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"Section Five: PMP Functions and Duties
Responsibilities of PMPs include the following:
K. Maintain in the medical record current information relating to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services provided to enrolled recipients including those services received by the recipient in other care settings. PMPs are responsible for ensuring that children receive or are referred for EPSDT services. PMPs should have in place a tracking system for ensuring appropriate screenings." Alabama PMP, page 10.
"Section Nine: Medicaid Benefits...
C. EPSDT Services
PMPs are requested to either perform or make arrangements for EPSDT screenings. The PMP is responsible for ensuring that age appropriate EPSDT screenings are provided.
In situations where a PMP has authorized another provider to perform EPSDT services, the patient's medical record must contain documentation of such services. Documentation must include: the date the service was provided, nature of the service, who provided the service and the findings...
PMPs are required to have a tracking system in place to ensure that these services are being rendered appropriately and in the specified timeframe." Alabama PMP, pages 17-18.
"PATIENT 1ST REFERRED SERVICES
The following services DO REQUIRE a referral from the Patient's Primary Medical Provider...
Service... EPSDT Screenings." Alabama PMP, Attachment 4, unnumbered pages.
"MANDATORY CAPITATED SERVICES...
Newborns..." California Contract, Attachment A, page AI, AII.
"Services to be managed
1. General Services. It is agreed that the MediPass provider will provide patient management for the following services for each patient: ...GA
Child Health Check-Up Services (formerly EPSDT)..." Florida Agreement, page 4.
"908. Health Check Services [Early Periodic Screening Diagnosis and Treatment Program (EPSDT)] HEALTH CHECK services is a program of comprehensive health screening, diagnosis, referral and treatment of children under twenty-one (21) years of age. The goal of the HEALTH CHECK program is to direct attention to the importance of preventive health services, early detection, and treatment of conditions in children before their health problems become chronic or irreversible. HEALTH CHECK requires periodic screening services aimed at identifying medical conditions that meet all federal requirements of the HEALTH CHECK (EPSDT) program." Georgia Agreement, page IX-4.
"4. Health Watch/EPSDT Services
The PMP will promote and provide Health Watch services for recipients under age 21 or refer recipients to other appropriate providers. Refer to the Indiana Medicaid EPSDT/Health Watch Provider Manual for more detailed information." Indiana Addendum, page 3.
"H. Promote and provide KAN Be Healthy (KBH) medical screens and continuous care services for all assigned beneficiaries under age 21 or provide a written referral to an appropriate specialist or health department for KAN Be Healthy medical screens...
KAN Be Healthy Screens
The KAN Be Healthy screening schedule follows the American Academy of Pediatrics (AAP) Periodicity Schedule. Refer to the Medicaid Professional Services Manual Section 2020 for screening schedule.
Current SRS policy requires the following additional screening and services:
1. Participants may have a dental screening at the age of twelve (12) months, but must have a dental screening annually if three (3) years or older. Those beneficiaries requesting orthodontia must have a medical screening in addition to the dental screening. Some dental services require prior authorization.
2. Participants must have a vision exam at the age of three (3) years. Examinations every two (2) years and treatment for medical conditions of the eye are covered.
3. Participants must have a hearing screen at the age of three (3) years. Examinations every three (3) years and treatment for medical conditions of the ear are covered.
4. Additional treatment and services which are covered only for KAN Be Healthy program participants which include, but are not limited to, elective surgery, antihistamine drugs, and additional specialized services are allowed." Kansas Contract, page 3.
"E. 'Exempt Services' are those Medicaid services which do not need to be provided or authorized by the enrollee's primary care provider. Exempt services include the following: ...
The following subcategories of PASSPORT-managed services do not require authorization:
vision and dental components of well-child screen.." Montana Agreement, pages 2-3.
"IV. RESPONSIBILITIES OF THE PRIMARY CARE PROVIDER (PCP)...
6. Provide or arrange for screening and preventive health services for persons under the age of twenty-one (21), in accordance with the periodicity schedule recommended in the Medicaid EPSDT Provider Manual." Montana Agreement, page 5.
"1.1.34 The Term 'NHC Benefits Package', also commonly referred to as the Basic Benefits Package, shall include the following medical/surgical services, representing a minimum benefits package, as defined in this contract and 471Nebraska Administrative Code (NAC), that shall be arranged for by the Contractor to clients enrolled in the NHC: ...
(e) HEALTH CHECK (Early Periodic Screening and Diagnosis and Treatment as federally mandated) services (See 471NAC 33000 and 7.36 of this contract)..." Nebraska Contract, pages 5- 7.
"7.36.4 Contractor Requirement: The Contractor shall counsel the family on the importance of health supervision and regular checkups and assist in removing barriers to care, and if necessary, assist families with appointment scheduling and transportation. At minimum, efforts shall include:
(a) HEALTH CHECK (EPSDT) Screening: The Contractor shall provide HEALRHCHECK (EPSDT) services pursuant to 471NAC;
(1) Upon receipt of information necessary to perform from the State EBSOR PCP, the Contractor shall outreach to HEALTH CHECK (EPSDT ) eligible children who need to be scheduled for HEALTH CHECK (EPSDT) examinations. Targeted groups are
a. Newly Medicaid eligible and other children who have not had a timely HEALTH CHECK (EPSDT) examination;
b. Children who have been identified as not having ever been screened or not having received HEALTH CHECK (EPSDT) services within established timelines based on the periodicity schedule; and
c. Children from birth to the second birthday, particularly infants and toddlers that may need immunizations, lead level testing, developmental testing and hearing testing.
(2) When the Contractor becomes aware of the following, the Contractor shall contact the EBS regarding
a. Screening appointments missed without cancellation to determine the barriers to care, to assist in scheduling the appointment, and to counsel the family about keeping appointments; and
b. Screening results from a referral for treatment and the client who does not follow up with treatment services identified by the Contractor.
(3) The Contractor shall assist the PCP to establish a system for HEALTH CHECK (EPSDT) examinations. The system may provide notification through phone call or mail. The Contractor may substitute their system in place of the PCP's;
(4) The Contractor shall use continuous quality improvement methods to achieve a performance goal of HEALTH CHECK (EPSDT) screens at the recommended participation rate, pursuant to the contract utilizing internal and Departmental data; and
(b) If a client requests a HEALTH CHECK (EPSDT) screen for the initial screen, the screen, the Contractor shall arrange that the screening examination(s) within sixty (60) days. Subsequent screening exams (hearing, medical) shall be provided according to the periodicity schedule, or an interperiodic examination if appropriate.
(c) The Contractor shall encourage the administration of immunizations pursuant to this Contract. All pediatricians and Family Practice Physicians shall be encouraged to participate in the Vaccine for Children (VFC) program provide childhood immunizations to Medicaid eligible children. The VFC program was established to ensure that children will have access to childhood immunizations and the protection they provide. The requirements of the VFC program administered will be reported with the appropriate procedure code and '52' modifier to identify them as VFC vaccine immunizations. Vaccine not available through the VFC program, but recommended and published by the Academy of Pediatrics shall be provided and reimbursed by the Contractor to the PCP. The Contractor shall promote increasing immunization levels to reach the State's Healthy 2000 immunization level goals.
(d) The PCP/Contractor shall take a proactive approach to ensure clients obtain HEALTH CHECK (EPSDT) screening services and medically necessary diagnosis and treatment services. A proactive approach may include:
(1) Written notification and phone protocols for upcoming or missed appointments within a set period of time ;
(2) Protocols for conducting out reach with non-compliant members;
(3) Outreach and follow-up to children with special health needs, e.g., children in foster care, pregnant adolescents;
(4) Provision of demographic information to public health agencies when HEALTH CHECK (EPSDT) screening identifies children with elevated blood lead levels (EBLL); and." Nebraska Contract, pages 75-76.
"The Health Check Program is a preventive care program for Medicaid children ages birth through 20. A Health Check Screening is the only well child care visit reimbursable by Medicaid. Recipients are encouraged to receive their comprehensive health checkups and immunizations on a regular schedule. A complete Health Check screening consists of the following age appropriate components required to be done at each visit unless otherwise noted:Sickle Cell Testing: Sickle Cell test is recommended to be performed by 12 months. North Carolina hospitals are required to screen all newborns before discharge. If a child has been properly tested then the test need not be repeated. Results must be documented in the child's record.
Comprehensive unclothed physical examination Comprehensive health history Anticipatory guidance/health education Measurements, blood pressure, and vital signs Blood pressure is recommended to become a part of the exam between ages 3 and 4. Developmental screening, including mental, emotional and behavioral Perform age appropriate evaluation at each screening. In addition, three written developmental assessments should be performed: the first by 12 months, the second by 24 months and the third by 60 months. Immunizations
Federal Law states that immunizations are to be provided at the time of screening if they are needed.
Vision and hearing screenings Visual assessment should be administered a minimum of two times in the first year of life, at 3 years of age, once between 4 and 5 years of age, and then every three years thereafter.Hearing assessment should be administered a minimum of two times in the first year of life, annually until age 3, once between 4 and 5 years of age, and then every three years thereafter. Laboratory procedures Includes hemoglobin/hematocrit, urinalysis, sickle cell, tuberculin skin test, lead screening. Hemoglobin or Hematocrit: Hemoglobin and hematocrit should be measured once during infancy (between 1 and 9 months) for all children and once during adolescence for menstruating teenagers. An annual hemoglobin/hematocrit screening for adolescent females (ages 11 to 21 years) should be nutritional deficit, or athletic activity. For hemoglobin/hematocrit guidelines for children in the Women, Infants, and Children's (WIC) Program, please call your local WIC program.
Urinalysis: Urinalysis should be performed once at 5 years of age. Also, dipstick leukocyt4 esterase testing to screen for infections should be performed at least once between 11 and 21 years of age, preferably at age 14, or more often as clinically indicated.
Tuberculin Testing: Children at increased risk of exposure to tuberculosis should be tested and only PPD (Purified Protein Derivative) by Mantoux method should be used. Routine tuberculin skin testing of children with no risk factors residing in low prevalence areas is not indicated.Children with the following risk factors should be tested:
1. Close contacts to a case of TB disease
2. Children with clinical or radiographic symptoms suggestive of TB
3. Children immigrating within the past 5 years from high-prevalence countries (e.g., Asia, Africa, Latin America, or the Pacific Islands)
4. Children who are HIV infected (annually)
5. Children with continuos exposure to high-risk adults (e.g., HIV infected persons; homeless; injected drug users; migrant farm workers) (every 2-3 years)
6. Children living in locally identified high prevalence areas as determined by local health department TB control programs (baseline)
Lead Screening: All Medicaid-enrolled children are required to have a blood lead test at 12 and 24 months of age. Children between 36-72 months must be tested if they have not previously been tested. Providers can always do a lead screen if they feel there is a reason to do so.
Medical follow-up does not begin until the blood level is greater than or equal to 10 ul/dl. Capillary blood lead samples are adequate for the initial screening test. Venous blood lead samples should be collected for confirmation of all elevated blood lead results." North Carolina Agreement, Health Check Screening Component, pages 1-2.
"2.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) A. The Contractor shall comply with the Authority requirements regarding periodicity of EPSDT screens and services, and shall make EPSDT a priority in his/her health care for recipients under the age of twenty-one (21).
The Contractor shall:
1) Schedule the following EPSDT appointments for all recipients under the age of 21;
a) Six (6) visits during the first year of life;
b) Two (2) visits in the second year of life;
c) One (1) visit yearly for ages two through five;
d) One (1) visit every other year for ages six through twenty.
2) Conduct and document follow up with all members under the age of 21 who have missed appointments;
3) Conduct and document EPSDT outreach to ensure that members under the age of twenty-one (21) are current with respect to the periodicity schedule in 2.6(A)(1);
4) Educate families who have members under the age of twenty-one (21) about the EPSDT Program and its importance to the health of children and adolescents." Oklahoma Agreement, page 8.
"Texas Health Steps (EPSDT)
Early, Periodic Screening, Diagnosis and Treatment (EPSDT), known in Texas as Texas Healthy Steps, is a program aimed at assuring children early access to preventive services and timely intervention when medical needs are identified. A protocol of services and a periodicity schedule has been established. Network providers are expected to employ active outreach as a means to ,ensure that children are seen according to a prescribed, age appropriate schedule. The STAR Network Administrator is expected to monitor the efforts of network providers and to provide assistance in the form of counseling and possible contract sanction if the network provider fails to perform as expected." Texas RFP, page 3.
"10. The PCD will assure that any children or adolescents enrolled with the PCD are screened according to the requirements of the Vermont Department of Health's EPSDT periodicity schedule." Vermont Agreement, page 3.
"5. Complete a BabyCare risk screen on every MEDALLION patient assigned to the PCP's panel who is eligible to receive a risk screen. If the patient is determined to be at risk and eligible to receive BabyCare services, the PCP must either provide BabyCare services (if the PCP is an enrolled BabyCare Provider) or refer the eligible patient to a Medicaid enrolled BabyCare Provider.
6. Enroll and participate in the Commonwealth of Virginia's Vaccines for Children (VFC) Program." Virginia Agreement, Appendix A, page A-1.
"IV. IT IS AGREED THAT THE PAAS PHYSICIAN OR CLINIC WILL: ...
F. Provide or refer, through pre-established formalized agreements with other providers, EPSDT, services to children ages 0 to 21." West Virginia PAAS, page 3.