The purpose of this chapter is to help Head Start better understand Medicaid and EPSDT services. Head Start personnel are encouraged to contact State EPSDT coordinators (see Appendix B) and other Medicaid agency staff for additional information.
Overview
Established by law in 1965, Medicaid is an entitlement program that finances medical services for certain individuals and families with low incomes and resources. Medicaid is a jointly funded Federal-State program that is administered by the States under broad Federal guidelines. The Medicaid program varies considerably from State to State, as each State adapts the program to meet local needs.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is the comprehensive child health component of the Medicaid program. EPSDT is a preventive and comprehensive health program available to most Medicaid-eligible individuals under age 21. EPSDT is called by different names in different states. The term EPSDT describes the program's goals and gives information regarding the services that it covers:
Early: assessing a child's health early in life so that potential diseases and disabilities can be prevented or detected in the early stages, when they are most effectively treated.
Periodic: assessing a child's health at key points in the child's life to assure continued healthy development.
Screening: the use of tests and procedures to determine if children being examined have conditions requiring closer medical (including mental health) or dental attention.
Diagnostic: determination of the nature and cause of conditions identified by screenings and those that require further attention.
Treatment: the provision of services needed to control, correct, or reduce health problems.
In carrying out the Federal mandate to provide EPSDT services, States are responsible for:
- Seeking out eligible children and families to: encourage their participation in EPSDT,inform them of the availability and benefits of preventive services, provide assistance with scheduling and transportation, and help them use health resources effectively and efficiently;
- Assuring that providers assess health needs through initial and regular periodic examinations; and
- Assuring that detected health problems are diagnosed and treated early, before they become more complex and their treatment more costly.
A State EPSDT program is often part of a larger network of social services and health programs for- children and families. Coordination among administrative-agencies is essential to prevent duplication and maximize access to services. Medicaid agencies are required to coordinate services with Maternal and Child Health (MCH) Programs, and WIC. Medicaid agencies are also expected to coordinate with additional programs such as Head Start, State and local educational agencies, and social service agencies. This coordination can include interagency agreements, cross-referrals, child health coordinating committees, and other activities that encourage coordination.Eligibility: Who can be Served?
Most children under age 21 who are eligible for Medicaid are automatically eligible for EPSDT services and can receive EPSDT services at any time. Family income is one of the main criteria used for eligibility determination, but not all children in families with incomes below the federal poverty level are eligible for Medicaid. The following are Medicaid eligibility groups that include children under age 21:
- Beneficiaries of Aid to Families w-ith Dependent Children (AFDC);
- Supplemental Security Income (SSI) beneficiaries;
- Infants less than 1 year of age born to Medicaid-eligible pregnant women;
- Beneficiaries of adoption assistance and foster care under Title IV-E of the Social Security Act; and
States are required to extend Medicaid eligibility to all children born after September 30, 1983, in families with incomes at or below 100% of the Federal poverty level. This phases in coverage so that by the year 2002, all children under age 19 in such families will be covered. In addition, States have the option to provide coverage to other groups of individuals.
- Infants and children -under age 6 and pregnant women whose family income is at or below 133 percent of the Federal poverty level.
Some States use their own money to expand coverage. A State can also receive a waiver from the Federal government to do this. Medicaid eligibility is a complicated subject and criteria vary significantly from State to State. Head Start programs should contact their State Medicaid office (Appendix B contains the phone numbers of State EPSDT Coordinators) for more specific information on Medicaid eligibility.
State EPSDT Requirements: What Services are Covered?
Each State must develop a State Plan which lists eligibility criteria, the services covered, and other information required by Federal regulations.
Like other health insurance programs, State Medicaid programs- sometimes limit the type of services covered. Children eligible for EPSDT services may receive Medicaid coverage for services that are not covered for adults. States are required to cover the following services under the EPSDT program:
- Screening services, including: a comprehensive health and developmental history, including a physical and mental health assessment; a comprehensive unclothed physical examination; appropriate immunizations according to the Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) schedule; - laboratory tests, including blood lead level; and health education, including anticipatory guidance.
- Dental services;
- Hearing services, including hearing aids;
- Vision services, including eyeglasses; and
The services are to be available in accordance with a State's periodicity schedule (or timetable). States must consult with medical and dental organizations involved in child health care to develop periodicity schedules. Screening services are also covered at times other than the regularly scheduled intervals, if there is reason to suspect an illness or condition that did not exist or was not identified at the regular periodic screening.
- Any other necessary health care to correct or improve illnesses and conditions found in screenings.
Diagnostic services are covered whenever a screening examination indicates the need to conduct a more in-depth evaluation. Treatment services are covered whenever they are medically necessary to correct or improve defects, physical or mental illnesses, or other conditions discovered or found to have worsened through an EPSDT screening.
Some support services are also required under the EPSDT program. Assistance with transportation and scheduling appointments must be offered and provided to ensure that beneficiaries have access to needed EPSDT services.
EPSDT Providers: Who Provides Services?
The use of all types of EPSDT providers is encouraged. Each State, however, has distinct licensing and certification rules. EPSDT services may be provided by physicians, dentists, or other types of providers, such as nurse practitioners in States where they are authorized to provide services. If more than one provider is needed to provide the full range of EPSDT services to a child, the services should be coordinated to ensure that the child receives all necessary services and to avoid duplication. - Services may be provided within schools, Head Start programs, State and local health departments, managed care organizations, and physician offices.
Reimbursement under Medicaid
States pay providers for Medicaid services and then are reimbursed by the Federal government for a share of the costs they incur for Medicaid activities. Some administrative expenses for functions such as outreach, follow-up, eligibility determination, provider relations, and some transportation activities, are usually reimbursed by the Federal government at a rate of 50 percent. Expenditures for medical services, including screening, diagnosis, and treatment, are reimbursed by the Federal government at State-specific rates. This rate varies from 50 to 83 percent with poorer States receiving a higher rate for the cost of Medicaid medical services and wealthier States receiving a lower rate.
Key Medicaid Principles
When developing linkages to Medicaid, Head Start programs must follow certain fundamental Medicaid principles. The fundamental principles are:
- Preserving confidentiality;
- Billing liable third parties;
- Reimbursing for services that would not otherwise be provided without charge;
- Assuring beneficiary freedom of choice of providers.
Preserving confidentiality is important to both Head Start and Medicaid. Medical information is privileged and, in most instances, is only released with the parent's permission.Probably the most difficult issue for Head Start programs regarding confidentiality has been how to identify Medicaid-eligible children. In some States, if Head Start programs are involved in Medicaid administrative activities, such as outreach or certain case management activities, the Head Start program may obtain lists of Medicaid-eligible children from the State. Otherwise, Head Start programs may only request information to verify Medicaid enrollment status. Head Start programs should contact their Medicaid agency for requirements for release of information.
Medicaid providers are normally responsible for billing liable third parties, such as private health insurance, before billing Medicaid. However, an exception is made for preventive pediatric care, including early and periodic screening and diagnostic services. For preventive pediatric care, the provider can bill Medicaid first. Medicaid then pays the claim to the provider and seeks reimbursement from liable third parties. This is known as "pay and chase." This exception applies to treatment whenever the treatment is provided by the same provider who performs the early and periodic screening and diagnostic services.
The Federal government does not generally match State expenditures for services to Medicaid eligible children that are available to others without charge. Exceptions to this principle include many services furnished by local health departments and certain services to children with disabilities provided under IDEA that are specified in a child's Individual Education Plan or Individual Family Service Plan.
Finally, in the absence of certain Federal waivers, including those for managed care arrangements, Medicaid beneficiaries have the freedom to choose their providers. Head Start programs may encourage, but may not require, Medicaid-eligible children to receive EPSDT services through the Head Start program.