If accepted by the legislature, the new definition reads as follows:
Medically necessary services for eligible Medicaid participants under the age of twenty-one (21) are health care, diagnostic services, treatment, and other measures described in Section 1905(a) of the Social Security Act (SSA) necessary to correct or ameliorate defects, physical and mental illness, and conditions discovered by the screening services as defined in Section 1905(r) of the SSA, whether or not such services are covered under the State Plan. Services must be considered safe, effective, and meet acceptable standards of medical practice.
On July 20, 2012, Centers for Medicare and Medicaid Services (CMS), the federal agency that monitors a state’s compliance with the Medicaid program sent the IDHW two letters detailing its review of Idaho Medicaid’s Early, Periodic, Screening, Diagnostic, and Treatment (EPSDT) benefit for children under the age of 21.
As a result of this monitoring event, Idaho Medicaid was found out of compliance in four areas and specifically regarding the use of the state definition for medical necessity as applied to service requests for Medicaid eligible children under the age of 21.
Specifically, CMS wrote on page 8 of a report dated and sent to the IDHW on July 20, 2012:
Findings: Idaho’s definition of medical necessity found in the aforementioned documents requires that “services are medically necessary if they can be reasonably calculated to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functionally significant deformity or malfunction; and there is no other equally effective course of treatment available or suitable for the participant requesting the service which is more conservative or substantially less costly. Medically necessary services must also be of a quality that meets professionally-recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality.” This definition of medical necessity is not consistent with federal rules and is too narrow in scope to be applied to Medicaid-eligible children. EPSDT services include Section 1905(r)(5) of the Act requiring that “necessary heath care, diagnostic services, treatment and other measures described in Section 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” This requirement to cover all medically necessary Section 1905(a) coverable services to individuals under the age of 21 ensures that these individuals receive any services determined to be appropriate for their specific illness or condition, regardless of any limitations a state may include in the Medicaid or CHIP state plan. Idaho must revise its definition of medical necessity in all of its publications, State rules, the Medicaid State plan (including the benchmarks), and the State’s beneficiary and provider handbooks.
Corrective Action Required: Idaho is required to submit a CAP (Corrective Action Plan) to CMS within 90 days of this report detailing the changes that will be made, and the processes by which the State will notify providers, update the definition, and any applicable rules, and/or policies/procedures. In addition, CMS expects the State to provide a timeline of when they will submit SPAs correcting all areas where the State’s medical necessity definition and/or limits on Medicaid services is not in compliance with federal statute and regulations.
Other findings of non-compliance in the July 20, 2012 report are as follows:
· Informing – Idaho’s provider manuals, and Idaho’s booklet entitled “Idaho Health Plan Coverage – A Benefits Guide to Medicaid, Children’s Health Insurance Program (CHIP) and Premium Assistance” (Idaho’s primary informing material for participants) are inconsistent when explaining covered services in excess of limits, and appears to limit EPSDT services to conditions discovered only during a well-child screen;
· Access to Services – The State’s requirement that parents facilitate the completion of the multi-page form entitled “Request for Additional Services (RAS) (EPSDT),” in order to receive prior authorization for 12 select services above the limits specified in the Medicaid State plan, burdens parents with obtaining complicated medical documentation, and has the potential to present barriers to beneficiaries under 21 years old accessing medically necessary services;
As a result of its investigation, CMS made several other statements in the July 20, 2012 report regarding children’s Medicaid services in Idaho and recommended that Idaho Medicaid:
· Perform additional education to enrolled Medicaid providers related to both the availability of, and processes and procedures regarding how to request services beyond limits for the under 21 population (page 3);
· Ensure that all informational materials contain consistent language and messaging regarding service availability, limits, and prior authorization processes (page 4); and
· Ensure that Health Connections (HC) representatives emphasize to Primary Care Physicians (PCP) that receipt of services beyond limits is not contingent upon a Medicaid/CHIP client being up-to-date on well-child checks (page 4).
On page 14 of the July 20, 2012 report, CMS found the following:
· Findings: The State’s Requirement that parents facilitate the completion of the multi-page form entitled “RAS (EPSDT),” in order to receive prior authorization for 12 select services provided by DDA above the limits specified in the Medicaid State plan, burdens parents with obtaining complicated medical documentation and has the potential to present barriers to children accessing medically necessary services. States can specify the amount, duration, and scope for services in the State plan. However, limitations cannot be based on the location of a provider (i.e., school district, outpatient community setting, etc.). Furthermore, the State cannot set limits on a subset of providers that are qualified to provide a specific service (i.e., all physical therapists that meet the required qualifications and have signed a provider agreement as a Medicaid provider in Idaho are subject to the same rules for State plan services).
Corrective Action Required: The State must immediately revise its RAS form so that parents are not burdened with obtaining complicated medical documentation. Additionally, the State must submit a SPA (State Plan Amendment) or SPAs to correct the inconsistencies in the current Basic and Enhanced benefit packages where limitations are different for services based on the location of the provider. The State must provide evidence to CMS within 90 days of this report documenting the required changes to the RAS form have been made.
Regarding limits on services and services coordination, on page 17, CMS in its July 20, 2012 report required that:
· The State must remove and/or revise all language in published materials (IDAPA rules, provide handbooks/manuals, beneficiary information, etc.), to clarify that medically necessary services over and above Medicaid State plan limits are available for individuals under the age of 21. Additionally, within 90 days from the date of this report, the State will provide a timeline for amending all publications. In addition, the State must amend the provider manual to remove the service coordination limit to accurately reflect the State plan.
· For service coordination and mental health, there were zero requests for services beyond limits, and a high ratio of therapy requests were denied for not being submitted in advance of rendering services. While this may indicate that service limits in Idaho are set so that very few eligible beneficiaries need additional services, CMS is concerned that it may indicate a lack of familiarity with the prior authorization limits and process. The State should distribute information regularly in the Medicaid Provider Newsletter to ensure providers have current information regarding the prior authorization process, and that services beyond regular limits should be requested for patients under the age of 21 when the provider believes them to be necessary.
In another letter sent to the IDHW by CMS dated July 20, 2012, CMS explains in Attachment B necessary specific language revisions that must be made to IDHW Information Materials. Specifically, the Children’s System Re-Design Frequently Asked Questions must contain:
· Language must specify that all individuals under age 21 are eligibility (sic) for EPSDT services, even if enrolled in the adult HCBS waivers. More clarity is needed to specify which services are Medicaid 1905(a) services, and which are HCBS services.
Attachment E of the July 20, 2012 letter addresses the Fair Hearing Process. CMS made the following comments:
· Services cannot have a lifetime limit of 36 months. There is no information on how the family can appeal the decision or request a fair hearing.
If anyone is interested in receiving a copy of the final evaluation by CMS, please contact the DRI Pocatello Office.