In Part I in this series, we discussed the state of Medicaid and the EPSDT – the Early and Periodic Screening, Diagnosis, and Treatment benefit – which covers most American children with disabilities from birth until 19 (21 in some states) years of age. Since 1989, EPSDT has required each state in the Union to provide each child with “all medically necessary services” that were available under the federal government’s Medicaid program, even if that state did not offer that service to adults. This coverage is broad enough to dwarf most private insurance.
What is ‘medically necessary’?
One important difference is that most states adopt a definition of “medically necessary” that only includes those services that “improve or eliminate a condition,” at least for adults. But EPSDT’s definition of includes services that “correct or ameliorate defects and physical and mental illnesses and conditions.” It may not seem like a big difference, but it is huge.
This is because “correct or improve” includes services that stabilize a medically unstable person (ie vital signs are not consistently within the defined safe range). So if you are 20 years and 262 days old and your epilepsy takes you to the hospital because you were seriously injured, EPSDT kicks in and all the services needed to stabilize you are paid for. If you’re 21 by seven o’clock when you land in the hospital, that bill (usually quite large) is sent to your parents’ insurance, and suddenly large copays and deductions apply.
Similarly, “correct or improve” includes services that maintain function in someone who would not normally function without specific ongoing intervention. (Maintenance is not ‘improve nor eliminate’). By far the most common example is ADHD medication, which is covered by EPSDT up to age 21, and then depending on your precise prescription, the cost can go as high as $ 300 / month with no assistance available regardless of your income level.
A state of exposure
States have fairly wide discretion when it comes to designing the benefit packages they offer to adults enrolled in Medicaid. They are required to provide coverage for a specific list of services, including (but not limited to):
• The Early Periodic Screening, Diagnosis and Treatment (EPSDT) program,
• Inpatient and outpatient hospital care,
• Medical services,
• Use of the health center, rural health clinic and nursing home,
• Services of Nurse Midwife, Certified Family and Pediatric Care Nurse and Independent Birthing Center,
• Laboratory and X-ray use, and
• Transportation services (for medical reasons only).
This means that they are not required to provide Medicaid programs that cover:
• Prescription drugs,
• Clinical services (that is, any non-hospital medical facility),
• Therapy services, including physical, occupational, behavioral, etc.
• Dental, vision, speech, hearing and language services,
• Respiratory care,
• Podiatry,
• Prosthetics and
• Private duty nursing.
As you can see, if you are an adult with Medicaid, you may be very well taken care of if you live in the right state … or you may be almost completely without coverage for the services you use the most, even if your state agreed to the Medicaid expansion. . Remember in the first post in the series we mentioned that most of the children who used EPSDT used it for developmental, mental, or emotional disabilities? Do you notice that all of them are within the “optional” services within this rubric? We’ll talk about what this means in more detail in the next post.