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

    (c) Alcohol and Drug Addiction Treatment and Support Act (ADATSA).

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.