Dokes v. Arkansas Petition for a Writ of Certiorari to the Supreme Court of Arkansas

    MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

19-610 IN GENERAL 

A. Screening, Diagnosis and Treatment of Physical and Mental Defects 
Tor Individuals Under 21 

The Medicaid (Title XIX) Program provides early and periodic 
screening and diagnosis to ascertain physical and mental defects, 
and treatment of conditions discovered within the limits of the 
medical assistance program. These services are available to all 
eligible individuals under 21 years of age, as are eyeglasses, 
hearing aids, other kinds of treatment Tor visual and hearing 
defects, and dental care as is necessary for relief of pain and 
infection and for restoration of teeth and maintenance of dental 
health. : 

The Department of Health and Hospitals (DHH) is responsible for 
administering the EPSDT program under Title XIX. For recipients 
in private and state-operated ICF/H facilities, the Regional 
Office Staff is responsible for performing EPSDT referrals for 
dental services, eyeglasses and other appliances. 

Rev.* 

ou : 
B. Definitions 

(1) Request for EPSDT services may be an unsolicited inquiry by a 
client for services, or a positive response by a client to an 

Rev.¥ inquiry or an offer of screening services. (NOTE: A 
Medicaid eligible woman's positive response to an -offer of 
EPSDT services during her medically confirmed pregnancy, . 
consitutes a request for services for the unborn child.” The 

yi request becomes effective on the date the child's eligibility 
*¥* is determined.) 

(2) Screening is the use of a quick, simple procedure carried out 
among large groups of people to sort out apparently well 
persons from those who have a disease or abnormality and to 
identify those in need of more definitive study of their 
physical or mental problems. The presence of a physician is 
not required during the screening procedure. Medical 

screenings may be performed by either a physician or a nurse. 
(3) Diagnosis is the determination of the nature or cause of 

physical or mental disease or abnormality through the 
combined use of health history, physical, developmental and 
psychological examination, and laboratory tests and X-rays. 
Although in some instances a presumptive diagnosis may be 
made at the time of screening, it will usually be necessary 
to refer the patient to the appropriate practitioner or 
medical facility for definitive evaluation. 

PART XVIII. EARLY AND PERIODIC SCREENING 
~——DIAGNOSIS AND TREATMENT PROGRAM (EPSDI) 
  

  

  

  

  

  

  

  

  

Reissued January 1, 1989 Page 1 of 19-6710 

Replacing January 1, 1983 issue A 

 



    

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

Rev.¥ 

¥* ¥* 

(4) Treatment means physician's or dentist's services, 
optometrist's or audiologist's services, hospital services 
(inpatient or outpatient), clinic services, laboratory and 
X-ray services; prescribed drugs, eyeglasses, hearing aids, 
prosthetic or orthotic devices, rehabilitation services 
including physical therapy, occupational therapy, speech 
pathology and audiology services to prevent, correct or 
ameliorate disease or abnormalities detected by screening and 
diagnostic procedures, and limited to Louisiana Medicaid 
Program for medical services. 

  

(5) Early means, in case of a family already receiving 
assistance, as early as possible in the child's life; or as 
soon as a family's eligibility for assistance has been 
established. 

(6) Periodic means at intervals established for screening by 
medical, dental and other health care experts at appropriate 
periods of time to assure that disease or disability is not 
incipient or present. 

  

(7) Informing means a face-to-face interview to explain the EPSDT 
program to applicants, followed by written information via 
Form EPSDT-5. At the time of certification, an offer will be 
made via Form EPSDT-8. Information about the EPSDT program 
is mailed annualy thereafter, with the Medicaid card. OED 
shall effectively inform those individuals who are blind or 
deaf, or who cannot read or understand the English language. 

  

(8) 60 Day Count is the time period in which newly-certified 
recipients must be informed and offered EPSDT, with the count 
beginning on the date Form 51-F is signed by the worker. 

  

(9) 120 Day Count is the time period in which the initial EPSDT 
Screening must be completed, with the count beginning on the 
date that EPSDT services are requested. ; 

  

(10) 180 Day Count is the time period in which medical treatment 
of a condition discovered at a screening must be initiated, 
with the count beginning on the date that EPSDT services are 
requested. 

  

Screening Providers 
  

EPSDT medical screenings are provided by all Public Health Units 
(except in Plaquemine and Orleans parishes), by New Orleans City 
Health Department, and by School Nurses in parishes whose school 
boards have contracted with DHH to provide screenings for specific 
age groups of school children. For parishes which do not have 
school board contracts, all screenings are done by Health Units 
(ages 0-21). For EPSDT eligibles who are too young or too old to 
be screened under school board contracts, screenings are done by 
Health Units (for Orleans Parish only - New Orleans City Health 
Department). 

  

Tssued January 1, 1939 Page 2 of 19-010 

 



  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

  

  

Rev.* 
>. D. Dental Referrals 

All dentists enrolled as providers in the Medical Assistance 
Prosnan may provide yearly dental screening to recipients age 3 to 

1 ° z 

E. Medical Screenings by Location/Age 

In parishes in which the local Health Unit is the sole EPSDT 
screening provider, all children from birth to age 21 are screened 

at the Health Unit. 

In Orleans Parish, New Orleans City Health screens all children 

age 0 to 5, and older children not in school up to age 21; the 

Orleans Parish School Nurse Program screens all children in 

school. 

The School Nurse Program screens all children in school ages 5 
through 20 in the following twelve parishes: 

Ascension Ouachita 
Avoyelles : Pointe Coupee 
Caddo : St. John 
Iberia : St. Mary 

Jefferson St. Tammany 
Orleans Tangipahoa 

7 The School Nurse Program in Plaquemines Parish screens children in 

hs school aged 4 through 20. 

The School Nurse Program in Natchitoches Parish screens children 
Sa in school, ages 8 through 20. 

19-611 WHO IS ELIGIBLE 
  

All persons who are under 21 years of age and identified in Section 
19-105 A are eligible for EPSDT services. 

19-612 IDENTIFICATION OF ELIGIBLES 
  

Persons eligible for EPSDT services are identified by an asterisk 

which is placed by their name on the Louisiana Medical Eligibility 

Card, Form 9. 

19-613 STEPS TO BE TAKEN IN ARRANGING FOR EPSDT SERVICES 
  

  

  

Rev .¥ 
A. Local Office Responsibility 

; {9 Informing/Offering 

The OED parish office will inform and offer EPSDT services so 

as to comply with federal regulations that all newly-made 

eligibles are informed and offered EPSDT services within the 
60-day count, as follows: 

Reissued January 1, 1989 19-610; 19-613 

Replacing January 1, 1383 issue 

 



     
MEDICAL VENDOR PAYMENTS Early and Periodic Screening 

Diagnosis and Treatment 

  

a. Make a face-to-face contact to explain the EPSDT services 
at application, or at reapplication after closure. 
Applicants who go on and off the rolls must be informed 
at least one time in a 12 month period. 

b. Obtain a parental consent form (in contract school board 
parishes only) from all applicants at application or 
at reapplication after closure. 

c. Give Form S5-EPSDT (written information on EPSDT services) 

to all applicants at application or reapplication after 

closure. : 

d. Complete Form EPSDT-8 to explain that all persons to be 
screened at local Health Units and at New Orleans City 

Health Department shall make their own appointments. The 
form will be completed by the parish with information 
needed for recipients to make their own appointments. 
Information on the form should contain specific addresses 
and telephone numbers needed to request EPSDT services. 

Mail Form EPSDT-8 (offer of EPSDT services) with each 
certification notice or notice of the addition of a 
person to the certification. 

In School Nurse Program parishes, Form EPSDT-8 will 
explain that the recipient requ=sting EPSDT services will 
contact the OED office; the OED office will make the 
referral to the School Nurse Program. 

e. Complete referral by Form 23-EPSDT, with Parental Consent 
Forms attached, to contract School Nurse Program when 
recipient requests a referral. Form 23-EPSDT will serve 
both as a referral and as documentation of acceptance of 
services. 

. f. Assist any client who contacts OED with questions about 
EPSDT servics. 

In no instance shall OED make a referral to a screening 
provider without the client's verbal or written request. 

When a recipient contacts the OED office to request an 
EPSDT screening of a school aged child in one of the 
contract School Nurse Program parishes, the designated 
OED employee shall complete Form 23-EPSDT. Form 23-EPSDT 
documents the date of acceptance of services, which 
begins the 120 and 180 days counts for completion of a 
screening and initiation of treatment. 

B. Documentation 
  

Complete and maintain documentation of informing, offer, and 
Jo0Sptanee of EPSDT services by filing in case record copies as 
ollows: 

  

Reissued January 1, 19837 Page 2 of 19-013 

Replacing November 1, 1987 issue 

 



     
MEDICAL VENDOR PAYMENTS Early and Periodic Screening 

Diagnosis and Treatment 

  

Informing: Form OFS-U4; Form 5-EPSDT 
Offer: Form EPSDT-8 
Acceptance: Form 23-EPSDT to School Nurse program 

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Providers are responsible for documentation as follows: 

1. Contract School Nurse Programs shall retain original Form 
23-EPSDT documenting date of acceptance of the service. 

5. Health Units and New Orleans City Health Department shall 

retain records documenting the date of initial contact by the 

recipient who accepts the service by requesting an appointment 

for EPSDT screening. Upon failure of the first appointment, 

all attempts to schedule a second appointment shall be 

documented. 

C. Denial of Services 
  

Failure to contact the OED office and/or appropriate provider to 

schedule an appointment subsequent to mailing of Form EPSDT-8 

shall constitute denial of that particular service offer. 

D. Transportation 
  

: OED will arrange transportation when possible to EPSDT 

#4 appointments for clients who request transportation. 

E. HEAD START RESPONSIBILITIES 
  

(1) Head Start will explain the EPSDT Program to the parents of 

children whom have determined to be Medicaid eligible. 

(2) Head Start will provide each EPSDT medical screening provider 

with a list of EPSDT eligible children enrolled in the Head 

Start Programs. The list shall contain the following 

information: : 

(a) Child's name 

(b) Date of birth 

(¢) Address 

(d) Parents or guardians' name 

(e) Medicaid eligibility number. 

(3) Head Start will refer to the appropriate screening provider 

the parents of those EPSDT/Head Start children whom the 

health facility has not screened previously through the EPSDT 

Program. The parent in this manner may request in person, by 

telephone or by letter, that the child(ren) be scheduled for 

an initial screening. 

  

Issued January 1, 1989 Page 3 of 19-013 

 



    
  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening 
Diagnosis and Treatment 

  

(4) Head Start will provide a signed parental consent form for 

release of data secured by OPHS and the New Orleans City 

Health Department during an EPSDT screening. 

(5) Head Start, upon notification of the child's appointment for 

the initial or periodic screening, will provide 

transportation and any other social services which may be 

required for the child to keep the scheduled appointment. 

(6) Head Start, upon notification by the medical screening 

provider of an appointment for diagnosis and/or treatment 

will provide medical transportation and any other social 

services to the EPSDT/Head Start child so that the 

appointment may be kept. 

(7) Head Start will advise the medical screening provider as to 

whether diagnostic and treatment appointments are Kept and if 

not kept, the reasons for their not being kept. 

(8) Head Start will be responsible for follow-up with the parent 

of EPSDT/Head Start children to assure that future medical 

appointments are kept. 

(9) Head Start will provide, at no cost to OED, screening 
procedures to EPSDT/Head Start eligibles not required by 

Louisiana EPSDT screening guidelines, but required in the 
Head Start Performance Guidelines. 

19-614 COVERED SERVICES 
  

A. Medical Screening 
  

The following are components of a medical screening: 

; A comprehensive physical, mental, and developmental history 

is obtained on first visit and updated at subsequent visits. 

A developmental questionnaire is administered. 

2. A comprehensive unclothed physical exam is completed at each 

visit to screen for obvious physical defects (orthopedic 

disorders, hernia, skin disease, genital abnormalities). 

a) height/weight, head circumference check 
b) heart and lungs check 
c) eye, ear, nose, throat check 
d) blood pressure check 

2 Immunization status is checked. Referrals for immunizations 

are made or immunizations are completed if not up to date. 

  

Issued January 1, 19389 19-613; 19-014 

 



     
MEDICAL VENDOR PAYMENTS Early and Periodic Screening 

Diagnosis and Treatment 

  

4, Vision screening 

5. Hearing screening 

Lab tests 

a) anemia screening 
b) sickle cell disease/trait screening 
¢c) urine screening 
d) lead poisening screening 
e) PKU/hyperthyroid screening 

7. Nutritional assessment 

Medical Screening Provider Follow-up/Periodicity Responsibility 
  

Medical screening providers shall screen children within 120 days 

from request for the initial screening. If a condition needing 

further diagnosis and/or treatment is found during the screening, 

it is the responsibility of the medical screening provider to make 

the referral, assist with the appointment scheduling and assure 

the child is treated within 180 days of the request for a 

screening. The medical screening provider will also be 

responsible for recalling the child for the next periodic 

screening once they have initially screened the child in 

accordance with the following schedule: 

within the 1st month of life 
between 2 months and 3 months of age 
between 6 months and 7 months of age 
between 8 months and 13 months of age 
within 60 days before or after the birth date at age 2 
within 60 days before or after the birth date at age 3 
within 120 days before or after the birth date at ages 5, 8, 

11, MW, 17, and 20, 

Dental Screening 
  

All children between ages 3 and 21 should receive an annual dental 

screening. Referrals of children under 3 years of age may be made 

on the basis of determinations by physicians and auxiliary 

personnel of their judgment of need for diagnosis and treatment by 

a dentist. 

Dental appointments may be made by the recipient contacting a 

dental provider directly. Parish OED Offices should maintain 

printouts of active dental providers and furnish their names to 

recipients upon request. 

  

Reissued January 1, 1989 Page 2 of 19-014 

Replacing July 1, 1977 issue 

 



     
MEDICAL VENDOR PAYMENTS Early and Periodic Screening 8 

Diagnosis and Treatment 

  

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\ 

C. Eyeglasses and Contact Lenses 
  

For children who are determined to need eyeglasses, EPSDT will 
reimburse at a set fee schedule for most eyeglasses without prior 
approval. Eyeglasses which are an exception, or contact lens 
requests, require prior authorization by DHH. Special eyeglasses 
or contact lenses denied by DHH for a foster child may be obtained 
through Foster Care funds upon request and approval by the Foster 
Care worker. 

D. Drugs 

Drugs are covered to the extent of coverage by the Medical 
Assistance Program. 

  

Issued January 1, 1989 Page 3 of 19-014