Mo. Code Regs. tit. 13 § 70-25.110

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-25.110 - Payment for Early Periodic Screening, Diagnostic, and Treatment Program Services

PURPOSE: This amendment updates language and removes an obsolete statutory reference.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) The Department of Social Services shall administer an Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Program. In Missouri the EPSDT Program is administered as the Healthy Children and Youth (HCY) Program. The EPSDT/HCY Program provides comprehensive and preventive health care services for MO HealthNet-eligible persons under twenty-one (21) years of age including those in the legal custody of the Department of Social Services or any division of the department at no cost to the child or to the parents or guardians if they accept the offer of this service. The services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the division and shall be included in the MO HealthNet provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website http://manuals.momed.com/manuals, November 25, 2020. This rule does not incorporate any subsequent amendments or additions.

(2) The EPSDT Program shall make a general physical examination available to eligible participants. The components of the general physical examination shall include a comprehensive health and developmental history, a comprehensive unclothed physical examination, appropriate immunizations, laboratory tests, health education, a vision screen, a dental screen, and hearing services. These screens will be made available at the frequency recommended by Bright Futures/American Academy of Pediatrics and the American Academy of Pediatric Dentists.

(A) Interperiodic screenings outside the recommendations of Bright Futures/American Academy of Pediatrics or the American Academy of Pediatric Dentists are available when medically indicated.

(B) Partial screens for vision, hearing, dental, unclothed physical examination, an interval history, appropriate laboratory tests, immunizations, developmental/mental health assessment, and anticipatory guidance shall be reimbursable services.

(3) Providers of the screening services must be enrolled MO HealthNet providers operating within their legal scope of practice.

(4) The MO HealthNet program will provide reimbursement for prescribed, medically necessary treatment identified as a result of the screening if the treatment is a covered service under Section 1905(a) of the Social Security Act. "Medically necessary" is defined as service(s) furnished or proposed to be furnished that is (are) reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury; to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the participant's condition or the quality of medical care rendered; and the service(s) is (are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Any service authorized must be effective in addressing the participant's need. Services may require prior-authorization to assure medical necessity.

(5) Medical and dental services that Section 1905(a) of the Social Security Act permits to be covered under MO HealthNet and that are medically necessary to treat or ameliorate defects, physical, and mental illness, or conditions identified by an EPSDT screen are covered regardless of whether the Medicaid state plan covers the services. Services provided under this program will be sufficient in amount, duration, and scope to reasonably achieve their purpose. Services beyond the scope of the Medicaid state plan that a screening identifies as needed require a plan of care. The plan of care must identify the treatment needs of the child in regard to amount, scope, and prognosis. Certain services and equipment require approval prior to provision of the service as a condition of reimbursement. Prior authorization is used to promote the most effective and appropriate use of available services and to determine the medical necessity of the service. Services may be made available in an inpatient, outpatient office, or home setting depending upon the medical condition of the participant and availability of services.

13 CSR 70-25.110

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2007.* This rule was previously filed as 13 CSR 40-81.015. Original rule filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed Jan. 13, 1992, effective Sept. 6, 1992. Amended: Filed Aug. 15, 2008, effective Feb. 28, 2009.

Amended by Missouri Register July 15, 2021/Volume 46, Number 14, effective 8/31/2021

*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.