By Summer Harrison, on February 22nd, 2010
The primary function of the Early Periodic Screening, Detection and Treatment program (EPSDT) is to ensure all kids on Medicaid get appropriate medical care, including all the normal baby exams, vaccines and the like. But for children with disabilities, EPSDT also includes a wide, sweeping civil right to what the child’s doctor says is medically necessary.
EPSDT was enacted under the federal Social Security Act in 1967. It functions inside the Medicaid program and applies to all children under the age of 21 who are signed up for Medicaid.
When the federal Department of Education was created in 1979, one of the first jobs of the first Secretary was to produce a handbook on how the schools could use EPSDT to “be an important means of improved identification of health problems, [and] of increasing students’ access to both curative and preventive health services.” The object was
“to assure provision of comprehensive, quality health care to children throughout their pediatric years. This entails giving attention to all aspects of health, including preventive health services, the care of medical emergencies and acute and chronic illnesses, and the establishment of a “medical home” environment for initiation of care, its coordination, evaluation and interpretation…”
In 1988, the Medicare Catastrophic Coverage Act (Public Law 100-360) clarified that state Medicaid programs were the payor of first resort for children enrolled in special education who were Medicaid eligible.
As part of the Omnibus Budget Reconciliation Act of 1989, EPSDT was expanded to include dental services, and Congress added a federal regulation to Title 42 “that took away a state’s discretion not to provide treatment for individuals under the age of twenty-one.”
When the Supreme Court published the Olmstead Decision in June 1999, it elevated EPSDT to a civil right for children who needed the “medical home” referred to in 1980. Olmstead said that institutionalization was a violation of the civil rights of people with disabilities, and that it was the responsibility of the government to ensure that this population had the home supports needed to prevent institutionalization.
DHHS sent a letter, “Olmstead Update No: 4″, to state Medicaid directors in January of 2001 explaining exactly the role EPSDT played in upholding Olmstead.
The combination of EPSDT and HCBS waiver services [home and community based services delivered to specified populations who have been enrolled in Medicaid on the basis of medical need, with no reference made to income] can allow children with special health care, as well as developmental and behavioral needs, to remain in their own homes and communities and receive the supports and services they need. The child and family can benefit most when the State coordinates its Medicaid benefits with special education…to enable the family to experience one system centered around the needs of the child.
Who decides what is medically necessary?
The controversy over who decides what is medically necessary for a child with disabilities continues to rage, however.
Since 1989, states have repeatedly tried to regain decision-making control over EPSDT. Court decisions in 1993, 1997, 2002, 2003, 2008 and 2009 have all determined states cannot decide medical necessity. As recently as August 2009, CMS wrote a corrective document to the state of Idaho for their EPSDT program which included a statement that ”any service required as a result of an EPSDT screen … will not be subject to amount, scope, and duration limitations.”
As for-profit health insurance companies gradually take over the Medicaid/Medicare industry, the battle over who decides what services a medically needy child receives is being fueled by mandatory profit margins written into state contracts.
CMS has been increasingly specific about the conflict of interest it perceives existing between Medicaid gatekeepers and the interests of the individual medically needy child.
For instance one of the services covered under EPSDT is case management. According to CMS, “Sections 1905(a)(19) and 1915(g)(2) of the Act (42 U.S.C. 1396d(a)(19) and 42 U.S.C. 1396n(g)(2), respectively) define case management as services which will assist an individual eligible under the state plan in gaining access to needed medical, social, educational, and other services.”
A CMS document published in the Federal Register on June 30, 2009 stated that case managers could not be employed by the Medicaid agency that stood in a position to approve or deny services.. The August 2009 letter to Idaho made the issue even more clear: “Case management must only be provided by a service coordination agency enrolled as a Medicaid provider.”
The same document goes on to state very bluntly ”providers of case management services do not exercise the agency’s authority to authorize or deny the provision of other services under the plan.”
In 1997, CMS published a guide for schools documenting all the Medicaid activities that schools could bill to Medicaid. This guide is important because it represents Federal Medicaid regulators definition of all the actual services, treatment and equipment states are to provide under the EPSDT entitlement. It’s my personal opinion that every parent of a child with an IEP would benefit from reading this brochure.
