Important Benefi ts for Medicaid Eligible Children: EPSDT EARLY & PERIODIC SCREENING DIAGNOSIS & TREATMENT Ohio Legal Rights Service
On October 26, 2005, Ohio Legal Rights Service (OLRS) fi led a lawsuit in federal court on behalf of children who are eligible for but are not receiving needed medical services under the state s Medicaid program. The class action complaint is brought against the director of the Ohio Department of Job and Family Services (ODJFS) on behalf of a class of Medicaid eligible children who are being denied the benefi ts of Ohio s Early and Periodic Screening Diagnosis and Treatment (EPSDT) program.
What is EPSDT? EPSDT, known in Ohio as Healthchek, is a required Medicaid program covering children under age 21. This program requires that state offi cials periodically screen Medicaid eligible children for health problems. If a child s screening identifi es health problems, the law also requires the EPSDT program to provide necessary health care, diagnostic services and treatment. Those services include medical, vision, hearing and lead testing. However, any service that will correct or improve a child s health problems must be provided if the service is included in a list of federal Medicaid services. This is true even if the service is not routinely covered by Ohio s Medicaid plan. In order to get EPSDT services, your child must be eligible for Medicaid and under the age of 21. The system for EPSDT services begins with a screening completed by your child s doctor. This screening is required to include a comprehensive health and developmental history, a comprehensive physical examination, appropriate immunizations, laboratory tests and health education. This screening may identify a medically necessary service for your child. Medically necessary services can also be covered when they are recommended by any qualifi ed provider (e.g., occupational therapist, psychologist, speech therapist). 1
EPSDT also includes vision, hearing, dental services and laboratory tests. Necessary healthcare, diagnostic services, treatment, and other medically necessary services must be provided through EPSDT if they can be covered by federal Medicaid. When requested, transportation assistance to medically necessary services must be provided. EPSDT services must be provided or arranged for within a reasonable period of time. What kinds of services can be provided through EPSDT? There is a list of 27 services under federal Medicaid that can be provided under EPSDT. That list includes: Physician and clinic services Inpatient and outpatient hospital services Laboratory and x-ray services Home health services and private duty nursing services Personal care services (not in Ohio s Medicaid Plan but covered by EPSDT) Case management services 2
Physical therapy and related services Any medical care or other type of remedial care (e.g., occupational therapy) recognized under state law (some are not in Ohio s Medicaid Plan but covered by EPSDT) Other diagnostic, screening and rehabilitative services recommended by a licensed practitioner of the healing arts Durable medical equipment Dental services Certifi ed pediatric nurse practitioner services Nursing facility services, intermediate care facility for the mentally retarded services and inpatient psychiatric hospital services Respiratory care services How do I get EPSDT services for my child? OLRS fi led the lawsuit in part because there is no clear process for a parent to apply for EPSDT services. OLRS recommends that you take the following steps to try to access EPSDT services. In order to be covered under EPSDT, a service must be medically necessary. You should get a letter of medical necessity from the person recommending the service your child needs. This letter should detail 3
the specifi c service your child needs and WHY the service is medically necessary. It should also specify how much service is needed, how often it should be provided and how long the service is needed. You or your physician can contact your county and state Healthchek coordinator who should be able to assist you with accessing services. You should make it clear that you are requesting services for your child under EPSDT. (You can locate your county Healthchek coordinator by looking on the Ohio Department of Job and Family Services website at http://jfs.ohio.gov/. Once in the site, go to the site index and then to Healthchek Coordinators. This will give you a list of all county Healthchek coordinators.) You can also contact the Medicaid Consumer Hotline at 800-324-8680, 800-292-3572 (TDD), Monday - Friday, 7am to 8pm, Saturday - Sunday, 8am to 5pm, or leave a message anytime. You can ask to speak with the state EPSDT Program Coordinator. Who pays for EPSDT services? The law requires that the Ohio Department of Job and Family Services (ODJFS) (Ohio s Medicaid Agency) provide or arrange for EPSDT services. If the service your child needs is available through an existing program, that program can be utilized. If an existing program is not available and your child needs 4
a Medicaid covered service, then ODJFS is required to fund that service. The service will be paid for through federal and state dollars (known as state match ). In the past, many children received services (including therapies and psychological services) under the Community Alternative Funding System (CAFS) program. The state voluntarily ended that program on June 30, 2005. The CAFS program received funding from the federal government, along with match from local county boards of developmental disabilities or local school districts to provide theses services. Although the CAFS program is gone, a child needing therapy services previously covered under CAFS is still entitled to necessary services which the state Medicaid agency must fund if other funding is not available. As discussed above, Medicaid is a federal and state funded program in which the federal government pays approximately 60 percent of the cost of a service and the state pays approximately 40 percent. In Ohio, some of the Medicaid programs (including CAFS) have utilized local money for the 40 percent state share. However, ODJFS cannot deny a necessary service to your child if there is no local money for the state share. What can I do if I cannot access services through EPSDT? 5
If you are having trouble accessing services through EPSDT CONTACT OLRS Clearly document the steps you took to try to access EPSDT services. Document whether you were successful or unsuccessful in getting services. You should keep copies of any letters you wrote and any letters or evaluations you have. You should also keep written records of any telephone calls you made including who you talked to and what you talked about and the date of your conversation. Contact OLRS and tell us your experience: Ohio Legal Rights Service 50 W. Broad St., Suite 1400 Columbus, Ohio 43215-5923 TEL 614-466-7264 or TEL 800-282-9181 (toll free in Ohio only) TTY 614-728-2553 or TTY 800-858-3542 (toll free in Ohio only) FAX 614-644-1888 WEB http://olrs.ohio.gov Funding for this booklet was provided by the Administration for Developmental Disabilities of the U.S. Department of Health and Human Services. OLRS does not discriminate in provision of services or employment because of race, color, religion, sex,sexual orientation, national origin, military service, disability, or age. Produced January 2006