Accessing Medicaid Healthcare for Children

– Hi, thank you for joining us today. My name is Alison McKay and I am an attorney with
Disability Rights Ohio. And today, we will be discussing in our third Facebook Live series, Accessing Healthcare for Children. I just want to make clear, we won’t be discussing
Medicaid eligibility, but we will be discussing the Medicaid programs and services that are available to children. If you have other ideas for topics that you’d like us to cover in the future, please let us know. And if you’d like to follow
along with our video, we have posted a copy of
our PowerPoint presentation that we’ll be using on our website and we will post a link to that webpage in the comments of the video. Please know that Disability Rights Ohio is providing this video as
an informational resource. We’re not providing legal advice. If you seek help regarding
a specific situation, you are welcome to contact
our Intake Department. And also feel free to ask questions or comment throughout the video, and we will do our best to respond. Please do not post
confidential information, like your children’s names, in the comment section. Again, if you have specific
questions regarding a situation, you can contact our Intake Department. But we will do our best to respond to those questions at the
end of the presentation. To get us started, let me introduce you
to our speakers today. We have Kristin Hildebrant who is a Senior Attorney
with Disability Rights Ohio, and manages our Special Education team. Next to Kristin is Earnestine Hargett who is a Senior Advocate
with Disability Rights Ohio and also a member of our
Special Education team. And again, my name is Alison McKay. I’m an attorney with
Disability Rights Ohio and coordinate our Claim
Assistance program, and also our Medicaid pro bono program. For more background information about Disability Rights Ohio, please look at our prior
Facebook Live videos, which are posted on our website. But as a brief review, Disability Rights Ohio is
a nonprofit organization. We are Ohio’s designated
protection and advocacy system for people with disabilities in Ohio. And our mission is to advocate for the human, civil and legal rights of people with disabilities. In order to be eligible for our services, you have to be a person with a disability. There’s no income requirement. And our clients are not
charged for our services. And again, if you are
seeking help from our office, you are welcome to contact
our Intake Department. Our number is 1800-282-9181, and you can press Option two
to reach our Intake Department. And then also be aware
that we have a website with many different
self-advocacy resources. Our website is So today’s topics that
we will be discussing are the Early and Periodic Screening, Diagnostic and Treatment services program, which is often referred to as EPSDT, and also referred to
in Ohio as Healthchek. And Kristin Hildebrant will be providing more information about that. And then Earnestine will
be providing information about Ohio’s Medicaid in Schools Program. And then finally, at the
end of our presentation, I will provide some information about Disability Rights Ohio’s
Medicaid pro bono program. All right, well I will hand
it over to Kristin Hildebrant. – Thank you, Alison. The Early and Periodic Screening, Diagnostic and Treatment
program, or EPSDT, is a federal Medicaid program that covers children from birth, until they turn 21 years old. The purpose of the program
is to find and treat conditions or illnesses that children have so that they are treated
early, they don’t get worse, and children have a better life outcomes with that early treatment that they can receive through the program. This program has been around since 1967, so it’s not a new program. But it’s not widely known
by parents or providers or people who work in the Medicaid system. So it wouldn’t be unusual as a parent to have never heard of this program or to have tried to access
services through this program and not gotten them because
it hasn’t been implemented correctly in Ohio. So part of the reason we wanted to talk to you about this today is that you understand what the benefit is and how you can access
those services for your kid. The bottom line to remember about EPSDT is that this program is in place so children get more services than are typically provided
through Medicaid for adults in the state of Ohio; if those services are medically
necessary for the kid. And we’ll talk about what that means, and how to access those services. First, I wanna tell you
about the breadth and scope of the services that are
available through EPSDT. The very initial service that is provided through this program is screening for kids to try to identify any
physical or mental conditions that need to be followed
up on for that child. The screening services
are provided periodically throughout that child’s life. And in Ohio and many other states, the state provides
those screening services according to a schedule
that has been established by the American Academy of Pediatrics. The schedule is called Bright Futures. You might have heard of
a Well-Child Check-Up. That’s part of that periodicity
schedule of screenings. But essentially it establishes
screenings that are required throughout a child’s
life, as the child grows, at critical times, to try to
determine whether this child is developing as we want them to develop or if there are some conditions that are causing problems for that child. The program also require
state (audio cutting out) and vision services to
children in that age span, birth through to 21. For vision services, it requires the state to add a minimum provide
diagnosis and treatment for defects in vision,
including eye glasses. But if additional vision services
are necessary for a child, the program needs to provide
those services as well. The program also provide dental services to children who are
eligible for the program. And that requires, at a minimum, relief for pain and infections, restoration of teeth, and sort of routine
maintenance in dental health. But other services can be
accessed through EPSDT as well. A common request of families
is orthodontist services. And they’re often turned
down for those services, but there is a part of EPSDT
that would allow a child to access orthodonture services if the need is great enough, is medically necessary for the child to have their teeth straightened. EPSDT also provides hearing services. And again, at a minimum,
it’s your routine kind of diagnosis and treatment
to determine if the child has any kind of hearing
loss or hearing defects and might need hearing aids for example. But, again, because the breadth
of this program is great, if there are other hearing services that would be medically
necessary for a child, they can be accessed through EPSDT. So, in addition to the screening
component of this program, it also requires that when a screen that’s conducted on a child indicates the need for further evaluation, or follow-up treatment, that those kinds of services
are provided to a child. So if a screen indicates that there might be a problem
with a child’s development, the next step in the process is for that child to be
referred to a provider who can diagnose whether
there is in fact a problem, where there needs to be a
follow-up or services provided. Another aspect of this program is that services provided through EPSDT need to be done in a timely fashion so there isn’t a delay in that child either getting a diagnosis or receiving follow-up treatment. Going back to the reason for this program, and that is to find problems early, treat them so that the child life outcomes are as good as they can be, it’s important that there aren’t lags in between the steps in the EPSDT process. So timeliness is a big
focus of this program. Once the child has been screened and a diagnosis of an issue has occurred, then follow-up treatment is to be provided through the EPSDT program. That treatment component of the EPSDT is very broadly defined. And in fact, there’s a special definition of a medically necessary
services for children in the federal EPSDT program and also in Ohio state program. So in Ohio, a service that is medically
necessary for a child is any service that is necessary
to correct or ameliorate, and ameliorate means to make better, defects and physical and
mental illnesses and condition that are discovered by the
screening component of EPSDT. This is a much broader definition than the one that we apply to adults when we’re looking at the provision of Medicaid services to people at the age of 21 and older. So under EPSDT, Ohio needs
to provide the children any additional healthcare services that are covered under the
federal Medicaid program, that are medically necessary, regardless of whether
that service is covered in Ohio’s Medicaid plan for adults. So just by way of a little
bit more explanation there, the federal Medicaid program has a list of all of the
services that it covers. States are allowed to pick and choose what services they’re
gonna cover as a state, within certain parameters
that Medicaid’s at. All states have to implement
the EPSDT component. So that’s the requirement of the law that means that the states have to provide all available federal
services to children, where they can pick and choose which services they’re gonna
be providing to adults. So that’s what I mean when I say, children get more under EPSDT because they have access to all of the federal Medicaid services. In addition to children
being able to access the full list of federal
Medicaid services, they also are entitled to services in greater scope and duration and amount. So in Medicaid for adults, states can also limit the amount of a particular service that they provide. So a good example would
be physical therapy. They might limit the amount of physical therapy
treatment an adult can get. But under EPSDT, if a child needs more
than that state limit, because it’s medically necessary, they’re entitled to it. So they can get more of
a particular service, and they can also get the service for a greater period of time. So if the state limits an adult service to a certain duration, a child can get a service
for a longer period of time, because of the EPSDT expanded scope. And this, of course, is as long as the services are medically necessary. And that’s true for the
whole Medicaid program. They don’t pay for services
that aren’t medically necessary. All right, so in Ohio we have chosen to name our EPSDT program Healthchek. So if you hear that name, Healthchek, what that means is that
Ohio is talking about how it implements the
federal EPSDT program. All right, the EPSDT
program, Healthchek in Ohio, is administered by the County Department of Job and Family Services. But also administered by
the Department of Medicaid at the state level. So if you, as a family, are trying to access services through Healthchek, where you go is through
your County Department of Job and Family Services. How do you get EPSDT services? Well, they are available to any child that is Medicaid-eligible
in the state of Ohio. It does not matter how your child has become eligible for Medicaid. So some kids are eligible
because of disabilities, some are eligible because of income, and some kids are eligible
because they are on, what we call, a Medicaid
waiver in our state. So regardless of how the child
is eligible for Medicaid, as long as they are eligible, they’re also eligible for
this expanded EPSDT component. Treatment, if you are asking for services that go beyond some of the limitations that the state has set up
in their Medicaid plan, the way to access additional services is through a process
called Prior Authorization. And you may have already
been through that process, outside of what you thought
was the EPSDT program. But that’s the way to get additional medically necessary
services that are needed. Any Medicaid provider
can recommend services beyond the state plan limits
that we were talking about, under that EPSDT standard. And I just wanna clarify that EPSDT is not considered a separate
Medicaid program in Ohio. It is just a separate
benefit, essentially, that allows children to
access additional services. You don’t have to sign
up for the EPSDT program. Once you’re Medicaid eligible,
you’re covered by it. So you just need to access
the additional services through the Prior Authorization process. The provider who’s
recommending the service is the one who goes through the
Prior Authorization process. And what we have found in our work with children in this state is that sometimes Medicaid
providers don’t understand the expanded EPSDT benefit. So if you think your child
needs additional services, whether it’s occupational
therapy, physical therapy, speech, nursing, other kinds of services, and your provider says to you,
“Medicaid won’t cover that,” you should investigate whether or not that provider understands
the EPSDT benefit and is asking for additional medically necessary
services for your child, using that expanded coverage. All right, so I’m now gonna turn it over to Earnestine Hargett who is going to tell you
about another program where your children can
access Medicaid benefits. – Thank you. I’m Earnestine Hargett, a Senior Advocate here with the Disability Rights Ohio, and I wanna tell you a little bit about the Medicaid in Schools Program. Medicaid in schools is sort of a subset of all of the wonderful expansive services that Kristin’s just made you aware of in terms of making sure
that you understand the depths and breadths
of all of the things that are available to you, as long as you make sure that your provider knows about them, or that you educate yourself about them, and they’re medically
necessary for your child. The Medicaid in Schools Program
is actually only a subset of all of those wonderful services because those services are limited by the parameters of Special Education. Those of you who have
children in Special Education who require specifically
specially designed instruction and related services, that’s where the Medicaid in
Schools Program would come in, in terms of being a possibility
that your school district might be using that for you. The Medicaid in Schools
Program is administered jointly by the Ohio Department of Education, which administers Special Education, and also by the Ohio
Department of Medicaid, which is responsible
for the EPSDT program. The provision allows
reimbursement for valid and appropriately documented
Medicaid services, provided to students with disabilities under the Individuals with
Disabilities Education Act, which is known as Special
Education for the rest of us. To allow schools to
become Medicaid providers, for skilled therapies
and specific services, that’s why we have the
Medicaid in Schools Program. The federal government, who ultimately is responsible for Medicaid and administers that with all
50 states and territories, indicated that they were
willing, back in 2005, to allow schools to participate in accessing Medicaid services. But you can see that
that would be a subset of all the children who
are eligible for Medicaid, in the general sense, and all the children who are
eligible to go to school, because we’re only talking about those children with disabilities. So you could be eligible for Medicaid and not be eligible for
Medicaid Schools Program. You could have a disability, and still not be eligible for
Medicaid in Schools Program. And we’re gonna talk about that. In terms of the provider eligibility, it’s linked to the IEP, the Individual Education Program, that your child has if they’re identified
for Special Education. There also are children who are identified as having a disability
in the school system who are served under what’s called an Accommodation Plan, under section 504. Those children are not
included under this, whether they have Medicaid or not. So this is a small section of children, only those who are both Medicaid eligible, and eligible for an IEP,
under Special Education. (rustling paper) Schools are responsible for providing only those medically necessary
services that are included in the Free and Appropriate
Public Education. So there may be services that your child is medically in need of, but if they are not required for a Free and Appropriate
Public Education, they probably will not
be provided in your IEP, and therefore not delivered under the Medicaid Schools
Program in your public school. The frequency and the
amount and the duration of the school-based program,
is really important. As Kristin was saying, these are services that you can get, in addition to the state plan, but these are also services that are only provided at schools for the purpose of implementing the IEP. The IEP is about a Free and
Appropriate Public Education. And if this service isn’t necessary to facilitate that Public Education, it probably either won’t
be provided at all, or if it is provided, it will be provided in the
amount, duration and intensity of what is necessary for that Free and Appropriate Public Education. You may have a script that says your child needs to have a speech therapy once a week for 20 minutes. And your (audio cutting off) may also say, once a week for 20 minutes, but it may also be a group session, and it may also be an integrated session. And it could even be part
of the services provided as a consultative service with other people talking to other adults on your child’s behalf, trying to make sure that the service gets implemented in a
way that they believe will facilitate their education. So being aware of all those pieces that might look different in terms of the administration
of a Medicaid Schools Program for the Medicaid service
versus a clinical service that you would receive in the community, at Children’s Hospital
or whoever the providers. The covered services include
but are not limited to the speech therapy, the
occupational therapy, physical therapy, nursing
and mental health services, and aids services. The aids services are very limited in terms of only being those aids services that would otherwise
be covered by Medicaid. You may have an aids service
that the school is providing, but they’re not being reimbursed
from Medicaid for that unless it is medically necessary and fits the definition
under Medicaid services. I think I missed one of my slides. I wanted to tell you
which of the districts are able to provide these services. And that would be your local
Public School District, your Exempted Village School District, the School for the Deaf and Blind, and also Charter Schools, as
well as Community Schools, are able to provide these services. What you cannot get these services from, in terms of the billing aspect of it, would be from an
Educational Service Center. These services are tied to your IEP. Your IEP is a responsibility
of the district of residence of the parents or guardians. So unless you have that
kind of responsibility for the procedural safeguards and making sure that those services are provided in an appropriate way, you’re not allowed to
bill it to this program. Because that’s what the
federal government intended, to assist with those folks
who have a legal obligation, to make a Free and Appropriate
Public Education happen on behalf of children with disabilities. (paper rustling) The School District may ask a family, look, I’m getting too many
pages at once, sorry about that. It also includes
specialized transportation. Now we all know that transportation can be included on the
IEP as a related service. This is not one of the related services that they intend for this to be done under the Medicaid Schools Program. When we think of
specialized transportation, most of the time for
children with disabilities, it’s about getting from school and getting back home. This is not for that. Say for instance you live
in a small community, and you need your speech services but they’re provided
at the local hospital, and your child is transported from your Public School District to the local hospital and back, that could potentially be a service that could be reimbursed
by Medicaid in Schools. Not the trip from home to school or from school to home. There are some other activities that are indirectly billed. They are administrative pieces in terms of all the paperwork
that goes with this. And, trust me, there’s a lot of paperwork that goes with this. The medical equipment and supplies that the District may
choose to participate in in terms of that program. And there’s also equipment
that they could purchase that would be medically necessary to serve your child with a disability. But be aware that when they
purchase this kind of equipment, it does not belong to the child. It belongs to the District. (paper rustling) The District may ask you
to apply for Medicaid, if you’re not already
a Medicaid participant. Say for instance, they
may know that your child receives free or reduced price lunches, and feel like the poverty
level that you have may qualify you also for Medicaid. They can ask, but you
are under no obligation, whatsoever, to agree to put
forward that application, and it, in no way, should
affect your eligibility or the level of service
that your child receives for Special Education. You also should not, if you do agree to
participate in schools program by applying for Medicaid
or allowing them to use the Medicaid benefit
that you already have, you cannot incur any kind of expense. This is something that
is supposed to be a part of a Free and Appropriate
Public Education. And of all the parts of
a Free and Appropriate Public Education that
we get confused about, the free part is the clearest. Everybody knows what that means. So, if you’re incurring
some kind of a co-charge or other providers are giving
you some kind of a bill because you’re using the
Medicaid in Schools Program, that’s not acceptable. If you’re going to incur
any kind of charge, the School District
should be absorbing that. That should not come back to you. You are still entitled
to a Free and Appropriate Public Education. And your services cannot
be reduced or limited because you’ve decided,
for your own reasons, that you’d rather not participate either in Medicaid at all, or allow the District to
bill Medicaid in Schools. (paper rustling) This is the part that
gets a little tricky. If a Medicaid-enrolled child
also has private insurance. Back to the subsets of the
subsets of the subsets. This is an even smaller population within the community of
children who have disabilities who are eligible for Special Education. If you have both Medicaid
and private insurance, Medicaid is what is known
as a Payer of Last Resort. It means that if there’s
anybody else out there, any other agency, any other program, any other whatever, that is in a position
to cover and participate in one of these programs, and you want them to be
able to use Medicaid, you have to bill that program first. It does not mean that
that program has to pay. We work with families who
have private insurance but their private insurance
does not cover the services that your child is receiving at school. You need that to be documented so that they can move on, and go ahead and bill Medicaid. But if you either won’t let them contact your private insurance, or your private insurance won’t respond, then we need to have some
kind of documentation that says either that this
is not going to be available or we can’t bill Medicaid at all. Because Medicaid will
require documentation that says that they are being charged, as the Payer of Last Resort. And it’s only the last resort, when no one else is responsible. The IDEA regulations do not affect the requirement under Medicaid that the state agency pursue
the third party payer. So it’s not as though they can say, “Oh nevermind, we don’t have to do that.” Even though the school
doesn’t have to do that, Medicaid does. So if you have a student who’s covered by both
private and Medicaid, the IDEA requires the public agency to obtain the parent’s consent to use the private insurance, or not use Medicaid at all. That’s where the signatures come in. (paper rustling) The right of a student to a Free and Appropriate Public Education is not dependent upon
whether the parent agrees to the public insurance or a Medicaid. The School District can ask you, but they cannot require
you to participate, as we’ve already said. You need this permission prior to disclosing anything to Medicaid. They can’t just send all
of the children’s names into Medicaid who might be
eligible and see what happens. They have to have your written consent before they share any information about your child as an individual, any personally identifiable information. The Medicaid folks aren’t
as worried about that as the people at school are, because they’re covered under the Family Educational Privacy Act that says basically they have to keep students information private. They have to keep it confidential, and they’re only allowed to share it under certain circumstances. And in order for them to share
it with the Medicaid agency, they would need your signed consent. There’s a form that ODE has
provided to school districts if they’d like to use it, I believe it’s optional. But it does need to be used if they’re participating in
the Medicaid Schools Program. And it’s the Prior Written Notice 10 form, that’s Parental Consent to
share health information with the Medicaid in Schools Program. The Family Rights and Privacy Act requires this to be signed
and dated as your consent, before the schools can disclose personally identifiable information from your educational records. Now in terms of this form, it’s a one time form. It’s not as though that they’re
gonna be turning around– There used to be some
language in the rules that talked about every
time they use a service they had to get your permission. And I’m not sure that they
really thought that through because that was gonna mean
that they were asking you every time they went to get
some kind of reimbursement, to please sign, to please
sign, and please sign again. So in terms of making this a more practical way of doing this, they’re gonna ask you to sign this, once. I mean, technically, you
have an annual meeting for your (audio cutting out) at least once a year. And they’ll usually ask you to sign that. But even if you’ve only signed it once, unless you change your mind, it will remain in effect. They will be able to continue to bill for Medicaid, from year to year to year, as long as you are in the same district. You do not have to be in the same school, you do not have to be in the same program, you have to continue to
be eligible for IDEA, Special Education services, and you have to continue to
be eligible for Medicaid, and your signature will still be good. If you change to another district, you move from Columbus to Westerville, from Westerville to Upper Arlington, from Cleveland to Toledo, every time you make one of those moves from district to district, or leave the state, then you have to
reinstate your permission. At any point, if you
want to change your mind, you’re also able to do that as well. And anything that they have planned to do, at that point forward, will no longer be allowed. But anything that they have
relied upon up to that point, that they have already billed for, will remain appropriate. (paper rustling) If a parent consents
to the School Districts to use their Community Medicaid benefits to access their Medicaid
community services under EPSDT, they should not be limited. We were a part of some of the discussions when this program was
being put into effect, and we were very very
very conscious of the fact that this is about making sure that the school is able to get
the additional resources that will help them provide a Free and Appropriate Public
Education to your child, but at the same time, not curtail your ability as a parent, to get the medically
necessary services under EPSDT that you still continue
to require for your child. So your child’s entitled to both a Free and Appropriate Public Education in a restrictive environment, as well as to access the
medically necessary services that are made available
to your child’s EPSDT. Thank you. (loud banging drowning woman whispering) – So thank you Kristin and Earnestine. That was a lot of really
nice helpful information about all the services that
are available to children through EPSDT and the
Medicaid in Schools Program. Before we conclude our video today, I wanted to spend a few
minutes letting you know about a specific program that we have within Disability Rights Ohio to help people with disabilities or family members or children who are receiving Medicaid
and have experienced either reductions in their benefits, or maybe they’ve applied
for a Medicaid program, like a Medicaid waiver, and they’ve been denied. Generally, you have the right to appeal those types of decisions. And navigating that appeal
process can be difficult. So to help more families be able to navigate the Medicaid appeal process, Disability Rights Ohio has
established partnerships with Nationwide Insurance and
McDonald Hopkins law firm, and both the greater Cleveland
area in Northeast Ohio, and also within Central Ohio, to provide or connect people with attorneys or paralegals to provide free legal
representation in Medicaid appeals. So we work collaboratively with the firms. So if you’ve experienced a reduction in your Medicaid services, or you’ve applied and been denied, you would want to contact
our Intake Department, and we could evaluate
whether yours qualifies for a referral for our pro bono program. And then we work collaboratively
with our volunteers to provide support and
training throughout the case while they can provide
legal representation in the state hearing. And as I mentioned, the
program is limited right now to geographic areas where
the firms are located. We’re hoping to expand the
program in the coming years. So right now, we have
about 40 counties covered. And I won’t go through them now, but you can find more information about which counties are
covered, on our website. We have an FAQ specific to
the Medicaid pro bono program, on our Self-Advocacy Resource (audio cutting out) page for Medicaid. So issues that might potentially qualify for a referral to our
pro bono program would be you’ve been denied eligibility
for a Medicaid waiver; you’ve been determined
that you don’t qualify to be on the Wait List for a waiver through the Developmental
Disability System; perhaps you have requested
assisted technology or a medical equipment
such as a wheelchair, or a speech generating
device, and it’s been denied; maybe you’ve applied
for home modifications, or you’ve been receiving nursing or aid services in your home and you’ve gotten a notice that those are going to be reduced or stopped; or potentially therapy services, like occupational physical therapy, like Kristin was talking about earlier. Those are the types of issues that may qualify for a referral
to our pro bono program to connect people with
volunteer attorneys. Even if you’re eligible for a referral, it doesn’t necessarily mean that we would be able to
connect you with an attorney. Because we can’t guarantee that a volunteer would
be able to take the case. But if you have questions
about our pro bono program, or you would like to see if
you qualify for a referral, please feel free to contact
our Intake Department. And again, our number is 1800-282-9181, and press Option two for Intake. And I think we might have some questions so I’m going to look at them quickly. So the first question is, where can a family get contact information for their local JFS~ office, and especially who can they ask for when they’re seeking
EPSDT Healthchek services? And I might hand it over to Kristin. Let me see if we can fix our video to get her back in the screen. – Okay, every County Department
of Job and Family Services has some person who is called
the Healthchek Coordinator. So if you’re trying to just
get general information about the Healthchek program, or access some services, you can contact your County Department of Job and Family Services, and ask for the Healthchek Coordinator. If that is not successful, like, they don’t have a coordinator, or they don’t understand
what you’re asking for, the best way to access
help from your local county is to go to the Ohio
Department of Medicaid, and on their website, you
can search Healthchek, and information about how
to find help in your county, would be available on their website. Another way to find your local County Department of
Job and Family Services is just to google your county department, and that information should come up. And it’s possible that their website would also have information
about the Healthchek program. – All right, well I think that
concludes our video today. Thank you so much for watching and stay tuned for our
feature videos, hopefully. (faint rustling)

One Reply to “Accessing Medicaid Healthcare for Children”

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