TennCare Standard Operating Procedures
STATE OF TENNESSEE
BUREAU OF TENNCARE
DEPARTMENT OF FINANCE AND ADMINISTRATION
729 CHURCH STREET
NASHVILLE, TENNESSEE 37247-6501
MEMORANDUM
DATE: April, 1999
TO: TennCare MCOs & BHOs
TSOP: 036 Addendum 1
FROM: Brian Lapps, Sr.
Director of TennCare
SUBJECT: EPSDT Outreach and Informing Requirements
NOTE: The EPSDT outreach and informing requirements stated in this TSOP must be put in place as soon as possible by MCOs and BHOs and maintained thereafter. The Bureau of TennCare will inform all contractors of any changes that must be made in a timely manner. These changes may occur as a result in changes: in federal or state laws, made by HCFA, and/or the rules and regulations of the TennCare program.
I. General Information
The Bureau of TennCare and its MCOs and BHOs are required to inform all TennCare enrollees under age 21 about the availability of and how to access EPSDT services. There is flexibility in how this is accomplished as long as the outcome is effective and is achieved in a timely manner, generally within 60 days of the MCO's/BHO's receipt of notification of the child's TennCare eligibility. For Medicaid-eligible (DHS) enrollees, the process of informing will begin at the intake interview. Non-Medicaid and SSI eligibles will receive information in their "welcome" letter from TennCare about EPSDT. All eligibles will receive information from their assigned MCO/BHO.
Methods of communication used are to be such that enrollees can clearly and easily understand EPSDT, ensuring that they have the information they need to use services to which they are entitled. A combination of face-to-face, oral, and written informing activities have been shown to be the most effective methods. HCFA considers "oral" methods to include face-to-face informing by eligibility case workers, health aides, and providers, as well as public service announcements, community awareness campaigns, audio-visual films, and film strips.
II. Individuals to be Informed About the EPSDT Program
- Inform all TennCare-eligible children under age 21 and their parents or other responsible parties;
- Inform newly eligible children under age 21 and their parents or other responsible parties, either determined eligible for the first time, or determined eligible after a period of ineligibility if they have not used EPSDT services for at least 12 months. Individuals/families that go on and off eligibility rolls should be informed at least once every 12 months;
- For children in institutions, notification is to include the administrator of the institution;
- Inform TennCare eligible pregnant women about the availability of EPSDT services for children under age 21 (including children eligible as newborns). A TennCare eligible woman's positive response to an offer of EPSDT services during her pregnancy, which is medically confirmed, constitutes a request for EPSDT services for the child at birth. For a child eligible at birth (i.e., as a newborn for a woman who is eligible for and receiving Medicaid), the request for EPSDT services is effective with the birth of the child. The parent or guardian of an infant who is not deemed eligible at birth as a newborn must be informed about the availability of EPSDT services at the time the infant's eligibility is determined.
III. The Role Of the Bureau of TennCare
A. The Bureau will work with other Bureaus within the Department of Health (TDH) and the local county health departments, the Department of Human Services (DHS), the Department of Children's Services (DCS), Local Education Agencies (LEAs), schools, day care centers, and other agencies, to inform an enrollee's parents or other responsible parties of the purpose and availability of EPSDT services. This does not replace nor relieve the MCOs or BHOs of their responsibilities to inform their enrollees of such services.
The Bureau will include in letters to new non-Medicaid enrollees the following statement concerning EPSDT:
TennCare has a special program for children under age 21. This program is called "EPSDT" (Early and Periodic Screening, Diagnosis, and Treatment). Your child's TennCare plan will do regular check-ups for your child. Then your child's TennCare plan and Partners plan will treat health, developmental, and behavioral problems that are found.
Call your child's main doctor or nurse for a checkup anytime you think your child may have a problem. If you don't know who your child's doctor is, or if your child's regular doctor does not do EPSDT checkups, call your TennCare plan for help.
You also should take your child in for regular check-ups even when your child seems healthy. These check-ups help us find problems early and treat them so that your child will stay healthy. If you need transportation to get to the doctor's office, call your TennCare plan for help.
EPSDT check-ups are free. They can help find problems such as:
Health problems Eye problems
Hearing problems Drug and alcohol problems
Slow development Nerve problems
Dental problems
If you have TennCare premiums, you will have your usual co-insurance payments on treatment services.
B. The Bureau, through the Office of Contract Development and Compliance, will review all material - including but not limited to - mail outs to enrollees about EPSDT, statements in the members' handbook, promotional material, public service announcements, media advertisements, posters, etc. - before they are used by the MCO/BHO to inform enrollees about EPSDT services.
C. The Bureau will gather, compile, and analyze all data from the MCOs and BHOs relating to MCO/BHO EPSDT outreach and information activities to educate enrollees. This information will be used to prepare and submit reports to the proper entities as required by HCFA and the Consent Decree. MCOs and BHOs shall provide such data to the Bureau annually on the calendar year basis (January - December). Failure to timely submit [within 90 days of the end of the year] the requested data may result in liquidated damages as described in the TennCare & MCO/BHO contracts.
MCOs and BHOs are expected to document to the Bureau their outreach activities and what efforts were made to inform enrollees and/or their parents or other responsible parties about the availability of EPSDT services and how to access such services. Information to be provided shall include what form of contact was used (i.e., special mailings, health fairs, etc.), the intended target audience (was the information sent to all enrollees or only those cases which included pregnant women, and/or children under 21), outreach/information activities coordinated with appropriate providers, public service announcements, etc. The Bureau encourages MCOs to make use of enrollee newsletters, as called for in the Contract Section 2-6.b.2., to communicate the importance of preventive health care and the use of EPSDT services.
D. If the Bureau determines that an MCO or BHO has failed to reach particular groups of EPSDT-eligibles, the MCO or BHO shall be instructed to focus on particular "at risk" groups. Examples of such groups are, but not limited to, families with infants or adolescents, first time eligibles, those not using the EPSDT program for over two (2) years, and families participating in the WIC program.
IV. The Role Of MCOs & BHOs
BHOs are responsible for providing mental health and substance abuse services to TennCare enrollees under the age of 21. MCOs are responsible for providing all other EPSDT services to TennCare enrollees under the age of 21. Requirements such as amount, scope, and duration are applicable equally to MCOs and BHOs.
MCOs/BHOs are responsible for informing and outreaching their enrollees with regard to EPSDT benefits provided through their respective plans.
A. Contents and Methods
1. EPSDT information sent to eligibles and their families or other responsible parties shall emphasize that preventive health care is provided to all TennCare enrollees at no cost to the enrollee. Additionally, that prior authorization is not required in order to obtain EPSDT screening services provided by a participating provider.
2. MCOs and BHOs shall aggressively and effectively inform all TennCare enrollees about the existence and availability of EPSDT services for those under age 21. The notice is to include information about the availability of specific EPSDT screening and treatment services.
3. Notice shall be given in a timely manner, generally within 60 days of the TennCare MCO's receipt of notification of the child's enrollment in its plan. This information shall be issued no less often than annually.
4. MCOs/BHOs shall use clear and non-technical terms to provide a combination of written and oral information so that the program is clearly and easily understood. Materials used in this process shall continue to be prepared at the 6th grade level as determined by the Flesch-Kincaid Index, Flesch Index, or the Fog Index. Such information shall include the following: (a) the benefits of preventive health care; (b) the services available under the EPSDT program and where and how to obtain those services; (c) the recommended frequency of EPSDT checkups, with additional information that screens can be requested anytime a parent, teacher, or someone else involved with the child thinks there is a problem; (d) that the preventive services provided under the EPSDT program are without cost to enrollees; and (e) that necessary transportation and scheduling assistance are available to EPSDT eligibles upon request.
5. MCOs/BHOs shall use accepted methods for informing persons who are illiterate, blind, deaf, or cannot understand the English language about the availability and use of EPSDT services. Lacking in-house expertise in these areas, MCOs /BHOs should work in collaboration with agencies which have established procedures for working with such individuals.
B. Additional Outreach Requirements
MCOs/BHOs shall establish a system whereby families can readily access an accurate list of names and telephone numbers of contract providers who are currently accepting TennCare. This system shall also indicate which providers may perform EPSDT screens.
MCOs/BHOs shall offer and provide enrollees with assistance in scheduling appointments and obtaining transportation prior to the date of each periodic examination as requested and necessary.
MCOs/BHOs shall document services declined by a parent, guardian, or mature competent child1, specifying the particular service declined so that outreach and education for other EPSDT services continue. MCOs/BHOs may either maintain such information themselves or opt to require their network providers to maintain such information in the patient's medical file.
MCOs/BHOs shall maintain records of the efforts taken to reach out to children who have missed screening appointments when scheduled or who have failed to schedule regular check-ups.
V. The Role of the Local County Health Department
The local county health department shall provide information on EPSDT and other covered services to adolescent prenatal patients who enter TennCare through presumptive eligibility. Assistance shall also be offered to these patients in making a timely first prenatal care appointment. For a woman past her first trimester, this appointment should occur within 15 days. MCOs may want to consider establishing an internal contact point to aid the county health offices in identifying providers who are taking new patients and to offer other assistance as necessary.
Local county health departments shall also provide information about EPSDT benefits to uninsured/uninsurable applicants when assisting them in applying for TennCare.
VI. The Role of the Department of Children's Services (DCS)
Where eligible enrollees in State custody live in institutions or other residential treatment settings, other than with their natural or adoptive parents, DCS shall inform the institution/residential treatment program annually as to the benefits of the EPSDT program, or more often when the need arises, including when a change of administrators, social workers, or foster parents occur.
VII. Compliance
All MCOs and BHOs must document and maintain records of all outreach efforts made to inform enrollees about the availability of EPSDT services.
1 A "mature competent child" is defined as a minor who has the capacity to consent to and appreciate the nature, the risks, and the consequences of the medical services involved. Recognizing that minors achieve varying degrees of maturity and responsibility (capacity), the mature minor exception is also guided by the Rule of Sevens which provides as follows: under the age of seven (7), no capacity; between seven (7) and fourteen (14), a rebuttable presumption of no capacity; between fourteen (14) and twenty-one (21), a rebuttable presumption of capacity. (Cardwell v. Bechtol, Tennessee Supreme Court, 724 S.W.2d (Tenn. 1987))
TennCare Authority:
42 U.S.C. § § 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)
42 C.F.R. § 440.230
42 C.F.R. § 441, Subpart B
HCFA's State Medicaid Manual
TennCare Rules and Regulation 1200-13-12-.04(1)(w)
TennCare/MCO Contract Section 2-3.a.1.; Section 4-8.
TennCare/BHO Contract Section 2.6.1.; Section 5.3.3.1.
