DAR File No. 43837

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-71

Early and Periodic Screening, Diagnostic and Treatment Program

Notice of Proposed Rule

(New Rule)

DAR File No.: 43837
Filed: 06/28/2019 01:04:16 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to implement, by rule, Medicaid policy for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program.

Summary of the rule or change:

This new rule specifies criteria for eligibility and access to the EPSDT Program. It also outlines coverage for Medicaid members who are eligible to receive EPSDT services.

Statutory or constitutional authorization for this rule:

• 42 CFR 440.40(b)
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rule only implements current policy for the EPSDT Program. It neither affects member services nor provider reimbursement.

local governments:

There is no impact on local governments because they neither fund nor provide services under the EPSDT Program.

small businesses:

There is no impact on small businesses because this rule only implements current policy for the EPSDT Program. It neither affects member services nor provider reimbursement.

persons other than small businesses, businesses, or local governmental entities:

There is no impact on Medicaid providers and Medicaid members because this rule only implements current policy for the EPSDT Program. It neither affects member services nor provider reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because this rule only implements current policy for the EPSDT Program. It neither affects member services nor provider reimbursement.

Comments by the department head on the fiscal impact the rule may have on businesses:

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/14/2019

This rule may become effective on:

08/21/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2020	FY 2021	FY 2022
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$0	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	$0	$0	$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non-Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non-Small Businesses

None of the approximate 27,000 non-small business providers of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services will be impacted because this new rule because it only implements current policy for the EPSDT program.

 

 

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-71. Early and Periodic Screening, Diagnostic and Treatment Program.

R414-71-1. Introduction and Authority.

(1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program provides comprehensive prevention, diagnostic, and treatment services for Medicaid members.

(a) Treatment or services that are necessary to correct or ameliorate defects and physical and mental illnesses or conditions.

(2) EPSDT services provide coverage of all medically necessary services included within the categories of mandatory and optional services listed in Subsection 1905(a) of the Social Security Act.

(3) The EPSDT Program is authorized by Subsections 1902(a)(43) and 1905(a)(4)(B) of the Social Security Act, 42 CFR 440.40(b), and 42 CFR Part 441, Subpart B.

 

R414-71-2. Definitions.

In addition to the definitions in Section R414-1-2, the following definition applies to this rule:

(1) "EPSDT" means "Early and Periodic Screening, Diagnosis, and Treatment" used to determine physical or mental defects in members. The EPSDT Program provides:

(a) health care;

(b) treatment; and

(c) other measures to correct or ameliorate any defects and chronic conditions discovered.

 

R414-71-3. Member Eligibility Requirements.

(1) Eligible members who are enrolled in Traditional Medicaid, and are zero through 20 years of age, may receive EPSDT services.

(2) Individuals who are 19 through 20 years of age and enrolled in Non-Traditional Medicaid, Adult Expansion Medicaid, or Targeted Adult Medicaid, are not eligible for EPSDT services.

 

R414-71-4. Program Access Requirements.

(1) An eligible member must obtain EPSDT services from a Utah Medicaid enrolled provider.

(2) A member enrolled in a managed care entity must obtain EPSDT services through that entity.

 

R414-71-5. Service Coverage and Limitations.

(1) Screening and diagnostic services to determine physical or mental defects.

(2) Screening services include:

(a) a comprehensive health and developmental history, including the assessment of phys ical and mental development;

(b) d ental and oral health screening;

(c) comprehensive physical examination;

(d) vision screening;

(e) hearing assessment;

(f) speech and language development;

(g) appropriate immunizations according to age and health history;

(h) laboratory tests, including blood lead level assessment appropriate to age and risk; and

(i) health education, including anticipatory guidance.

(3) When a screening indicates the need for further evaluation, diagnostic services must be provided.

(4) Medically necessary services are available for treatment of all physical and mental illnesses or conditions discovered by any screening or diagnostic procedures.

(5) Additional services include:

(a) chiropractic services;

(b) orthodontia;

(c) occupational therapy;

(d) physical therapy;

(e) speech-language services;

(f) private duty nursing;

(g) at a minimum, diagnosis and treatment for defects in vision, including eyeglasses;

(h) at a minimum, dental services for the relief of pain and infections, restoration of teeth, maintenance of dental health, including examinations, cleanings, and fluoride treatments;

(i) at a minimum, diagnosis and treatment for hearing defects, including hearing aids; and

(j) additional health care services coverable under Subsection 1905(a) of the Social Security Act and found to be medically necessary to treat, correct, or ameliorate illness and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

(6) The Department determines whether a service is medically necessary.

(7) Medically necessary services do not include:

(a) experimental or investigational treatments;

(b) reconstructive and cosmetic procedures as noted in Section R414-1-29;

(c) services for caregivers or for provider convenience; or

(d) duplicative services.

(8) The Department may consider the relative cost effectiveness of alternatives as part of the prior authorization process described in Section R414-1-2.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2019

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3