1304 EPSDT
User Manual: 1304-EPSDT
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DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION EPSDT: 1304 TEMPORARY CASH ASSISTANCE MANUAL COMAR 10.09.23.037 SUPPPORTIVE SERVICES 1300 1304.1 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is offered by the Maryland Department of Health and Mental Hygiene. A. EPSDT is mandated by the federal government. B. States must cover certain benefits for Medicaid recipients from birth through 20 years of age, benefits that are not necessarily covered for recipients who are 21 years of age and older. C. The Maryland Healthy Kids Program and the Maryland Department of Health and Mental Hygiene offer services to EPSDT providers including training and support services provided by nurse consultants and free vaccines through the Vaccines for Children Program. D. Maryland Medicaid also operates similar programs for moderate to low-income children, who are eligible for Medicaid through the Maryland Children’s Health Program (MCHP) and MCHP Premium Program. Medicaid, MCHP and MCHP Premium provide children with the same comprehensive EPSDT benefit package and all fall under the Healthy Kids Program. E. The Early and Periodic Screening, Diagnosis, and Treatment program is a separate Department of Health and Mental Hygiene program to which Family Investment case managers make referrals. Program information, including basic eligibility requirements, is provided here. 1304.2 OVERVIEW The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is designed to provide regular checkups (required for children in TCA households) and follow-up treatment for people under 21 who receive Medical Assistance (MA) 1304.3 REQUIREMENTS A. The TCA case manager: 1. Advises all EPSDT eligible households of the availability of the service for those under 21 2. Provides assistance, upon request, with: REVISED JULY 2008 Page 1 DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION TEMPORARY CASH ASSISTANCE MANUAL EPSDT: 1304 3. COMAR 10.09.23.037 SUPPPORTIVE SERVICES 1300 • Arranging transportation to and from EPSDT covered medical services • Scheduling appointments for covered services Arranges for EPSDT participating health professionals to provide corrective treatment of any health problems found B. After a referral from the case manager, the EPSDT program’s healthcare professionals provide full and partial screening services, using a set schedule to periodically: 1. Identify physical, mental, or developmental problems or conditions 2. Recommend a course of treatment C. EPSDT covers all medically necessary services needed to correct physical and mental problems identified during screenings and includes the following services: 1. Dental 2. Vision 3. Hearing 1304.4 LIMITATIONS AND PREAUTHORIZATIONS A. There are no treatment or service limitations for individuals under 21 when medically necessary to correct or lessen health problems B. There is a limit of one EPSDT screen for each age interval, except when additional screening is deemed medically necessary by the healthcare professional performing the screening C. Orthodontic care is limited to individuals who: 1. Score within a certain range on a widely accepted index for determining speech and eating problems, and 2. Are determined to be dysfunctional D. Dental services are limited to an initial or periodic exam every 6 months, except when medically justified by a dentist REVISED JULY 2008 Page 2 DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION TEMPORARY CASH ASSISTANCE MANUAL EPSDT: 1304 COMAR 10.09.23.037 SUPPPORTIVE SERVICES 1300 E. Vision services, including examinations and eyeglasses or contact lenses, are limited to once a year, after EPSDT referral, except when deemed medically necessary by an eye care specialist F. Hearing assessment and services are limited to once a year, after EPSDT referral, unless time limitations are waived, and provide the following: 1. One hearing aid per hearing evaluation 2. Replacement of lost, stolen, or damaged hearing aids 3. Annual purchase of batteries for customers with hearing aids G. DHMH pre-authorizes services if the provider can document that: 1. EPSDT procedures were followed 2. Program limitations were met 3. The service was necessary and appropriate ADDITIONAL INFORMATION • Other Programs and Services — Medical Assistance • Post Eligibility Benefits — Medical Assistance • Medical Assistance Manual REVISED JULY 2008 Page 3
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