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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

V

Health Services

Chapter:

A

Health Services

5-10-2004

Subchapter:

3

Medicaid

Issuance:

800

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

 

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)         5-10-2004

 

EPSDT is Medicaid's comprehensive and preventive child health program for children birth through age 21 who are eligible for Medicaid and are enrolled in fee-for-service or managed care plans.  This program provides regular medical checkups, dental checkups, treatment and services, at no cost, to children birth through age 21, including those who are in an out-of-home placement paid for by CP&P.  Managed care plans provide different EPSDT benefit levels.  The level of service provided is dependent on family income.  Questions about EPSDT coverage levels under Medicaid managed care should be directed to the Division of Medical Assistance and Health Services' Hotline at 1-800-356-1561.

 

Medicaid fee-for-service and all Medicaid contracted Health Maintenance Organizations (HMO's) are required to provide EPSDT services.

 

Purpose        5-10-2004

 

The goal of EPSDT is to:

 

·         Assess a child's healthcare needs through initial and periodic examinations (screenings);

 

·         Provide health education and guidance;

 

·         Prevent and/or diagnose health problems as early as possible; and

 

·         Provide treatment and referral services as necessary.

     

Eligibility       5-10-2004

 

EPSDT services are immediately available to a child under CP&P supervision when:

 

·         The child is under 21 years of age and residing in an out-of-home placement paid for by CP&P;

 

·         The child is determined eligible for the Medicaid Code 60 program.  See CP&P-V-A-2-200 , Children Eligible for the Medicaid Code 60 Program Through CP&P; and

 

·         The child is receiving Medicaid through another source, such as NJ Family Care or SSI.

 

A child enrolled in the Medicaid Code 65 program is not eligible for EPSDT services.  See CP&P-V-A-4-100, Code 65 Medical Services.

 

Role of the CP&P Worker             5-10-2004

 

The CP&P Worker is responsible for:

 

·         Determining Medicaid eligibility;

 

·         Completing the line of service (LOS);

 

·                                 Informing the caregiver and child about EPSDT services;

 

·         Providing the caregiver with the bilingual Division of Medical Assistance and Health Services (DMAHS) flyer regarding EPSDT services;

 

·         Assuring the child receives age appropriate EPSDT services;

 

·         Providing the caregiver with the CP&P Form 11-10, Health Passport and Placement Assessment, to give to the health care provider;

 

·         Assisting the caregiver in providing all health related information and health related history known about the child to the health care provider;

 

·         Assisting the caregiver and child in scheduling medical examinations, if requested by the caregiver; and

 

·         Assisting the caregiver and child with transportation to obtain medical services, if requested by the caregiver.

 

Click here to view the bilingual DMAHS flyer regarding EPSDT services.

 

Rights of CP&P Caregiver/Child Eligible for EPSDT Services      5-10-2004

 

A caregiver and child have the same rights in regard to the EPSDT program as they do throughout the Medicaid program.  These rights include the right to refuse service, to choose the service provider, and to nondiscriminatory service provision.

 

Caregivers receiving board payments from CP&P may not refuse to cooperate with the agency's health care program.  Any situation in which a caregiver refuses to cooperate with the EPSDT program must be reported to the Supervisor and/or Casework Supervisor for resolution.  Supervisors and/or Casework Supervisors must advise their Resource Family Support Unit and the Office of Licensing when a resource parent demonstrates continued resistance to participate in the EPSDT program.  Repeated resistance to participate in the EPSDT program may result in the closure of the resource parent's home.

 

EPSDT Services     5-10-2004

 

A child eligible for the Medicaid Code 60 program receives the following age appropriate EPSDT services:

 

·         Comprehensive health and developmental history assessments;

 

·         Developmental assessments to determine whether a child's developmental processes fall within a normal range of achievement according to age group and cultural background of the child;

 

·         Comprehensive unclothed physical examinations including vision, hearing and dental screenings and nutritional assessments;

 

·         Appropriate immunizations for children according to age, health history and the schedule established by the Centers for Disease Control and Prevention, National Immunization Program;

 

·         Vision services, including eyeglasses;

 

·         Hearing services, including hearing aids;

 

·         Dental services, including examination and treatment by a dentist;

 

·         Blood lead poisoning risk assessment and screening;

 

·         Laboratory and other diagnostic tests, including hemoglobin and hematocrit, urinalysis, tuberculin, and other tests as may be appropriate and medically necessary;

 

·         Age-appropriate health education and anticipatory guidance to caregivers and children;

 

·         Referrals for further diagnosis and treatment or follow-up of all identified health needs that are treatable/correctable or require maintenance or therapy; and

 

·         Referrals to the Special Supplemental Food Program for Women, Infants and Children (WIC) for children under five years of age and for pregnant and lactating women.

 

Schedule of EPSDT Screenings                        5-10-2004

 

Frequent checkups are important at early ages.  Every child should receive an EPSDT examination as follows:

 

·         Birth;

 

·         Under six weeks old;

 

·         Two months;

 

·         Four months;

 

·         Six months;

 

·         Nine months;

 

·         Twelve months;

 

·         Fifteen months;

 

·         Eighteen months;

 

·         Twenty-four months; and

 

·         Then once each year through 21 years of age.

 

See CP&P-V-A-1-250 regarding CP&P policy concerning children's physical examinations.

 

Informing the Caregiver and Child about EPSDT Services            5-10-2004

 

The CP&P Worker is responsible for informing the caregiver and child about the EPSDT program and services.  When informing the caregiver and child about the EPSDT program and services, the Worker presents the EPSDT information in a manner that is culturally sensitive and considers any disability the caregiver or child may have.  The Worker informs the caregiver and child of the following:

 

·         The benefits of preventive health services (such as early identification of health problems and prevention of disability);

 

·         How and where EPSDT services can be obtained;

 

·         Screening services that are offered under the EPSDT program;

 

·         Summary of the EPSDT screening schedule;

 

·         That the child should receive EPSDT screenings according to the EPSDT screening schedule;

 

·         That the treatment services identified through screenings will be covered by Medicaid;

 

·         That the Worker provides assistance with transportation, if the caregiver or child requests it;

 

·         That the Worker assists in scheduling appointments if the caregiver or child requests it;

 

·         That as long as the child remains eligible for the Medicaid Code 60 program or other Medicaid program's, such as NJ Family Care or SSI (not including Code 65 Medical Services Program), the child may access EPSDT services;

 

·         That the caregiver or child may choose to receive EPSDT from a Medicaid Contracted Health Maintenance Organization (HMO) provider of their choice, and if the provider does not offer the full range of EPSDT services as specified in the plan, the Worker will assist in finding a provider who offers EPSDT services; and

 

·         That EPSDT services, including treatment, are available at no cost.

 

The Worker informs the caregiver and child of EPSDT services when:

 

·         A child is determined eligible and newly enrolled in the Medicaid Code 60 program;

 

·         At the time of placement; and

 

·         When a child is due to have an appointment according to the EPSDT screening schedule.

 

Support Services and Arranging the EPSDT Examination                        5-10-2004

 

Support services such as arranging transportation or scheduling medical examinations are offered to the caregiver and child to facilitate EPSDT services.  The Worker only provides transportation for the caregiver and child when no other means of transportation is available to take the child to a medical care provider. 

 

Procedures Related to Participating in EPSDT         5-10-2004

 

RESPONSIBILITY

ACTION REQUIRED

 

 

Worker

1.    Determine child's eligibility for Medicaid Code 60 Program.

 

Clerk/Worker

2.    Complete line of service (LOS), enrolling child in the Medicaid 60 Program.

 

Worker

3.    Inform, in person, the child and caregiver about EPSDT services and:

 

      Provide bilingual DMAHS flyer to the child and caregiver regarding the EPSDT program. Click here to view the bilingual DMAHS flyer;

 

      Advise the child and caregiver of the benefits of preventive health care and that EPSDT screening is due according to the screening schedule;

 

      Offer support services including assistance in scheduling appointments; and

 

      Give the Health Passport and Placement Assessment, CP&P Form 11-10, to the person taking the child to the screening examination.

 

Caregiver/Worker

4.    Take the child to the health care provider.

 

5.    Take the child to see a dentist. Recommended at age 1, mandatory at age 3.

 

6.    Give the health care provider the CP&P Form 11-10.