N.J. Admin. Code § 10:66-2.4

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

Section 10:66-2.4 - Early and periodic screening, diagnostic and treatment (EPSDT) services program

(a) The early and periodic screening, diagnostic and treatment (EPSDT) services program is a Federally mandated comprehensive child health program for Medicaid and NJ FamilyCare fee-for-service beneficiaries from birth through 20 years of age. (See 42 CFR 441 Subpart B.)

(b) EPSDT includes screening services; vision services; dental services; hearing services; and other necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.

1. An expanded program for Medicaid and NJ FamilyCare fee-for-service beneficiaries up to the age of two is known as HealthStart. For additional information, including provider enrollment requirements, see N.J.A.C. 10:66-3.

(c) Components of an EPSDT screening are as follows:

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

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

3. Appropriate immunizations according to age and health history;

4. Appropriate tests, including:

i. Hemoglobin/hematocrit;

ii. Urinalysis;

iii. Tuberculin test;

iv. Blood lead level assessment shall be performed for all children between nine through 18 months of age (preferably at 12 months) and again at two years of age. In addition, between the ages of two and six years, a child shall be screened if there is no evidence of prior screening;

v. Other medically-necessary procedures;

5. Health education, including anticipatory guidance; and

6. Referral for further diagnosis and treatment or follow up to correct or ameliorate abnormalities, uncovered or suspected. Referral may be to the provider conducting the screening examination, or to another provider, as appropriate.

(d) EPSDT screening services (unless modified as follows in (e), (f) and (g) below) shall be provided periodically according to the following schedule which reflects the age of the child:

1. Under six weeks;

2. Two months;

3. Four months;

4. Six months;

5. Nine months;

6. 12 months;

7. 15 months;

8. 18 months;

9. 24 months; and

10. Annually through age 20.

(e) Vision screening shall include the following:

1. A newborn examination including general inspection of the eyes, visualization of the red reflex, and evaluation of ocular motility;

2. An appropriate medical and family history;

3. An evaluation, by age six months, of eye fixation preference, muscle imbalance, and pupillary light reflex;

4. A repeated examination with visual acuity testing by age three or four years;

5. Periodicity testing for school-aged children as follows:

i. Kindergarten or first grade (five or six years);

ii. Second grade (seven years);

iii. Fifth grade (10-11 years);

iv. Eighth grade (13-14 years); and

v. Tenth or eleventh grades (15-17 years).

6. Children should be referred for further evaluation if they:

i. Cannot read the majority of the 20/40 line before their fifth birthday;

ii. Have a two-line difference of visual acuity between the eyes;

iii. Have suspected strabismus; or

iv. Have an abnormal light or red reflex.

(f) The following apply to dental screening:

1. Intraoral examination is an integral part of a general physical examination.

2. A formal referral to a dentist is recommended at one year of age. It is mandatory for children three years of age and older.

3. Dental inspection and prophylaxis should be carried out every six months until 17 years of age, then annually.

(g) The following apply to hearing screening:

1. Hearing screening shall be included in all preventive periodic examinations.

2. Audiometric testing shall be administered annually to all children between three and eight years of age. After age eight, children shall be tested every other year.

N.J. Admin. Code § 10:66-2.4

Recodified from N.J.A.C. 10:66-2.2 and amended by R.1998 d.577, effective 12/7/1998.
See: 30 N.J.R. 3434(a), 30 N.J.R. 4225(b).
Inserted references to NJ KidCare fee-for-service and substituted references to beneficiaries for references to recipients throughout. Former N.J.A.C. 10:66-2.4, Laboratory, recodified to N.J.A.C. 10:66-2.6.
Amended by R.2004 d.208, effective 6/7/2004.
See: 36 N.J.R. 324(a), 36 N.J.R. 2834(a).
Rewrote the section.
Amended by R.2009 d.376, effective 12/21/2009.
See: 41 N.J.R. 2561(a), 41 N.J.R. 4791(a).
Section was "Early and periodic screening, diagnosis and treatment (EPSDT)". In (a), substituted "The early" for "Early" and "diagnostic" for "diagnosis", and inserted "services program".