Early and Periodic Screening, Diagnostic and Treatment. (EPSDT): The Contractor shall provide comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21. The Contractor shall ensure that these members receive required health screenings, including developmental and behavioral health screenings, in compliance with the AHCCCS EPSDT Periodicity Schedule, and the AHCCCS Dental Periodicity Schedule (Exhibit 430-1 in the AMPM).
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT) Services: The Contractor shall provide comprehensive health care services through primary prevention, early intervention, diagnosis, and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21. EPSDT includes, but is not limited to, coverage of inpatient and outpatient hospital services, laboratory and x-ray services, physician services, naturopathic services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical equipment, medical appliances and medical supplies, orthotics, prosthetic devices, eyeglasses, (eyeglasses and other vision services, including replacement and repair of eyeglasses, for members under the age of 21 years are covered, without restrictions, by AHCCCS to correct or ameliorate conditions discovered during vision screenings for EPSDT), transportation, family planning services and supplies, women’s preventive care services, and maternity care services, when applicable. EPSDT also includes diagnostic, screening, preventive, and rehabilitative services. The Contractor shall ensure that these members receive required health screenings and referrals as specified in AMPM Policy 430.
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT) – The federally required program for clients under the age of 21, as defined in Section 1905(r) of the Social Security Act and 42 CFR Part 441, Subpart B. It includes periodic comprehensive screening and diagnostic services to determine health care needs as well as the provision of all Medically Necessary services listed in Section 1905(a) of the Social Security Act even if the service is not available under the State’s Medicaid plan.
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT): The Contractor shall provide comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21. The Contractor shall ensure that these members receive required health screenings, including developmental and behavioral health screenings, in compliance with the AHCCCS EPSDT Periodicity Schedule, and the AHCCCS Dental Periodicity Schedule (Exhibit 430-1 and 430-1A in the AMPM), including appropriate oral health screening intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician’s assistant or nurse practitioner.
Early and Periodic Screening, Diagnostic and Treatment. 4.1.8.1 The MCO must provide the full range of preventive, screening, diagnostic and treatment services including all medically necessary 1905(a) services that correct or ameliorate physical and mental illnesses and conditions for EPSDT eligible beneficiaries ages birth to twenty-one in accordance with 1905(r) of the Social Security Act. [42 CFR 438.210(a)(5)]
4.1.8.2 The MCO shall determine whether a service is Medically Necessary on a case by case basis, taking into account the medical necessity criteria specific to EPSDT defined in 42 U.S.C. Section 1396d(r), 42 CFR 438.210, and42 CFR Subpart B—Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21, and the particular needs of the child and consistent with the definition for Medical Necessity included in this Agreement.
4.1.8.3 Upon conclusion of an individualized review of medical necessity, the MCO shall cover all Medically Necessary services that are included within the categories of mandatory and optional services listed in 42 U.S.C. Section 1396d(a), regardless of whether such services are covered under the Medicaid State Plan and regardless of whether the request is labeled as such, with the exception of all services excluded from the MCO.
4.1.8.4 The MCO may provide Medically Necessary services in the most economic mode possible, as long as:
4.1.8.4.1 The treatment made available is similarly efficacious to the service requested by the Member’s physician, therapist, or other licensed practitioner;
4.1.8.4.2 The determination process does not delay the delivery of the needed service; and
4.1.8.4.3 The determination does not limit the Member’s right to a free choice of Participating Providers within the MCO’s network.
4.1.8.5 Specific limits (number of hours, number of visits, or other limitations on scope, amount or frequency, multiple services same day, or location of service) in the MCO clinical coverage policies, service definitions, or billing codes do not apply to Medicaid Members less than twenty-one (21) years of age, when those services are determined to be Medically Necessary per federal EPSDT criteria. If a service is requested in quantities, frequencies, or at locations or times exceeding policy limits and the request is reviewed and approved per EPSDT criteria as Medically Necessary to correct or ameliorate a defect, physical or mental illness, it must be provided. This includes limits on visits to physicians, therapists, dentists, or other licensed,...
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT): — Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. Periodicity schedules for Periodic Screening, Vision, and Hearing must be provided at intervals that meet reasonable standards of medical practice. Dental services must be provided at intervals that meet reasonable standards of dental practices. Screening Services must include all of the following services: • Comprehensive health and developmental history-(including assessment both, physical and mental health development) • Comprehensive unclothed physical exam • Appropriate immunizations • Laboratory tests • Health Education • Vision Services • Dental Services • Hearing Services • Other Necessary Health Care
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT)
a. Consistent with 42 CFR Part 441, Subpart B, Contractor shall meet the following requirements relating to Early and Periodic Screening, Diagnostic, and Treatment services for Members under age 21
Early and Periodic Screening, Diagnostic and Treatment. (EPSDT) Services
a. The Contractor must provide EPSDT services as medically necessary in accordance with 42 USC Sec. 1396d(r)(3)(5), 42 CFR part 441, Subpart B, and MSA 16-01 (Appendix M) whether or not such services are covered under the State Plan and without regard to established limits.
b. Contractor must have a process that provides services to Enrollees for services not covered under the State Plan that have been determined to be medically necessary.
c. The Contractor must provide Enrollees with all covered services in accordance with the Michigan Dental Periodicity Schedule (Appendix L) as adopted from the American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling.
d. Contractor must not have overly burdensome prior authorization requirements for referrals for diagnostic and/or treatment services determined necessary by the Enrollee’s dental provider. This includes, but is not limited to:
i. Must make any prior authorization requirements available to its providers.
ii. Must establish appropriate clinical basis for prior authorization criteria.
iii. Must respond to prior authorization requests in accordance with 42 CFR 438.210(d), not later than 72 hours for urgent requests and 14 days for routine dental service requests.
e. Contractor must provide all treatment and diagnostic services as determined necessary by the referring dental provider to correct or ameliorate any conditions found by the referring dental provider.
f. Contractor must provide outreach to Enrollees due or overdue for well-child (preventive)/EPSDT visits, including phone, mail, home-visiting or other means of communication acceptable to the Enrollee; the Contractor may meet this requirement by contracting or collaborating with community-based organizations and providers.
g. The State will inform HKD beneficiaries of their EPSDT benefits.
Early and Periodic Screening, Diagnostic and Treatment
