CurrentADAPolicy N/A

troupe-soi-final.pdf

Federal Department of Justice and HCFA/HCBS attachments clarifying interpretation of EPSDT screening requirements and guidance on State authority and limits under 1915(c) HCBS waivers, including access to services, participant limits, sufficiency of amount/duration/scope, amendments lowering eligibles, and applicability to children.

Policy Summary

PayerADA

Policytroupe-soi-final.pdf

Policy CodePolicy N/A

Change TypeClarification

Effective DateJan 10, 2001

Next Review DateN/A

Key ActionProviders should document any encounter addressing a child's behavioral or health problem as an EPSDT screening request; formal use of the term 'EPSDT screen' is not required.

SourceLink

POLICY UPDATE CHANGES

CMS clarified that any encounter with a health care professional within scope of practice can be an inter-periodic EPSDT screening (CMS Letter #01-006).

HCFA clarified that once enrolled in a 1915(c) waiver, individuals must have access to needed waiver services and States may not cap number of enrollees who may receive a particular waiver service.

HCFA explained States may set overall enrollment limits for waivers and may derive limits from fiscal appropriations but must notify HCFA and supply calculations.

1CMS guidance letter referenced

1915(c)HCBS waiver statutory authority

42 CFR 441.303(f)(6)Regulation requiring enrollment limits

42 CFR 440.230(b)Regulation on sufficiency of services

Policy summary & scope

Background: This document contains a Department of Justice Statement of Interest clarifying the proper interpretation of EPSDT (Early and Periodic Screening, Diagnostic and Treatment) obligations in litigation and attachments to HCFA Olmstead Update No. 4 (SMDL #01-006, Jan 10, 2001) that explain allowable limits and State options in 1915(c) HCBS waivers. The Statement emphasizes that routine medical encounters addressing a child's health or behavioral problem qualify as EPSDT screenings and that families need not label visits as an 'EPSDT screen' to trigger screening obligations.

Scope summary: The guidance explains the interaction between EPSDT and HCBS waivers: children under 21, including those enrolled through 1915(c) waivers, must receive EPSDT screening and all medically necessary Medicaid-coverable services identified by those screens; enrollment in an HCBS waiver cannot be used to deny, delay, or limit EPSDT services; States may set overall enrollment limits for waivers (and may derive those limits from fiscal appropriations) but, once enrolled, individuals must have access to needed waiver and State plan services determined by assessment and a written plan of care; States may impose reasonable utilization limits on amount/duration/scope but may not cap access to a covered service for enrollees or deny needed covered services to enrolled individuals.

Key State obligations and protections for children: States must specify the number of unduplicated recipients to be served under a waiver each year (42 CFR 441.303(f)(6)) and notify HCFA if limits are derived from appropriations and supply the calculations; HCFA reviews waiver sufficiency under the requirement that services be sufficient in amount, duration, and scope to achieve waiver purposes (42 CFR 440.230(b)); waiver amendments that lower potential eligibles require HCFA consideration of litigation/civil rights, protections for current participants, transition methods, and assurances of capacity; children cannot be placed on waiting lists for Medicaid-coverable EPSDT services and must have access to the full range of EPSDT screening components and medically necessary treatment services.

Dates and status: Effective: January 10, 2001; Last review: September 6, 2013; Status: CURRENT.

Policy snapshot

Effective Date2001-01-10

Last Review2013-09-06

StatusCURRENT

SubjectEPSDT and HCBS waiver interaction / Olmstead guidance

PayerDepartment of Health & Human Services / HCFA (Medicaid)

Policy DocumentOlmstead Update No. 4 (SMDL #01-006) — attachments: 'Allowable Limits and State Options in HCBS Waivers' and 'EPSDT and HCBS waivers' (troupe-soi-final.pdf)

DefinitionsEPSDT (Early and Periodic Screening, Diagnostic and Treatment) and HCBS waiver (1915(c) Home and Community-Based Services)

EPSDT screening applicability & coverage principles

EPSDT screening request applicability

Covered when ANY of the following demonstrate a screening request:

Any encounter/visit with a qualified medical professional addressing a behavioral or health problem constitutes an EPSDT screening request (no need to use the term 'EPSDT screen').

Based on CMS guidance that any encounter within scope of practice is an inter-periodic screening.

Periodic scheduled examinations and inter-periodic contacts qualify as screenings per 42 C.F.R. § 441.56(b) and CMS guidance (CMS Letter #01-006).

Regulatory definition and CMS Letter clarification.

EPSDT and HCBS waivers for children

Requirements specific to children under EPSDT when enrolled in HCBS waivers:

Children under 21, including those enrolled via HCBS waivers, must receive EPSDT screening and all medically necessary Medicaid-coverable services identified by EPSDT screens.

1915(c) HCBS waiver participant limits and State obligations

State HCBS waiver participant limits and obligations

Rules governing limits on participants and access to services within 1915(c) waivers:

Overall enrollment limit: State must specify number of unduplicated recipients to be served each year under 42 C.F.R. 441.303(f)(6); that number constitutes a limit unless amended and approved.42 C.F.R. 441.303(f)(6)

Funding-derived limits: State may derive approved maximum participants from fiscal appropriation (option to use funding-derived limit), but must notify HCFA of such derivation and supply calculations.

Access to services for enrolled individuals: Once enrolled, an individual must have opportunity for access to all needed services covered by the waiver and Medicaid State plan based on assessment and written plan of care; State may not cap number of enrollees who may receive a particular waiver service.

Operational actions, documentation & compliance risks

Documentation Required

Treat ordinary medical encounters as EPSDT screening requests

Providers should document any encounter addressing a child's behavioral or health problem as an EPSDT screening request; formal use of the term 'EPSDT screen' is not required. Document routine medical encounters (including inter-periodic contacts and visits within a provider's scope of practice) as screening events so the child can be evaluated for medically necessary EPSDT services.

Documentation Required

Assessment and written plan of care/support required

States and providers must assess need and prepare a written plan of care/support to determine entitlement to waiver services; documentation should support that services are needed per assessment. Ensure assessments and written plans are used to establish which waiver and Medicaid services a child requires, and retain those records to demonstrate entitlement to needed services.

Definitions & FAQs

Preface: Below are brief definitions and quick answers to common questions about EPSDT and HCBS waivers.

Definitions & quick answers: EPSDT — Early and Periodic Screening, Diagnostic and Treatment services (section 1905(r)) requiring screenings and coverage of medically necessary Medicaid-coverable services for children under 21; any encounter with a qualified health professional can constitute an EPSDT screening. HCBS waiver / 1915(c) — Home and Community-Based Services waiver allowing States to provide community-based services as an alternative to institutional care and to expand eligibility in some cases.

Quick answers: No — a parent does not need to request an 'EPSDT screening' explicitly; any visit/contact addressing a child's health or behavioral problem satisfies the screening requirement. No — once enrolled in a 1915(c) waiver, States may not cap how many enrolled participants may receive a particular covered waiver service; enrollees must have access to needed services based on assessment and a written plan of care.

Term	Definition
EPSDT	Early and Periodic Screening, Diagnostic and Treatment services under Medicaid (section 1905(r) of the Social Security Act) requiring screenings and coverage of medically necessary services for eligible children under 21.
HCBS waiver / 1915(c)	Home and Community-Based Services waiver under section 1915(c) of the Social Security Act allowing States to provide community-based services as an alternative to institutional care and to expand eligibility in some cases.

Question	Answer
Does a parent need to request an 'EPSDT screening' explicitly?	No; any visit or contact with a qualified medical professional addressing a child's health or behavioral problem qualifies as an EPSDT screening request; families need not use the term 'EPSDT screen' to trigger screening obligations.
Can a State cap how many enrolled waiver participants may receive a specific waiver service?	No; once enrolled, individuals must have the opportunity to access all needed services covered by the waiver based on assessment and plan of care; States may not impose service-specific caps on enrollees though they may set overall enrollment limits for the waiver.

Document changes & clarifications

2001-01-10clarified

CMS clarified (CMS Letter #01-006) that any encounter with a health care professional practicing within the scope of his/her practice may constitute an inter-periodic EPSDT screening; families need not request a formal 'EPSDT screen' or use that term to trigger screening obligations.

2001-01-10clarified

HCFA affirmed that States may set an overall enrollment limit for a 1915(c) HCBS waiver (the State must specify the number of unduplicated beneficiaries under 42 C.F.R. 441.303(f)(6)) and that the State may derive that limit from fiscal appropriations, provided the State notifies HCFA and supplies the calculations; waiver amendments may be requested and may be retroactive to the start of the waiver year.

2001-01-10clarified

Policy Summary

PayerADA

Policytroupe-soi-final.pdf

Policy CodePolicy N/A

Change TypeClarification

Effective DateJan 10, 2001

Next Review DateN/A

Key ActionProviders should document any encounter addressing a child's behavioral or health problem as an EPSDT screening request; formal use of the term 'EPSDT screen' is not required.

SourceLink

On This Page

Enrollment in HCBS waiver cannot be used to deny, delay, or limit access to medically necessary EPSDT services; children cannot be put on waiting lists for Medicaid-coverable EPSDT services.

EPSDT medical screen components: comprehensive health/developmental history including physical and mental health assessment; comprehensive unclothed physical exam; immunizations; appropriate labs (including lead screening as age/risk indicate); health education/anticipatory guidance.

HCBS waivers may provide additional services (e.g., homemaker, habilitation, prevocational/supported employment, respite) and may extend Medicaid eligibility to avoid institutionalization; these supplement but do not supplant EPSDT obligations.

Reasonable utilization controls: States may impose reasonable utilization controls on amount/duration/scope of services, but limits cannot deny a needed and covered service to enrolled individuals.

Reasonable promptness factors: Reasonable promptness governs timeliness of providing needed services; urgency, health/welfare, service nature, provider supply, availability of alternatives are factors in determining promptness.

HCFA review principles for waiver sufficiency and amendments

Principles applied when reviewing waiver design, sufficiency and amendments:

Sufficiency review: HCFA evaluates whether amount, duration, and scope of services (waiver + State plan + other services) are sufficient to achieve waiver purpose as a community alternative to institutionalization (42 C.F.R. 440.230(b)).42 C.F.R. 440.230(b)

Manifestly incapable waivers: If waiver design is manifestly incapable of serving target group or threatens health/welfare, HCFA expects State to adjust waiver design.

Amendment considerations: When lowering potential number of participants via amendment, HCFA considers existing litigation/civil rights complaints, impact on current participants, assurances of capacity, transition methodology, and protections (e.g., fair hearings).

Consolidation of target groups: States may consolidate target groups that cross regulatory categories to avoid administrative duplication, provided criteria are reasonable and definable (42 C.F.R. 441.301(b)(6)).42 C.F.R. 441.301(b)(6)

Prior Authorization

State waiver amendments and HCFA notification

States may set overall enrollment limits for 1915(c) waivers and may derive those limits from fiscal appropriations, but they must notify HCFA and provide the calculations used to derive any funding-based limit. Waiver amendments that lower potential eligibles may require assurances to HCFA (and, when relevant, notification to courts or DHHS Office for Civil Rights) and may be reviewed for impacts on current participants and transition safeguards.

Denial Risk

Prohibition on capping access to specific waiver services

Once individuals are enrolled in a waiver, States may not cap or limit the number of enrolled participants who may receive a covered waiver service found necessary by assessment; denying a needed, covered service to enrollees based on service-specific caps or budget overruns risks noncompliance and jeopardizes health and welfare. Use assessments and written plans to establish individual entitlement and avoid arbitrary service caps.

HCFA clarified that once individuals are enrolled in a 1915(c) waiver, the State must provide enrolled individuals the opportunity to access all needed waiver and Medicaid State plan services determined by assessment and a written plan of care; States may impose reasonable utilization controls on amount/duration/scope but may not cap the number of enrollees who may receive a particular waiver service or deny a needed, covered service to enrolled individuals.