Section 51340.1 - Requirements Applicable to EPSDT Supplemental Services(a) When the particular EPSDT Supplemental Services identified in this section are requested, the request for service shall be approved only when the criteria and requirements set forth in this section are met. Requests for all other EPSDT Supplemental Services shall be approved only when the requirements set forth in Section 51340(e)(1) or (e)(3) are met.(b) Dental Services (1) Dental services, other than orthodontic services Requests for dental services, as EPSDT Supplemental Services, including but not limited to services necessary for the relief of pain and infections, restoration of teeth or maintenance of dental health, shall be evaluated under Section 51340(e)(1) or (e)(3), as applicable.
(2) Orthodontic services Orthodontic services are covered only:
(A) When medically necessary pursuant to the criteria set forth in the Medi-Cal "Manual of Criteria for Medi-Cal Authorization," Chapter 8.1, as incorporated by reference in Section 51003(e) or(B) When medically necessary for the relief of pain and infections, restoration of teeth, maintenance of dental health, or the treatment of other conditions or defects, pursuant to the criteria set forth in Section 51340(e)(1) or (e)(3), as applicable.(c) Hearing Services (1) Requests for hearing services, as EPSDT Supplemental Services, including but not limited to services necessary for the diagnosis and treatment for defects in hearing, including hearing aids, shall be evaluated under Section 51340(e)(1) or (e)(3), as applicable.(2) When a hearing aid is approved under the standards of Section 51340(e)(3), one package of six hearing aid batteries, size 675, 13, 312 or 10A, may be furnished on a quarterly basis without prior authorization. Batteries in sizes other than those listed, and hearing aid batteries provided at more frequent intervals, shall be subject to prior authorization.(d) Onsite Investigations to Detect the Source of Lead Contamination (1) Onsite investigations to detect the source of lead contamination are covered as an EPSDT supplement service only when:(A) The results of two consecutive laboratory tests performed on a blood specimen collected from a child at least 30 days apart document that the child has a venous blood lead level equal to or greater than 15 micrograms per deciliter (ug/dL); or(B) The results of one laboratory test establishes that the child has a venous blood lead level equal to or greater than 20 micrograms per deciliter (ug/dL); and(C) The onsite investigation has been recommended as a medically necessary part of the management and treatment of the child by the physician who ordered the laboratory tests specified in this section and who has received notification that the child has been found to have an elevated blood lead level, as specified in (A) or (B) above; and(D) The onsite investigation is conducted by an individual who meets the criteria specified in Section 51242(i).(2) A second onsite investigation is covered only when the child's home or primary residence changes and the child's blood lead level increases above the last level recorded prior to the child's change of residence.(3) The onsite investigation shall be limited to the home or primary residence of the child with the elevated blood lead level. For the purposes of this subsection only, the following shall apply: (A) "Onsite investigation" means an interview with the family of the child to gather basic information about the habits of the child and an assessment of the environment using a portable X-ray fluorescence (XRF) analyzer or equivalent device.(B) "Home or primary residence" means all the interior rooms in the residential unit within the main structure/building in which the child resides, including window panes and frames, doors, walls, baseboards and handrails, water pipes, furniture, utensils, toys and dust; and the exterior including the garage, porch, storage rooms, detached structures, patio, backyard, abandoned cars, trailers and appliances, front lawn, fences and any other objects or structures on the property which are accessible to the child.(4) Onsite investigations do not include: (A) Removal of lead sources;(B) Provision of alternate housing;(C) Collection or laboratory analysis of environmental samples.(5) Onsite investigations of public housing, publicly-assisted housing or federally assisted housing are not covered.(6) Onsite investigations conducted at the same address for several children in the same family shall be considered one investigation.(7) Notwithstanding the requirements of Section 51340(c), onsite investigations shall not be subject to prior authorization or the documentation requirements of Section 51340(d) if all the requirements of this subsection are met.(e) Pediatric day health care services (1) Pediatric day health care services provided to a beneficiary shall be covered only after prior authorization has been obtained from the designated Medi-Cal consultant, as set forth in Section 50009, before services are initiated in the EPSDT pediatric day health care facility. The hours of attendance in the pediatric day health care facility shall be authorized by the designated Medi-Cal consultant. The total number of hours authorized for the pediatric day health care facility may be substituted for a portion of the authorized in-home nursing care services but at no time shall exceed the number of hours allowed under Section 51340(m). Prior authorization and reauthorization requests shall be initiated by the facility.(2) In determining the need for pediatric day health care services, the plan of treatment developed by the facility shall document the need for:(A) Skilled nursing services during each day of attendance by licensed nursing personnel. The need for skilled nursing services may be demonstrated by, but not be limited to, one or more of the following: 1. Skilled nursing assessment.2. Mechanical ventilation.3. Tracheotomy care and suctioning.4. Respiratory treatment, which may involve oxygen administration or suctioning.5. Medication administration, either oral, enteral, parenteral or inhalation.6. Enteral or parenteral nutrition, or intravenous fluid administration.(B) A developmental program of activities structured to promote or maintain the beneficiary's optimal functional potential, and the probable benefit from therapeutic intervention. The need for physical therapy, occupational therapy, speech therapy or medical nutrition therapy must be documented by specific assessments and individualized recommendations to include measurable goals and the expected benefits from the therapeutic interventions.(C) Therapy services that shall be provided as follows: 1. The pediatric day health care facility shall provide occupational therapy, physical therapy, speech therapy and medical nutrition therapy in accordance with the plan of treatment. Such therapy shall be provided by licensed or registered therapists. Authorization for occupational therapy, physical therapy and speech therapy shall be in accordance with Section 51309. Authorization for medical nutrition therapy shall be in accordance with Section 51340.2. Interventions specified in the individual plan of treatment that do not require the judgment, knowledge and skills of a licensed or registered therapist shall be provided by appropriately trained nursing personnel. These interventions shall be considered part of the nursing services and developmental activities.(3) The initial request for prior authorization shall be accompanied by the individual plan of care approved and signed by the attending physician. Initial authorization requests may be granted for up to three months. In addition to the information specified in paragraph (e)(2) of this section, the plan of treatment shall include the following:(A) Primary diagnosis and significant associated diagnoses.(B) Clinical summary of the beneficiary's medical condition, including history, a physical examination documented as rendered within the last three months, functional status, and treatment services received prior to admission to the pediatric day health care facility.(C) Specific types and frequency of interventions to be rendered by each discipline, and medical necessity for these services to be rendered in the facility.(D) Medications to be administered, including method of administration, dosage and frequency.(E) Diet, including type, method of administration and frequency.(F) For technology dependent beneficiaries, as defined in Section 1760.2 of the Health and Safety Code, a plan for treatment and monitoring of the medical equipment to be used.(G) Scheduled day(s) and hours of attendance.(H) Signed consent of parent, foster parent or legal guardian granting the facility permission to transfer the child to the hospital or other health facility in case of an emergency.(4) Reauthorization requests for continuation of pediatric day health care EPSDT services may be granted for up to six months, and shall be:(A) Accompanied by an updated individual plan of treatment describing the beneficiary's progress toward achieving therapeutic goals.(B) Received by the designated Medi-Cal consultant on or before the expiration of a current authorization. If the request is received by the designated Medi-Cal consultant after the previously authorized period has expired, the request shall be effective on the date when it is received by the Medi-Cal consultant.(5) The pediatric day health care facility shall assist the beneficiary's parent, foster parent or legal guardian in arranging for or obtaining medically necessary services outside the scope of the pediatric day health care EPSDT services. However, the parent, foster parent or legal guardian shall maintain primary responsibility for obtaining these other medically necessary services.(6) Pediatric day health care facilities shall not provide EPSDT services for inpatients of the following health facilities which are licensed pursuant to Division 2, Chapter 2, commencing with Section 1250 of the Health and Safety Code: (A) General acute care hospital.(B) Skilled nursing facility.(C) Intermediate care facility.(D) Intermediate care facility for the developmentally disabled.(E) Intermediate care facility for the developmentally disabled-habilitative.(F) Intermediate care facility for the developmentally disabled-nursing.(G) Congregate living health facility, including a congregate living health facility which is certified as a nursing facility.Cal. Code Regs. Tit. 22, § 51340.1
1. New section filed 4-27-95; operative 4-27-95 (Register 95, No. 17).
2. Amendment and redesignation of first paragraph as subsection (a), subsection relettering, new subsections (d)-(d)(7) and amendment of NOTE filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
3. Amendment and redesignation of first paragraph as subsection (a), subsection relettering, new subsections (d)-(d)(7) and amendment of NOTE refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
4. New subsections (e)-(e)(6)(G) and amendment of NOTE filed 11-10-99 as an emergency; operative 11-10-99 (Register 99, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-9-2000 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-5-99 order, including further amendment of subsection (d)(1)(A), transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
6. Certificate of Compliance as to 11-10-99 order, including further amendment of subsections (e)(2)(B) and (e)(2)(C)1., transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No. 16). Note: Authority cited: Sections 10725, 14124.5 and 14195, Welfare and Institutions Code. Reference: Sections 14059, 14132 and 14132.10, Welfare and Institutions Code; Sections 100275, 125000 and 125100, Health and Safety Code; and 42 U.S.C. 1396d(r).
1. New section filed 4-27-95; operative 4-27-95 (Register 95, No. 17).
2. Amendment and redesignation of first paragraph as subsection (a), subsection relettering, new subsections (d)-(d)(7) and amendment of Note filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
3. Amendment and redesignation of first paragraph as subsection (a), subsection relettering, new subsections (d)-(d)(7) and amendment of Note refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
4. New subsections (e)-(e)(6)(G) and amendment of Note filed 11-10-99 as an emergency; operative 11-10-99 (Register 99, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-9-2000 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-5-99 order, including further amendment of subsection (d)(1)(A), transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
6. Certificate of Compliance as to 11-10-99 order, including further amendment of subsections (e)(2)(B) and (e)(2)(C)1., transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No. 16).