Cal. Code Regs. Tit. 22, § 51340 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services and EPSDT Supplemental Services
(a) EPSDT screening services as defined in
Section 51184(a)(1) are a
program benefit when provided through the Child Health and Disability
Prevention program in accordance with Title 17, California Code of Regulations,
Sections 6800 et seq. EPSDT screening
services as defined in Sections
51184(a)(2) and
(a)(3) are covered when provided by a
certified Medi-Cal provider meeting the requirements of this chapter, if such
services are otherwise reimbursable under the program.
(b) EPSDT diagnosis and treatment services as
defined in Section
51184(b) are
covered subject to the provisions of this chapter.
(c) Unless otherwise specified in this
Chapter, EPSDT supplemental services are covered subject to prior authorization
if the requirements of subsections (e) or (f), as appropriate, are met. The
Department shall review requests for services resulting from EPSDT screening
services for compliance with this section whether the screen was performed by a
Medi-Cal provider or a non-Medi-Cal provider.
(d) Requests for prior authorization for
EPSDT supplemental services pursuant to subsection (c) shall state explicitly
that the request is for EPSDT supplemental services, and shall be accompanied
by the following information:
(1) The
principal diagnosis and significant associated diagnoses.
(2) Prognosis.
(3) Date of onset of the illness or
condition, and etiology if known.
(4) Clinical significance or functional
impairment caused by the illness or condition.
(5) Specific types of services to be rendered
by each discipline with physician's prescription where applicable.
(6) The therapeutic goals to be achieved by
each discipline, and anticipated time for achievement of goals.
(7) The extent to which health care services
have been previously provided to address the illness or condition, and results
demonstrated by prior care.
(8) Any
other documentation available which may assist the Department in making the
determinations required by this section.
(e) EPSDT supplemental services must meet one
of the following standards, as determined by the Department:
(1) The standards and requirements set forth
in Sections
51003 and
51303, and any specific
requirements applicable to a specific service that are based on the standards
and requirements of those sections other than the service-specific requirements
set forth in Section
51340.1.
(2) The service-specific requirements
applicable to EPSDT Supplemental Services set forth in Section
51340.1.
(3) When the standards set forth in paragraph
(e)(1) or (e)(2) are not applicable to the services being requested, all of the
following criteria, where applicable:
(A) The
services are necessary to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by the screening services as defined in
subsection (a) of this section.
(B)
The supplies, items, or equipment to be provided are medical in
nature.
(C) The services are not
requested solely for the convenience of the beneficiary, family, physician or
another provider of services.
(D)
The services are not unsafe for the individual EPSDT-eligible beneficiary, and
are not experimental.
(E) The
services are neither primarily cosmetic in nature nor primarily for the purpose
of improving the beneficiary's appearance. The correction of severe or
disabling disfigurement shall not be considered to be primarily cosmetic nor
primarily for the purpose of improving the beneficiary's appearance.
(F) Where alternative medically accepted
modes of treatment are available, the services are the most
cost-effective.
(G) The services to
be provided:
1. Are generally accepted by the
professional medical and dental community as effective and proven treatments
for the conditions for which they are proposed to be used. Such acceptance
shall be demonstrated by scientific evidence, consisting of well designed and
well conducted investigations published in peer-review journals, and, when
available, opinions and evaluations published by national medical and dental
organizations, consensus panels, and other technology evaluation bodies. Such
evidence shall demonstrate that the services can correct or ameliorate the
conditions for which they are prescribed.
2. Are within the authorized scope of
practice of the provider, and are an appropriate mode of treatment for the
health condition of the beneficiary.
(H) The predicted beneficial outcome of the
services outweighs potential harmful effects.
(I) Available scientific evidence, as
described in paragraph (e)(3)(G)1., demonstrates that the services improve the
overall health outcomes as much as, or more than, established
alternatives.
(f)
(1)
Notwithstanding subsection (e), EPSDT case management services as specified in
paragraph (j)(3) may be covered for the EPSDT-eligible beneficiary when
accompanied by the information described in subsection (d) if the Department
determines that both of the following criteria are met:
(A) The service to which access is to be
gained through case management is medically necessary for the EPSDT-eligible
beneficiary. For purposes of this subsection, medical necessity is established
if the service meets the criteria set forth in subsection (e)(1), (e)(2), or
(e)(3).
(B) The EPSDT-eligible
beneficiary has a medical or mental health condition or
diagnosis.
(2) Requests
for EPSDT case management services shall not be approved if the Department
determines that EPSDT case management services appropriate to the
EPSDT-eligible beneficiary's needs can reasonably be obtained through the use
of family, agency, or institutional assistance that is typically used by the
general public in assuring that children obtain necessary medical, social,
educational, or other services. In making the determination described in this
paragraph, the Department may take into account the following factors:
(A) Whether or not the beneficiary has a
complicated medical condition, including a history of multiple or complex
medical or mental health diagnoses, frequent recent hospitalizations, use of
emergency rooms, or other indicators of medical or mental health conditions
resulting in significant impairment.
(B) Whether or not the beneficiary has a
history of one or more environmental risk factors, including:
1. parent, guardian, or primary care-giver
mental retardation or mental illness, physical or sensory disability, substance
abuse, under age 18 years, prolonged absence, or
2. other environmental stressors, which may
result in neglect, abuse, lack of stable housing, or otherwise compromise the
parent's, guardian's, or primary caregiver's ability to assist the beneficiary
in gaining access to the necessary medical, social, educational, and other
services.
(g) If reimbursement is being sought on a "by
report" basis, a description of the service, the proposed unit of service, and
the requested dollar amount shall be included with the request for
authorization. A "by report" service or item is any service for which a maximum
allowance has not been established because the item is rarely billed to the
Medi-Cal program or because the service is unusual, variable or new.
(h) EPSDT supplemental services requested as
a result of EPSDT screening services are exempt from the benefit limitations in
Section 51304, and may be covered subject
to prior authorization as defined in Section
51003 if the requirements of
subsection (e) of this section are met.
(i) Regardless of the source of the referral
for the service, requests for EPSDT diagnostic and treatment services and EPSDT
supplemental services pursuant to the requirements of this chapter shall be
reviewed pursuant to this section.
(j)
(1)
Requests for EPSDT case management services shall not be authorized where the
Department has determined that appropriate case management services may be
obtained through a targeted case management (TCM) provider under contract with
a participating local governmental agency that has elected to provide case
management services pursuant to Section
14132.44
of the Welfare and Institutions Code, or where TCM services are available
pursuant to Section
14132.48
of the Welfare and Institutions Code.
(2) Where the Department determines that
EPSDT case management services are not provided or available pursuant to
paragraph (j)(1), requests for EPSDT case management services may be referred
to the unit within the Department designated by the Director.
(3) Where the Department determines that
EPSDT case management services are not provided or available pursuant to
paragraph (j)(1) or (j)(2), the Department may authorize EPSDT case management
services through an EPSDT case manager described in Section
51184(h)(4).
(k) For members of Medi-Cal managed care
plans, the Medi-Cal managed care plan shall determine whether EPSDT case
management services are medically necessary based on subsection (f). If the
plan determines EPSDT case management services are medically necessary, the
plan shall refer the members to an appropriate EPSDT case manager described in
paragraph (h)(1) or (h)(2) of Section
51184. Services shall first be
sought pursuant to paragraph (j)(1). If services are not available pursuant to
paragraph (j)(1), the plan shall provide, or arrange and pay for, the EPSDT
case management services. For purposes of this subsection, Medi-Cal managed
care plan means any entity that has entered into a contract with the Department
to provide, or arrange for, comprehensive health care to enrolled Medi-Cal
beneficiaries pursuant to Chapter 8 or Articles 2.7, 2.8, 2.9 and 2.91 of
Chapter 7 of Part 3, Division 9, of the Welfare and Institutions
Code.
(l) The Department shall not
approve an EPSDT supplemental service pursuant to this section if the
Department determines that the service to be provided is accessible and
available in an appropriate and timely manner as an EPSDT diagnostic and
treatment service.
(m) The
Department shall not approve a request for EPSDT diagnostic and treatment
services or EPSDT supplemental services in home and community-based settings if
the Department determines that the total cost incurred by the Medi-Cal program
for providing such services to the beneficiary is greater than the total costs
incurred by the Medi-Cal program in providing medically equivalent services at
the beneficiary's otherwise appropriate institutional level of care, where
medically equivalent services at the appropriate level are available in a
timely manner.
Notes
2. Change without regulatory effect of NOTE (Register 86, No. 49).
3. Amendment of section heading, text, and NOTE 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.
4. Amendment of section heading, text and NOTE 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.
5. Editorial correction of printing errors in subsections (d)(1), (e) and (i) (Register 94, No. 31).
6. Amendment of section heading, text and NOTE 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.
7. Amendment of section heading, text and NOTE 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.
8. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
9. Amendment of subsection (c) and amendment of NOTE filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
10. Amendment of subsection (c) and amendment of NOTE refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14059 and 14132, Welfare and Institutions Code; Sections 306- 309, Health and Safety Code; and 42 U.S.C. 1396d(r).
2. Change without regulatory effect of NOTE (Register 86, No. 49).
3. Amendment of section heading, text, and Note 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.
4. Amendment of section heading, text and Note 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.
5. Editorial correction of printing errors in subsections (d)(1), (e) and (i) (Register 94, No. 31).
6. Amendment of section heading, text and Note 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.
7. Amendment of section heading, text and Note 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.
8. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
9. Amendment of subsection (c) and amendment of Note filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
10. Amendment of subsection (c) and amendment of Note refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
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