Statutes, codes, and regulations
Colorado Administrative Code
Department 2505 - Department of Health Care Policy and FinancingDivision 2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
Rule 10 CCR 2505-10-8.200 - MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT
Section 10 CCR 2505-10-8.280 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT

10 Colo. Code Regs. § 2505-10-8.280

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Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.280 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
8.280.1DEFINITIONS

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) means the child health component of Medicaid. The EPSDT program requires coverage of periodic and interperiodic screens, vision, dental and hearing care, diagnostic services needed to confirm the existence of a physical or mental illness or condition, and all medical assistance services that are recognized under Section 1905 of the Social Security Act, even if not offered under the state plan pursuant to federal laws applicable to the program (including 1905(a), 42 U.S.C. §§ 1396a(a)(42), 1396d(a)(4)(B) and 1396d(r)).

EPSDT Case Management means an activity that assists Medicaid clients in getting and/or coordinating services based on individual need.

EPSDT Outreach means methods to inform recipients or potential recipients, such as those found to be presumptively eligible, to enter into care.

EPSDT Outreach and Case Management Entity means an entity that has contracted with the Department to provide the activities specified in 8.280.3 below.

Personal Care Services means assistance with non-skilled activities of daily living in order to meet the client's physical, maintenance and supportive needs. This assistance may take the form of hands-on assistance (actually performing a task for the person), or prompting or cueing the client to complete the task.

8.280.2EPSDT ELIGIBILITY

A child or youth age 20 and under enrolled in Medicaid are eligible for EPSDT services.

8.280.3EPSDT OUTREACH AND CASE MANAGEMENT
8.280.3.A. EPSDT Outreach and Case Management entities shall provide pregnant women, children, their parents or legal guardians (based on the current eligibility information received from the Department) the following within 60 days of eligibility through oral communication including face to face meetings, discussions or telephone conversations, as well as written materials:
1. Information about EPSDT services and how to access them.
2. Education on the importance of preventive health care with an emphasis on well child exams, developmental and depression screenings, dental examinations, immunizations, and prenatal care.
3. Assistance in selecting a Primary Care Physician (PCP) or Managed Care Organization (MCO), and to supply a list of available options if requested. Children without a PCP shall be informed of the choices of PCPs and/or MCOs. Families/children shall notify the enrollment broker of their choice as described in 10 C.C.R. 2505-10, Section 8.205.
4. Assist clients in choosing an Accountable Care Organization if appropriate.
5. Assistance with coordinating primary health coverage with Medicaid benefits.
6. Assistance with coordinating appointments with providers, including assistance with missed appointments.
7. Assistance with reporting the birth of newborns to the local department of human/social services.
8. A current list of covered and uncovered services available in the community.
9. Information regarding the availability of non-emergency medical transportation.
8.280.4EPSDT SERVICES
8.280.4.A. Periodic screening is a procedure used to determine a child's mental and physical growth progress, and to identify a disease or abnormality. Screening identifies additional diagnosis and treatments of physical or emotional problems.
1. Screening shall include a comprehensive health assessment performed soon after birth or as early as possible in a child's life and repeated at periodic intervals of time as recommended by the Colorado periodicity schedules.
2. The periodicity schedules describe the intervals at which preventive physical, sensory, developmental and behavioral screening, including vision; hearing and dental services shall be performed for enrolled children and youth age 20 and under. The periodicity schedules also include the recommended frequency of follow-up examinations.
3. The components of a screen shall include:
a. A comprehensive unclothed physical exam.
b. A detailed health and development history.
c. An assessment of vision, hearing, mouth, oral cavity and teeth, including referral to a dentist beginning at age 1, and other systems including but not limited to: Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Neurologic, Psychiatric/Emotional/Education, and Nutrition.
d. A developmental screening including a range of activities to determine whether a child's emotional and developmental processes fall within a benchmarked range of achievement schedule according to the child's age group and cultural background. This screening shall include self-help and self-care skills, gross and fine motor development, communication skills or language development, social-emotional development, cognitive skills and appropriate mental/behavioral health screening.
e. Appropriate immunizations according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines.
f. Lead Toxicity Screening- All children are considered at risk and should be screened for lead poisoning via blood testing. Children between the ages of 36 months and 72 months of age should receive a blood lead test if they have not been previously tested for lead poisoning.
g. Any appropriate age-specific screening or laboratory tests at intervals recommended by the Colorado Periodicity Schedule.
h. Health education and anticipatory guidance.
4. Screenings shall be age appropriate and performed in a culturally and linguistically sensitive manner by a provider qualified to furnish primary medical and/or mental health care services.
5. Results of screenings and examinations shall be recorded in the child's medical record. Documentation shall include at a minimum identified problems and negative findings and further diagnostic studies and/or treatments needed and date ordered.
8.280.4.B. Inter-Periodic exam

Inter-periodic exam shall be any health care that occurs outside the periodic preventive care screening such as a further diagnosis, evaluation, acute or sick care.

8.280.4.C. Diagnosis and treatment
1. When a screening examination indicates the need for further evaluation of the individual's health, diagnostic services are provided.
2. If the screening provider is not licensed or equipped to render the necessary treatment or further diagnosis, the screening provider shall refer the individual to an appropriate enrolled practitioner or facility, or to the EPSDT Outreach and Case Management Office for supportive help in locating an appropriate provider.
3. Treatment to correct or ameliorate defects, physical and mental illnesses or conditions discovered by the screening and diagnostic services shall be available.
8.280.4.D. Personal Care Services

Personal Care Services as defined in 8.280.1, are a benefit for clients age 20 and under who meet the criteria for EPSDT.

8.280.4.EOther EPSDT Benefits
1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b- g.
8.280.5LIMITATIONS/SPECIAL CONSIDERATIONS
8.280.5.A. Experimental services or procedures are excluded.
8.280.5.B. Services or items not generally accepted as effective by the medical community are excluded.
8.280.5.C. Pharmaceutical items not requiring a prescription are excluded unless prior authorized and medically necessary.
8.280.5.D. Eyeglasses are a benefit only when ordered by an ophthalmologist or an optometrist.

Vision benefits are limited to single or multi-focal clear plastic lenses and one standard frame.

8.280.5.E. Contact lenses or orthoptic vision treatment services shall be a benefit when medically necessary and shall require prior authorization submitted by an Ophthalmologist, Optometrist, or Optician.
8.280.5.F. Orthodontic services are available for children with congenital, severe developmental or acquired handicapping malocclusions when the orthodontist documents Medical Necessity that is confirmed by pre-treatment case review. Orthodontists shall submit requests for prior authorization of covered orthodontic services.
8.280.5.G. Early language intervention for children age birth through three with a hearing loss may be provided by audiologists, speech therapists, speech pathologists and Colorado Home Intervention Program (CHIP) providers
8.280.6REFERRALS

When a client is enrolled a managed care plan, a referral from his/her primary care physician may be required for care provided by anyone other than the primary care physician. Any client may self-refer for routine vision, dental, hearing, mental health services or family planning services.

8.280.7PRIOR AUTHORIZATIONS

Providers shall be responsible for obtaining prior authorization when required for identified services such as home health, orthodontia, private duty nursing and pharmaceuticals. Prior authorization of services is not a guarantee of payment.

8.280.8MANAGED CARE AND CONTRACTED HEALTH CARE SERVICES
8.280.8.A The Contractor must ensure the delivery of EPSDT services for Contractor Covered Services. The Contractor must have written policies and procedures for providing EPSDT services including lead testing and immunizations to the eligible population.
8.280.8..B. The Contractor must comply with all EPSDT regulations set forth in 1905(a), 42 USC 1396d(r)(5) and 42 USC 1396d(a), and performance will be verified by paid claims.
8.280.8.C. The Contractor must assure the provision of all required components of periodic health screens.
8.280.8.D. At a minimum, such efforts shall include:
1. education and outreach to eligibles of the importance of EPSDT services;
2. a proactive approach to ensure eligibles obtain EPSDT services;
3. systematic communication process with network providers regarding the Department's EPSDT requirements;
4. process to measure and assure compliance with the EPSDT schedule; and,
5. a process to assure that the medically necessary services not covered by the Contractor are referred to the Office of Clinical Services for action; and,
6. comply with all reporting requirements and data needs for federal reporting.
8.280.9REIMBURSEMENT

Reimbursement shall be in accordance with the regulations for pricing health services as reflected at 10 C.C.R. 2505-10, Section 8.200 for all EPSDT medical screening, diagnostic and treatment services

10 CCR 2505-10-8.280