Medical Assistance Programs

Medical Assistance Programs - EPSDT

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Medical Assistance Programs - EPSDT

Revised April 3, 2012

Purpose: This category pertains to Medical Assistance only. The department operates a specially focused health care program for infants, children and teens. The program provides Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for individuals up through the day before their 21st birthday.

WAC 182-534-0100

EPSDT

WAC 182-534-0100

Effective December 3, 2012

WAC 182-534-0100 EPSDT

(1) Persons who are eligible for medicaid, except those identified in subsection (4) of this section, are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.

     (2) Access and services for EPSDT are governed by federal rules at 42 CFR, Part 441, Subpart B which were in effect as of January 1, 1998.

     (a) The standard for coverage for EPSDT is that the services, treatment or other measures are:

     (i) Medically necessary;

     (ii) Safe and effective; and

     (iii) Not experimental.

     (b) EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-0200.

     (c) Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:

     (i) Nutritional counseling;

     (ii) Chiropractic care;

     (iii) Orthodontics; and

     (iv) Occupational therapy (not otherwise covered under the MN program).

     (d) Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.

     (3) Transportation requirements of 42 CFR 441, Subpart B are met through a contract with transportation brokers throughout the state.

(4) Persons who are nineteen through twenty years of age who are eligible for any of the following programs that receive medicaid funding under the transitional bridge demonstration waiver allowed under section 1115 (a) (2) of the Social Security Act are not eligible for EPSDT services:

(a) Basic health;

(b) Medical care services; or

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

This program provides preventive and enhanced service coverage for minors who are eligible for Apple Health for Kids. It is available to clients through their Services Card and requires no special handling by the CSO. The significance of this program is that medically necessary services identified within the periodic EPSDT screening performed by medical service providers are covered by the program even if the services are not otherwise covered services under the standard scope of care. For more information, see Scope of Care.

EPSDT applies to all children who are eligible for Medical Assistance programs. Parents who are under 21 years or age and who are on CN or MN coverage are also eligible for EPSDT services. "Under 21" means through the day before their 21^st birthday.

CSOs SHOULD HAVE THE FOLLOWING BROCHURE IN STOCK:

Brochure: "How to get a well-child checkup for your child or teen - EPSDT Early Periodic Screening, Diagnosis and Treatment" DSHS 22-019 (X)

Request the brochure at:

Department of Printing - General Store

Email: http://hrsa.dshs.wa.gov/mpapublications.shtml

Phone: (360) 586-6360
Fax: (360) 586-8831

Modification Date: April 3, 2012