Chapter 182-534 WAC

Last Update: 5/29/15

EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)

WAC Sections

182-534-0100EPSDT.
182-534-0200Enhanced payments for EPSDT screens for children in out-of-home placement.


182-534-0100
EPSDT.

(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.
(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.
[Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-534-0100, filed 7/24/14, effective 8/24/14. 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.]



182-534-0200
Enhanced payments for EPSDT screens for children in out-of-home placement.

The medicaid agency pays providers an enhanced fee for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screens provided to children in out-of-home placement. See the agency's EPSDT provider guide for specific billing code requirements, and see the agency's fee schedule for the fee.
(1) For the purposes of this section, out-of-home placement means temporary, twenty-four hour per day, substitute care for a child:
(a) Placed away from the child's parents or guardians in licensed, paid, out-of-home care; and
(b) For whom the department of social and health services or a licensed or certified child placing agency has placement and care responsibility.
(2) The agency pays an enhanced fee to the providers listed in subsection (3) of this section for EPSDT screens provided to only those children in out-of-home placement.
(3) The following providers are eligible to perform EPSDT screens and bill the enhanced rate for children in out-of-home placement:
(a) EPSDT clinics;
(b) Physicians;
(c) Advanced registered nurse practitioners (ARNPs); and
(d) Physician assistants (PAs) working under a physician's guidance.
(4) To be paid an enhanced fee, services furnished by the providers listed in subsection (3) of this section must meet the federal requirements for EPSDT screens at 42 C.F.R. Part 441 Subpart B.
(5) The provider must retain documentation of the EPSDT screens in the client's medical file. The provider must use the agency's Well Child Exam forms or provide equivalent information. The Well Child Exam forms include the required elements for an EPSDT screen. The Well Child Exam forms are available for downloading at no charge at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.
(6) The agency evaluates client files and payments made under this program. The agency may recover the enhanced payment amount when:
(a) The client was not in out-of-home placement as defined in subsection (1) of this section when the EPSDT screen was provided; or
(b) Documentation was not in the client's medical file (see subsection (5) of this section).
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-12-074, § 182-534-0200, filed 5/29/15, effective 7/1/15. WSR 11-14-075, recodified as § 182-534-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-534-0200, filed 9/14/10, effective 10/15/10. 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, § 388-534-0200, filed 3/8/02, effective 4/8/02.]