EPSDT – A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents

JUNE 2014

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

Available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html

Produced in collaboration with the National Health Law Program under subcontract to NORC at the University of Chicago www.NORC.org

EPSDT’s goal is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.

“The Medicaid program’s benefit for children and adolescents is known as Early and Periodic Screening, Diagnostic and Treatment services, or EPSDT. EPSDT provides a comprehensive array of prevention, diagnostic, and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.”

Ten Ways the Affordable Care Act Helps Older Adults and People with Disabilities

Source: Ten Ways the Affordable Care Act Helps Older Adults and People with Disabilities

Executive Summary Ten Ways ACA Helps Older Adults

NHeLP Senior Policy Analyst David Machledt  provides a succinct examination of the ways the Affordable Care Act is improving the lives of older adults and people with disabilities. For example, the ACA bars health plans from discriminating against those with pre-existing conditions and since its enactment 3.6 million people with pre-existing conditions have gained health care coverage.

Health Services in Schools: Medicaid and Special Education Services

Executive Summary

This NHeLP fact sheet provides information about health services for children, under age of 21, in schools. Many of the services are provided in schools, and some these services are provided Medicaid and/or the Individuals with Disabilities Education Act, or IDEA.

DOWNLOAD PUBLICATION (IDEA – Health Services in Schools – 1 Pager)

Source: Health Services in Schools: Medicaid and Special Education Services

Health services in schools.

  • Services provided in schools can play an important role in child and adolescent health care.
  • Many services are already provided in schools: through school-based health clinics, school nurses, or through special education programs. This includes services such as mental health services and physical, occupational, and speech therapies.
  • Some of these services can be covered by Medicaid.
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

Medicaid services for children.

  • Medicaid requires that children under age 21 get Early and Periodic Screening, Diagnostic, and Treatment services, or EPSDT.
  • EPSDT covers screenings (checkups) and treatment for medical, mental health, dental, vision, and hearing problems.
  • Treatment includes services that can provided in schools, like:

    Physical, occupational, and speech therapy.
    Vaccinations.
    Hearing and vision screenings.
    Behavioral health services.

What Makes Medicaid, Medicaid? — Access

By Abbi Coursolle, David Machledt, Wayne Turner

Executive Summary

In the fourth paper in our “What Makes Medicaid, Medicaid?” series, NHeLP experts explain the provisions and protections that ensure Medicaid beneficiaries gain access to quality health care services. Senior Attorney Abigail Coursolle, Senior Policy Analyst David Machledt, and Senior Attorney Wayne Turner write, “Medicaid is designed to include many protections that ensure that beneficiaries get more than a coverage card. Medicaid ensures that beneficiaries have access to a range of services specifically designed for their needs.”

Source: What Makes Medicaid, Medicaid? — Access – DOWNLOAD PUBLICATION

Key Takeaways
  • Under current law, states have tremendous flexibility in designing their Medicaid programs to determine low-income people eligible and enroll them in coverage.
  • Medicaid operates efficiently by ensuring that low-income people are enrolled into coverage when they need it.
  • Medicaid coverage is designed to provide continuous coverage for pregnant women and newborns.
  • Medicaid ensures that beneficiaries can get to their medical and specialty care appointments through transportation assistance.
  • Medicaid contains protections designed to get beneficiaries who need prescription medication access to their treatment quickly.
  • Medicaid gives beneficiaries the right to access the providers they need to treat their health conditions.

Disability Rights – National Health Law Program

Medicaid provides health coverage and protections for persons with physical, intellectual and developmental disabilities. NHeLP works with state health advocates and litigates when necessary to protect the rights of vulnerable persons, making sure persons with disabilities receive the care they need and are legally entitled to, as well as protecting their rights when care is denied, terminated or reduced without notice or a hearing.

Source: Disability Rights – National Health Law Program

 

Study finds $200 billion in avoidable health care costs | American Pharmacists Association

Source: Study finds $200 billion in avoidable health care costs | American Pharmacists Association

Medication misuse, non-adherence, errors contribute to wasteful spending

Health care costs caused by improper and unnecessary use of medications exceeded $200 billion in 2012, amounting to an estimated 10 million hospital admissions, 78 million outpatient treatments, 246 million prescriptions, and 4 million emergency department visits annually, according to a new report from the IMS Institute for Healthcare Informatics.

This amount, representing 8% of the nation’s health care spending that year, “could pay for the health care of more than 24 million currently uninsured U.S. citizens,” said Murray Aitken, IMS Executive Director, in a news release announcing the report, Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly.

These avoidable costs arose when patients failed to receive the right medications at the right time or in the right way, or received them but failed to take them, according to the report. Improvement is necessary in six areas: medication nonadherence, lag in adoption of evidence-based treatment practice, misuse of antibiotics, medication errors, suboptimal use of generics, and mismanaged polypharmacy in older adults.

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Medicaid Restructuring Under the American Health Care Act and Nonelderly Adults with Disabilities | The Henry J. Kaiser Family Foundation

Medicaid covers more than three in 10 non-elderly adults with disabilities, providing a broad range of medical and long-term care services that enable people with disabilities to live and work in the community.

Source: Medicaid Restructuring Under the American Health Care Act and Nonelderly Adults with Disabilities | The Henry J. Kaiser Family Foundation

Key Takeaways
This brief describes Medicaid’s role for nearly 7 million nonelderly adults with disabilities living in the community to help inform the debate about the American Health Care Act’s proposals to end enhanced federal funding under the ACA and reduce federal Medicaid funding under a per capita cap.Medicaid covers more than three in 10 nonelderly adults with disabilities, providing a broad range of medical and long-term care services that enable people with disabilities to live and work in the community. 

  • Over half of nonelderly Medicaid adults with disabilities live below the federal poverty level, and nearly 85% have incomes below 200% of poverty ($24,120/year for an individual in 2017).
  • Nonelderly Medicaid adults with disabilities are four times as likely to receive nursing or other health care at home, more than 2.5 times as likely to have three or more functional limitations, and more than 1.5 times as likely to have 10 or more health care visits in a year compared to people with disabilities who are privately insured.

People with disabilities account for 15% of total Medicaid enrollment but 42% of program spending due to their greater health needs and more intensive service use.   

Medicaid spending per enrollee for people with disabilities is substantially higher than for those without disabilities, due to their greater health needs and reliance on Medicaid for expensive but necessary services, especially long-term care in the community and nursing homes, that are generally unavailable through private insurance and too costly to afford out-of-pocket.  Medicaid spending per enrollee for people with disabilities also varies substantially by state (from $10,142 in AL to $33,808 in NY in 2011).

Nonelderly adults with disabilities may be particularly affected by Medicaid changes in the American Health Care Act (AHCA), including the fundamental shift to per capita capped financing.

  • Most Medicaid disability-related coverage pathways and community-based long-term care services are provided at state option, making them subject to cuts as states adjust to substantial federal funding reductions under a per capita cap.  The CBO estimates that the AHCA will reduce Medicaid spending by $880 billion from 2017 to 2026.
  • The AHCA also would end enhanced federal funding for the ACA’s Medicaid expansion, which covers some nonelderly adults with disabilities, and Community First Choice attendant care services for people with disabilities, which could jeopardize states’ ability to continue to finance these options.

Well-being of Young Children after Experiencing Homelessness

“Compared to national norms, young children who have stayed in shelter have higher risk for developmental delays and higher rates of behavioral challenges”

Using data from the U.S. Department of Housing and Urban Development’s Family Options Study, Well-being of Young Children after Experiencing Homelessness (2017, OPRE Report No. 2017-06), examines the well-being of young children 20 months after staying in emergency homeless shelters with their families. The brief explores young children’s: pre-reading skills, pre-math skills, developmental delays, and behavior challenges. It discusses comparisons between children who experienced homelessness and national norms for children of the same age.

“Twenty months after staying in an emergency shelter with their families, children between 18 and 41 months were at somewhat higher risk for early developmental delays compared to national norms for children their age. They were at lowest risk for delays in their development of general activity and movement (although still at higher risk than national norms) and at highest risk for fine motor skill delays. Based on national norms, we would expect 84 to 88 percent of children to pass screening in all five domains assessed; however, only 77 percent of children who had been in shelter 20 months earlier passed all five domains.”2

Well-being of Young Children after Experiencing Homelessness HOMELESS FAMILIES RESEARCH BRIEF OPRE Report No. 2017-06 January 2017 by Scott R. Brown, Marybeth Shinn, and Jill Khadduri

Draft Principles for a Person-Centered Approach to Serious or Advanced Illness

Deadline: May 12, 2017

http://ltcombudsman.org/uploads/files/support/acl-person-centered-principles.pdf
ACL, in consultation with stakeholders from the aging and disability communities, has drafted a set of principles to guide their work, and to enhance existing programs and services related to serious or advanced illness for older adults and people with disabilities. ACL is now seeking input from the people they serve-older adults, people with dementia, people with all types of disabilities, and families and caregivers, as well as partners in the aging and disability networks.  The Draft Principles for a Person-Centered Approach to Serious or Advanced Illness is available here. Send your comments, by May 12, 2017, to AdvancedIllness@acl.hhs.gov.