Changes in Medicaid Rules that Affect Children and Medicaid HMO's
Part 4, Chapter 13: Specialized Situations: Programs for Children and Adults with Disabilities and Special Health Care Needs Page 6
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Recent Changes in Medicaid Rules
Once the issue of eligibility has been resolved, and an individual is covered by Medicaid, it's important to understand the program rules in order to obtain appropriate benefits. Unfortunately, those rules are complex and are often difficult to comprehend. In addition, the rules under which the Medicaid program operates have changed significantly over the years.
One change that directly affects children with disabilities involves the establishment of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT provides for a periodic medical screening for children with disabilities. In many cases, a medical need identified as a result of that screening may be eligible for Medicaid coverage as long as it is covered under federal rules, even if that need would not ordinarily be covered under the rules of the particular state's Medicaid program. The EPSDT Reference Law Manual describes current EPSDT regulations. That manual is available through the National Health Law Program (See Appendix B). Although the manual is technical in nature, it may be helpful to parents of children with disabilities, since it is highly specific regarding childrens' rights to medical services.
Another more recent change involves the shift to managed care. Medicaid HMOs (Health Maintenance Organizations) are rapidly becoming an important part of the Medicaid system in many states. In some ways, the development of Medicaid HMOs may make it easier for Medicaid recipients to obtain medical care, since there is a specific network of providers available to meet their needs. Thus, patients may avoid unnecessary trips to the hospital emergency room.
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