DCS Comprehensive Health Plan

EPSDT Monitoring and Performance

Statement/Purpose

DCS CHP provides and monitors comprehensive and preventive health services for enrolled children and youth through its Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Definitions

Arizona Health Care Cost Containment System (AHCCCS): Founded in 1982, the Arizona Health Care Cost Containment System is Arizona's Medicaid program, a federal health care program jointly funded by the federal and state governments for individuals and families who qualify based on income level.

Centers for Medicaid and Medicaid Services (CMS): CMS is part of the U.S. Department of Health and Human Services which administers Medicare and Medicaid in partnership with state governments.

CMS 416: The CMS 416 is a form used by CMS to collect basic information on State Medicaid to assess the effectiveness of EPSDT services/participation. Specific reporting instructions are located on both AHCCCS’ and CMS’ website.

Early Periodic Screening, Diagnostic and Treatment (EPSDT): A benefit that provides comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment and follow-up care of physical and behavioral health conditions for children and youth under age 21.

Health Effectiveness Data Information System (HEDIS): A comprehensive set of standardized performance measures established by National Committee for Quality Assurance (NCQA). These measures identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards that allow comparison with other plans.

Policy

DCS CHP uses metrics and specific performance measures to track its enrollees’ receipt of EPSDT services.

Specific EPSDT performance measures are used to meet the following:

• AHCCCS and Medicaid requirements;

• DCS CHP, Mercy Care contract requirements; and

• Federal child welfare requirements.

These performance measures may be modified based on the following:

• Instructions from AHCCCS;

• Technological advancements;

• DCS CHP oversight enhancements; or

• Other identified needs within DCS.

The specific measures are reviewed for accuracy during programming to ensure data integrity. Changes to the data collection may occur when there are discrepancies noted or if there are changes to billing, coding or measure specifications

Procedure

EPSDT Participation

DCS CHP tracks EPSDT participation through its use of the CMS 416 form, CMS 416 methodology and AHCCCS instruction.

Reporting Frequency

DCS CHP reports Medicaid eligible children to AHCCCS as part of the DCS CHP Performance Measure Monitoring Report. If the report, requirement or methodology is no longer reported to AHCCCS, DCS CHP will continue to report EPSDT Participation on a quarterly basis.

In addition to AHCCCS reporting for Medicaid eligible children, DCS CHP tracks EPSDT participation for non-Medicaid eligible children using the same methodology.

EPSDT Monitoring

EPSDT monitoring and improvement efforts include tracking through CMS 416 reporting as well as other activities, and include, but are not limited to, the following:

• Member outreach requirements;

• Provider outreach requirements;

• Child and adolescent performance measures (CMS Core, AHCCCS and HEDIS methodologies) which include access to care, well-care visits and dental visits; and

• Childhood immunizations through the EPSDT and Adult Quarterly Monitoring Report, immunization audits, Arizona State Immunization Information System (ASIIS), etc.

EPSDT Within 30 Days of Entering Care

DCS CHP monitors the enrollees’ receipt of EPSDT services within 30 days of entering care through the use of claims data (regardless of payment status).

Well Visits

Numerator - Of the members who qualify (denominator), the number of individual members who had a well visit as indicated by the presence of a CPT code of 99381, 99382, 99383, 99384, 99391, 99392, 99393 & 99394 in the first 30 days of entry into care.

Denominator - number of individual members who entered the health plan in the measurement period and remained in the health plan for 30 days.

Additional tracking up to 60 and 90 days is measured using similar methodology.

Reporting Timeline Example:

Care management - For those members whose well visit(s) are not, or will not be captured through administrative data (claims), DCS CHP uses care management outreach data to report performance. Care management data may be appended to the administrative data to provide additional information.

Dental Visits

Using similar methodology to well visits, DCS CHP monitors the enrollees’ receipt of dental visits using dental procedure (CDT) codes.

Additional Well Visit and Dental Visit Measurement Specifications

At times a child may not receive an EPSDT or preventative dental visit within 30 days for extenuating circumstances (hospitalization, caregiver scheduling, etc). For this reason, CHP reviews whether members who remain within the health plan longer than 30 days received services.

As such, review includes members up to 60 days and up to 90 days in order to document completed services. Both EPSDT and dental metrics follow methodology of recorded service outlined above with corresponding “up to 60” or “up to 90” days as the numerator for the 60 day or 90-day metrics.

The denominator is the number of eligible members who were in the health plan a minimum of 30 days, and “up to 60” days for the 60 day metric and “up to 90” days for the 90 day metric.

EPSDT Specialty Referrals

DCS CHP monitors the receipt of specialty services noted on the EPSDT tracking form, as appropriate, for its members. Members should receive these services within 60 days.

Administrative (claims) methodology is the primary source for reporting. As such, data is to be restated on a routine basis to account for data lag in provider claims submittal.

Specialty Referral metrics are to be included in the DCS CHP Business Review document.

Reporting

Performance measures are reported in several settings including, but not limited to:

• Quality Management Performance Improvement (quarterly) meetings;

• Medical Management (MM) (quarterly) meetings;

• DCS CHP Business Review (monthly) meetings as appropriate; and

• Applicable quarterly report submissions to AHCCCS set forth in the AHCCCS and DCS CHP contract.