FAQs
- Children’s Benefit Redesign and EPSD
- I used to get individual developmental disability services to help me but now I have to get those services in a group of people. This is not working for me. Is there anything I can do?
- My child gets 22 hours of developmental therapy a week. How is that going to change with the Medicaid redesign of children’s services?
- Children’s Benefit Redesign and EPSDT - Can a child under Children’s Benefit Redesign get more services through the Early Periodic Screening Diagnosis and Treatment or EPSDT?
- Currently, many parents have questions about the redesign of Medicaid services for their children with developmental disabilities under the Children’s Benefit Redesign (CBR) system. The new redesigned services are being phased in to replace the current Developmental Therapy (DT) and Intensive Behavioral Intervention (IBI). (See additional detail under another question in this FAQ section of the Council website) As a child reaches their annual redetermination date, the parents will receive information about the new system and directed to have an evaluation conducted by the Idaho Center on Disabilities Evaluation (ICDE). This evaluation will determine what the budget will be for the child’s services under redesign. The family can then work with their child’s case manager to plan services within the budget.
Families are encouraged to switch from the current services to the new redesigned system after the child’s evaluation. However, since the current services and the redesigned services are both offered, families can opt to stay with the current services if they feel these better meet their child’s needs. However, families who choose to wait until the old services are ending to switch services, may experience a gap in service for their child. The Department has not yet said when the end date would be for the old services.
In the current system, there are limits to the number of hours of DT and IBI services that a child may receive. If additional services are medically necessary, the family can apply for more services through the Early Periodic Screening Diagnosis and Treatment or EPSDT process. Under the new system, there are no longer limits on hours of service. Instead, children are assigned a budget to provide the services the child needs as determined through the evaluation process. There are a variety of services ranging from respite care to habilitative intervention. Some parents are finding the amount of funds allocated in their child’s budget is not adequate to pay for the amount of services their child needs to continue to develop and progress.
The Council asked the Department of Health and Welfare if the EPSDT process could be used by these parents as a way to access additional, medically necessary services their child may need under the redesigned system. The response from the Division of Medicaid can be found here: Letter from Dave Simnit
There is some question about whether the EPSDT process can be used to provide services in the new redesigned system. But since states are required to provide medically necessary services to children under EPSDT, parents have been using this form to gather and present information to Medicaid about the additional services their child needs. It may be helpful when filling out the form to list the additional services under the “Other” category since the form does not currently include a listing of the services provided in the new redesign system.
Click here to open the EPSDT form on the Department of Health and Welfare's website. Updated December 2012.
This requires significant documentation by the child’s doctor and other health care professionals. Even then, there is no guarantee that these additional services will be approved. Once the information is compiled and the forms are completed, they can be submitted to the Department by:- Emailing the information to: Request@dhw.idaho.go
- Faxing the information to: 208-364-1811, ATTENTION: EPSDT Request
- Mailing the information to EPSDT Request, IDHW-Division of Medicaid, P.O. Box 83720, Boise, ID 83720-0036
Questions about EPSDT, should be directed to Lauren Ertz at 364-1835 or ertzl@dhw.idaho.gov. - I used to get individual developmental disability services to help me but now I have to get those services in a group of people. This is not working for me. Is there anything I can do?
- Maybe. You are being put into a group because Medicaid changed how they pay your service provider. There used to be different payment rates for individual services and for group services. Now there is just one rate for providing services to people in the community. This is called a “blended rate.” To save money, providers are having people work in groups. First, you should talk with your provider about this. Let them know what is working for you and what is not. It is important that services to help you meet your goals are written into your plan. The services in your plan are the ones you should be getting now. Your provider may tell you that the state is making them put people into groups to get services. This is not true. The new Medicaid rules make it ok for them to do this, but Medicaid did not say they must provide services in groups. Talk to your service coordinator and see if she can help you talk with your provider. You may want to think about changing to another agency. Bigger agencies may be able to give you individual services. But most providers are serving people in a group. If you are on the Home and Community Based Services Waiver for adults with developmental disabilities (HCBS/DD waiver), you may want to think about self-direction. This is also called My Voice My Choice. It lets you choose your providers and they do not have to be from an agency. You can also decide what you pay them. This gives you more control over the services you get. If you are interested in this option, contact your regional Medicaid care manager.
- My child gets 22 hours of developmental therapy a week. How is that going to change with the Medicaid redesign of children’s services?
Currently, any child with a developmental disability in Idaho can get up to 22 hours a week of developmental therapy to build the child’s skills. Children with challenging behaviors and intense needs may qualify for Intensive Behavioral Intervention (IBI), a more intense 1-to-1 intervention. IBI is limited to no more than 36 months but those months do not have to be continuous unless the child is using the service every month. Developmental therapy is not limited to a certain number of months or years. It can be provided as long as the child is eligible and has a demonstrated need for the service.
With the redesign of children’s Medicaid services, there will be no developmental therapy, no intensive behavioral intervention, and no limits on the numbers of hours. Instead, there will be alternative services and the limits will be set by the budget that is authorized for your child. This budget will be based on an assessment (the Scales of Independent Behavior – Revised or SIB-R) plus other information. The level of need from this assessment will determine which of 5 budget tiers that your child falls into.
In Tier 1 are children who have a developmental disability but who do not qualify for services in an institution or group home. The services that are available are habilitative supportive services, respite care, and family education. The budget for children in this tier is $4,900 a year. Here are some examples of what this budget could purchase:
- 7 hours of individual respite a week, OR
- 4-5 hours of individual habilitative supports each week, OR
- a combination, such as 8 hours of respite in a group plus 2 hours of individual habilitative supports weekly and 1 hour of family education each year
Budget Tiers 2-4 are for children with developmental disabilities who have greater needs and would qualify for services in an institution or group home. In these tiers, the services that your child can get are the services in Tier 1 plus some more intensive skill building and therapeutic services plus family training (teaching parents skills to help their child). Budgets in these tiers are higher, ranging from $6,200 for children with fewer needs to $14,900 each year for a child with greater needs. Here is an example of what your child and family could receive with a budget of $13,300:
- An annual 3-hour assessment, AND
- 1 hour of family training each month, AND
- 5 hours of respite each month, AND
- 5 hours of individualized intervention services each week
If your child needs more intervention services, the other items would have to be cut or eliminated. Or if your child has a smaller budget, there would be fewer or less services. The services in these tiers are called Children’s Waiver Services.
Tier 5 is for children between the ages of 3 and 6 with the most challenging behaviors and/or who have autism. All the services provided to children in the other four budget tiers are available to these children but they are even more intensive and parents must participate in their child’s treatment at least 20% of the time. This tier has the highest budget at $29,300/year. But the services that are needed by these children are the most intensive and the most expensive. This category is called the Act Early Waiver.
Families with children in Tiers 1-4 (the first two categories – State Plan and Children’s Waiver) can choose to direct their child’s services through Family Directed Services. That is not an option for families with children in the Act Early waiver.
Medicaid services provided in schools are separate from all of these and not “charged against” the child’s budget. The same goes for related services such as physical therapy, speech therapy or occupational therapy. Those benefits are billed separately to the child’s Medicaid card.
The redesign of Children’s Medicaid Services was scheduled to start on July 1, 2011. Because there have been some problems with implementation, families can choose to go with the new redesigned services after October 1, 2011 or continue to get developmental therapy and IBI for another year.
For information and updates on the redesign, go to the Children's System Redesign Website or email your questions to redesign@dhw.idaho.gov.
For more information on Intensive Behavioral Intervention, download the IBI Parent Guide.
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