TennCare Standard Operating Procedures
STATE OF TENNESSEE
BUREAU OF TENNCARE
DEPARTMENT OF FINANCE AND ADMINISTRATION
729 CHURCH STREET
NASHVILLE, TENNESSEE 37247-6501
MEMORANDUM
DATE: April, 1999
TO: TennCare MCOs & BHOs TSOP: 036
FROM: Brian Lapps, Sr.
Director of TennCare
SUBJECT: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a required service under the Medicaid program for categorically needy individuals under age 21. The EPSDT benefit is optional for the medically needy population. However, if the EPSDT benefit is elected for the medically needy population, the EPSDT benefit must be made available to all Medicaid eligibles under age 21. Under its former Medicaid program, the State of Tennessee had already extended the EPSDT benefit to the medically needy population. The TennCare program extends the EPSDT benefit to also include the uninsured/uninsurable under age 21 population.
The purpose of this TSOP and subsequent addendums is to outline and explain the various requirements and responsibilities for assuring compliance with federal and state law concerning the EPSDT benefit under TennCare. Periodicity schedules and other items affecting EPSDT screens and treatments will also be addressed.
The EPSDT program consists of two (2) mutually supportive, operational components:
(1) Assuring the availability and accessibility of required health care resources, and
(2) Helping TennCare enrollees and their parents or other responsible parties effectively use those resources.
These components enable TennCare through the MCOs, BHOs, and the Department of Children's Services (DCS) to manage a comprehensive child health program of prevention and treatment and to systematically:
- Seek out eligibles and inform them of the benefits of prevention and health services and assistance available;
- Help them and their families use health resources, including their own talents and knowledge, effectively and efficiently;
- Identify the child's health needs through initial and periodic examinations and evaluation; and to
- Assure that health problems found are diagnosed and treated early before they become more complex and their treatment more costly.
While Title XIX establishes the framework of standards and requirements that must be met, the Bureau has the flexibility within the Federal statutes and regulations to design an EPSDT program that meets the health needs of its enrollees. The Bureau will work with the MCOs/BHOs and DCS to develop an EPSDT program that meets the requirements imposed by HCFA, as well as the EPSDT Consent Decree.
42 U.S.C.§ § 1396a(43), 1396d(a)(4)(B), and 1396d(r) set forth the basic requirements for the EPSDT program. Under the EPSDT benefit, TennCare, through its contractors, must provide for well-child screenings, vision, hearing, and dental screenings at the intervals recommended by the American Academy of Pediatrics (AAP). Interperiodic screenings are required outside the AAP periodicity schedule whenever health problems are suspected. Additionally, it is required that any service which the Bureau is permitted to cover under the federal Medicaid program that is necessary to treat or ameliorate a defect, physical or mental illness, or a condition identified by a screen, must be provided to EPSDT participants regardless of whether the service or item is otherwise included in Tennessee's Medicaid plan.
The Medicaid Act provides an exception to comparability for EPSDT. Under this exception, the amount, duration, and scope of the services provided under the EPSDT program are not required to be provided to other TennCare enrollees or outside the EPSDT benefit. Services under EPSDT must be sufficient in amount, duration, and scope to reasonably achieve their purpose. 42 C.F.R. § 440.230(b). The amount, duration, or scope of EPSDT services to enrollees may not be denied arbitrarily or reduced solely because of the diagnosis, type of illness, or condition. 42 C.F.R. § 440.230(c). Appropriate limits may be placed on EPSDT services based on medical necessity, including reasonable requirements for prior authorization and to implement tentative service limits. However, if a service is medically necessary and a covered service within its State contract, it must be provided by the MCO/BHO without regard to the tentative service benefits limits. Whenever an MCO or BHO states that there is a tentative limit on EPSDT services, enrollees and providers must be told that, if medical necessity can be shown, such limit(s) can be waived. Medical necessity must be decided on a case-by-case basis.
Utilization controls cannot unreasonably delay the initial or continued receipt of services, nor can they cause enrollees to go without needed care. There must be an expeditious process in place to ensure that children receive, without interruption, any medically necessary services that exceed tentative limits. For example, an MCO may approve a block of six (6) physical therapy visits, the block of services is used up, and the MCO requires a whole new authorization process for the next block of PT, which could cause the child to go without services in the interim. If the provider requests continuation of the services before the end of an approved block of services, those services are to continue without interruption.
Any denial of a timely request from the provider who originally prescribed an ongoing service for continuation of the service beyond tentative limits shall be attended by notice to the enrollee prior to reduction or termination of the services. If the denial is appealed in a timely fashion, the services shall be continued pending appeal without regard to the MCO's tentative limits. A request from a provider for continuation of a service shall be considered timely if it is made prior to termination of the treatment interval previously approved by the MCO. A request from a provider for the continuation of services an enrollee is receiving shall not impact on the enrollee's own right to request a continuation of services pending the results of the enrollee's appeal, as stated in TennCare rule 1200-13-12-.11(2)(i). The Bureau will review the MCOs' prior approval/utilization review processes on an annual basis to assure that tentative limits approved by MCOs are appropriate.
When making medical necessity decisions, MCOs, BHOs and the Department of Children's Services must adhere to the definition of "Medically Necessary" as defined in the TennCare/MCO and TennCare BHO contracts and printed here.
Medically Necessary - shall mean services or supplies provided by an institution, physician, or other provider that are required to identify or treat a TennCare enrollee's
illness, disease, or injury and which are:
a) Consistent with the symptoms or diagnosis and treatment of the enrollee's
illness, disease, or injury; and
b) Appropriate with regard to standards of good medical practice; and
c) Not solely for the convenience of an enrollee, physician, institution, or other provider; and
d) The most appropriate supply or level of services that can safely be provided to the enrollee. When applied to the care of an inpatient, it further means that services for the enrollee's medical symptoms or condition require that the services cannot be safely provided to the enrollee as an outpatient; and
e) When applied to enrollees under 21 years of age, services shall be provided in accordance with EPSDT requirements including federal regulations as described in 42 CFR Part 441, Subpart B, and the Omnibus Budget Reconciliation Act of 1989.
This should not be interpreted to limit the MCO's or BHO's ability to use or establish mechanisms to apply the TennCare contractual medical necessity definitions or to direct patients to medically appropriate, more cost effective alternatives, provided these services would adequately address the patient's medical needs.
As previously stated, the Bureau will be issuing addendums to this TSOP to further explain expectations for the EPSDT program under TennCare. MCO, BHO, and DCS input are welcomed.
TennCare Authority:
42 U.S.C. § § 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)
42 C.F.R. § 440.230
42 C.F.R. § 441, Subpart B
HCFA's State Medicaid Manual
TennCare Rules and Regulation 1200-13-12-.04(1)(w)
TennCare/MCO Contract Section 2-3.a.1.; Section 4-8.
TennCare/BHO Contract Section 2.6.1.; Section 5.3.3.1.
