Obtaining Insurance Coverage for Children’s Respiratory Care-1

by Jane Perkins

December 1999

This is a forthcoming article in ADVANCE newsmagazine for respiratory care providers

Tami is a 6-year-old with spina bifida. She is extremely fragile and needs continuous medical intervention throughout each day. This includes breathing treatment, suctioning, position changes, supplemental oxygen through a nasal canula, and tube feedings. She also requires physical and occupational therapy. Despite her medical problems, Tami is far from vegetative. She understands what is said to her and communicates through sounds and gestures. Unfortunately, Tami’s health insurance benefits have reached the policy maximum and will be terminated. Her family and physician are searching for alternative insurance.

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Alicia is very poor. She lives in the city and is suffering increasingly violent asthma attacks. Alicia’s family has no regular source of health care other than the hospital emergency room. That is where Alicia goes when she has an asthma attack.

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Derrick is a robust little boy who is the terror of the third grade. His mother says that Derrick is in pretty good health, although he does get a bad cough whenever he has one of his frequent colds.

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These three examples illustrate the range of needs experienced by children with respiratory conditions. Of course, addressing these conditions costs money, and families and health care professionals often encounter more uncertainty about how to pay for needed care than what care actually is needed.

In each of the above cases, Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program may help. EPSDT recognizes the disproportionate health care needs of limited-income families and children with disabling and chronic conditions.

EPSDT OVERVIEW

In return for millions of dollars in federal Medicaid funds, states are supposed to operate EPSDT programs that comply with a minimum set of federal requirements. The basic premise of the program is straightforward: Medicaid-eligible children and youth under age 21 are entitled to receive EPSDT, which includes screening services, treatment and outreach. The EPSDT requirements exist, whether or not the state is contracting with managed care entities to provide services to Medicaid-eligible children.

Four separate types of screens, or well-child checkups, are basic elements of the EPSDT program. They include medical, vision, hearing and dental.

The medical screen must provide at least the following five components:

Each of the four types of screens must be performed at distinct intervals, as determined by “periodicity schedules” that meet the standards of pediatric and adolescent medical and dental practice. Each type of screen should have its own periodicity schedule.

In addition to covering scheduled, periodic checkups, EPSDT covers visits to a health care provider when needed outside of the periodicity schedule to determine whether a child has a condition that needs further care. These types of screens are called “interperiodic screens.” Persons outside the health care system (for example, a teacher or parent) can determine the need for an interperiodic screen.

The Health Care Financing Administration of the Department of Health and Human Services, which administers Medicaid federally, has said that “any encounter with a health care professional acting within the scope of practice is considered to be an interperiodic screen, whether or not the provider is participating in the Medicaid program at the time those screening services are furnished.”

This is important because, if an illness or condition is diagnosed during either a periodic or interperiodic screen, EPSDT requires state Medicaid agencies to “arrange for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment.”

Thus, while the state generally is required only to pay for most services when medically necessary, the state must provide or arrange for EPSDT. This imposes an affirmative obligation on the state to ensure that children actually receive needed care.

REQUIREMENTS FOR TREATMENT

The Medicaid Act defines a comprehensive package of EPSDT benefits, and it sets forth the medical necessity standard that must be applied on an individual basis to each eligible child. The benefit package includes all the services that the state can cover under Medicaid, whether or not such services are covered for adults. The following list shows some of the services that must be provided to children when medically necessary:

In addition to offering a broad benefit package, the Medicaid statute recognizes children’s ongoing needs. State Medicaid programs must cover “necessary health care, diagnostic services, treatment, and other measures ? to correct or ameliorate defects and physical and mental illnesses and conditions.” This definition is an important departure from those private health insurance plans that limit coverage to only those services that will rehabilitate (as opposed to ameliorate) the patient’s condition and that contain quantitative caps on coverage (e.g. 60 physical therapy visits or $500,000 maximum lifetime benefits).

HCFA has given some examples of services that can be covered through EPSDT, if they are based on a physician’s order that the treatment is medically necessary and the services are provided by a Medicaid-qualified provider:

REQUIREMENTS FOR INFORMING

If EPSDT is to work, there is an absolute need for effective outreach and informing. As noted by the Seventh Circuit Court of Appeals: [States cannot] expect that children of needy parents will volunteer themselves or that their parents will voluntarily deliver them to the providers of health services for early medical screening and diagnosis. By the time [a child] is brought for treatment it may too often be on a stretcher ? EPSDT programs must be brought to the recipients; the recipients will not ordinarily go to the programs until it is too late to accomplish the congressional purpose.

In the EPSDT legislation, Congress has required states to inform all Medicaid-eligible persons in the state who are under age 21 of the availability of EPSDT and immunizations. States must use a combination of written and oral methods to effectively inform eligible individuals about the benefits of preventive health care; the services available through EPSDT; that services are without charge, except for premiums for certain families; and that support services, specifically transportation and appointment scheduling assistance, are available on request. Notably, states must offer transportation and appointment scheduling assistance prior to each due date of a child’s periodic examination.

LOOKING BACK

Reviewing the case examples provided at the beginning of this article, it’s clear that EPSDT can help each of the children. Derrick should be able to obtain periodic checkups that will monitor his growth and development and determine, at as early a stage as possible, whether his frequent colds indicate a more serious health problem.

Alicia should be able to obtain checkups and health education through EPSDT to help her recognize and respond to the symptoms of an asthma attack. The inpatient and outpatient treatment services that she needs also should be covered through EPSDT.

Finally, Medicaid EPSDT can provide Tami with the treatment services that she needs on an ongoing basis to ameliorate her condition and allow her to remain at home, including respiratory care, physical and occupational therapy, home health care, personal care services, and durable medical equipment.

If you’re having difficulty obtaining insurance coverage for your patients who are children, consider working with the child’s family to submit a request through the Medicaid EPSDT program.

Jane Perkins works with the National Health Law Program’s Child Health Policy and Law Project. NHeLP is a public interest law firm working to improve health care for children, low income people, minorities, and individuals with disabilities. She is also an adjunct associate professor at the University of North Carolina School of Social Work in Chapel Hill, where she teaches health policy.