Medical Assistance Programs - EPSDT
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Medical Assistance Programs - EPSDT

Revised October 28, 2007

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. In Washington, this program is called Healthy Kids.
WAC 388-534-0100EPSDT

EPSDT

WAC 388-534-0100
WAC 388-534-0100

Effective January 29, 2001

WAC 388-534-0100 EPSDT

  1. Persons who are eligible for Medicaid are eligible for EPSDT 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.

    1. The standard for coverage for healthy kids is that the services, treatment or other measures are:

      1. Medically necessary;

      2. Safe and effective; and

      3. Not experimental.

    2. 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 388-545-300, 388-545-500, 388-545-700.

    3. 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:

      1. Nutritional counseling;

      2. Chiropractic care;

      3. Orthodontics; and

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

    4. 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.

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 otherwise eligible for medical assistance. It is available to clients through their CN, MN or "H" Medical Identification cards and requires no special handling by the CSO. The significance of this program is that medically necessary services identified within the periodic Healthy Kids 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.

Healthy Kids 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 Healthy Kids services. "Under 21" means through the day before their 21st birthday.

In the past, there has been confusion between the terms "Healthy Kids" and "H" medical. "H" medical is a coverage program for children based on established income standards (see Family Medical). Children on "H" medical are eligible for Healthy Kids as are children on CN and MN medical coverage.

CSOs SHOULD HAVE THE FOLLOWING IN STOCK:

  • Brochure: "Healthy Options for Healthy Kids" DSHS 22-022 (X)


    This brochure provides information about the Healthy Options program for children.

  • Brochure: "Healthy Kids" DSHS 22-019 (X)


    This brochure provides information about fee-for-service coverage for children.

  • Flyer: "Health Care for Kids" DSHS 22-750(X)


    This annual flyer is prepared and distributed by the Medical Assistance Administration. The intent is to increase client awareness of the Healthy Kids program. When clients receive these flyers, they may inquire at the CSO. The intent is that CSOs would respond by supplying the appropriate brochure as described above.



 

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Modification Date: October 28, 2007
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