 4 The State Medicaid agency is also responsible under EPSDT for providing assistance with scheduling appointments for screening and treatment services and for providing assistance with transportation to screening and treatment appointments. 5 The program also is significant in that the State must pay for treatments or services for children and young adults under EPSDT that the State might not otherwise cover for adults with similar conditions or illnesses. 6 CHDP incorporates parts of the EPSDT program: The periodic screenings and assistance with scheduling and transportation. 7 CHDP provides care coordination to assist families with medical appointment scheduling and transportation and access to diagnostic and treatment services. 8 If a condition or illness is found and the child is on Medi-Cal, Medi-Cal pays for the diagnosis and treatment of the condition. If the child is not eligible for Medi-Cal, CHDP will refer the child to a provider who has agreed to provide diagnosis and treatment for free or at a reduced rate. 9 The program first must refer a child to the child s usual source of health care, and if the child has no usual source, then the program gives the parent a list of three qualified providers. 10 Who is eligible for CHDP services? CHDP screenings cover children from birth and young adults up to age 21 who are eligible under EPSDT (i.e. Medi-Cal beneficiaries). 11 For all children who are not Medi-Cal beneficiaries, CHDP covers health assessments from birth to 90 days after entrance into the first grade. 12 CHDP also covers health assessments for children and young adults under 19 years of age whose family income is not more than 200% of the federal poverty level. 13 A parent or caretaker of a child needing CHDP services will complete a one-page eligibility form at the health provider s office. Every child, within 90 days of entrance into the first grade, must provide a certification or waiver, signed by a parent or guardian, that the child has received the health screening and evaluation within Materials developed by the HEALTH CONSUMER ALLIANCE 8/2001

2 the past eighteen months. 14 The governing bodies of school districts and private schools must work with the local CHDP program to inform parents or guardians of this requirement. 15 School districts may exclude children for up to five days for failure to provide a certificate or waiver within 90 days of beginning first grade. 16 How is the program structured? The Department of Health Services (DHS) administers the program and sets the program standards. 17 The program is largely implemented through county governing bodies. Most counties have a CHDP office, with a few counties sharing responsibility under joint programs. 18 A statewide office in Sacramento has the responsibility for supervising the program, providing coordination and administration, and contracting with county agencies for CHDP services; however, the state office is severely understaffed and thus unable to offer much assistance or oversight. 19 Local advisory boards meet at least twice a year, once before March 1, and once after March 1, but before September Meetings must be publicly noticed and open to the public. 21 By March 15 of each year, the advisory board must submit a summary of its activities, a description of the program to be offered in the next fiscal year, and a budget for the year beginning the following July Verification of training and education in CHDP services for county social services and welfare eligibility personnel also must be included in the plans. 23 Local programs that fail to comply with federal or state law or regulations regarding the CHDP services can be sanctioned for noncompliance. 24 When the Healthy Families Program plan was submitted to the federal government, the State proposed making CHDP a gateway to the Health Families Program. 25 This integration of the two programs has not occurred, and CHDP has not been updated to reflect the changes in health care coverage with the introduction of Healthy Families. 26 Sections 6860 and 6862 of Title 17 of the California Code of Regulations list the requirements for provider participation in the CHDP program, including written notification by providers stating which, if not all, the health assessment services they will provide 27, who may provide health assessments, and responsibilities of providers to assume overall case management of the patient if s/he is referred for diagnosis and treatment. 28 Who pays for the CHDP services? The State of California pays for all CHDP services for Medi-Cal beneficiaries from birth to twenty-one years of age. 29 Costs for diagnosis and treatment of these children are reimbursed according to Medi-Cal fee schedules. 30 For children who are not Medi-Cal beneficiaries, the State will pay the costs of health assessments and referrals to diagnosis and treatment, limited to funding appropriated by the Legislature. 31 The State may not cover the cost of treatment for the non-medi- Cal eligible child. The legislature explicitly will not reimburse counties for treatment of disabilities identified as a result of the program. 32 However, counties may bill third parties or the Medi-Cal program where such billing and reimbursement is appropriate. 33 If the child has a severe Page 2

3 disability, s/he may be eligible for California Children s Services or regional center assistance for treatment. For either a health assessment or dental services, a patient first is referred to his/her usual provider of medical or dental care. 34 Medi-Cal beneficiaries who are in a managed care health plan are referred to their health plan for CHDP screenings according to the contract between DHS and the health plan. 35 If the person has no usual source of care, s/he is given the names and addresses of three sources of care. 36 Although a person may get services from the provider of his/her choice, the State will only reimburse health assessments performed by providers who participate in the CHDP program and dental services performed by providers participating in the Medi-Cal program. 37 A provider who bills the CHDP program for a health assessment must accept the program s reimbursement as payment in full for those services. 38 The provider may not charge any additional amounts to the CHDP program or to an individual. 39 Likewise, clinical laboratories must accept the CHDP payment as payment in full, and they may not bill any individual, provider, or the CHDP program. 40 Reimbursement rates are listed at 17 Cal. Code of Regulations Counties must bill Medi-Cal for CHDP services to Medi-Cal beneficiaries. 41 CHDP programs also must inquire into third party reimbursement entitlement (i.e. private insurance), and if that entitlement exists, the third party must be billed. 42 What is included in the health assessment or screening? The health assessment or screening includes: 1. A comprehensive health and developmental history, and a physical examination; 2. Appropriate health screening procedures and immunizations; 3. Evaluation of results in terms of needed diagnosis and treatment; 4. Providing the person screened with a copy of the results and an explanation of their meaning; and 5. Health education appropriate to the person s age and health status, including antitobacco use education. 43 Health assessments must also include 44 : An unclothed physical examination, including assessment of physical growth; Assessment of nutritional status; Inspection of ears, nose, mouth, throat, teeth and gums; Vision screening; Hearing screening; Tuberculin testing; Page 3

4 Laboratory tests appropriate to the child s age and sex, including tests for anemia, diabetes, and urinary tract infections; Testing for sickle cell trait and lead poisoning where appropriate; Immunizations appropriate to the age and health history of the child, including any immunizations needed to bring the child s immunizations current; Health education and anticipatory guidance appropriate to the child s age and health status; Additional screening procedures if the local program so designates and the State approves; One recheck if medically indicated because of questionable or marginal results during the first assessment or in the laboratory test results. The health assessment includes an inspection of the teeth, gums, and mouth, and a child should be referred to a dentist if appropriate. 45 Providers must provide the person a copy of the results of the screening tests, with an explanation of the results. 46 Results of the health assessment must be recorded on forms provided by the Department of Health Services, and the local CHDP program maintains records of the health assessments. 47 What other services are covered under CHDP? Each community CHDP program must include: Outreach and health education, including anti-tobacco use education; Referral to a dentist; Referral to a health assessment; Health assessment; Certification for school entry; Referral to diagnosis and treatment; and Diagnosis and treatment. 48 Local programs must keep records of the results of health assessments, follow-up to diagnosis and treatment, and other data. 49 What kind of outreach or education to CHDP eligible children and their parents is required? State regulations require CHDP to use [c]lear, nontechnical materials for those families who are to be informed in writing. 50 CHDP informing procedures must also be suitable for non- English speaking persons, people with disabilities, and people who are illiterate. 51 Families must also receive information about the benefits of preventive services, the services offered, and the State s periodicity schedule. 52 The CHDP program must inform families that referral assistance shall be provided and that the family may receive assistance with referrals and transportation. 53 The program also must advise eligible families that the CHDP services are available at no cost from approved providers. 54 Page 4

5 Medi-Cal beneficiaries must receive information about CHDP no later than 60 days following the initial Medi-Cal eligibility determination or determination after a period of ineligibility. 55 Beneficiaries must receive this information in writing and with a face-to-face meeting with a person who is able to explain the services and benefits. 56 If no member of an eligible family takes part in the program, the family must be informed in writing at least annually. 57 Annual informing includes offering CHDP services, offering assistance with transportation and scheduling appointments, and documenting the family s responses. 58 Community CHDP programs must design their outreach and education programs such that the only reason eligible persons do not participate in the health assessment and referral for diagnosis and treatment portions of the program is because they intelligently and knowingly decline such participation for reasons unrelated to availability and accessibility of the health assessment, diagnosis, and treatment services. 59 How often are health assessments required? While health assessments are available to Medi-Cal beneficiaries under 21 (as required by EPSDT) and certain other children who are not Medi-Cal beneficiaries (see eligibility requirements above), the regulations infer that only Medi-Cal beneficiaries are eligible for periodic health assessments. 60 The State s periodicity table is a guide for the minimum frequency of health assessments. 61 A periodic assessment may be done at any time from the beginning to the end of each of the following age periods 62 : Under 1 month old 2 years old 1 through 2 months old 3 years old 3 through 4 months old 4 through 5 years old 5 through 6 months old 6 through 8 years old 7 through 9 months old 9 through 12 years old 10 through 12 months old 13 through 16 years old 13 through 17 months old 17 through 20 years old 18 through 23 months old More frequent health assessments are reimbursed when the provider deems the additional health assessment appropriate. 63 More frequent assessments may be necessary if the parents or child have a particular need for education and guidance, there is the possibility or presence of perinatal disorders, or the child will be exposed to a potentially stressful environment, such as at camp or during contact sports. 64 However, CHDP will not pay for more frequent health assessments for the purpose of monitoring or treating a disease or disorder or for ongoing treatment. 65 Nevertheless, advocates should be aware that federal EPSDT regulations require Medi-Cal to pay for monitoring a disease or disorder and for ongoing treatment, even if these services are not considered part of the CHDP program and even if Medi-Cal would not cover the same services for an adult over 21 years of age. 66 Page 5

6 Appointments for health assessments should be completed in a reasonable period of time, normally not to exceed 60 days. 67 Medi-Cal beneficiaries age three or older must be offered a referral to a dentist annually. 68 The California regulations require that these dentists be reimbursed for diagnosis and dental care required for relief of pain and infections, restoration of teeth and maintenance of dental health. 69 However, advocates should be aware that under the broader requirements of EPSDT, children on Medi-Cal might be entitled to a broader range of services, including medically necessary orthodontia. 70 A periodic dental examination should be completed within 120 days from the beneficiary s request or from the last day of the month in which the annual dental exam was due. 71 What happens to children who are found to have health conditions or illnesses? Appointments for diagnostic and treatment services must be completed in a reasonable period of time, normally not to exceed 60 days from the date of the health assessment. 72 Medi-Cal beneficiaries who requested assistance with transportation or scheduling the health assessment must be offered the same assistance for diagnosis and treatment. 73 Children on Medi-Cal are referred to providers participating in the Medi-Cal program. 74 While the regulation states that diagnostic and treatment services shall be subject to any applicable Medi-Cal program limitations, in fact, under EPSDT, Medi-Cal must provide all mandatory and state optional services under the Medicaid Act to cure or ameliorate the person s condition. 75 Non-Medi-Cal beneficiaries are referred for diagnosis and treatment to providers expressing a willingness to furnish treatment services at little or no expense to the family. 76 The local CHDP program must also identify and inform those children who are eligible for medical or remedial services under Title V of the Social Security Act (including Maternal and Child Health and California Children s Services). 77 How can advocates make a difference?!"each year, the county CHDP office must submit a budget and plan, including a description of the program s proposed outreach activities. Advocates can urge greater allocation of funding to the program and more attention to outreach and informing activities. Is informing occurring? Is the outreach and education effective? Does the local advisory body budget enough money to CHDP outreach and education to make it an effective program?!"is the outreach effective for reaching both children who receive Medi-Cal and those who do not? Does the outreach include moving uninsured children into Medi-Cal and Healthy Families? How is your county informing children on Medi-Cal now that the state has eliminated face-to-face interviews at which the informing previously occurred?!"are children in the community not taking part in CHDP due to lack of availability and accessibility of the services? If so, this is a violation of Cal. Code Regs. Title 17,

7 6842(b)(1). The local CHDP program also may not be informing Medi-Cal beneficiaries of their rights to assistance with scheduling appointments and transportation to appointments.!"since 6852 states that diagnosis and treatment services are subject to Medi-Cal program limitations, some children may experience difficulties getting services covered that the State must cover under the EPSDT program. Advocates should see if the services the child needs are listed in the federal mandatory and optional services. If so, then an advocate can argue that the Medi-Cal program must pay for these services under the Medicaid Act.!"Are non-medi-cal children receiving diagnosis and treatment services? The State s approved brochure infers that only children receiving Medi-Cal can get CHDP services. Advocates should look to see if local CHDP programs are doing enough to ensure that there are adequate providers willing to provide low or no cost services and whether these children are screened for Title V eligibility.!"are children in managed care health plans getting periodic health assessments? Many health plans may not be performing regular assessments. For children in Medi-Cal managed care health plans or in Healthy Families, check the plan s contract with DHS (for Medi-Cal) or the Managed Risk Medical Insurance Board (MRMIB, for Healthy Families) to see what health assessments, their frequency, and outreach requirements the contract contains.!"are CHDP providers charging families for the health assessments? Some advocates have indicated that this is occurring, and families should not need to pay anything for CHDP services. ENDNOTES 1 Developed by NHeLP with the assistance of Marilyn Holle of Protection & Advocacy, Inc. 2 See 42 U.S.C. 1396d(a)(4)(B), 1396d(r), and 1396a(a)(43) U.S.C. 1396d(r) U.S.C. 1396d(r)(5) U.S.C. ' 1396a(a)(43)(B), (C); 42 C.F.R. ' (transportation and scheduling assistance); State Medicaid Manual ' C (EPSDT FFP reimbursement for transportation and Arelated travel expenses@ as a service or administrative expense), HCFA-Pub. 45-5, Transmittal No. 10 (Apr. 1995) U.S.C. 1396d(r)(5). 7 CHDP also makes necessary assistance with scheduling appointments for services and with transportation for Medi-Cal eligible children a program requirement. Cal. Health & Safety Code Cal. Code Regs., tit. 17 ' 6824(b)(4)(I) [transportation], (J) [scheduling], (K) [may request such assistance initially and subsequently], and ' See, DHS form PM 357 (3-99) referring Medi-Cal beneficiaries to the county CHDP program including for assistance with transportation and/or scheduling. See, also, DHS= Children=s Medical Services model interagency agreement between the county CHDP program and the county social service agency and probation department (8-98). Merced County, in an undated explanation of its procedures for following up on PM 357 referrals, explains: When the client requests assistance with transportation, bus schedules are offered. If this mode of transportation is not suitable, transportation services are requested from the eligibility worker at Human Services Agency (HSA). If transportation is needed immediately and the client cannot use the above means of transportation, the EPSDT worker will transport the client to the appointment.

8 From discovery in Emily Q. v. Bontá, Case No. CV AHM (AIJx), plaintiffs= exhibit 148. See, also, Cal. Code Regs., tit. 17 ' From an explanation of the CHDP program by Children=s Medical Services Branch, DHS, gov/pcfh/cms/html/chdp.htm 9 Cal. Code Regs. Tit. 17, 6802(a)(2), 6850(a)(1). The State s CHDP regulations have not yet been updated to reflect that this provider may be a child s Healthy Families Program provider. 10 Cal. Health & Safety Code Cal. Health & Safety Code , Cal. Code Regs. Tit. 17, Id., 6830(b). 13 Id. In Los Angeles County, and possibly in other counties, foster children have a CHDP screening yearly. Los Angeles also requires that they receive an exam within 30 days of a new foster care placement. (Telephone conversation with CHDP worker, Fall 2000.) 14 Cal. Health & Safety Code ; Cal. Code Regs. Tit. 17, 6802(a)(3), 6824(e)(5), Cal. Code Regs. Tit. 17, 6842(b)(2). 16 Cal. Health & Safety Code Cal. Health & Safety Code This section previously required input from an advisory board, but that requirement was eliminated in AB 430, Section 12.5, Chaptered August 10, 2001 as urgency legislation. 18 County CHDP programs also coordinate work and share experiences through five regional associations. 19 In a recent (October 2000) telephone conversation with a representative of the state CHDP office, we found that the office has only four nurse consultants for the entire state. Another people do some part-time or occasional work on the program, mostly data collection and synthesis. One Branch Chief who also oversees the California Children s Services program oversees the program. The state office provides counties with a basic outreach brochure, which the county programs customize. Most outreach materials are coming out of the county CHDP programs. 20 Cal. Code Regs. Tit. 17, 6820(d). 21 Id. 22 Cal. Code Regs. Tit. 17, 6824(a). 23 Cal. Code Regs. Tit. 17, 6824(c)(3). 24 Cal. Code Regs. Tit. 17, See California s proposal for the Healthy Families Program that was submitted to HCFA on November 18, 1997 at 16. The plan is available on the Internet at: splan.htm. 26 Legislative Analyst s Office, Obstructed Entry: CHDP Fails as Gateway to Affordable Health Care, An LAO Report, January 30, 2001, at 2. The report is available at: 27 Cal. Code Regs, Tit. 17, Cal. Code Regs, Tit. 17, 6862(a), (d)(3). 29 Cal. Code Regs. Tit. 17, 6802(a)(1). 30 Cal. Code Regs. Tit. 17, 6832(c). 31 Cal. Code Regs. Tit. 17, 6802(a)(2), 6832(b). It is not clear at this point whether counties, in fact, may have a duty to pay for diagnosis and treatment. Conversations with CHDP workers indicate that some counties may be paying for diagnosis and treatment. With the passage of Proposition 99 (The Tobacco Tax and Health Protection Act) in 1989, counties were supposed to receive Proposition 99 money in return were supposed to provide treatment services for medical conditions revealed in the CHDP health assessments. In the fiscal year, money from the General Fund replaced the portion of CHDP funded by Proposition 99 money. See, Legislative Analyst s Office, Obstructed Entry: CHDP Fails as Gateway to Affordable Health Care, An LAO Report, January 30, 2001, at 2. The report is available at: 32 Cal. Health & Safety Code , However, see previous footnote. 33 Cal. Health & Safety Code (a). 34 Cal. Code Regs. Tit. 17, 6844(a)(3), 6843(f). 35 Cal. Code Regs. Tit. 17, 6866(a)(3). 36 Id. 37 Id. 38 Cal. Code Regs. Tit. 17, 6866(c). 39 Id., Cal. Code Regs. Tit (b)(4)(M).

9 40 Cal. Code Regs. Tit. 17, 6866(e)(1). 41 Cal. Health & Safety Code (a). 42 Id. 43 Cal. Code Regs. Tit. 17, Cal. Code Regs. Tit. 17, 6846(b), 6848(d). 45 Cal. Code Regs. Tit. 17, 6843(a)(2). 46 Cal. Code Regs. Tit. 17, 6846(e)(1). 47 Cal. Code Regs. Tit. 17, 6846(e)(2), 6824(f). 48 Cal. Code Regs. Tit. 17, 6824(e). 49 Cal. Code Regs. Tit. 17, 6824(f), Cal. Code Regs. Tit. 17, 6824(b)(3)(A). 51 Cal. Code Regs. Tit. 17, 6824(b)(3)(B). 52 Cal. Code Regs. Tit. 17, 6824(b)(4). 53 Id. 54 Cal. Code Regs. Tit. 17, 6824(b)(4)(M). 55 Cal. Code Regs. Tit. 17, 6824(b)(1). 56 Id. 57 Cal. Code Regs. Tit. 17, 6824(b)(2). 58 Id. 59 Cal. Code Regs. Tit. 17, 6842(b)(1). 60 Cal. Code Regs. Tit. 17, 6847(a) states, Medi-Cal beneficiaries who have received an initial health assessment are also eligible for subsequent, periodic health assessments. The balance of this regulation on Periodicity of Health Assessments speaks of persons eligible for periodic health assessments. Section 6830, which describes eligibility for services, speaks of periodic health assessments for Medi-Cal beneficiaries, but is silent on periodic assessments for other children. 61 Cal. Code Regs. Tit. 17, 6847(c). Under revisions to Cal. Health & Safety Code in AB 430, Section 12.7, Chaptered August 10, 2001, DHS may revise the frequency of health assessments and immunizations. Health assessments may be provided at the frequency provided under the Healthy Families Program and permitted in Medi-Cal managed care. Immunizations may be provided as recommended by the Committee on Infectious Disease of the American Academy of Pediatrics and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. 62 Id. 63 Cal. Code Regs. Tit. 17, 6847(d). 64 Id. 65 Cal. Code Regs. Tit. 17, 6847(e) U.S.C. 1396a(a)(43), 1396d(r)(5). 67 Cal. Code Regs. Tit. 17, 6844(a)(2). 68 Cal. Code Regs. Tit. 17, 6843(c). 69 Cal. Code Regs. Tit. 17, 6843(c). 70 HCFA, State Medicaid Manual 5124.B. See e.g. Philadelphia Welfare Rights Org. v. Shapp, 602 F.2d 1114, (3 rd Cir. 1979), cert. den. 444 U.S (1980); Persico v. Maher, 465 A.2d 308 (Conn. 1983); Biewald v. Maine, 451 A.2d 98 (Me. 1982); Brown v. Kizer, No (Alameda Co. Cal. Super. Ct., Dec. 12, 1989) (available from NHeLP). In California, some medically necessary orthodontia for low-income children is provided through the California Children s Services (CCS) program. 71 Cal. Code Regs. Tit. 17, 6843(e). 72 Cal. Code Regs. Tit. 17, 6850(a)(2). 73 Cal. Code Regs. Tit. 17, 6850(b)(1). 74 Cal. Code Regs. Tit. 17, 6852(a). 75 Id., 42 U.S.C. 1396a(a)(43), 1396d(r)(5), see 42. U.S.C. 1396d for a list of all mandatory and optional services. 76 Cal. Code Regs. Tit. 17, 6850(a)(1). For many children, this may be their health care providers under the Healthy Families Program. 77 Cal. Code Regs. Tit. 17, 6850(a)(5).