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WAC 182-534-0100

Agency filings affecting this section

EPSDT.

(1) Persons who are eligible for medicaid, except those identified in subsection (4) of this section, 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.
(a) The standard for coverage for EPSDT is that the services, treatment or other measures are:
(i) Medically necessary;
(ii) Safe and effective; and
(iii) Not experimental.
(b) 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.
(c) 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:
(i) Nutritional counseling;
(ii) Chiropractic care;
(iii) Orthodontics; and
(iv) Occupational therapy (not otherwise covered under the MN program).
(d) 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.
(4) Persons who are nineteen through twenty years of age who are eligible for any of the following programs that receive medicaid funding under the transitional bridge demonstration waiver allowed under section 1115 (a)(2) of the Social Security Act are not eligible for EPSDT services:
(a) Basic health;
(b) Medical care services; or
(c) Alcohol and Drug Addiction Treatment and Support Act (ADATSA).
[Statutory Authority: RCW 41.05.021 and section 1115 (a)(2) of the Social Security Act. WSR 12-22-046, § 182-534-0100, filed 11/2/12, effective 12/3/12. WSR 11-14-075, recodified as § 182-534-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-534-0100, filed 12/29/00, effective 1/29/01. WSR 00-11-183, recodified as § 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. WSR 90-12-061 (Order 3019), § 388-86-027, filed 5/31/90, effective 7/1/90; WSR 82-01-001 (Order 1725), § 388-86-027, filed 12/3/81; WSR 81-10-015 (Order 1647), § 388-86-027, filed 4/27/81; WSR 80-15-034 (Order 1554), § 388-86-027, filed 10/9/80; WSR 79-12-047 (Order 1457), § 388-86-027, filed 11/26/79; Order 1112, § 388-86-027, filed 4/15/76; Order 738, § 388-86-027, filed 11/22/72.]