WSR 10-21-116

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed October 20, 2010, 11:10 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 09-22-070.

Title of Rule and Other Identifying Information: Chapter 388-534 WAC, Early and periodic screening, diagnosis, and treatment (EPSDT) and WAC 388-865-0350 Mental health screening for children.

Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on November 23, 2010, at 10:00 a.m.

Date of Intended Adoption: Not sooner than November 24, 2010.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 1115 Washington Street S.E., Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on November 23, 2010.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by November 9, 2010, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is updating and clarifying EPSDT policy for all healthcare services, including medical, dental, and behavioral health services.

Reasons Supporting Proposal: This will make the EPSDT policy more transparent to clients, providers, and agency staff.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090.

Statute Being Implemented: 42 C.F.R., Part 441, Subpart B.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1344; Implementation and Enforcement: Sharon Reddick, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1656.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Does not impact small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. Exempt per RCW 34.05.328 (5)(b)(v) because content of the rule is dictated by federal statute.

October 14, 2010

Katherine I. Vasquez

Rules Coordinator

4241.2
AMENDATORY SECTION(Amending WSR 02-07-016, filed 3/8/02, effective 4/8/02)

WAC 388-534-0100   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 CFR, 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 388-545-300, 388-545-500, and 388-545-700.

(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 CFR 441, Subpart B are met through a contract with transportation brokers throughout the state)) The early and periodic screening, diagnosis and treatment (EPSDT) program is a federal preventive health care benefit for children and youth. The purpose of this program is to provide comprehensive, periodic, preventive health screenings to clients under age twenty-one in order to identify potential physical and/or behavioral health conditions and to provide diagnosis and medically necessary treatment to correct or ameliorate defects and physical and mental illnesses and conditions. EPSDT is designed to encourage early and continuing access to health care for children and youth. Social Security Act 1905(r) (42 U.S.C. 1396d(r)).

(2) The EPSDT program is defined by federal rules at 42 C.F.R., Part 441, Subpart B. EPSDT services and treatment must be medically necessary, as defined in WAC 388-500-0005.

(3) It is the department's intent that all eligible children receive EPSDT screenings to thoroughly and comprehensively assess each child's health and wellness.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. 02-07-016, 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. 01-02-076, 388-534-0100, filed 12/29/00, effective 1/29/01. 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. 98-16-044, 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. 90-12-061 (Order 3019), 388-86-027, filed 5/31/90, effective 7/1/90; 82-01-001 (Order 1725), 388-86-027, filed 12/3/81; 81-10-015 (Order 1647), 388-86-027, filed 4/27/81; 80-15-034 (Order 1554), 388-86-027, filed 10/9/80; 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.]


NEW SECTION
WAC 388-534-0110   EPSDT--Definitions.   The following definitions and those found in WAC 388-500-0005 apply to this chapter:

"Behavioral health" - A continuum of health and/or clinical services for individuals at risk for, or suffering from, emotional, mental, substance abuse, chemical dependency and/or other behavioral conditions.

"Periodicity schedule" - The schedule for periodic health and wellness screenings provided at age appropriate intervals as determined by the department after consultation with recognized children's medical and dental care professional organizations.

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NEW SECTION
WAC 388-534-0120   EPSDT--Eligible clients.   All clients under age twenty-one who are covered by the department's medical assistance programs are eligible for services under the early and periodic screening, diagnosis and treatment (EPSDT) program.

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NEW SECTION
WAC 388-534-0125   EPSDT--Components.   The early and periodic screening, diagnosis and treatment (EPSDT) program components include:

(1) Screening - Upon request and according to the department's periodicity schedule, the department pays for screenings to include regularly scheduled examinations and evaluations of general physical and behavioral health, growth, development, and nutritional status of infants, children, and youth to detect potential health conditions.

(a) To be considered an EPSDT screening, all of the following elements must be performed:

(i) Comprehensive health history and assessment;

(ii) Comprehensive developmental history and age-appropriate assessment;

(iii) Comprehensive unclothed physical examination;

(iv) Appropriate behavioral health and substance abuse screening;

(v) Health education and counseling (including anticipatory guidance according to age and health history);

(vi) Appropriate vision testing;

(vii) Appropriate hearing testing;

(viii) Appropriate laboratory testing;

(ix) Dental screening services; and

(x) Immunizations.

(b) An EPSDT screening must be provided in accordance with reasonable standards of practice determined by the department after consultation with recognized organizations involved in child healthcare.

(c) The provider performing the screening may order components of the EPSDT screening from other licensed providers acting within their scope of practice. The department encourages the provider to perform as many of the components as possible to provide a fuller understanding of the client's health.

(2) Diagnosis - When a healthcare risk is identified in an EPSDT screening, additional diagnostic procedures may be performed by a qualified provider to determine if further evaluation or treatment is required.

(3) Treatment - Medically necessary services that are not excluded by federal law are provided to address healthcare conditions identified as the result of an EPSDT screening. When a healthcare condition is identified, the provider(s) will:

(a) Treat the client (only if it is within the provider's scope of practice); or

(b) Refer the client to an appropriate provider for treatment.

(i) This may include additional testing or specialty evaluations, such as developmental assessment, comprehensive mental health, substance abuse evaluation, or nutritional counseling.

(ii) Treating providers are required to communicate the results of their services to the EPSDT screening provider(s).

(4) The department or its designee considers requests for authorization of treatment that include services not listed as covered in WAC 388-501-0060, WAC 388-106-0200, and other specific program WAC, or that are listed as noncovered in WAC 388-501-0070 and specific program WAC, only when determined to be medically necessary and recommended by a provider after a current EPSDT screening. If a child's EPSDT screening is current according to the periodicity schedule, a new screening is not required before the noncovered service may be requested and authorized.

(5) If any of the elements of an EPSDT screening indicate there is a need for a more complete evaluation of the client's health or some specific condition, that evaluation, diagnosis, and medically necessary treatment must be provided to the client.

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NEW SECTION
WAC 388-534-0130   EPSDT--Covered services and authorization of payment.   (1) The early and periodic screening, diagnosis and treatment (EPSDT) program services are exempt from specific coverage or service limitations that apply to other department healthcare programs (except for services excluded under federal law). This means that services not listed as covered in WAC 388-501-0060, WAC 388-106-0200, and other specific program WAC provisions, or listed as noncovered in WAC 388-501-0070 and specific program WAC, may be paid for as EPSDT services if:

(a) They are among the services listed in 42 U.S.C. 1396d(a) that state medicaid programs may cover;

(b) They are determined by the provider to be medically necessary;

(c) They are determined medically necessary and are prior authorized by the department or its designee in accordance with the process described in WAC 388-501-0165; and

(d) The client's EPSDT screening is current according to the periodicity schedule.

(2) Eligible clients may receive medically necessary covered healthcare services with or without an EPSDT screening or referral. Certain covered healthcare services may require prior authorization by the department or its designee.

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AMENDATORY SECTION(Amending WSR 01-12-047, filed 5/31/01, effective 7/1/01)

WAC 388-865-0350   ((Mental)) EPSDT health ((screening)) services for children.   ((The mental health prepaid health plan is responsible for conducting mental health screening and treatment for children eligible under the federal Title XIX early and periodic screening, diagnosis, and treatment (EPSDT) program. This includes:

(1) Providing resource management services for children eligible under the federal Title XIX early and periodic screening, diagnosis, and treatment program as specified in contract with the mental health division;

(2) Developing and maintaining an oversight committee for the coordination of the early and periodic screening, diagnosis and treatment program. The oversight committee must include representation from parents of medicaid-eligible children)) Persons under the age of twenty-one who are eligible for department medical assistance programs may also receive mental health services through the early and periodic screening, diagnosis, and treatment (EPSDT) program in accordance with chapter 388-534 WAC.

[Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800, 9.41.047, 43.20B.020, and 43.20B.335. 01-12-047, 388-865-0350, filed 5/31/01, effective 7/1/01.]

Washington State Code Reviser's Office