(c)
Hearing Services
(1) Requests for hearing
services, as EPSDT Supplemental Services, including but not limited to services
necessary for the diagnosis and treatment for defects in hearing, including
hearing aids, shall be evaluated under Section
51340(e)(1) or
(e)(3), as applicable.
(2) When a hearing aid is approved under the
standards of Section
51340(e)(3), one
package of six hearing aid batteries, size 675, 13, 312 or 10A, may be
furnished on a quarterly basis without prior authorization. Batteries in sizes
other than those listed, and hearing aid batteries provided at more frequent
intervals, shall be subject to prior authorization.
(d) Onsite Investigations to Detect the
Source of Lead Contamination
(1) Onsite
investigations to detect the source of lead contamination are covered as an
EPSDT supplement service only when:
(A) The
results of two consecutive laboratory tests performed on a blood specimen
collected from a child at least 30 days apart document that the child has a
venous blood lead level equal to or greater than 15 micrograms per deciliter
(ug/dL); or
(B) The results of one
laboratory test establishes that the child has a venous blood lead level equal
to or greater than 20 micrograms per deciliter (ug/dL); and
(C) The onsite investigation has been
recommended as a medically necessary part of the management and treatment of
the child by the physician who ordered the laboratory tests specified in this
section and who has received notification that the child has been found to have
an elevated blood lead level, as specified in (A) or (B) above; and
(D) The onsite investigation is conducted by
an individual who meets the criteria specified in Section
51242(i).
(2) A second onsite investigation is covered
only when the child's home or primary residence changes and the child's blood
lead level increases above the last level recorded prior to the child's change
of residence.
(3) The onsite
investigation shall be limited to the home or primary residence of the child
with the elevated blood lead level. For the purposes of this subsection only,
the following shall apply:
(A) "Onsite
investigation" means an interview with the family of the child to gather basic
information about the habits of the child and an assessment of the environment
using a portable X-ray fluorescence (XRF) analyzer or equivalent
device.
(B) "Home or primary
residence" means all the interior rooms in the residential unit within the main
structure/building in which the child resides, including window panes and
frames, doors, walls, baseboards and handrails, water pipes, furniture,
utensils, toys and dust; and the exterior including the garage, porch, storage
rooms, detached structures, patio, backyard, abandoned cars, trailers and
appliances, front lawn, fences and any other objects or structures on the
property which are accessible to the child.
(4) Onsite investigations do not include:
(A) Removal of lead sources;
(B) Provision of alternate housing;
(C) Collection or laboratory analysis of
environmental samples.
(5) Onsite investigations of public housing,
publicly-assisted housing or federally assisted housing are not
covered.
(6) Onsite investigations
conducted at the same address for several children in the same family shall be
considered one investigation.
(7)
Notwithstanding the requirements of Section
51340(c), onsite
investigations shall not be subject to prior authorization or the documentation
requirements of Section
51340(d) if all
the requirements of this subsection are met.
(e) Pediatric day health care services
(1) Pediatric day health care services
provided to a beneficiary shall be covered only after prior authorization has
been obtained from the designated Medi-Cal consultant, as set forth in Section
50009, before services are
initiated in the EPSDT pediatric day health care facility. The hours of
attendance in the pediatric day health care facility shall be authorized by the
designated Medi-Cal consultant. The total number of hours authorized for the
pediatric day health care facility may be substituted for a portion of the
authorized in-home nursing care services but at no time shall exceed the number
of hours allowed under Section
51340(m). Prior
authorization and reauthorization requests shall be initiated by the
facility.
(2) In determining the
need for pediatric day health care services, the plan of treatment developed by
the facility shall document the need for:
(A)
Skilled nursing services during each day of attendance by licensed nursing
personnel. The need for skilled nursing services may be demonstrated by, but
not be limited to, one or more of the following:
1. Skilled nursing assessment.
2. Mechanical ventilation.
3. Tracheotomy care and suctioning.
4. Respiratory treatment, which may involve
oxygen administration or suctioning.
5. Medication administration, either oral,
enteral, parenteral or inhalation.
6. Enteral or parenteral nutrition, or
intravenous fluid administration.
(B) A developmental program of activities
structured to promote or maintain the beneficiary's optimal functional
potential, and the probable benefit from therapeutic intervention. The need for
physical therapy, occupational therapy, speech therapy or medical nutrition
therapy must be documented by specific assessments and individualized
recommendations to include measurable goals and the expected benefits from the
therapeutic interventions.
(C)
Therapy services that shall be provided as follows:
1. The pediatric day health care facility
shall provide occupational therapy, physical therapy, speech therapy and
medical nutrition therapy in accordance with the plan of treatment. Such
therapy shall be provided by licensed or registered therapists. Authorization
for occupational therapy, physical therapy and speech therapy shall be in
accordance with Section
51309. Authorization for medical
nutrition therapy shall be in accordance with Section
51340.
2. Interventions specified in the individual
plan of treatment that do not require the judgment, knowledge and skills of a
licensed or registered therapist shall be provided by appropriately trained
nursing personnel. These interventions shall be considered part of the nursing
services and developmental activities.
(3) The initial request for prior
authorization shall be accompanied by the individual plan of care approved and
signed by the attending physician. Initial authorization requests may be
granted for up to three months. In addition to the information specified in
paragraph (e)(2) of this section, the plan of treatment shall include the
following:
(A) Primary diagnosis and
significant associated diagnoses.
(B) Clinical summary of the beneficiary's
medical condition, including history, a physical examination documented as
rendered within the last three months, functional status, and treatment
services received prior to admission to the pediatric day health care
facility.
(C) Specific types and
frequency of interventions to be rendered by each discipline, and medical
necessity for these services to be rendered in the facility.
(D) Medications to be administered, including
method of administration, dosage and frequency.
(E) Diet, including type, method of
administration and frequency.
(F)
For technology dependent beneficiaries, as defined in Section
1760.2
of the Health and Safety Code, a plan for treatment and monitoring of the
medical equipment to be used.
(G)
Scheduled day(s) and hours of attendance.
(H) Signed consent of parent, foster parent
or legal guardian granting the facility permission to transfer the child to the
hospital or other health facility in case of an emergency.
(4) Reauthorization requests for continuation
of pediatric day health care EPSDT services may be granted for up to six
months, and shall be:
(A) Accompanied by an
updated individual plan of treatment describing the beneficiary's progress
toward achieving therapeutic goals.
(B) Received by the designated Medi-Cal
consultant on or before the expiration of a current authorization. If the
request is received by the designated Medi-Cal consultant after the previously
authorized period has expired, the request shall be effective on the date when
it is received by the Medi-Cal consultant.
(5) The pediatric day health care facility
shall assist the beneficiary's parent, foster parent or legal guardian in
arranging for or obtaining medically necessary services outside the scope of
the pediatric day health care EPSDT services. However, the parent, foster
parent or legal guardian shall maintain primary responsibility for obtaining
these other medically necessary services.
(6) Pediatric day health care facilities
shall not provide EPSDT services for inpatients of the following health
facilities which are licensed pursuant to Division 2, Chapter 2, commencing
with Section
1250
of the Health and Safety Code:
(A) General
acute care hospital.
(B) Skilled
nursing facility.
(C) Intermediate
care facility.
(D) Intermediate
care facility for the developmentally disabled.
(E) Intermediate care facility for the
developmentally disabled-habilitative.
(F) Intermediate care facility for the
developmentally disabled-nursing.
(G) Congregate living health facility,
including a congregate living health facility which is certified as a nursing
facility.