June
2004
What
is case management under the Early Periodic Screening, Diagnosis,
and Treatment Program and what is the regulatory basis for it?
The Early
Periodic Screening, Diagnosis, and Treatment Program (EPSDT) requires
“early and periodic screening, diagnostic, and treatment services
(as defined in subsection [r]) for individuals who are eligible under
the plan (i.e., for Medicaid) and are under the age of 21.”
(See Section 1905 [a] [4] [B] of the Social Security Act.)
States must also inform families with Medicaid-eligible children under
the age of 21 years about the availability and importance of EPSDT
services and must make arrangements for the provision of these services
for families who request them. Further, the statute requires that
the states must provide certain services including “comprehensive
health and developmental history (including assessment of both physical
and mental health development)” (Section 1905 [r]][1] [B]
[i]). These services must meet reasonable standards of care and
be provided at reasonable intervals after consultation with recognized
medical and dental organizations involved in child health care so
as to enable providers to determine the existence of physical and
mental illnesses and conditions (Sections 1905 [r] [1][A] [i]
and [ii]). Further, the states are required to provide necessary
health care, diagnostic, and treatment services that are required
to “correct or ameliorate defects and physical and mental illnesses
and conditions discovered by the screening services, whether or not
such services are covered under the State Plan” (Section
1905 [r] [5]). The federal regulation reiterates and expands
on these requirements (42 CFR, Section 441.56). Thus the
federal statute and regulations require that State Medicaid agencies
implement a complex and comprehensive program of screening, diagnostic,
and treatment services, including mental health services.
The term,
“case management” first appears in the EPSDT guidelines
as part of the State Medicaid Manual, CMS-Pub.45-5. In the “Overview”
portion of the guidelines, it states that the EPSDT program consists
of two, mutually supportive, operational components:
-
Ensuring the availability and accessibility of
required health care resources
-
Helping Medicaid recipients and their parents
or guardians effectively use them
In order
to enable Medicaid State agencies to manage the EPSDT program states
must:
-
Ensure that health problems found are diagnosed
and treated early, before they become more complex and their treatment
more costly. Although “case management” does not appear
in the statutory provisions pertaining to the EPSDT benefit, the
concept has been recognized as a means of increasing program efficiency
and effectiveness by ensuring that needed services are provided
timely and efficiently, and that duplicated and unnecessary services
are avoided (State Medicaid Manual [CMS-Pub. 45-5, Section 5010]).
Case management services
are specifically cited in several other places in the State Medicaid
Manual. In Section 5230 of the State Medicaid Manual, Coordination
with Related Agencies and Programs, public agencies such as social
services agencies funded through Title XX of the Social Security Act
are mentioned as having the potential roles of providing supportive
services that include case management. The State Maternal and Child
Health (MCH) agencies, funded through Title V of Social Security Act/MCH
Block Grant, are cited as having a major coordinative role in the
EPSDT program. Specifically cited is their role in case management
(State Medicaid Manual [CMS-Pub. 45-5, Section 5230 and 5230.1]).
The Mental Health State agency is also a public agency given the statutory
and regulatory requirement to screen, diagnose, and treat children
for mental health issues. All three of these programs have roles in
serving children and adolescents with behavioral health issues. Part
B of IDEA serves children ages 3 to 21 years who have at least one
of thirteen disabilities including autism or emotional disturbances
as well as physical health disabilities and developmental delays.
MCH provides services to many of the same population served by Medicaid
and have special interests in early identification and treatment of
young children at risk for emotional disturbances.
The EPSDT
guidelines also cite case management in the Continuing Care section
of the State Medicaid Manual, Section 5240. That section
details the concept of providing a continuum of services that includes
EPSDT screening, diagnostic, and treatment services, acute illness
care and referral to specialty providers when necessary including
mental health services. The Manual stipulates that:
-
States are responsible for ensuring that there
is adequate tracking or case management for continuing care services
-
These services can either be provided by the
“continuing care provider” or through other arrangements
-
States must monitor that the actual services
including case management are being provided.
Payment
for Case Management under EPSDT
Federal financial
participation (FFP) is available to cover the costs to public agencies
such as Title XX and MCH that provide direct support to the Medicaid
State agency in administering the EPSDT program. Among the services
listed is case management. Written agreements, while not absolutely
required under the federal guidelines, have been “deemed essential”
to effective working relationships with these public agencies. Each
agreement must specify the participating parties; their intent; mutual
objectives; the services each party offers and in what circumstances;
exchange of reports of services furnished; methods for review and
joint planning; abd liaison between parties including designation
of staff and joint evaluation of policies. Cooperative agreements
or contracts with other agencies and programs, such as Title V, may
include payment for certain administrative functions such as outreach
and case management (State Medicaid Manual, CMS-Pub. 45-5, Sections
5230 and 5340).
Further,
75% FFP is available for the “cost of skilled professional medical
personnel and directly supporting staff employed by the Title XIX
State agency or other public agency if they meet the requirements
of 42 CFR 432.50” (State Medicaid Manual, CMS-Pub. 45-5,
Section 4340, B Reimbursement, Services/Administrative Functions).
Under 42 CFR 432.50, (b), (1), there is a cross reference
to another section of the federal Medicaid regulation that defines
these staff (42 CFR, Section 432.2). The pertinent definitions
for this discussion include:
-
“Skilled professional medical personnel”
means physicians, dentists, nurses, and other specialized personnel
who have professional education and training in the field of medical
care or appropriate medical practice and who are in an employer-employee
relationship with the Medicaid agency. It does not include other
non-medical health professionals such as public administrators,
medical analysts, lobbyists, senior managers, or administrators
of public assistance programs or the Medicaid program.
-
“Directly supporting staff” means
secretarial, stenographic. . . services that directly support the
responsibilities of skilled professional medical personnel, and
who are in employer-employee relationship with the Medicaid agency.
-
“Staff of other public agencies”
means skilled medical personnel and directly supporting staff employed
in state or local agencies other than the Medicaid agency that perform
duties that directly relate to the administration of the Medicaid
program.
Therefore,
individuals who are employed either by the Medicaid state agency and
another public agency, such as the Mental Health state agency and
the/Title V state agency who are providing case management to ensure
that children and adolescents needing mental health, developmental,
and other services would be viewed as either skilled professional
personnel, or supporting staff of other agencies. Thus, the Medicaid
state agency could draw down 75% FFP for these services. The Medicaid
state agency could reimburse the Mental Health state agency for its
case management services with regard to ensuring that mental health
services are provided on a timely basis.
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