Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 452. EPSDT program

7 AAC 43.452. EPSDT program

(a) A Medicaid recipient under 21 years of age is eligible for the early periodic screening, diagnosis, and treatment program (EPSDT).

(b) Subject to AS 47.05, AS 47.07, and this chapter, the division will reimburse for an EPSDT screening that is provided to an eligible recipient by an enrolled health care provider in accordance with the periodicity schedules in (d) - (f) of this section. An EPSDT screening includes

(1) a health and developmental history;

(2) an unclothed physical examination, including a head-to-toe systemic review;

(3) a dental screening and, beginning at age three or at an earlier age if medically necessary, referral to a dentist for a dental examination;

(4) a vision screening and, beginning at age five or at an earlier age if medically necessary, referral to a vision care services provider for a vision examination;

(5) a hearing screening and, if medically necessary, referral for diagnosis and treatment of defects in hearing;

(6) a developmental assessment, including gross and fine motor development, communication skills or language development, self-help and self-care skills, and social-emotional development;

(7) a determination of immunization status and administration of immunizations in accordance with the most current version of the Recommended Childhood Immunization Schedule approved by the Advisory Committee on Immunization Practices (ACIP);

(8) a determination of nutritional status;

(9) health-related measurements, including height, weight, blood pressure, and other appropriate measures and indicators of health;

(10) hemoglobin or hematocrit testing at the ages of nine months, four years, eight years, and eighteen years unless more frequent testing is medically necessary;

(11) other tests and procedures that are age appropriate and medically necessary, including urinalysis, pap smears, and pelvic examinations;

(12) an intradermal purified protein derivative (PPD) skin test for tuberculosis at the ages of one year, three years, five years, and 12 years;

(13) a referral to the Women, Infants, and Children (WIC) program established under 42 U.S.C. 1786, if a recipient does not already participate in the program and is under age five or pregnant; and

(14) referrals to other medical providers and programs, as appropriate to the recipient's age and condition.

(c) Subject to AS 47.05, AS 47.07, and this chapter, the division will reimburse the following enrolled providers for EPSDT screenings:

(1) a physician;

(2) a licensed or certified health care practitioner who performs a screening under the supervision of an enrolled physician, if the health care practitioner may perform screenings under the health care practitioner's licensed or certified scope of practice;

(3) the division of public health in the department;

(4) the United States Indian Health Service or a hospital or clinic operated by a tribal organization, as defined in 25 U.S.C. 450b(1), under a funding agreement under 25 U.S.C. 450-458aaa (Indian Self-Determination and Education Assistance Act) as amended by P.L. 106-260 (Tribal Self-Governance Amendments of 2000);

(5) a licensed advanced nurse practitioner;

(6) a rural health clinic that meets the requirements of 7 AAC 43.850;

(7) a municipal health department;

(8) a school district;

(9) a federally qualified health center that meets the requirements of 7 AAC 43.870.

(d) The periodicity schedule for an EPSDT screening is as follows, with additional screenings performed as medically necessary:

(1) beginning at birth through age two, nine screenings performed at the following ages:

(A) between birth and three weeks;

(B) two months;

(C) four months;

(D) six months;

(E) nine months;

(F) 12 months;

(G) 15 months;

(H) 18 months;

(I) 24 months;

(2) beginning at three years of age through six years of age, annual screenings;

(3) beginning at seven years of age through 20 years of age, biennial screenings.

(e) The periodicity schedule for dental examinations by a dentist is biannual examinations beginning at age 3, with earlier or more frequent examinations performed as medically necessary.

(f) The periodicity schedule for vision examinations by a vision care provider is an annual examination beginning at age five, with earlier or more frequent examinations performed as medically necessary.

(g) Notwithstanding other reimbursement provisions in this chapter, the division will reimburse an enrolled provider for preventive medicine evaluation and management of infants, children, and adolescents at the rate identified in the fee schedule established under 7 AAC 43.108 for physicians.

(h) Any medically necessary service specified as a covered service in this chapter and recommended as a result of an EPSDT screening is Medicaid reimbursable.

History: Eff. 12/31/92, Register 124; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 3/3/2001, Register 157

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.452 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. The Recommended Childhood Immunization Schedule approved by the Advisory Committee on Immunization Practices (ACIP) can be obtained from the Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia 30333.