Our training

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Welcome to the webinar.

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Today, I will be presenting a general overview

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of the EPSDT program

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and how Aetna Better Health of Kansas can support your practice

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as they navigate the EPSDT benefit for children on Medicaid.

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So first, let's review what EPSDT means.

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You'll find the acronyms spelled out on the slide.

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Here we have E for early,

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as in assessing for and identifying potential health concerns

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on a timely basis.

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Periodic,

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monitoring overall health at age-appropriate times.

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Screening, providing appropriate screening tests.

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Diagnosis, includes follow up and referrals

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when a health risk is identified.

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And treatment, meaning correction, reduction,

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or maintenance of health problems identified.

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As a reminder, EPSDT is a federally-mandated benefit

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that supports children throughout their growing years

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in order to ensure they receive the care they need

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by supporting their physical health, mental health, and development.

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Note that Kansas follows

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the American Academy of Pediatricians' Bright Futures periodicity schedule

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regarding recommended visited timeline.

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EPSDT covers children from birth up to the age of 21

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and includes children in the foster care system.

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Members do not sign up for this program.

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They are automatically enrolled if they meet the age requirement.

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In the same way, members cannot opt out of EPSDT.

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They KanBeHealthy exam, or the KBH, is the starting point for EPSDT.

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In other words,

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this is how most members will access the benefit.

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The KBH begins the process of screening children,

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and the vast majority of children

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may not need the other services EPSDT covers.

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However, without regular KBHs,

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conditions that are treatable may be missed.

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This slide lists out the benefits of an annual KanBeHealthy visit.

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We have making sure required health care resources

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are available and accessible.

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It assists families by helping Medicaid recipients

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and their parents or guardians

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effectively identify and use these resources,

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by assessing the individual child's needs

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through initial and periodic examination and evaluation,

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assisting with early diagnosis and treatment of health problems

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by including medical, vision, dental, and hearing screenings,

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as well as referrals and treatments,

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by including developmental screenings to include identification, referral,

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and treatment of delays in a child's development,

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by including diagnostic services

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when a screening indicates the need for further follow up.

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This slide goes into more information on what services ABH covers

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and the focus of the EPSDT program.

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So, EPSDT is a key service

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that ensures children and adolescents under age 21

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receive appropriate preventative physical,

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dental, mental health, developmental, and specialty services.

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The overall goal of the program

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is to ensure that individual children and adolescents get the care they need

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when they need it –

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the right care to the right child at the right time in the right setting.

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This slide discusses what ABH does

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to make sure our members are aware of the EPSDT program.

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You might have seen a member handbook.

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These are sent after enrollment in Medicaid,

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and it contains information on EPSDT services.

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Our members also receive text reminders,

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IVR reminders via our outreach campaigns.

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These are sent to the parents or guardians about our healthcare visits that are due.

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Educational materials are also made available.

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These are also mailed to the parents and guardians.

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Our foster care contractors receive gap in care reports

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and these reports provide information regarding when a KBH visit is needed,

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as well as educational materials that are handed out at community events.

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We just participated in the event in Kansas City, Kansas.

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It was the Vibrant Health fair,

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and our table had so many different brochures and pamphlets

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in English and in Spanish,

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and we were able to engage with a lot of our community.

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That was a lot of fun.

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Now, I'll start discussing the individual steps in EPSDT

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The 1st letter E stands for early.

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The earlier conditions are identified, the more successful the treatment.

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Here, we have an example at the bottom of the slide

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where a mom takes her nine-month-old son to the pediatrician for a well visit.

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The second letter stands for periodic.

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Here's where the Bright Futures schedule really comes into play.

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Making sure the parents understand the recommended schedule of visits.

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You may have received access to a patient portal as a parent

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that reminds you of your child's visit.

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You may have also received a pamphlet or a little booklet

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to remind you and keep track of your baby's growth and development.

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Those can all be examples

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of that periodicity schedule that we follow.

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Next letter stands for screening.

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This slide lists the various types of screenings

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that children should receive during the KBH

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as they grow and develop.

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Again, an example of what this screening entails

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can be a mom expressing concern

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that her nine-month-old son isn't sitting up on his own

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during the check up,

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and then the pediatrician will come in and complete a full exam,

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obtain all of that physical history during the appointment.

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Regular screening tests help detect potential health concerns,

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and they include health and developmental history,

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including behavioral health, comprehensive physical exams,

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appropriate immunizations, laboratory testing,

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vision, dental, hearing, and lead screening.

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Now, lead screening receives it's own slide here,

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because it's an important screening test and it's a required component of EPSDT.

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The KBH includes a verbal screening for lead,

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but this does not count as an actual lead screening.

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All that screening must consist of a serum blood test

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and should be completed before the child turns two.

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However, for children older than two who have not previously been screened,

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this test should be completed as soon as possible,

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no matter the age.

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The 4th letter stands for diagnosis.

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Some screenings may identify concerns and additional testing is required.

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The provider should make a referral as soon as the concern is identified

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so that the child can receive treatment if necessary.

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Note the example at the bottom of the slide

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where the pediatrician notes the delays in motor skills

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Let's say were discussing that nine-month-old son

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that the mom brought in,

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the pediatrician will then create a referral

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to see a physical therapist

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that specializes in children's development.

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The final letter, T, stands for treatment.

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Once diagnosed,

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the goal is to have the child receive treatment right away

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so that problems can be corrected.

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Some problems may not be able to be fully corrected,

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but treatment can lessen the severity

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and ensure the child is able to live their fullest life.

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Here, again, is another example

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where the child begins therapy sessions with the physical therapist

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and future visits with the original pediatrician

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will evaluate the progress of those physical therapy visits

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and make further recommendations as needed.

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This slide introduces the terminology "medical necessity."

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Most services are included in the EPSDT benefit,

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but on occasion,

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a provider may recommend a treatment that is not routinely covered,

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but that the provider considers medically necessary.

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The EPSDT benefit can cover these services

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once a medical director on the Aetna team approves the provider's plan

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and agrees with the medical necessity of the service.

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You will see on the slide the three bulleted items

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which, according to Kan Care and Aetna,

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would not be considered medically necessary.

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So, here, we have experimental treatments or items,

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services or items determined to be unsafe or ineffective,

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and services specifically for caregiver convenience.

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Services cannot be denied arbitrarily;

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it will still go through that approval process.

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And a continuation of the discussion on medical necessity,

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states such as Kansas can determine limits

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for any services considered medically necessary,

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and Aetna is required to uphold any limits KanCare stipulates.

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This slide talks about

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the Managed Care Organizations' responsibility

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in determining medical necessity.

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Each case is reviewed by both a nurse and a physician,

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and the guidelines used are national standards.

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The medical director makes the final determination.

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However, providers can appeal these determinations if they desire.

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A side note here,

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the more information provider offices can add to the initial PA form,

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the better.

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In many instances,

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additional information given during the appeal

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is enough to overturn the initial determination.

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In the case of any dispute, the state makes the final determination.

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This slide walks through an example of a child who was diagnosed with ADHD,

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where the mother is seeking respite care services.

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Under the current guidelines,

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respite care is not covered by the EPSDT benefit,

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therefore, this request would be denied.

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So, to recap,

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EPSDT covers children from birth up until they turn 21.

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Children should be receiving annual well-child or KBH visits

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so that their growth and development can be tracked

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and any problems or concerns identified early.

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By staying on track,

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health concerns can be treated early and either corrected or lessened.

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The number at the bottom was the number of children in Kansas

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that would be covered by EPSDT as of August 2022.

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So, I wanted to leave our contact information here.

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We have a Carson Boyd.

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She's our HEDIS quality management manager

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and her email is boydc@aetna.com.

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She can be contacted for any HEDIS-related questions.

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And myself, Tiffany Barrett, I am the EPSDT coordinator here,

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and my email address is barrettt6@aetna.com.

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I can be reached out to for any EPSDT-related question.

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And does anyone have any questions that I may be able to address here?

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We have a little bit of time left.

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Okay. Well, that concludes today's webinar.

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Thank you for joining.

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I will be sending everyone a copy of the slides

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and the participation survey.

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I'll give you your time back. Everyone, have a great day.

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You, too. Thank you.