EPSDT/CHDP (epsdt chdp) - Medi-Cal

[Pages:30]EPSDT/CHDP

epsdt chdp 1

Page updated: September 2020

This section contains information about the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) health care benefit and the Child Health and Disability Prevention (CHDP) program. In California, the CHDP program administers the Early and Periodic screening component of the federally mandated EPSDT benefit for individuals under the age of 21 who are enrolled in the Medi-Cal fee-for-service health care delivery system.

CHDP Program Overview

The CHDP program is administered by the Integrated Systems of Care Division (ISCD) of the Department of Health Care Services (DHCS). The program is operated by local county health departments and offices in the cities of Berkeley, Long Beach and Pasadena. The CHDP program is designed to ensure that eligible children and youth receive periodic health assessments and have access to ongoing health care from a medical and dental home.

CHDP Program Background

In 2019, the CHDP program completed a multi-year, multi-phase project that transitioned CHDP providers from billing non-HIPAA compliant two-character codes on the Confidential Screening/Billing Report (PM 160) claim form to billing HIPAA-compliant codes on the national CMS-1500 or UB-04 claim form. The project decommissioned a CHDP-specific claims processing sub-system. EPSDT/CHDP claims are now processed as standard MediCal claims through the California Medicaid Management Information System (CA-MMIS) claims processing system.

On July 1, 2016, the CHDP program adopted the American Academy of Pediatrics (AAP), Bright Futures Recommendations for Pediatric Preventive Care. The CHDP periodicity schedule is the Bright Futures/AAP Periodicity Schedule, and the CHDP program Health Assessment Guidelines (HAG) mirror the Bright Futures/AAP guidelines except where State statute or regulations are more stringent. CHDP program providers are required to comply with State and Federal laws and regulations.

Effective May 1, 2016, pursuant to Welfare and Institutions Code (W&I Code), Section 14007.8, an individual who is under 19 years of age and formerly received CHDP state-only services is eligible for full-scope Medi-Cal state-only services for concerns identified during a periodic preventive health assessment, as well as any medically necessary Medi-Cal services.

Part 2 ? EPSDT/CHDP

epsdt chdp 2

Page updated: September 2020 As of July 1, 2016, all Medi-Cal managed care plans (MCPs) are capitated for EPSDT services. The expansion of the Medi-Cal program resulted in the majority of EPSDT-eligible children enrolled in an MCP. The local CHDP program continues to provide care coordination for EPSDT-eligible children who are enrolled in the Medi-Cal fee-for-service health care delivery system. Managed care plans provide care coordination for MCP-enrolled members.

CHDP Program Responsibilities

The local county CHDP programs are responsible for day-to-day program operations, including the following:

? Provider recruitment, review and approval ? Provider education and quality assurance ? Liaison with schools and various community agencies ? Education and outreach to eligible families ? Assistance to families in obtaining services, including transportation for medical

appointments and services ? Assistance to providers in contacting patients and scheduling appointments with other

providers ? Collaboration with the Department of Education to assist families with children entering

kindergarten or the first grade to obtain a health assessment and/or a signed certification of health assessment

Part 2 ? EPSDT/CHDP

epsdt chdp 3

Page updated: September 2020

Provider Information

CHDP Provider Participation

Provider enrollment in the CHDP program is accomplished through a partnership among DHCS, ISCD and local CHDP programs. The following Medi-Cal-enrolled providers are eligible to participate in the CHDP program as health assessment providers if they meet CHDP enrollment requirements.

? Physicians ? Independent pediatric nurse practitioners ? Independent family nurse practitioners ? Medical groups that employ physicians who meet the requirements outlined in this

section ? Health clinics that employ physicians who meet the requirements outlined in this

section ? Laboratory providers

Conditions of Participation CHDP providers must:

? Participate in the Vaccines For Children (VFC) program. ? Successfully complete a medical record review by the local CHDP program. The

medical record review is performed to assess format, documentation, coordination and continuity of care in order to ensure that children and youth receiving EPSDT/CHDP services are receiving the appropriate level of care. Successfully complete a facility site review to ensure each service location is safe and readily accessible to individuals with disabilities. This does not mean CHDP providers must make each of their existing facilities or every part of the facility accessible to and usable by people with disabilities if other methods are effective in achieving compliance. A facility review may also include, but is not limited to, the review of licensure and or certification, personnel qualifications, site management, Clinical Laboratory Improvement Amendments of 1988 (CLIA) compliance, and the availability of emergency medical equipment and examination equipment appropriate to the population served. ? Utilize clinicians that meet CHDP standards.

Part 2 ? EPSDT/CHDP

epsdt chdp 4

Page updated: September 2020

Laboratory Providers

The following Medi-Cal enrolled providers are eligible to participate in the CHDP program as laboratory providers if they meet CHDP enrollment requirements: A clinical laboratory. This lab must be:

? Licensed or registered by the California Department of Public Health (CDPH) according to Business and Professions Code, Section 1265; and

? Appropriately certified or approved under CLIA for the level of testing done in the laboratory

A clinical laboratory with blood lead proficiency. This lab must be: ? Certified or approved under CLIA for non-waived testing, and for subspecialty toxicology, analyte blood lead; and ? Enrolled in and qualified as proficient in blood lead level analysis by the California Blood Lead Proficiency Assurance Program administered by the CDPH Environmental Health Laboratory Branch. ? Non-waived is a term that incorporates both moderately complex and highly complex testing in the final CLIA regulations published in the Federal Register, January 24, 2003, 42 CFR, Part 493

All CHDP laboratory providers are required to maintain enrollment in the CHDP program. In addition, laboratory providers are responsible for the following:

? Maintaining active status as a Medi-Cal provider ? Referring families and/or patients to their health care provider for obtaining results of

the tests ? Maintaining licensure or registration as a clinical laboratory in accordance with CDPH

standards ? Maintaining proficiency in blood lead analysis in accordance with CDPH standards (for

blood lead labs only)

Part 2 ? EPSDT/CHDP

epsdt chdp 5

Page updated: September 2020

Lead Laboratory Providers A health assessment provider who is proficient in blood lead analysis must be:

? Certified under CLIA for waived status for the LeadCare II Blood Lead Test System ? Enrolled in and qualified as proficient in blood lead analysis by the California Blood

Lead Proficiency Assurance Program administered by the CDPH Environmental Health Laboratory Branch Laboratory Providers Laboratory providers are responsible for referring families and/or recipients to their health care provider for obtaining results of the tests.

CHDP Health Assessment Guidelines

The CHDP Health Assessment Guidelines incorporate the Bright Futures recommendations and include policies and procedures for provision of EPSDT/CHDP services. The guidelines include a detailed explanation of what is expected of a CHDP provider. A copy of the guidelines is available from local CHDP programs or may be accessed on the Child Health and Disability Prevention Program page of the DHCS website at dhcs.services/chdp.

Appointment Scheduling

Patients are referred to providers from a variety of sources, including parents or caregivers, foster program parents, CHDP program staff, local health departments, schools, caseworkers and other Medi-Cal providers. Providers must offer appointments to referred patients on a timely basis. At the time of an EPSDT/CHDP health assessment, and in accordance with the CHDP Health Assessment Guidelines, providers must:

? Schedule an appointment for the next periodic health assessment for children younger than 2 years of age

? Inform the family and/or patient in writing of the date when the next examination is due for children 2 years of age and older

Part 2 ? EPSDT/CHDP

epsdt chdp 6

Page updated: September 2020

Determining Recipient Eligibility

Prior to rendering services to a recipient, providers are responsible for determining recipient eligibility. Refer to "Eligibility Verification" in this section for information.

Informing Patients

Providers are responsible for informing patients about the availability of EPSDT/CHDP services and assisting recipients, in coordination with the local CHDP program, to obtain preventive health services for which they are eligible. Additional information about EPSDT informing requirements is located in the EPSDT section of this manual. Lead Poisoning Prevention Informing Requirement In accordance with California Health and Safety Code (H&S Code), Section 105286, health care providers must inform parents and guardians about all of the following:

? The risks and effects of childhood lead exposure. ? The requirement that children enrolled in Medi-Cal receive blood lead tests at specified

ages. ? The requirement that children not enrolled in Medi-Cal who are at high risk of lead

exposure receive blood lead tests.

Obtaining Consent:

Providers must obtain voluntary written consent prior to examination and treatment, with appropriate regard to the recipient's age and following State and Federal laws. Consent also must be obtained prior to release of recipient information. Minor Consent Minors (recipients younger than 18 years of age) may provide their own legal consent for EPSDT/CHDP health assessment services, if:

? The minor is emancipated, as determined by the court. ? The minor is, or has been, married. ? Parental consent for the service is not necessary under State or Federal law.

Part 2 ? EPSDT/CHDP

epsdt chdp 7

Page updated: September 2020

Physician Provider Minimum Requirements:

A physician may be eligible to participate as a CHDP provider if he or she is a pediatrician or family practice physician. Internists may provide services to children 14 years of age or older. All physicians must meet the following requirements:

? Hold an unrestricted California physician and surgeon license issued by the licensing section of the Medical Board of California or the Osteopathic Medical Board of California; and

? Be enrolled as an active Medi-Cal provider (an active Medi-Cal provider means the physician has a current, unrevoked and unsuspended Medi-Cal enrolled NPI); and

? Be board certified in pediatrics, family practice or internal medicine ? If not board certified in pediatrics, family practice or internal medicine, the physician

must meet either of the following: ? Be an active candidate for the certifying examination (active candidate means a

physician who has applied to take the certifying examination, and who provides written documentation of being scheduled to take the certifying examination; or ? Have other evidence regarding eligibility to take the board examination such as a letter signed by the program director of his or her residency program verifying satisfactory completion of training. The residency program must be approved by the Accreditation Council for Graduate Medical Education. The local CHDP director may make an exception to the physician qualification requirements based on his/her practice location within a primary care health professional shortage area or medically underserved areas/medically underserved population if the physician also meets the following criteria to provide EPSDT/CHDP services: ? Holds an unrestricted California physician and surgeon license issued by the licensing section of the Medical Board of California or the Osteopathic Medical Board of California; and ? Provides documentation of 480 hours of post-graduate supervised pediatric training in an accredited medical institution or facility; or ? Provides documentation of clinical experience within the last three years of at least six months experience with the pediatric age group to be served.

Part 2 ? EPSDT/CHDP

epsdt chdp 8

Page updated: September 2020

Independent Nurse Practitioner Requirements:

An independent nurse practitioner is eligible to participate as a CHDP provider if certified as a family nurse practitioner or a pediatric nurse practitioner and meets the requirements of the California Code of Regulations (CCR), Title 22, Section 51170.3. An independent nurse practitioner must hold an unrestricted California license issued by the Board of Registered Nursing and possess a written agreement with a physician who is also a CHDP provider in the local health jurisdiction of application or a contiguous county.

Physician Group or Health Clinic Minimum Requirements:

Physician groups or health clinics may be eligible to participate as CHDP providers if they have an active Medi-Cal enrolled NPI in the Medi-Cal program, meet the licensure requirements and employ physicians, nurse practitioners or physician assistants who meet the conditions of participation for CHDP providers.

Non-Physician Medical Practitioner Qualifications:

Qualifications for Non-physician Medical Practitioners (NMPs) (nurse practitioners and physician assistants) rendering CHDP services are as follows.

Nurse Practitioners A certified pediatric or family nurse practitioner may render EPSDT/CHDP services at a CHDP provider site. Other nurse practitioners, as employees of a CHDP provider must:

? Provide documentation of 600 hours of postgraduate onsite supervised primary care experience within the past three years in the pediatric age group to be served. Supervision of the 600 hours must have been by a family practice or pediatric physician, or an internal medicine specialist who serves children 14 years of age and older. The documentation for this requirement may be, at a minimum, provided in an up-to-date curriculum vitae.

? Hold an unrestricted California license issued by the Board of Registered Nursing. ? Possess written protocols that describe the review process by the physician of record

when examination findings are suspect or abnormal.

Part 2 ? EPSDT/CHDP

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download