EPSDT and SUD Treatment in California

Presentation to CBHDA Governing BoardDecember 9, 2015

Lucy Pagel, Molly Brassil, and Don Kingdon, Harbage Consulting

Overview of Presentation

EPSDT Benefit Description of Services

Screening Treatment

Federal Assurances and Requirements CA State Assurances and Requirements

Medicaid State Plan 1115 Waiver DMC-ODS Pilot Program

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3 EPSDT Benefit & Services

EPSDT Benefit

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.

States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines.

“The right care to the right child at the right time in the right setting.” (Medicaid.gov)

States share responsibility for implementing the EPSDT benefit with the Centers for Medicare & Medicaid Services.

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EPSDT Benefit Cont.

Early Assessing and identifying problems early

Periodic Checking children's health at periodic, age-appropriate intervals

Screening Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

Diagnostic

Performing diagnostic tests to follow up when a risk is identified, and

Treatment

Control, correct or reduce health problems found

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EPSDT Services

Screening Services Comprehensive health and developmental (including behavioral) history; Physical

exam; Immunizations; Laboratory Tests (including lead toxicity screening); and Health education

Vision services Dental services Hearing services Other necessary health services

Any additional health care services that are coverable by Medicaid and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in a state's Medicaid plan

Diagnostic services When a screening indicates the need for further evaluation, diagnostic services

must be provided and necessary referrals must be made without delay) Treatment

Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures

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EPSDT Screening

The state must determine and implement a periodicity schedule for each type of screening service available to beneficiaries.

Screenings can be conducted by any providers operating within their scope of practice.

The managed care plans (MCPs) in California are required to meet these screening requirements.

Child Health and Disability Prevention (CHDP) exams are also required for all children entering foster care.

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EPSDT Treatment

EPSDT services do not need to cure a disability or restore an individual to a previous functional level, as is the case with Medicaid in general

EPSDT services are covered when they ameliorate a condition, for example: mental health or substance abuse rehabilitative services needed to promote development. These can include: Community based services, individualized mental

health and/or substance abuse services, medication management, counseling and therapy and rehabilitative equipment

9 Federal Assurances & Requirements

Federal EPSDT Assurance

Section 1905(a) of the Social Security Act (SSA) requires that states provide certain assurances to Medicaid beneficiaries under the age of 21

States must provide EPSDT coverage for all Medicaid eligible children, providing access to appropriate and medically necessary services needed to “correct or ameliorate defects, physical and mental illnesses, and conditions discovered by the screening services”

These services must be provided regardless of whether they are required under the state’s Medicaid plan

Access to full EPSDT services must be provided through a benchmark, or benchmark equivalent plan, or as additional benefits

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11 California Assurances & Requirements

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California’s Medicaid State Plan

“EPSDT services are covered for Medi-Cal eligibles under 21 years of age. This includes rehabilitative mental health services: collateral, assessment, individual therapy, group therapy, medication service, crisis intervention, day treatment intensive, day rehabilitation offered in local and mental health clinics or in the community as described in [MH Rehab SPA 10-016]. Prior authorization is not required. Medical necessity is the only limitation.” SUBSTANCE USE DISORDER TREATMENT

The state assures that substance use disorder treatment services shall be available to children and youth found to be eligible under the provisions of SSA 1905(r)(5). [SPA 13-038]

In cases where additional EPSDT services are needed for individuals under 21, these services are available subject to prior authorization. [SPA 13-038]

Outpatient heroin or other detox services are covered for beneficiaries under the age of 21 when medically necessary. [SPA 13-038]

California’s 1115 Waiver DMC-ODS Pilot Program

No age restrictions Program Medical Criteria for Youth under 21:

Enrolled in Medi-Cal Reside in Participating County Meet Medical Necessity Criteria:

Be assessed to be at risk for developing a substance use disorder Meet the ASAM adolescent treatment criteria (if applicable)

Excerpt from the Standard Terms and Conditions: “As a point of clarification, beneficiaries under age 21 are eligible

to receive Medicaid services pursuant to the Early Periodic Screening, Diagnostic and Treatment (EPSDT) mandate. Under the EPSDT mandate, beneficiaries under age 21 are eligible to receive all appropriate and medically necessary services needed to correct and ameliorate health conditions that are coverable under Section 1905(a) Medicaid authority. Nothing in the DMC-ODS Pilot overrides any EPSDT requirements.”

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Lucy Pagel, MPH, Policy Consultant lucy@harbageconsulting.com

Molly Brassil, MSW, Deputy Director, Behavioral Health Integration

molly@harbageconsulting.com Don Kingdon, PhD, Director of Behavioral Health Integration

don@harbageconsulting.com