General eligibility requirements that apply to all Apple Health programs

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Scope of care Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Revised Date: 
November 24, 2020

Purpose: 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.

WAC 182-534-0100  EPSDT

Effective August 24, 2014

  1. Persons who are eligible for medicaid 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 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
    1. The standard for coverage for EPSDT 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 182-545-200.
    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 C.F.R. 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 anyone under 21 years of age who is eligible for Apple Health CN or MN coverage. Parents who are under 21 years of age and who are on CN or MN coverage are also eligible for EPSDT services. "Under 21" means through the day before their 21st birthday.

The significance of this program is that medically necessary services identified within the periodic EPSDT 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.

More information is also available in the brochure - EPSDT Well-child checkups for your child or teen (HCA 19-0056).