Category Archives: EPSDT
There are a number of federal regulations that, if I were in charge, would be immediately amended. Obviously, I am not in charge, so despite my best blogging efforts, my blogs do not change federal law. Today, however, I had the honor and privilege to speak to someone who may have the clout and political pull to fix some of the calamities found in the Code of Federal Regulations (CFRs) that are so detrimental to health care providers who accept Medicare and Medicaid across the country.
My husband, daughter, and I ride horses nearly every weekend. We ride Western and on trails all over North Carolina and Virginia, mostly on charity rides. And over the past few years, I have, sadly, gone through over 5 horses. Not because the horses have passed. But because each horse had an oddity or behavior issue that either (a) I didn’t want to deal with; or (2) terrified me.
For example, Twist of Luck (Twist) is a gorgeous pure, white horse with a yellow tail and mane and brilliant, blue eyes. But he was what you call, “proud cut.” Meaning that because he sired so many foals, even after he became a gelding he thought like a stallion. One weekend we were at Uwharrie National Park and when I saddled up Twist and mounted him, he decided that he did not want me on his back. My husband said Twist looked like a “poster horse” for a rodeo with his back completely rounded like an angry cat and all four of his hooves in the air. Needless to say, I found myself quite quickly on the ground with a sore tooshie, and Twist found himself sold.
Since I do not have the time to actually train my horse, I need a trained horse.
With my hobby of horseback riding, a well-trained horse is imperative…not only for safety, but for my enjoyment as well.
In the area of Medicare and Medicaid, it is imperative for enough physicians, dentists, and other health care providers to accept Medicare and Medicaid. You see, health care providers choose to accept Medicare and Medicaid. And not all health care providers agree to accept Medicare or Medicaid. But it is important for enough health care providers to accept Medicare and Medicaid patients otherwise the Medicare or Medicaid card in a person’s hand is worthless. Same as Twist was worthless to me that day in Uwharrie. If you can’t ride a horse, what is the point of owning it? If you can’t find a health care provider, what is the use of having coverage?
Here in North Carolina, we decided to not expand Medicaid. This blog is not going to address the ever-growing discontent in the media as to the decision, although you can see my blog: “Medicaid Expansion: Bad for the Poor.”
Instead, this blog will address my idea that I pitched to Congresswoman Renee Ellmers over lunch last week and discussed today with her legislative counsel today as to how it can be implemented.
Here’s my idea:
According to most data, not expanding Medicaid in North Carolina is affecting approximately 1.6 million uninsured North Carolinians. But to my point of the shortage of health care providers accepting Medicaid, what is the point of having an insurance card that no health care provider accepts? Therefore, I propose a pilot program here in NC…a pilot program to help the approximate 1.6 million uninsured in NC. Besides the moral issue that everyone deserves quality health care, fiscally, it is sound to provide the uninsured with quality health care (notice that I did not say to provide the uninsured with Medicaid). When the uninsured go to emergency rooms it costs the taxpayers more than if the uninsured had an insurance policy that would allow primary care and specialty doctor appointments. But with Medicaid…you can count out most specialty care, even some basic necessary care like dental care.
Most of the uninsured in NC are non-disabled men. I say this because it is usually easier to get a child on Medicaid with the Early, Periodic, Screening, Diagnostic, Testing (EPSDT) laws. See my blog: “How EPSDT Allows Medicaid Recipients Under the Age of 21 To Receive More Services Than Covered by the State Plan” for an explanation of EPSDT. Many women receive Medicaid based on having dependent children. “In most states, adults without dependent children are ineligible for Medicaid, regardless of their income, and income limits for parents were very low—often below half the poverty level.” See Kaiser Foundation. Which means, generally, many of our uninsured are men without dependents. However, that does not mean they are not fathers. Many of the uninsured are fathers.
Two-thirds of the uninsured live in families where there is at least one full-time worker. However, the percentage of uninsured who live in families with no workers, part-time workers and only one full-time worker has increased 12 percentage points over 5 years. See Demographics.
So how do we help the uninsured without merely handing all uninsured a Medicaid card that will not give them quality health care because not enough trained health care providers accept Medicaid patients?
By giving the uninsured health care insurance, of course! But not Medicaid coverage…oh, no! By giving the uninsured private insurance that will be accepted by all health care providers, all specialists, all durable medical equipment companies, all dentists…
We could partner up with a larger insurer like Blue Cross Blue Shield (BCBS) and create a premium health care insurance on which the insured would pay no premiums or co-pays. Instead, federal grant money would cover the premiums. All that money that NC did not receive based on our decision to not expand Medicaid…can go toward this pilot program to purchase the private insurance for the uninsured.
In order to qualify for this premium, free, private insurance the person must:
1. Be a legal resident;
2. NOT qualify for Medicaid; and
3. Maintain a part time job.
The reasoning behind the criterion of maintaining a part-time job is simple.
It is indisputable that the Affordable Care Act (ACA) has motivated employers across America to decrease the number of full-time jobs due to the mandatory expense of employers providing health care to full-time employees.
Obviously, part-time work does not pay well. It is difficult to even maintain a living on part-time work’s low hourly wages. Many people are forced to hold down two-part time jobs in order to survive. If you can not work and receive more government hand outs, what is the incentive to work?
If my idea comes to fruition and many of our uninsured carry a private insurance card and receive quality health care from the providers of their choice, we could create a whole new group of North Carolinians not only contributing to the community by working, but also contributing to their own homes, and improving themselves and those around them.
I don’t want to provide anyone a useless piece of paper that does not provide quality health care. We may as well give everyone a “proud cut” horse that no one could ride.
Thank you, Congresswoman Renee Ellmers, for being willing to listen to me regarding the uninsured and actually follow-up with the intent to implement.
Quality health care is imperative. Necessary. Needed. We need to fix this system.
New revisions to Medicaid policy limit the number of home health aide services for Medicaid recipients, regardless of medical need.
North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) revised the Clinical Policy 3A. The revised policy took effect July 1, 2013.
Prior to this revised policy, home health aide services were limited to the amount, frequency, and duration of services as ordered by the physician and documented in the Plan of Care (POC). As in, if you needed services four times a week, if your physician ordered the services and the need for such services were documented on the POC, you could receive home health aide services four times a week.
What are home health aide services?
“Home Health (not aide) Services, generally, include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to beneficiaries who live in primary private residences. Skilled nursing, specialized therapies, and medical supplies can also be provided if the beneficiary resides in an adult care home (such as a rest home or family care home).”
Home health aide services are a subpart of Home Health Services.
“Home health aide services are hands-on paraprofessional services provided by a Nurse Aide I or II (NA I or NA II) under the supervision of the RN. The services are provided in accordance with the established POC to support or assist the skilled service (skilled nursing and specialized therapies).
Home health aide services help maintain a beneficiary’s health and facilitate treatment of the beneficiary’s illness or injury. Typical tasks include:
a. Assisting with activities such as bathing, caring for hair and teeth, eating, exercising, transferring, and eliminating.
b. Assisting a beneficiary in taking self-administered medications that do not require the skills of a licensed nurse to be provided safely and effectively.
c. Assisting with home maintenance that is incidental to a beneficiary’s medical care needs, such as doing light cleaning, preparing meals, taking out trash, and shopping for groceries.
d. Performing simple delegated tasks such as taking a beneficiary’s temperature, pulse, respiration, and blood pressure; weighing the beneficiary; changing dressings that do not require the skills of a licensed nurse; and reporting changes in the beneficiary’s condition and needs to an appropriate health care professional.”
See DMA Clinical Policy 3A, p. 1-3 (emphasis added).
The revised Policy 3A has 5 additional pages (it went from 29 pages to 34 pages, in total), but many more restrictions, many of which are without regard to medical necessity.
Such as, “Home health aide services must be limited to 100 total visits per year per beneficiary.” Click here for the full text of the revised Policy 3A. Of course, always remember the exception for children: EPSDT.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid beneficiary under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (includes any evaluation by a physician or other licensed clinician).
For more information on EPSDT, see my blog: “EPSDT’s Impact on Medicaid Audits.”
Now, going back to our Medicaid recipient in medical need of 4 home health aide services/week (208 visits/year), he or she is now limited to 100/year (almost 2 visits/week) (This math is using 52 week/year, not 52.1775).
There are other services possible, depending on the medical necessity. But as for home health aide services, you only get 100.
Remember, this limit not only affects Medicaid recipients (obviously the limit impacts the recipients most greatly), but, also, providers will have less work for their home health aides. As one of my readers pointed out to me, the aides are only making around $8/hour.
DMA Clinical Policy 3A, revised July 1, 2013, has other restrictions. See below for some other restrictions.
Skilled Nursing Visits
Pre-filling insulin syringes/Medi-Planner visits (RC 581) must be limited to a maximum of one visit every two (2) weeks with one (1) additional PRN visit allowed each month. There is a limit of 75 skilled nursing visits (inclusive of, and in any combination with, RC 550, RC 551, RC 559, RC 580, RC 581, and RC 589) per beneficiary per state fiscal year.
Miscellaneous Code T1999
Use of the T1999 code for billing miscellaneous supplies is limited as follows:
- A maximum of $250 per beneficiary per state fiscal year may be billed without prior approval required.
- Any amount over $250 per beneficiary per state fiscal year, whether for a single item or a cumulative total, requires prior approval.
- A maximum of $1,500 per beneficiary per state fiscal year may be billed.
Are these new restrictions only because of a tight Medicaid budget? My question is when does medical necessity for Medicaid recipients become a factor in policy limits?