5160-14-01 Healthchek: early and periodic screening, diagnostic and treatment (EPSDT) mandatory services for medicaid recipients under twenty-one years of age.

(A) Definitions. The following definitions apply to Chapter 5101:3-14 of the Administrative Code:

(1) "Current procedural terminology" (CPT) has the same meaning as in Chapter 5101:3-1 of the Administrative Code.

(2) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit for all medicaid recipients under twenty-one years of age.

(3) "Healthchek services," also known as "EPSDT services," has the same meaning as in rule 5101:1-38-05 of the Administrative Code.

(4) "Medically necessary services" has the same meaning as in rule 5101:3-1-01 of the Administrative Code.

(5) "Prior authorization" for a member of a medicaid managed care plan is the process established by the medicaid managed care plan as required by rule 5101:3-26-05.1 of the Administrative Code. For all other medicaid recipients, prior authorization is the process outlined in rule 5101:3-1-31 of the Administrative Code.

(6) "Screening" means the identification of individuals at risk of health problems. Results of a screening do not represent a diagnosis, but rather may indicate the need for referral to an appropriate resource for additional evaluation, diagnosis, treatment, or other follow-up when concerns or questions remain as a result of the screening.

(B) Subject to the limitations of 42 U.S.C. 1396d(r) (1/1/2011), healthchek requires the coverage of the following screening services, described in Chapter 5101:3-14 of the Administrative Code:

(1) A comprehensive health and developmental history (including assessment of both physical and mental health development);

(2) A comprehensive unclothed physical examination;

(3) Appropriate immunizations;

(4) Appropriate vision testing;

(5) Appropriate laboratory tests; and

(6) Appropriate dental screenings.

(C) Healthchek requires coverage of all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) (1/1/2011) to correct or ameliorate defects and physical and mental illness and conditions discovered by a screening service described in paragraph (B) of this rule. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a) (1/1/2011) that are in excess of state medicaid plan limits applicable to adults. Nothing in Chapter 5101:3-14 requires healthchek to cover services or items that are not listed in 42 U.S.C. 1396d(a) (1/1/2011).

Replaces: 5101:3-14-01

Effective: 02/14/2011
R.C. 119.032 review dates: 02/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 9/1/87, 2/17/91, 8/1/01, 7/1/06