From: National Health Law Program
To: National Association of Protection and
Advocacy Systems
Medicaid Early and Periodic Screening, Diagnosis and
Treatment
As A Source of Funding Early Intervention Services
Prepared by: Jane Perkins
“All children are born wired
for feelings and ready to learn.”
National Research
Council and
The
term “early intervention services” refers to formal attempts by persons outside
of the family to work with the child and family to address cognitive,
emotional, and resource limitations that exist in the child’s environment. These services target the first few years of
life and include health, education, and social services. Health services include comprehensive diagnostic
screenings; nutrition
services; behavior therapies; physical, speech and occupational therapies; day
treatment; family support services; and
health education describing expected developmental milestones.
Congress
has provided for the coverage of early intervention services in a number of
federal statutes. For example, the
Individuals with Disabilities Education Act provides federal funding for
developmental and behavioral services infants and children under age three who
have developmental delays or are at risk of delays.[1] The Title V Maternal and Child Health
Services Block Grant allows federal funding to ensure maternal and child access
to quality health services and to increase the numbers of young children who
receive check ups and needed follow-up care.[2] This issue brief focuses on Medicaid,
particularly the Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
benefit, as an important, but underused source of federal funding for early
intervention services. It will summarize
the importance of early childhood intervention and then discuss how early
intervention services can be provided as EPSDT.
The National
Research Council and Institute of Medicine recently issued a voluminous report,
From Neurons to Neighborhoods, that presents scientific evidence showing
the importance of early childhood development and early intervention services.[3] It finds that the brain and nervous system
undergo their most dramatic development during the first few years of life.
From birth to age five, children develop foundational linguistic, cognitive,
emotional, social, and moral capabilities upon which subsequent development
builds.[4] The differences among what children know and
can do are obvious by kindergarten.
These differences are strongly associated with social and economic
circumstances, and are predictive of subsequent academic performance. Redressing these disparities through early
intervention services is critical, both for the child and for society.[5] Parents and other regular caregivers are
“active ingredients” of environmental influence during a child’s early years.[6] The report also finds that very young
children can experience deep and lasting grief, sadness, and emotional impairment. Given the short- and long-term risks that
accompany early mental health impairments, there is an urgent need to address
the severe shortage of programs and professionals with the necessary expertise.[7]
Though
this report provides crucial support to proponents of early intervention
services, the effectiveness of these services has been previously documented in
a variety of studies. For example:
·
Breast-feeding is
recommended by pediatricians to help infants grow and to anchor mother-infant
interactions. A survey by The
Commonwealth Fund found that mothers are much more likely to breast feed when
educated and encouraged to do so by their doctor or nurse and when they receive
post partum home visits by nurses.[8]
·
Consistent
reading times and daily home-life routines have been shown to influence healthy
brain development in very young children.
The majority of low-income parents surveyed by The Commonwealth Fund
wanted information from providers on how to optimize their child’s development,
including information on how to discipline the child, toilet training, and
sleep habits. (Unfortunately, the vast
majority of low-income families reported these matters were not discussed
during visits with providers.)[9]
·
Educating parents
about infant communication has resulted in significant differences between the
intervention group and the control group regarding sensitivity to communication
cues and social-emotional growth-fostering behaviors.[10]
·
Guidance from the
pediatrician during office-based visits has resulted in intervention group
infants showing advanced vocal imitation compared with the control group and
the intervention mothers being rated higher on their interactions with their
children.[11]
·
Education and
assistance provided to mothers in an intensive care unit nursery had a
significant effect on the cognitive development of low birth weight infants, to
the point where their development approximated that of normal birth weight
infants.[12]
·
Home-based
parent-training of low-income, African-American, teenage mothers of pre-term
infants resulted in their infants rating higher on standardized intervention
tests than control group infants.[13]
·
The children of
mothers who participated in a high-risk prenatal/early infancy home visitation
program of health education experienced fewer accidents and emergency room
visits, compared to a control group.
These mothers initiated breast feeding more frequently and improved the
home environment more frequently than the control group.[14] A fifteen year follow-up of the children, when
compared to control groups, showed them to have experienced fewer instances of
running away and fewer arrests, lifetime sex partners, cigarettes a day, and
days having consumed alcohol.[15]
Findings such as these
establish the following potential benefits of early intervention services for
low-income children: improved emotional
and cognitive development, improved educational outcomes, increased economic
self-sufficiency for the parent and later the child, and improvements in
health-related indicators such as reproductive health and substance abuse.[16] While only a few studies have compared the
costs and benefits of these services, a 1998 study by researchers at the RAND
Corporation concluded that early childhood intervention services are a
potential source of cost savings.[17]
Unfortunately, many children
are not receiving the early intervention services they need. Ignorance about funding sources has been one
impediment. Many states and health care providers operate under
the impression that only limited early intervention services can be covered
through Medicaid. To the contrary, the
Medicaid Early and Periodic Screening, Diagnosis and Treatment service can be
used to cover a broad array of early intervention services.[18]
Medicaid-eligible children and youth under age 21 are
entitled to receive EPSDT.[19] EPSDT is a comprehensive benefit that
includes: screening, diagnosis, and
treatment services and outreach. Four
separate screening services—medical, vision, hearing, and dental—must be
offered at pre-determined, periodic intervals.
From birth through age five, the American Academy of Pediatrics
recommends fourteen medical screening visits.[20] For Medicaid-eligible children, the medical
screen must include:
• a
comprehensive health and intervention history which assesses both physical and
mental health;
• a
comprehensive, unclothed physical examination;
• appropriate
immunizations;
• laboratory
tests (including lead blood testing at 12 and 24 months and otherwise according
to age and risk factors); and
• health
education, including “anticipatory guidance to the child (or the child’s parent
or guardian).”[21]
The EPSDT screen is an essential early intervention
service. Properly focused, this screen
can be used to diagnosis developmental problems and risks and to provide health
education to the child and family about expected developmental milestones and
activities for maximizing the child’s early growth. Therefore, it is critical for health care
providers who are treating young children to know the full scope of EPSDT. A variety of avenues can be used for
disseminating this information, including regulations, Medicaid managed care
contract requirements,[22]
provider manuals, provider bulletins, provider training, and EPSDT screening
forms.
The EPSDT screening form is a pre-printed, uniform
encounter form that a number of states have developed for providers to record
and track activities that occur during a child’s visit. Copies of the completed form typically are
placed in the child’s medical record and may also be sent to the Medicaid
agency. Use of these forms has been
associated with improved well-child visits.[23] In recent years, some states have developed
sets of screening forms that focus on age-appropriate activities.[24]
At least 27 states have developed EPSDT screening
forms for participating providers.[25] The National Health Law Program recently
reviewed these screening forms to determine the extent to which they target
early intervention services. Table 1
shows that a number of states’ forms place at least some emphasis on early
intervention. In particular, the
following should be noted:
•
Diagnostic
assessment. All of the forms specifically required a diagnostic
assessment.[26] Nine states included age-specific prompts
(e.g. Arizona, Maine, and Texas). For
example, for the 15 month visit, some forms ask whether the toddler can point
to one or more body parts, walk well, feed self with fingers, listen to a
story, put blocks in a cup, and wave bye-bye.
•
Nutritional
Assessment. All of the forms included reference to nutritional
assessment. Fourteen included a question
about the Women Infant and Children (WIC) program, and ten specifically
addressed breast-feeding and formula.
•
Vision,
Hearing, Speech, and Dental Assessments. All of the forms required vision and hearing
assessments. The majority also included
either a dental assessment or a referral to dental care. Nine of the forms included a speech
assessment.
•
Health
Education. Virtually all of the forms referred to health
education, counseling, and/or anticipatory guidance. Ten included age-specific prompts (e.g.,
postpartum adjustment, reading to the child).
For example, for the three year visit, some forms ask about reading to
the child, dental care, limiting TV, eating healthy foods, and/or referrals to
Head Start.
•
Social Service
Referrals. Fourteen forms suggested a referral to the
WIC program. Several forms, and most
notably West Virginia’s form, included referrals to other social service
agencies, including early intervention, family planning, further health
education, and Head Start.
In sum, the effectiveness of EPSDT
screening forms has been well documented.
A number of states have included information on these forms to prompt EPSDT
medical screeners to provide age-appropriate early intervention screening and
make needed referrals for follow up services and treatment.
Covering Early Intervention
Services as EPSDT Treatment Services
If an illness or condition is
diagnosed during a screen, EPSDT requires state Medicaid agencies to “arrange
for (directly or through referral to appropriate agencies, organizations, or
individuals) corrective treatment.”[27] EPSDT benefits include all of the services
that the state can cover under § 1396d(a) of the Medicaid Act, whether or not
such services are covered for adults.[28] Table 2 lists these services. In addition, the Medicaid Act says the
service must be covered for a child if it is “necessary . . . to correct or
ameliorate defects and physical and mental illnesses and conditions[.]”[29]
The Medicaid Act, §
1396d(a), does not uniformly list covered services using the terminology that
health care providers may use when describing an early intervention need. In these cases, it must be determined whether
the service described by the provider fits within a category that is included
in the Medicaid Act. In other words,
Medicaid can cover the early intervention service only to the extent that the
service fits within a Medicaid service category.
Table 3 lists a range of early intervention services,
showing which Medicaid service category, if any, the service may be coverable
through and whether the Centers for Medicare and Medicaid Services (CMS) has
issued any specific statements regarding coverage of the service. Table 3 shows that CMS has approved EPSDT
coverage of a number of early intervention services, including:
In addition, CMS has
recognized Medicaid coverage to fund preparation and use of pocket-sized
records for young children (sometimes called “health passports”); health
diaries for new mothers; telephone support services to children and their
families; brochures, videos, and newsletters that are explicitly directed at
assisting Medicaid-eligible individuals to access Medicaid services; and home
visiting programs that include parent education. CMS has discussed limits, however:
•
Medical
necessity. The service must be medically necessary; in
other words, it must be needed to “correct or ameliorate” a physical or mental
condition.[30]
•
Focus on the
child. Family members may be included in health
education, case management, counseling, and therapy; however, the services must
be directed exclusively toward the treatment/benefit of the child. For example, if directed exclusively to the
treatment of the child, mental health services can include individual, family,
and group skills training, family psychotherapy, and family skills
training. However, the services cannot
extend to a point where they become a means of treating persons other than the
Medicaid-eligible child. As recently
noted by CMS in reference to case management services, “[P]olicy permits contacts with non-eligible
… individuals to be considered Medicaid case management activity, and to be
billed to Medicaid, when the purpose of the contact is directly related to the
management of the eligible individual’s care.
It may be appropriate to have family members involved in all components
related to the eligible individual’s case management.… On the other hand, contacts with
non-eligibles … that relate directly to the identification and management of
the non-eligible[’s] … needs and care cannot be billed to Medicaid.”[31]
•
Health
education. Health education is not considered by CMS to
be a separate billable Medicaid service.
Rather, it is considered an essential component of every health visit.
Case Study: Pediatric
Specialty Care v. Arkansas Dep’t of Human Services
Citing a budget shortfall, Arkansas
announced a plan to eliminate early intervention treatment services as an EPSDT
benefit. While diagnostic services would
be maintained, children would be referred to other federally and state funded
programs for treatment. Thereafter,
child providers and parents filed the lawsuit and obtained an injunction from
the district court.
On appeal, the Eighth Circuit held that “a
Medicaid eligible individual has a federal right to early intervention day
treatment when a physician recommends such treatment.”[33]
[W]e believe that the State [Medicaid] Plan need not specifically list every treatment service conceivably available under the EPSDT mandate. The State Plan, however, must pay part or all of the cost of treatments to ameliorate conditions discovered by the screening process when those treatments meet the definitions set forth in [the statute].[34]
Here,
the early intervention day treatment services met the definition of
rehabilitation services set forth in § 1396d(a)(13) (defining medical
assistance reimbursable by Medicaid as “other diagnostic, screening,
preventive, and rehabilitative services, including any medical or remedial
services … recommended by a physician … for the maximum reduction of physical
and mental disability and restoration of an individual to the best possible
functional level”). Therefore, the Court
held that when the physician prescribes early intervention day treatment as a
rehabilitative service under EPSDT, the Arkansas Medicaid agency must reimburse
the treatment. It is not enough to
simply refer the recipient to another source of federal or state funding for
the service.
The Court closed its decision with a
reminder to the state that EPSDT provisions (§ 1396a(a)(43)) obligate it
to inform recipients about the EPSDT services that are available to them and that it must arrange for the corrective treatments prescribed by physicians. The state may not shirk its responsibilities to Medicaid recipients by burying information about available services in a complex bureaucratic scheme.[35]
Research has shown that, once on the
Medicaid program, low-income children are more likely to have a routine source
of care. This is important for the
provision of early childhood intervention services because it means that these
provider visits offer increased opportunities to provide needed services.
Health care practitioners need to be
paid for the early intervention services they provide. Unfortunately, the provision of these
services has been hampered by lack of knowledge of funding sources. The Medicaid EPSDT program exists to provide
comprehensive and continuous care to America’s poor children and children with
special health care needs. EPSDT
screening forms have been developed that cue providers to early intervention
services that should be provided during the screening encounter and that
identify children needing follow up intervention services. As recently illustrated by a federal circuit
court of appeals, EPSDT is also a significant source of funding for the
provision of early intervention treatment services that young children need.
Table
1: Developmental Services and EPSDT Screening Forms
|
|
AL |
AK |
AZ |
AR |
CA |
CO |
CT |
FL |
GA |
IA |
KS |
ME |
MD |
MO |
NV |
NJ |
NM |
ND |
OK |
PA |
SC |
TX |
WA |
WV |
WI |
WY |
|
Patient
Medical History |
● |
● |
● |
|
● |
● |
● |
● |
● |
● |
● |
● |
● |
● |
● |
|
● |
● |
● |
● |
● |
● |
● |
|
|
|
|
Perinatal/Birth
History |
|
|
|
|
|
|
|
|
● |
|
● |
● |
● |
● |
● |
|
|
|
|
|
|
● |
|
|
● |
|
|
Family
Medical History |
● |
|
|
|
|
|
|
● |
● |
|
● |
|
● |
● |
● |
|