Protection & Advocacy Inc. - Publications - Children's Health and Mental health - EPSDT nursing for Medi-Cal Children in Optima Orange County, English

Memorandum

 

Date:      April 23, 1996

To:         Orange County Advocates

From:     Marcie Gladson, Client Rights Advocate, RCOC, 530 South Main Street, Orange CA 92667, (714) 973-1999 x 135; Marilyn Holle and Melinda Bird, address and phone above.

Re:          EPSDT nursing for Medi-Cal Children in Optima Orange County

 

For Children who have a CCS eligible condition and the nursing is needed because of the CCS eligible condition:

 

EPSDT[1] nursing services would be subject to the CCS carve out.  Welfare & Institutions Code § 14094.3(b).  The original of the EPSDT nursing Treatment Authorization Request or TAR and supporting documents would go to In Home Operations.[2]  As a first step in the process In Home Operations will send information to Orange County CCS for a determination that (a) the child has a CCS eligible condition and (b) the nursing is needed because of the CCS eligible condition.  In Home Operations, pursuant to an agreement with CCS, will make the TAR determination on nursing.  However, the formal authorization will come from CCS.

 

To expedite matters, we recommend that a copy of the TAR package (cover plus documentation) go to Orange County CCS at the same time the original TAR package is sent to Medi-Cal.  You should include the Medi-Cal beneficiary's CCS number.

 

Except in the rarest of circumstances, the cost of the EPSDT nursing cannot be more than the Medi-Cal cost if the child were placed in a facility.  Our experience is that In-Home Operations, without the benefit of regional center expertise and experience, will presume the child's needs could be met at a lower cost facility.  Therefore, for regional center clients, we recommend that a RCOC nurse consultant write a letter explaining where the child would be placed if placed out of home and why.  The letter should be included as part of the TAR package.   

 

For Children who do not have a CCS eligible condition and need nursing, or who have a CCS eligible condition but the nursing is not needed because of the CCS eligible condition:

 

The request for EPSDT nursing in cases not subject to the CCS carve out should be addressed directly to the managed care plan itself.  The first step is to ask the gatekeeper physician, or the specialist with primary responsibility for the child's care, to request authorization for home nursing.  If the plan doctor agrees that nursing is needed but the plan denies authorization, the family simultaneously may (a) pursue the internal grievance procedure, and (b) file an appeal with the Medi-Cal program by sending a letter addressed as follows:

 

Chief ALJ

Administrative Adjudications Division

Department of Social Services

744 "P" Street, Sacramento CA 95814

 

Re:     Medi-Cal Managed Care Fair Hearing

Optima/name of plan

Name of Medi-Cal beneficiary

Medi-Cal number

Parent's name, address & phone

 

If, on the other hand, the plan doctor or specialist says the child does not need nursing, then two things should happen if the client is a regional center client:  First, the regional center should conduct a nursing assessment.  If the regional center agrees that nursing is needed under the EPSDT medical necessity standard -- i.e., necessary to correct or ameliorate the child's condition -- the regional center should write the physician with a copy of the nursing assessment, asking for a reconsideration of the original decision.  If there is no response or the response is negative, a Medi-Cal fair hearing should be requested as indicated above.  However, in addition to requesting a fair hearing, we recommend that you include the following sentence:

 

Enclosed is an independent assessment documenting the need for EPSDT home health care.  We believe that the plan denial was based in part on the fact that it would be contrary to the plan's financial interest to authorize nursing.  Therefore we request that the ALJ exercise its authority under 42 CFR § 431.240(b) to order an independent medical assessment as part of the hearing process.

 

Help from Protection & Advocacy, including the Protection & Advocacy Client Rights Advocate at RCOC:

 

We are still in the shake-down phase of figuring out how things will work in Orange County with Cal Optima, EPSDT, and the CCS carve out.  Please call us for help.

 

We and Area Board XI want to know about anyone asking for a Medi-Cal fair hearing against Cal Optima or one of the participating managed care plans.  Area Board XI is maintaining a file of Managed Care hearing requests.  Please mail or fax a copy of any fair hearing request to

 

Area Board XI on Developmental Disabilities

Attn:  Holly Craig

250 South El Camino Real, Suite 110, Tustin CA 92680

Facsimile:  (714) 558-4298

 

cc:       Rhys Burchill and Holly Craig, Area Board XI, voice (714) 731-4787


[1]  EPSDT stands for "Early and Periodic Screening, Diagnosis and Treatment," a federal requirement imposed on Medi-Cal as a condition of receiving federal Medicaid dollars.  Under EPSDT, Medi-Cal children are entitled to receive the services they need under the more commonsense federal standard even if those services are beyond the scope of services available to adults.  For instance nursing is available to children even though not available to adults except through a waiver.

[2]  Medi-Cal Field Office, In-Home Operations, 107 South Broadway, Room 6037, Los Angeles CA 90012.  Or to In-Home Operations, Medi-Cal Operations Division, Department of Health Services, 1801 7th Street, P.O. Box 942732, Sacramento CA 94234-7320.  The TAR should be marked "EPSDT" and should include the documentation justification required under 22 CCR § 51340(d).  If there is private health care coverage, nursing needs to be requested first from the private health benefit plan.  If the private plan denies services or says it is not covered under the plan, a letter saying that needs to go with the TAR package. 

I recommend that you number the pages in the TAR package so that you can refer In-Home Operations consultants to a particular page when there is a question.  You also should document when the package is received by Medi-Cal because that starts the TAR clock running.  A TAR that is not acted upon in 30 days (denied, request for more information, modify) is automatically approved by operation of law.  Welfare & Institutions Code § 14103.6.