Children Services Policy

Early And Periodic Screening, Diagnosis And Treatment (EPSDT) Program Services 

Introduction

Title XIX of the Social Security Act provides for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of eligible Medicaid recipients under age 21 to ascertain physical and mental defects, and requires treatment to correct or ameliorate defects and medical conditions found. The Omnibus Budget Reconciliation Act of 1990 (OBRA '90) further mandates that, under EPSDT, services will be provided for such other medically necessary health care, diagnostic services, treatment and other measures described in section 1905(a) of the Social Security Act to correct or ameliorate defects, physical and mental illnesses, and medical conditions discovered by the screening services, whether or not such services are normally covered under the Medicaid Scope of Services. Eligible individuals under age 21 receive Medicaid services consistent with EPSDT requirements.

Prior Authorization is required for all EPSDT services that are not in the normal scope of covered services (refer to the Prior Authorization Requirements contained in this document to determine the need for prior authorization).

EPSDT Policy

Minor Assistive Devices
The Medicaid Program has provision to pay for certain minor assistive devices through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program for individuals who meet the following criteria:

  1. Must not have attained their 21st birthday.
  2. Not currently on a waiver program which provides coverage for the requested minor assistive device(s).
  3. The need for the device(s) is due to a documented medical need.

Procedures for Requesting Minor Assistive Services through the EPSDT Program:

  1. Physician certifies, in a letter, the medical need for the requested device(s). Physician’s letter must identify the medical problem and why the device(s) is necessary. Physician’s letter is sent to the DME provider who will be supplying the requested service.
  2. Provider of service completes the appropriate Prior Authorization form, attaches the above letter from the physician and submits to Hewlett Packard Enterprise (HPE) in the normal manner.
  3. HPE enters the PA into the system and forwards the request to EOHHS for approval
  4. EOHHS reviews the PA and makes the determination to either approve or disapprove the PA request, then forwards the response to HPE which then notifies the provider and/or recipient.

Limitations and Exclusions:

Minor Assistive Devices under EPSDT do not include:

  1. Devices or equipment permanently attached to a structure
  2. Ramps of any kind
  3. Lifts such as Van Lifts, chair lifts, or stair lifts
  4. Air conditioners
  5. Swimming pools or any type of whirlpool

Skilled Nursing Care and Home Health Aide Through EPSDT Program

Definitions

Nursing Agency - a provider type that meets the RI Department of Health definition of a certified home health agency or nursing agency and is licensed as such.

Nursing care plan - a plan for nursing intervention designed to meet the needs of the recipient which includes measurable goals and objectives.

Primary care giver - the individual, who is primarily responsible for providing care to the recipient, including specialized technical care.

Skilled nursing services - the planning, provision and evaluation of goal-oriented nursing care that requires specialized knowledge and skills and utilizes the nursing process as problem solving approach. This approach includes 5 components:

  1. assessment
  2. problem identification (Nursing diagnosis)
  3. planning
  4. implementation (Nursing intervention)
  5. evaluation

Pediatric private duty nursing - continuous, specialized skilled nursing services, provided by a licensed registered nurse or licensed practical nurse, the administration of which requires a visit of more that two hours. The nurse should have as a minimum, one year of nursing experience in the PICU or NICU.

  1. Authorization for these services must be approved by the office of Medical Services, Executive Office of Health and Human Services.
  2. The Waiver/Rehab Claim Form must be used when billing for these services.
  3. The HCPCS codes to be used when billing for these services is T1000. The HCPCS code for the second are paid at a flat rate, regardless of the shift or the provider with code T1000 UN. Each HCPCS must be billed on a separate line.

CNA Services

Service HCPCS Code
CNA S5125

Clinical Criteria for Services

Medicaid will pay for pediatric private duty nursing services based on the skilled nursing needs of the recipient, and not on the availability or unavailability of the recipient’s family or caregiver. All of the following conditions must be met in order for private duty nursing services to be authorized:

  • there is a clearly identifiable, specific medical need for skilled nursing care that requires more care than could be provided on an intermittent basis. EOHHS approves the amount and duration of the private duty nursing services based on the level of skilled nursing care determined by EOHHS to be medically necessary.
  • the nursing services must either improve or ameliorate the child’s condition
  • the nursing services are made available according to the medical/nursing needs of the child
  • the services are made available to a child who is considered severely disabled and/or technology dependent and would otherwise require inpatient care in a hospital or pediatric nursing facility
  • the recipient’s physician and the EOHHS nursing staff must determine that the child can be maintained safely in the community
  • the recipient has a medical condition requiring continuous skilled nursing care that includes documentation of assessment, intervention, teaching the family and caregivers who are caring for the child and the evaluation of clinical outcomes

Record Keeping Requirements

The nursing agency must maintain records for each recipient to whom private duty nursing services are provided. A summary of the child’s medical/nursing status must be submitted to DHS on a monthly basis and include at least the following:

  • the child’s name
  • an update of the child’s status, preferably by system, which reflects the goals and objectives stated in the nursing plan of care
  • a list of current medications and treatments and the frequency of each
  • any clinical tests and their results
  • the child’s developmental status and
  • any issues, including non-medical, impacting on the child’s care

Early Start/Therapeutic Remedial Treatment Program  

The Early Start/Therapeutic Remedial Treatment Program consists of the provision for an intensive, supervised, treatment program for children who exhibit social and/or emotional disturbances. The covered services under this program are designed to provide the necessary medical, psychological and developmental support services required to address the special needs of the child. Services must be administered by a master’s level clinician, physician or other licensed practitioner of the healing arts. The focus of the program is on remedial mental health services rendered to the child and the family in order to minimize the need for more intensive services and reduce the number of mental disabilities that develop.

Limitations

Provider participation is limited to those treatment programs under contract with and licensed by the Rhode Island Department of Children, Youth and Families.

The services provided under this program are for children up to three years of age.