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    EPSDT and The ID Waiver: Changes in Preauthorization of Children's Services

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    Billie_anderson2473
    1) Beginning January 1, 2011, eligible children in Virginia will be required to access medically necessary services like personal care, assistive technology, and therapeutic consultation through EPSDT prior to receiving them through the ID Waiver. 2) EPSDT provides these services to children with Medicaid who are under age 21 when they are medically necessary to improve health conditions. Services provided through EPSDT must be documented as needed in the individual support plan. 3) Providers must obtain preauthorization for EPSDT services by submitting documentation of need, such as a letter or DMAS form from a physician, to the assigned ODS consultant before beginning services.

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    EPSDT and The ID Waiver: Changes in Preauthorization of Children's Services

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    Billie_anderson2473
    101 views31 pages
    1) Beginning January 1, 2011, eligible children in Virginia will be required to access medically necessary services like personal care, assistive technology, and therapeutic consultation through EPSDT prior to receiving them through the ID Waiver. 2) EPSDT provides these services to children with Medicaid who are under age 21 when they are medically necessary to improve health conditions. Services provided through EPSDT must be documented as needed in the individual support plan. 3) Providers must obtain preauthorization for EPSDT services by submitting documentation of need, such as a letter or DMAS form from a physician, to the assigned ODS consultant before beginning services.

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    EPSDT and ID Waiver 11-18-10 Final

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    1) Beginning January 1, 2011, eligible children in Virginia will be required to access medically necessary services like personal care, assistive technology, and therapeutic consultation through EPSDT prior to receiving them through the ID Waiver. 2) EPSDT provides these services to children with Medicaid who are under age 21 when they are medically necessary to improve health conditions. Services provided through EPSDT must be documented as needed in the individual support plan. 3) Providers must obtain preauthorization for EPSDT services by submitting documentation of need, such as a letter or DMAS form from a physician, to the assigned ODS consultant before beginning services.

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    101 views31 pages

    EPSDT and The ID Waiver: Changes in Preauthorization of Children's Services

    Uploaded by

    Billie_anderson2473
    1) Beginning January 1, 2011, eligible children in Virginia will be required to access medically necessary services like personal care, assistive technology, and therapeutic consultation through EPSDT prior to receiving them through the ID Waiver. 2) EPSDT provides these services to children with Medicaid who are under age 21 when they are medically necessary to improve health conditions. Services provided through EPSDT must be documented as needed in the individual support plan. 3) Providers must obtain preauthorization for EPSDT services by submitting documentation of need, such as a letter or DMAS form from a physician, to the assigned ODS consultant before beginning services.

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    of 31

    EPSDT and the ID Waiver

    Changes in Preauthorization of
    Children’s Services

    Virginia Department of Behavioral Health & Developmental


    Services, Office of Developmental Services,
    in collaboration with Department of Medical Assistance
    Services, EPSDT
    1
    Centers for Medicaid and Medicare
    require eligible children to access EPSDT
    prior to Waiver for covered services.

    Beginning with annual ISP date


    January 1, 2011.

    2
    EPSDT Eligibility
    • Children with Medicaid
    • Under the age of 21
    • Require “medically necessary”
    supports

    3
    EPSDT Eligibility

    “Medically necessary” means


    needed to improve physical or
    mental health conditions.

    Needs determined by ISP process.

    4
    Services available under
    both EPSDT and Waiver:

    • Personal Care/Assistance
    • Assistive Technology
    • Therapeutic Consultation

    5
    Personal Care under EPSDT

    6
    EPSDT Personal Care

    • “Personal Assistance” under ID Waiver


    • Support with routine needs
    • “Medically necessary” supervision

    7
    EPSDT Personal Care is not:
    • General Supervision unrelated to
    safety
    • Respite
    • Support with employment tasks
    • Assistance provided
    in other funded settings

    8
    EPSDT Personal Care – Preauthorization
    ual l y !
    An n
    • Letter or DMAS-355 from
    MD
    • DMAS -7 from MD, PA or
    RNP
    • ID Waiver Personal
    Assistance ISARs

    Forward to assigned ODS PA Consultant


    prior to beginning services
    9
    EPSDT Personal Care/ID Waiver PA

    • Back-up plans required


    • Same providers
    • Same services
    • AD Personal Assistance
    • CD Personal Assistance

    10
    EPSDT Personal Care/ID Waiver PA
    Assessment: SIS
    If no SIS, ODS-approved assessment tool or
    DMAS-99
    Plan of care:
    PC ISP Plan for Support (Part V) or
    DMAS-7A with Personal Preferences tool

    Completed by:
    Registered Nurse,
    Services Facilitator or
    Program Manager

    11
    EPSDT Personal Care/ID Waiver PA
    Personal Preferences Tool
    for use with the DMAS 7A

    12
    EPSDT Personal Care

    Provider Reviews
    • Written reviews every 6 months
    • Verbal reports for 3 and 9 month reviews

    If the PA provider is a DBHDS licensed provider,


    quarterly reviews are required.

    Submit to SC!
    13
    EPSDT Assistive Technology

    14
    EPSDT Assistive Technology

    • Specialized medical equipment, supplies,


    devices, controls and appliances not
    available under DME
    • Increases independence or ability to
    perceive/communicate
    • Portable
    • Medically necessary

    15
    EPSDT Assistive Technology

    • Authorized up to 3 months
    • No dollar limit per item/per year

    16
    EPSDT AT -- Criteria

    • Reasonable
    • Included in the ISP
    • Consistent with individual’s needs
    • Not for the convenience of others
    • In accord with medical standards
    • Safe and cost effective

    17
    EPSDT AT -- Criteria
    • Must directly support the child
    • Must minimize the adverse effects of
    mental or physical condition
    • Must be of direct benefit to the child rather
    than enhance surroundings
    • Environmental modifications are not
    covered

    18
    Assistive Technology –
    under the ID Waiver

    • AT items not “medically


    necessary” should be requested
    under the ID Waiver
    • $5000.00 annual limit per
    calendar year for ID Waiver AT
    • Can be used in combination with
    AT under EPSDT

    19
    EPSDT AT – Preauthorization
    • Letter or DMAS-355 from
    MD
    • Written recommendation
    from professional
    • ID Waiver AT ISAR
    • Documentation to
    confirm need

    Forward to assigned ODS PA Consultant


    prior to beginning services
    20
    Assistive Technology
    Documentation must confirm:

    • Formal diagnosis related to need


    • Limitations/changes resulting in need for AT
    • How AT will be of benefit
    • Reason for quantity /quality
    • How often AT will be used
    • How long AT will be needed

    21
    Assistive Technology
    Documentation must confirm:

    • Other supportive therapies tried/previous efforts to


    meet needs
    • Successes/failures
    • How item is necessary at home/community
    • Individual/family interest in using the item

    22
    Therapeutic Consultation

    23
    Therapeutic Consultation
    Specialty areas under the ID Waiver:

    • Psychology
    • Behavioral consultation
    • Therapeutic recreation
    • Speech and language pathology
    • Occupational therapy
    • Physical therapy
    • Rehabilitation engineering

    24
    Therapeutic Consultation

    • EPSDT provides therapy and


    consultation when of medical
    benefit
    • Need documented in the PC ISP
    • Supports described in the TC Plan
    for Supports (Part V)

    25
    EPSDT TC – Preauthorization !
    n u a l ly
    An
    • Letter or DMAS-355 from
    MD

    • ID Waiver TC ISAR

    Forward to assigned ODS PA Consultant


    prior to beginning services
    26
    Don’t forget…
    Beginning January 1, 2011:

    • All children newly enrolling in


    Waiver, needing PA, AT or TC, will
    have these services authorized
    under EPSDT.
    I

    27
    Don’t forget…
    Beginning January 1, 2011:

    • PA, TC and AT received by children


    in the ID Waiver must be authorized
    under EPSDT with the child’s next
    annual ISP.
    I

    28
    Don’t forget…

    • That a child must receive at least one


    Waiver service to remain in the Waiver.

    • If the child’s supports can be provided


    under EPSDT alone, the Waiver services
    will need to be terminated and the slot
    reassigned. I

    29
    Don’t forget…
    • Children become ineligible for EPSDT on
    their 21st birthday.

    • PA, AT and TC will need to be authorized


    under the ID Waiver at that time

    30
    Contacts

    ODS Community Resource Consultants


    http://www.dbhds.virginia.gov/ODS-Contacts.htm

    DMAS EPSDT Services Supervisor


    Brian Campbell
    804-786-0342
    brian.campbell@dmas.virginia.gov

    31

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