R414-71. Early and Periodic Screening, Diagnostic and Treatment Program, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

R414. Health, Health Care Financing, Coverage and Reimbursement Policy

R414-71. Early and Periodic Screening, Diagnostic and Treatment Program

R414-71-1. Introduction and Authority

Latest version.

(1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program provides comprehensive prevention, diagnostic, and treatment services for Medicaid members.

(a) Treatment or services that are necessary to correct or ameliorate defects and physical and mental illnesses or conditions.

(2) EPSDT services provide coverage of all medically necessary services included within the categories of mandatory and optional services listed in Subsection 1905(a) of the Social Security Act.

(3) The EPSDT Program is authorized by Subsections 1902(a)(43) and 1905(a)(4)(B) of the Social Security Act, 42 CFR 440.40(b), and 42 CFR Part 441, Subpart B.

R414-71-2. Definitions

Latest version.

In addition to the definitions in Section R414-1-2, the following definition applies to this rule:

(1) "EPSDT" means "Early and Periodic Screening, Diagnosis, and Treatment" used to determine physical or mental defects in members. The EPSDT Program provides:

(a) health care;

(b) treatment; and

R414-71-3. Member Eligibility Requirements

Latest version.

(1) Eligible members who are enrolled in Traditional Medicaid, and are zero through 20 years of age, may receive EPSDT services.

(2) Individuals who are 19 through 20 years of age and enrolled in Non-Traditional Medicaid, Adult Expansion Medicaid, or Targeted Adult Medicaid, are not eligible for EPSDT services.

R414-71-4. Program Access Requirements

Latest version.

(1) An eligible member must obtain EPSDT services from a Utah Medicaid enrolled provider.

(2) A member enrolled in a managed care entity must obtain EPSDT services through that entity.

R414-71-5. Service Coverage and Limitations

Latest version.

(1) Screening and diagnostic services to determine physical or mental defects.

(2) Screening services include:

(a) a comprehensive health and developmental history, including the assessment of physical and mental development;

(b) dental and oral health screening;

(d) vision screening;

(e) hearing assessment;

(f) speech and language development;

(g) appropriate immunizationsimmunizations according to age and health history;

(h) laboratory testsLaboratory tests , including blood lead level assessment appropriate to age and risk; and

(i) health educationHealth education , including anticipatory guidance.

(3) When a screening indicates the need for further evaluation, diagnostic services must be provided.

(4) Medically necessary services are available for treatment of all physical and mental illnesses or conditions discovered by any screening or diagnostic procedures.

(5) Additional services include:

(a) chiropractic services;

(b) orthodontia;

(d) physical therapy;

(e) speech-language services;

(f) private duty nursing;

(g) at a minimum, diagnosis and treatment for defects in vision, including eyeglasses;

(h) at a minimum, dental services for the relief of pain and infections, restoration of teeth, maintenance of dental health, including examinations, cleanings, and fluoride treatments;

(i) at a minimum, diagnosis and treatment for hearing defects, including hearing aids; and

(j) additional health care services coverable under Subsection 1905(a) of the Social Security Act and found to be medically necessary to treat, correct, or ameliorate illness and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

(6) The Department determines whether a service is medically necessary.

(7) Medically necessary services do not include:

(a) experimental or investigational treatments;

(b) reconstructive and cosmetic procedures as noted in Section R414-1-29;

(d) duplicative services.

(8) The Department may consider the relative cost effectiveness of alternatives as part of the prior authorization process described in Section R414-1-2.