N.J. Admin. Code § 10:54-5.9

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:54-5.9 - EPSDT; services

(a) The required EPSDT services include the following:

1. Screening services (see (f) below for components of screening services);

2. Vision services;

3. Dental services;

4. Hearing services; and,

5. Other medically necessary health care, diagnostic services and treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.

i. For requirements for prior authorization for organ procurement and transplant services in general, see 10:54-5.32(a) and (d). For requirements for prior authorization for organ procurement and transplantation services for Medicaid/NJ FamilyCare program beneficiaries of EPSDT services, see 10:54-5.32(d).

(b) EPSDT Screening Services shall include the following components:

1. A comprehensive health and developmental history, including an assessment of both physical and mental health development;

2. A developmental assessment, which should be culturally sensitive and valid. The parameters used in assessing the beneficiary's developmental level and behavior must be appropriate for the age. While no specific test instrument is endorsed, it is expected that an evaluation of a young child would, at a minimum, address the gross and fine motor coordination, language/vocabulary and adaptive behavior including self-help and self-care skills and social emotional development. An assessment of a school age child should include school performance; peer relationships; social activity and/or behavior; physical and/or athletic aptitude; and sexual maturation;

3. A comprehensive unclothed physical examination including vision and hearing screening, dental inspection and nutritional assessment;

4. Appropriate immunizations according to age and health history;

5. Appropriate laboratory tests, including:

i. Hemoglobin or hemotocrit;

ii. Urinalysis;

iii. Tuberculin skin test (Mantoux), intradermal, administered annually and when medically indicated;

iv. Lead screening using blood lead level determinations between 6 and 12 months, at 2 years of age, and annually up to 6 years of age. At all other visits, screening shall consist of verbal risk assessment and blood level testing, as indicated.

v. Additional laboratory tests which may be appropriate and medically indicated (for example, for ova and parasites) shall be obtained, as necessary.

6. Health education including anticipatory guidance.

7. Referral for further diagnosis and treatment or follow-up of all correctable abnormalities, uncovered or suspected. Referral may be made to the provider conducting the screening examination or to another provider, as appropriate.

8. Referral to the Special Supplemental Food program for Women, Infants and Children (WIC) for children under five years of age and for pregnant or lactating women.

N.J. Admin. Code § 10:54-5.9

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (a)5i, substituted "beneficiaries" for "recipients" preceding "of EPSDT services,"; in (b)2, substituted "beneficiary's" for "recipient's" preceding "developmental level".
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (a)5i, inserted "/NJ FamilyCare program".