5101:3-14-05 Healthckek: covered diagnostic and treatment services under early and periodic screening, diagnosis, and treatment (EPSDT).

When a screening examination indicates the need for further evaluation of an individual's health, the provider shall make a referral for diagnosis and treatment without delay, and follow-up to make sure that the individual receives a complete diagnostic evaluation. Evaluation, diagnosis, and/or treatment may be provided at the time of the healthchek (EPSDT) screening visit if the health care professional is qualified to provide the services. Rule 5101:3-1-60 of the Administrative Code lists coverage of other codes that may be billed when services are provided as part of further evaluation, diagnosis, or treatment following a healthchek(EPSDT) screening visit.

(A) Vision services.

(1) The department covers vision services for the diagnosis and treatment of vision problems. The scope of vision services covered under the medicaid program are described in Chapter 5101:3-6 of the Administrative Code.

(2) The minimum periodicity schedule for screenings for individuals under twenty-one years of age is defined in accordance with rule 5101:3-14-03 of the Administrative Code.

(3) In addition to the vision screenings performed during the healthchek (EPSDT) screening visit, the department covers vision examinations of all levels (minimal through comprehensive) performed by eligible providers of vision services in accordance with Chapter 5101:3-6 of the Administrative Code.

(B) Hearing services.

(1) The department covers hearing services for the diagnosis and treatment of hearing problems. The scope of hearing services covered under the medicaid program includes hearing aids, which are covered as a medical supplier service in accordance with Chapter 5101:3-10 of the Administrative Code.

(2) The minimum periodicity schedule for hearing screenings for individuals under twenty-one years of age is defined in accordance with rule 5101:3-14-03 of the Administrative Code.

(3) In addition to the hearing screenings performed during the healthchek (EPSDT) screening visit, the department covers hearing screenings and other hearing services (including hearing aids) performed by eligible providers of hearing services.

(C) Dental services.

(1) The department covers dental services for the diagnosis and treatment of dental problems for individuals under age twenty-one. The scope of dental services covered under the medicaid program are described in Chapter 5101:3-5 of the Administrative Code.

(2) The department covers one diagnostic and preventive dental examination every six months. The minimum periodicity schedule for dental services for individuals under twenty-one years of age is defined in accordance with rule 5101:3-14-04 of the Administrative Code.

(3) Diagnostic and preventive dental examinations shall be provided to individuals at ages and at frequencies in accordance with American academy of pediatrics recommendations for preventative pediatric health care (March 2003), www.aap.org. Providers are encouraged to refer children, beginning at the age of two years to a dentist or to the county department of job and family services (CDJFS) for a referral to a dentist.

(4) Dental diagnostic and treatment services are covered for individuals under the age of twenty-one, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth, and maintenance of dental health as described in Chapter 5101:3-14-05 of the Administrative Code.

(5) Methods will be employed by the department to encourage dental examinations:

(a) Providers of healthchek (EPSDT) screening shall provide individuals ages three years and older with referrals to a dentist or to the (CDJFS) if the individual has not been seen during the last six months by a dentist or a dental hygienist under the supervision of a dentist; and

(b) The CDJFS shall notify medicaid eligible individuals under the age of twenty-one at least once a year that it is time for a dental examination in accordance with the minimal periodicity schedule for dental services.

(D) Interperiodic examinations, vision, hearing, and dental services that are medically necessary to determine the existence of suspected physical or mental illnesses or conditions are covered under medicaid and may be billed in accordance with Chapters 5101:3-4, 5101:3-5, and 5101:3-6 of the Administrative Code.

(E) Diagnostic and treatment services for individuals under age twenty-one are covered under the medicaid program when the services are medically necessary, as defined in rule 5101:3-1-01 of the Administrative Code, to treat or ameliorate a defect, physical or mental illness, or condition. Covered diagnostic and treatment services for individuals under age twenty-one include:

(1) Diagnostic and treatment services within the coverage and limitations set forth in Chapters 5101:3-1 to 5101:3-22, 5101:3-24 to 5101:3-30, and 5101:3-56 of the Administrative Code; and,

(2) Diagnostic and treatment services beyond the coverage and limitations set forth in Chapters 5101:3-1 to 5101:3-22, 5101:3-24 to 5101:3-30, and 5101:3-56 of the Administrative Code that are:

(a) Prior authorized by the department in accordance with rule 5101:3-1-31 of the Administrative Code, and when provided through the medicaid managed care program(MCP), in accordance with rule 5101:3-26-05.1 of the Administrative Code; and,

(b) Available in accordance with federal EPSDT requirements found at 42 U.S.C. 1396d(a) as amended.

(F) Additional services not usually covered under the medicaid program may be available in an institutional setting or through a home and community-based services (HCBS) waiver.

(G) Habilitation services are not covered and are not authorized under EPSDT on Ohio medicaid's state plan except when provided in an intermediate care facility for persons with mental retardation (ICF/MR). Habilitation services may also be provided to enrollees of ICF/MR based waivers if the habilitation service is a service covered by the waiver and if the service is medically necessary for the waiver enrollee.

Replaces: Part of 5101:3-14-06

Effective: 07/01/2006
R.C. 119.032 review dates: 11/10/2005 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 2/17/91, 8/1/01