Changes are Made to Medicaid

If your child is in enrolled in Medicaid, you have undoubtedly heard of the upcoming reductions concerning private therapy. Out of the areas being affected, this article will focus on the reductions of private rehabilitative therapy services with quotes from the lastest bulletin dated 1/31/2011 put out by SCDHHS (South Carolina Department of Health and Human Services). Currently, each child is allowed 75 visits per year for physical therapy and occupational therapy, and 150 visits per year for speech therapy. As of April 1, 2011, this is being cut or reduced to 75 total including speech, occupational and physical therapies. To only make matters worse, Medicaid has made these reductions retroactive back to July 1st of 2010. Many of our children enrolled in Medicaid will suddenly be "over the limit" come April 1st.  The state fiscal year begins July 1st and ends June 30th, so they will be counting these visits since July 1st of 2010.
 
Your child can qualify for more visits per year than the cap allows, when these therapy services are deemed "medically necessary" by the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) department of the SCDHHS.  The request must officially come from your pediatrician who is working together with the therapist. 
"Should a physician determine through an EPSDT visit that a child requires additional private rehabilitative therapy services, that physician must document the medical necessity and request additional visits in writing for review by the SCDHHS Medical Directors.  These pre-approved requests must include an evaluation overview, proposed treatment plan with expected outcomes, relative progress notes, and anticipated units of services needed to address need(s). The documentation must indicate the diagnosis and/or functional impairment that establishes medical necessity, and must be signed by the child's primary care physician. Documentation should be faxed to SCDHHS staff at 803-255-8222, attention Private Rehabilitative Therapy Services Authorization, prior to provision of the service."  
 
This process is one that the physicians and therapists are used to and have been through before. Remember, it had to be proven that the services were medically necessary for our children when we applied. Although I have heard about some services already being denied, I don't have any more information about that.  For more information about what EPSDT is and what services they cover, please go to the website of Protection and Advocacy for People with Disabilities, Inc.  atinfo@pandasc.org .  They have a few bulletins that are very clear concerning children's rights with Medicaid. They state clearly that "...SCDHHS cannot legally refuse to cover certain medical supplies for children or limit the number of doctor visits or therapy services per year, if the assistance is in fact medically necessary." It's the definition of medically necessary as determined by the EPSDT that we need to be worried about.
 
if you have questions you would like to put to Medicaid, Christopher Lykes is the person who seems to be handling the questions. He has recommended that we begin this process as soon as possible. While I have been told not to send in all the documentation for a request to extend visits too early, I also wouldn't want to be too late! 
 
The general phone number for Medicaid is 888-549-0820
The website is www.scdhhs.gov and here you can download all of the bulletins and see them in full.


On March 23 the following email was sent out by the Family Connection of South Carolina:

The South Carolina Department of Health and Human Services (SCDHHS) would like to clarify for families the process of seeking additional rehabilitation therapy hours over 75 per year listed in the December Medicaid beneficiary newsletter.  If your child is nearing 75 hours in one year, you should talk with your child's primary care physician about submitting a request to SCDHHS for additional therapy hours.  Your therapist can determine how many hours your child has already received.

Federal regulations require that the State has a process in place to provide medically necessary services to those children who have documented needs through their physician.  No child will be denied services that are determined to be medically necessary. This standard is also applied to other Medicaid services. 

Seventy-five hours is not a hard limit-it is a check point so that you, your child's therapist and your child's primary care physician can assess the progress being made under rehabilitation therapy.  Once we receive the information from your child's doctor, our medical staff will review the request and approve additional hours that are deemed medically necessary.  We are typically processing these requests in less than one week.

We greatly appreciate the feedback we have received from families and providers and will be happy to answer any questions and concerns you may have.  Please email Chris Lykes atlykes@scdhhs.gov if you need additional assistance.