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To describe Early and Periodic Screening, Diagnosis and Treatment (EPSDT) that is available to individuals under 21 years of age who are eligible for Apple Health CN or MN coverage.
Effective August 24, 2014
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.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federally mandated, comprehensive, and preventive health care benefit. The purpose of this program is to ensure children and adolescents age 20 and younger receive appropriate preventive, dental, mental health, developmental, and specialty services. Medically necessary treatment identified in the EPSDT well-child checkup is covered under the EPSDT benefit.
The following are descriptions of the components of the program:
Early: Assessing and monitoring a child's health and ongoing development early in life can help prevent, identify, and intervene, so potential diseases and disabilities can be addressed before they become more complex and are in their preliminary stages, when they are most effectively treated. This means as early as possible in a child's life in the case of a family already receiving medical benefits or as soon as a child's eligibility has been established.
Periodic: As children and adolescents grow, visits with their health care providers should occur at regular intervals to ensure continued healthy development and to monitor current or emerging needs. Section 1905 of the Social Security Act requires periodicity schedules sufficient to ensure that at least a minimum number of health examinations occur at critical points in a child’s life, and that medically necessary screenings are provided.
Screening: Providers use preventive services, including comprehensive interviews, medical examinations, and standardized tools, to identify children who require further diagnostic assessment or intervention for health and developmental issues. The five categories of screenings covered under this program are medical, vision, hearing, dental, and developmental. Screening services must be available both at established times and on an as-needed basis. When a screening indicates the need for further diagnostic assessment, a child and their family should be referred for diagnosis without delay.
Diagnosis: When there is an indication that a child or adolescent may have a health problem, a follow-up diagnostic assessment and additional evaluations must be provided. This includes recommendations and any necessary referrals to needed services when a diagnosis is determined.
Treatment: In response to an identified need, health care services needed to correct, ameliorate, or lessen health problems, including care coordination for chronic conditions, are offered and provided. Services provided to the child or adolescent must be considered medically necessary (see WAC 182-500-0070).