EPSDT Program Activities
Head Start programs can play a role in many of the EPSDT activities, especially outreach, case management, screening, diagnosis, and treatment.
Outreach/Informing
States conduct outreach activities to inform and recruit eligible individuals into the Medicaid program. In addition to broad-based outreach, States are required to ensure that all eligible Medicaid beneficiaries under age 21 be informed about EPSDT within 60 days of Medicaid eligibility determination. Both States and providers inform eligible individuals about the program and emphasize the importance of preventive health care.
Head Start programs can help to inform eligible children and families about the EPSDT program. The major advantage that Head Start programs have in this activity is their daily physical access to young children and their parents. Head Start programs can also reach siblings who are not in Head Start. See Chapter 4 for further information about linkages between Head Start and Medicaid.
Eligibility Determination
Medicaid eligibility, which includes EPSDT services, is generally determined by a local social service agency. If a child is determined to be Medicaid eligible, the family is informed of the EPSDT program. They decide whether or not to participate in the EPSDT program. The initial decision to decline EPSDT services does not preclude a child's obtaining such services at a later time.
Participation
Head Start programs may play a role in encouraging EPSDT participation. Head Start can assist families who accept EPSDT services by arranging an appointment for a health screening. They can also obtain lists of Medicaid providers (including managed care entities) from the Medicaid agency to help families select providers.
Scheduling an Appointment and Transportation
The family can make an appointment for screening services independently or the Medicaid agency staff can help set up an appointment for the child. The Medicaid agency must offer and provide transportation assistance to appointments to those in need. Head Start programs may be able to be reimbursed for providing scheduling and transportation assistance as a part of the health services they provide in the health component of the program.
It's Head Start recruitment time. Carlos' mother, who works at the local dry
dry cleaning store, takes him to the neighborhood Head Start center to enroll him
for next September. The Social Services Coordinator, Rebecca, conducts the intake
interview. To determine if Carlos is eligible for Head Start, she asks for the family
income. Carlos' mother replies that together, she and Carlos' father earn $13,500,
which is just over the poverty line for a family of three. Rebecca knows that she
can accept Carlos into the Head Start program because 10 percent of the children
enrolled can be from families with incomes over the poverty guidelines.Rebecca is interested in meeting all of the family's needs, and during the
interview discovers that the family does not have health insurance that covers
Carlos. Rebecca sees that the family income is below the the income eligibility
guidelines for Medicaid, which is 133 percent of the poverty line - $16386 for a
family of three. * Rebecca tells Carlos' mother about the Medicaid program. She
emphasizes the importance of the comprehensive preventive health services
available through Medicaid's EPSDT component. Carlos' mother is very interested
in applying for the Medicaid program so she can be sure Carlos receives all of his
health screenings and immunizations. Together, Rebecca assures Carlos' mother
that she will help her collect the necessary documents before the appointment.In some States, Rebecca could have done even more to help families like
Carlos'. Some States allow families to mail their Medicaid applications, which
makes the process easier on working families. In one of these States, Rebecca
could have assisted Carlos' mother in Completing the Medicaid application that
same day.Center on Budget and Policy Priorities, Start Healthy, Stay Healthy, August 1994.
*Note: Medicaid income eligibility guidelines may vary from State to State. All states must provide
Medicaid coverage to children under age six from families with incomes below 133 percent of the
poverty line. A number of States have expanded the income eligibility guidelines for this group.
Screening
Usually the most common activity for Head Start programs participating in the EPSDT program is providing screening services. These include:
· A comprehensive health and developmental history, which includes a physical and mental health assessment;
· A comprehensive unclothed physical exam;
· Appropriate immunizations according to the (ACIP-AAP-AAFP) schedule;
· Laboratory tests, including blood lead level; and
· Health education, including anticipatory guidance.Although an oral screening examination may be part of a physical examination, it does not substitute for examination by a dentist. Both the Head Start Performance Standards and the Medicaid periodicity schedule require a dental examination.
Assessment of Results
Results of the screening tests and procedures are noted in the child's health record. In those cases where results do NOT indicate the need for further assessment by a health professional, the Medicaid agency or Head Start program need only notify the child or family when the next periodic screening examination is due.
Cases where problems are indicated are referred for diagnosis. In some cases, diagnostic and treatment services are provided by the provider who completed the screening.
Jonathan, who is four years old, recently moved to the area. He is late
enrolling in the Head Start program, which is home based. The home visitor meets
with his mother, who mentions during their conversation that Jonathan is a very
picky eater and seems to tire easily. The Home Visitor asks if the family has a
health care provider. Jonathan's mother explains that, before they moved to the area,
they applied for Medicaid but were denied coverage. Although she does not recall
the reason for the denial, she remembers that she had to bring a lot of papers along
when she applied.During her next scheduled visit, the Home Visitor brings an application for
Medicaid. she helps Jonathan's mother fill out the application, and assembles the
papers she will need when she turns in her Medicaid application. The Home Visitor
also explains the EPSDT program to Jonathan's mother. Both she and Jonathan's
mother are very happy when they find out that the family has been determined
Medicaid eligible.
Diagnosis
The purpose of diagnosis is to determine the nature, cause, and extent of the problem found by the screening examination. Diagnosis may result in the development of a plan for treatment.
Treatment
Treatment services are covered whenever they are medically necessary to correct or improve defects, physical or mental illnesses, or other conditions discovered through an EPSDT screening.
Providers may not be limited to those qualified to furnish all diagnosis and treatment services. However, children with a family health care provider will receive most of their EPSDT screening, diagnosis, and treatment services from the same provider.
Continuing Care
Ideally, EPSDT services are part of a continuum of care where the child's health care services are delivered by someone familiar with the child's health history and family. Beneficiaries of EPSDT services have the option of enrolling with a continuing care provider who can furnish the full range of EPSDT screening, diagnosis, and treatment services. The provider may provide medical and dental services and assistance with transportation and scheduling. Continuing care providers, such as Head Start, schools, pediatricians, other physicians, managed care organizations, and community health centers, help further the EPSDT goal of connecting children and families with a regular source of health care.
Periodic Renotification
At intervals set by each State, eligible children should be rescreened in order to optimize preventive health efforts. These intervals are relatively short in the first few years of life and get longer as the child gets older. The State is responsible for ensuring that renotification occurs. Many States use contractors to conduct periodic renotification.
The periodic notification process has three purposes: to inform children and families that the next screening examination is due, to remind them of the benefits of participating in EPSDT, and to offer necessary support services for them to successfully complete the screening examination.
Medicaid Managed Care
For this guide, managed care is broadly defined as an arrangement among the State Medicaid agency, the Medicaid beneficiary, and a provider or set of providers that are responsible for the individual's health care. The provider may be reimbursed based on a capitated rate (lump sum), as is done in a Health Maintenance Organization (HMO), or based on fee-for-service.
There are varying degrees of coordination between managed care organizations and Head Start programs. It is important for Head Start to establish a relationship early with a managed care organization in which its students are enrolled. The State Medicaid agency can be helpful in developing an arrangement that is workable for all concerned parties. Arrangements for the reimbursement for care provided can take different forms. The Head Start program can be reimbursed by the managed care organization or the Head Start program can be reimbursed by the State Medicaid agency directly - a common arrangement in rural areas. In some cases, the Head Start program may be prohibited from providing services to the managed care enrollees. In this instance, the Head Start program should work closely with the managed care organization to ensure there are procedures in place for the sharing of pertinent medical information (with parental permission and in accordance with State confidentiality requirements).
Devonna is a three year old who is entering Head Start this fall. although
she as been diagnosed with allergies and asthma, and has been enrolled in Medicaid
for six months, she does not have a regular on-going source of medical care.
Recently, the State changed its traditional Medicaid program to a managed care
program.After Devonna enters Head Start, the Health Coordinator, Karen, sits down
with Devonna's mother and provides her with information about the various health
plans available under the new State Medicaid program. Prior to the meeting, Karen
contacted each of the Health Plans to make sure they could provide for all of
Devonna's health care needs, especially those related to her asthma and allergies.
Devonna's mother and Karen go over the information very carefully, and after much
discussion, decide that Company a can best meet Devonna's health care needs.
Karen works with Devonna's family throughout the school year to make sure they
have all the necessary forms completed for enrollment and to answer any questions.
She also makes a note in Devonna's record to arrange a follow-up meeting with the
family later in the school year to make sure they are satisfied with the care Devonna
is receiving.