(a)
EPSDT Screening Services means:
(1) An
initial, periodic, or additional health assessment of a Medi-Cal eligible
individual under 21 years of age provided in accordance with the requirements
of the Child Health and Disability Prevention (CHDP) program as set forth in
Title 17, Sections
6800 et seq.; or
(2) A health assessment, examination, or
evaluation of a Medi-Cal eligible individual under 21 years of age by a
licensed health care professional acting within his or her scope of practice,
at intervals other than those specified in paragraph (a)(1) to determine the
existence of physical or mental illnesses or conditions; or
(3) Any other encounter with a licensed
health care professional that results in the determination of the existence of
a suspected illness or condition or a change or complication in a condition for
a Medi-Cal eligible person under 21 years of age.
(b) EPSDT diagnosis and treatment services
means only those services provided to persons under 21 years of age that:
(1) Are identified in section
1396 d(r) of title 42 of the
United States Code,
(2) Are
available under this chapter without regard to the age of the recipient or that
are provided to persons under 21 years of age pursuant to any provision of
federal Medicaid law other than section
1396 d(a)(4)(B) and section
1396 a(a)(43) of title 42 of the
United States Code, and
(3) Meet
the standards and requirements of Sections
51003 and
51303, and any specific
requirements applicable to a particular service that are based on the standards
and requirements of those sections.
(c) EPSDT supplemental services means health
care, diagnostic services, treatment, and other measures, that:
(1) Are identified in Section
1396 d(r) of Title 42 of the
United States Code.
(2) Are
available only to persons under 21 years of age,
(3) Meet any one of the standards of medical
necessity as set forth in paragraphs (1), (2), or (3) of Section
51340(e),
and
(4) Are not EPSDT diagnosis and
treatment services.
(d)
EPSDT supplemental services include EPSDT case management services when
provided by EPSDT case managers described in paragraph (h)(4).
(e) EPSDT diagnosis and treatment provider
means any of the providers listed under Section
51051, other than EPSDT
supplemental services providers.
(f) EPSDT Supplemental Services Provider
means a person enrolled pursuant to Section
51242 to provide EPSDT
supplemental services as defined in subsection (c).
(g) EPSDT case management services means
services that will assist EPSDT-eligible individuals in gaining access to
needed medical, social, educational, and other services.
(h) EPSDT case manager means:
(1) A targeted case management (TCM) provider
under contract with a local governmental agency described in Section
14132.44
of the Welfare and Institutions Code.
(2) Entities and organizations, including
Regional Centers, that provide TCM services to persons described in Section
14132.48
of the Welfare and Institutions Code.
(3) A unit within the Department designated
by the Director.
(4) A child
protection agency, other agency or entity serving children, or an individual
provider, that the Department finds qualified by education, training, or
experience, and that the Department enrolls pursuant to Section
51242 to provide EPSDT case
management services.
(i)
For purposes of the EPSDT program, excepting pediatric day health care EPSDT
services provided as EPSDT supplemental services, the term "services" is deemed
to include supplies, items, or equipment.
(j) EPSDT supplemental services include
pediatric day health care EPSDT services when provided by a pediatric day
health care facility.
(k) For
purposes of pediatric day health care EPSDT services, the following definitions
shall apply:
(1) "Pediatric day health care
EPSDT services" means services that:
(A)
Promote the physical, developmental and psychosocial well-being of individuals
eligible for EPSDT services who are medically fragile as defined in Section
1760.2(b)
of the Health and Safety Code and who live with their parent, foster parent, or
legal guardian.
(B) Provide
medically necessary skilled nursing care and therapeutic interventions which
include occupational therapy, physical therapy, speech therapy and medical
nutrition therapy provided by licensed or registered therapists and furnished
in response to the attending physician's orders and in accordance with the
individual's plan of treatment. These services do not include respite care
pursuant to Section
14132.10(a),
of the Welfare and Institutions Code.
(C) Are provided in a day program of less
than 24 hours that is individualized and family-centered, with developmentally
appropriate activities of play, learning and social interaction designed to
optimize the individual's medical status and developmental functioning so that
he or she can remain within the family.
(2) "Pediatric day health care facility"
means a facility that is licensed pursuant to Section
1760
of the Health and Safety Code. For purposes of providing pediatric day health
care EPSDT services, a pediatric day health care facility may also be referred
to as the "facility".
(3)
"Pharmaceutical services" means medications, including prescription and
nonprescription, and total parental nutrition supplied to eligible
beneficiaries by licensed nursing personnel and administered upon orders of the
attending physician.
(4) "Nutrition
services" means a minimum of one meal per day, between meal nourishment, and
consultation services by the facility's dietitian.
Notes
Cal. Code Regs. Tit. 22, §
51184
1. New
section filed 4-4-94 as an emergency; operative 4-4-94 (Register 94, No. 14). A
Certificate of Compliance must be transmitted to OAL by 8-2-94 or emergency
language will be repealed by operation of law on the following
day.
2. New section refiled 8-1-94 as an emergency; operative 8-1-94
(Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL
by 11-29-94 or emergency language will be repealed by operation of law on the
following day.
3. New section refiled 10-24-94 as an emergency;
operative 10-24-94 (Register 94, No. 43). A Certificate of Compliance must be
transmitted to OAL by 2-21-95 or emergency language will be repealed by
operation of law on the following day.
4. New section refiled
2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of Compliance
must be transmitted to OAL by 6-22-95 or emergency language will be repealed by
operation of law on the following day.
5. Certificate of Compliance
as to 2-22-95 order including amendment of section transmitted to OAL 3-16-95
and filed 4-27-95 (Register 95, No. 17).
6. Amendment of subsection
(i), new subsections (j)-(k)(4) 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.
7. Certificate of
Compliance as to 11-10-99 order, including further amendment of subsection
(k)(1)(B) and (k)(4), 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; and Sections
100275,
125000
and
125100,
Health and Safety Code. Reference: Sections
14059,
14132
and
14132.10,
Welfare and Institutions Code; Sections
125000
and
125100,
Health and Safety Code; and 42 U.S.C.
1396d(r).
1. New section
filed 4-4-94 as an emergency; operative 4-4-94 (Register 94, No. 14). A
Certificate of Compliance must be transmitted to OAL by 8-2-94 or emergency
language will be repealed by operation of law on the following day.
2. New section refiled 8-1-94 as an emergency; operative 8-1-94 (Register 94,
No. 31). A Certificate of Compliance must be transmitted to OAL by 11-29-94 or
emergency language will be repealed by operation of law on the following
day.
3. New section refiled 10-24-94 as an emergency; operative
10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted
to OAL by 2-21-95 or emergency language will be repealed by operation of law on
the following day.
4. New section refiled 2-22-95; operative
2-22-95 (Register 95, No. 8). A Certificate of Compliance must be transmitted
to OAL by 6-22-95 or emergency language will be repealed by operation of law on
the following day.
5. Certificate of Compliance as to 2-22-95 order
including amendment of section transmitted to OAL 3-16-95 and filed 4-27-95
(Register 95, No. 17).
6. Amendment of subsection (i), new
subsections (j)-(k)(4) 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.
7. Certificate of Compliance
as to 11-10-99 order, including further amendment of subsection (k)(1)(B) and
(k)(4), transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No.
16).