EPSDT: Early and Periodic Screening, Diagnosis and Treatment ProgramPresenter:Diana M. StraubeNational Assistive Technology Advocacy Project, Neighborhood Legal Services
Medicaid covers DME that: • can withstand repeated use • are primarily and customarily used for medical purposes • are generally not useful in the absence of an illness or injury • usually not fitted, designed or fashioned for a particular individual’s use.
Equipment may also be covered under • physical therapy • occupational therapy • speech pathology services • rehabilitation • prosthetics • orthotics, etc.
Medical Necessity Prevent, diagnose, correct or cure a condition that: • causes acute suffering • endangers life • results in illness or infirmity • interferes with the capacity for normal activity • threatens to cause a significant handicap
EPSDT: • comprehensive and preventative health care program for recipients under 21 • early and periodic screening and diagnosis to ascertain physical or mental defects • such health care, treatment or other measures to correct or ameliorate defects and chronic conditions • broadens definition of medical necessity
Medicaid must provide: • Outreach and informing • Screening • Diagnosis • Treatment • Adequate provider participation • Reporting
EPSDT screenings (assessments) must include: • Gross and fine motor development • Communication skills or language development • Self-help or self-care skills • Social-emotional development • Ability to engage in social interaction • Cognitive skills, focusing on problem solving or reasoning
As children age, assessments should include: • Visual-motor integration • Visual-spatial organization • Visual sequencing processing skills • Auditory sequential memory
Assessments of adolescents should include: • Identification of potential learning disabilities • Peer relations • Psychological/psychiatric problems • Vocational skills
Matter of J.P., NY FH # 3689971R Sip-and-puff mechanism for wheelchair was necessary to: • maximize child’s opportunity for cognitive development • allow him to be more responsible for own self-care and safety • foster his learning capacity • foster his general ability to explore his environment “as is necessary for any child his age”
Matter of John, NY FH # 4337314K • Medicaid denied prior approval for power wheelchair for young child, claiming child always had a caregiver present who could push him. • Decision rejected agency’s argument that continued reliance on caregivers to push him would be developmentally inappropriate for child.
Following services are available if medically necessary: • computers, such as the Apple II Computer with printers, computer software • exercise equipment including exercise bikes, swing sets, and tricycles • communication devices such as the Dynavox • specialized eating utensils and other daily living aids