Speech Therapy Letter of Medical Necessity
Child’s Name _________________________
Child’s Medicaid ID # ___________________
Name of Caregiver _______________________
Reason child needs _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Treating physician’s signature _______________________________________
Date: ___________________________________________________________
*Protip – For immunocompromised children, heart transplant, etc… It is against the child’s best interest to leave the home to an outpatient center which is what MMA(s) across states tend to do.
For example, in the state of Fl, MMA’s are outsourcing their authorization to a medical coding company called ATA.
ATA is ONLY licensed to medically bill for outpatient services leaving thousands of children who require speech or feeding therapy without services.
This service requires an out of patient single patient agreement the MMA’s REFUSE to pay.
Florida is not the only state which allows MMA’s to engage in these practices.
MMA’s will tell caregives they must have a barium swallow study to qualify to buy time to render services.
In Fl, there are no speech therapists to offer Speech or Feeding therapies because they’re not in network with ATA.
*Pro tip 2 – based off ‘fee schedules’ through Medicaid program, each unit for any service is authorized in 15 minute increments.
So if given 3 speech visits per week, that is 9 units per week at 45 minute visits for speech
Medicaid is a federal program and any MMA participating in Medicaid must adhere to Federal legislation and ALL CMS guidelines.
Medicaid services
Mandatory services include:
Physicians Services
Laboratory/x-ray
In-patient, out-patient hospital and nursing facility
EPSDT
Family planning
FQHCs and rural health clinic services
Nursing facility services
Advanced Registered Nurse Practitioner Services
Home Health Care
The Federal laws cited:
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
§ 441.50 Basis and purpose.
§ 441.55 State plan requirements.
§ 441.56 Required activities.
§ 441.57 Discretionary services.
§ 441.58 Periodicity schedule.
§ 441.59 Treatment of requests for EPSDT screening services.
§ 441.60 Continuing care.
§ 441.61 Utilization of providers and coordination with related programs.
§ 441.62 Transportation and scheduling assistance.
-Americans with disabilities act sec 2, 5, and 7
-The Medicaid Act – sections 5&7
-CFR440.70
Laws used
42 CFR 441.15 Section 3
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
Defining the ‘T’ in “EPSDT”
In addition to screening, vision, dental and hearing services, the Medicaid Act defines the EPSDT benefit to include “necessary healthcare, diagnostic services, treatment, and other measures to correct or ameliorate defects, physical, mental illnesses and conditions.
If caregiver lives in the state of Florida, include below information.
For the state of Florida – -Smith Vs Benson (settled in the state of Florida).
In IJanuary 2010 , Smith vs Benson went to the supreme court for incontinence supplies.
This includes diapers, wipes, caths, chuckc. 40% zinc and nystatin ointment/powder heals bed sores with frequent turning q 2
q stands for every, the numbers stand for how many hours in a 24 hour period.
Supreme court ruled in favor of covering incontinence supplies
Smith VS Benson demonstrated the FEDERAL laws every state MMA must adhere to in order to run a medicaid or medicare plan in insert state.
https://casetext.com/case/smith-v-benson (Every caregiver) or administrator looking to ease the burden on discharge coordinators are invited to look over the laws and work them into hospital systems such as epic writing out templates for future letters of medical necessity.
Read carefully, in a fair hearing, a medical director (once an emergency room doctor) not a qualified G.I. will lie under oath and cite an amendment belonging to a case ‘Smith Vs Brown’. which has nothing to do with healthcare. Adjudicators in the state of Florida are clerks working for the dept of children and families. They are NOT trained in anatomy and physiology, from personal experience they cannot interpret basic legislation.
42 C.F.R. § 440.230
§ 440.230 Sufficiency of amount, duration, and scope
(a) The plan must specify the amount, duration, and scope of each service that it provides for –
(1) The categorically needy; and
(2) Each covered group of medically needy.
b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of the diagnosis, type of illness, or condition.
42 U.S.C. § 1396a
Section 1396a – State plans for medical assistance
A State plan for medical assistance must-
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
State laws:
409.905 (Mandatory Medicaid coverage for disabled children below the age of 21)
Please review Florida state legislation 409.905 Mandatory Medicaid services legislation. Please review section 2 EPSDT and Section 4 of this legislation which is why Florida ruled in favor of Smith under Home Health Services. Scroll down to the section entitled ‘Home Health’.
This includes all mandatory and optional services that the state CAN cover under medicaid, whether or not such services are covered for adults.
For example if the child needs personal care services to ameliorate a behavioral health problem, then ESPDT should cover the services to the extent the child needs them – even if the state places a quantitative limit on personal care services or does not cover them at all for adults.
See, AHCA Model Contract Attachment II, Exhibit II-‐A, at 5 regarding procedures managed care plans should follow and stating “authorization of any medically necessary service to enrollees under the age of twenty-‐one (21) years when the service is not listed in the service-‐specific Florida Medicaid Coverage and Limitations Handbook, Florida Medicaid Coverage Policy, or the associated Florida Medicaid fee schedule, or is not a covered service of the plan; or the amount, frequency, or duration of the service exceeds the limitations specified in the service-‐specific handbook or the corresponding fee schedule. The Managed Care Plan shall also include following language verbatim in its enrollee handbooks: [Insert Managed Care Plan name] must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if [Insert Managed Care Plan name] does not cover a service or the service has a limit. As long as your child’s services are medically necessary, services have:
No dollar limits; or
No time limits, like hourly or daily limits.
https://ahca.myflorida.com/Medicaid/statewide_mc/mma_plans_mc.shtml (Here is the link) For the above information.