Lawriter - OAC - 5160-1-14 Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services.

5160-1-14 Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services.

(A) Definitions.

(1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect 10/2017).

(2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care (rev. 2/2017), available at http://www.aap.org.

(3) "Medical necessity" and "medically necessary" have the same meaning as in rule 5160-1-01 of the Administrative Code.

(4) "Prior authorization" is one of two processes:

(a) For members of a medicaid managed care plan (MCP), it is the process established by the medicaid MCP as required by rule 5160-26-05.1 of the Administrative Code.

(b) For all other medicaid recipients, it is the process outlined in rule 5160-1-31 of the Administrative Code.

(B) Providers. Healthchek screening, diagnostic, and treatment services may be rendered by eligible providers in an appropriate discipline, acting within the scope of practice authorized under state law and as set forth in agency 5160 of the Administrative Code.

(C) Coverage. For medicaid-eligible individuals younger than twenty-one years of age, healthchek covers the following services and items:

(1) Screening services.

(a) Healthchek screening services include, but are not limited to, all of the following procedures:

(i) A comprehensive health and developmental history, including assessment of both physical and mental health development, as well as substance abuse disorders;

(ii) A comprehensive unclothed physical exam, when appropriate;

(iii) Immunizations appropriate to age and health history;

(iv) Laboratory tests, including lead blood level assessment appropriate to age and risk factors, as required by the centers for medicare and medicaid services (CMS);

(v) Nutritional status assessment; and

(vi) Health education, counseling, anticipatory guidance, and risk factor reduction intervention provided to an individual younger than twenty-one years of age and, as applicable, to another person responsible for the individual younger than twenty-one years of age.

(b) Healthchek screening services are covered at the following frequency:

(i) For immunizations, in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines established by the advisory committee on immunization practices of the centers for disease control and prevention, found athttp://www.cdc.gov/vaccines/hcp/acip-recs/index.html;

(ii) For other screening services, at ages and intervals in accordance with the bright futures guidelines; and

(iii) For all screening services, at such other intervals indicated as medically necessary to determine the existence of physical or mental illnesses or conditions.

(2) Vision services.

(a) Healthchek vision services include but are not limited to diagnosis and treatment for defects in vision, including eyeglasses.

(b) Healthchek vision services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(3) Dental services.

(a) Healthchek dental services include but are not limited to relief of pain and infections, restoration of teeth, and maintenance of dental health.

(b) Healthchek dental services are covered at the following frequency:

(i) For individuals six years of age or younger, at intervals that meet reasonable standards of dental practice in accordance with the bright futures guidelines;

(ii) For individuals older than six and younger than twenty-one years of age, at least once every one hundred eighty days; and

(iii) For all individuals younger than twenty-one years of age, at such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(4) Hearing services.

(a) Healthchek hearing services include but are not limited to diagnosis and treatment for defects in hearing, including hearing aids.

(b) Healthchek hearing services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(5) All medically necessary services and items set forth in agency 5160 of the Administrative Code.

(6) All medically necessary screenings, health care, diagnostic services, treatment, and other measures described in 42 U.S.C. 1396d(a) (as in effect 10/2017) to correct or ameliorate defects and physical and mental illnesses and conditions, regardless of whether such measures are addressed in agency 5160 of the Administrative Code.

(D) Additional provisions.

(1) Coverage limits that have been established may be exceeded, with prior authorization, for medically necessary services rendered to medicaid-eligible individuals younger than twenty-one years of age.

(2) Separate payment may be made for additional medically necessary services rendered during, as part of, or as a result of a screening visit. Payment may be made to a provider for necessary follow-up services rendered at the time of the screening visit if the provider is qualified to perform them.

(3) In accordance with guidance issued by CMS in "EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents" (June 2014, found at http://www.medicaid.gov), when a screening examination indicates the need for further evaluation of a child's health, the child must be appropriately referred without delay for diagnosis, necessary treatment, and follow-up.

Replaces: Part of 5160-14-01, part of 5160-14-03, part of 5160-14-04, part of 5160-14-09


Effective: 11/1/2017
Five Year Review (FYR) Dates: 11/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 11/01/1985, 09/01/1987, 02/17/1991, 04/01/1992 (Emer), 07/01/1992, 01/15/1995, 01/04/2000 (Emer), 03/20/2000, 08/01/2001, 07/01/2003, 07/01/2006, 02/14/2011