Ariz. Admin. Code § R9-22-213 - Early and Periodic Screening, Diagnosis, and Treatment Services (E.P.S.D.T.)

A. The following E.P.S.D.T. services are covered for a member less than 21 years of age:

1. Screening services including:

a. Comprehensive health and developmental history;

b. Comprehensive unclothed physical examination;

c. Appropriate immunizations according to age and health history;

d. Laboratory tests; and

e. Health education, including anticipatory guidance;

2. Vision services including:

a. Diagnosis and treatment for defects in vision;

b. Eye examinations for the provision of prescriptive lenses;

c. Prescriptive lenses; and

d. Frames.

3. Hearing services including:

a. Diagnosis and treatment for defects in hearing;

b. Testing to determine hearing impairment; and

c. Hearing aids;

4. Dental services including:

a. Emergency dental services as specified in R9-22-207;

b. Preventive services including screening, diagnosis, and treatment of dental disease; and

c. Therapeutic dental services including fillings, crowns, dentures, and other prosthetic devices;

5. Orthognathic surgery;

6. Medically necessary, nutritional assessment and nutritional therapy as specified in contract to provide complete daily dietary requirements or supplement a member's daily nutritional and caloric intake;

7. Behavioral health services under 9 A.A.C. 22, Article 12;

8. Hospice services do not include home-delivered meals or services provided and covered through Medicare. The following hospice services are covered:

a. Hospice services are covered only for a member who is in the final stages of a terminal illness and has a prognosis of death within six months;

b. Services available to a member receiving hospice care are limited to those allowable under 42 CFR 418.202, October 1, 2006, incorporated by reference and on file with the Administration. This incorporation by reference contains no future editions or amendments;

c. Hospice services do not include:

i. Medical services provided that are not related to the terminal illness; or

ii. Home-delivered meals; and

d. Hospice services that are provided and covered through Medicare are not covered by AHCCCS;

9. Incontinence briefs as specified under R9-22-212; and

10. Other necessary health care, diagnostic services, treatment, and measures required by 42 U.S.C. 1396 d(r)(5).

B.Providers of E.P.S.D.T. services shall meet the following standards:

1. Ensure that services are provided by or under the direction of the member's primary care provider, attending physician, practitioner, or dentist.

2. Perform tests and examinations under 42 CFR 441 Subpart B, October 1, 2006, which is incorporated by reference and on file with the Administration. This incorporation by reference contains no future editions or amendments.

3. Refer a member as necessary for dental diagnosis and treatment and necessary specialty care.

4. Refer a member as necessary for behavioral health evaluation and treatment services.

C.Contractors shall meet other E.P.S.D.T. requirements as specified in contract.

D.A primary care provider, attending physician, or practitioner shall refer a member with special health care needs under R9-7-301 to CRS.

Notes

Ariz. Admin. Code § R9-22-213

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-213 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22-213 repealed, new Section R9-22-213 adopted effective October 1, 1983 (Supp. 83-5). Amended effective October 1, 1985 (Supp. 85-5). Amended effective December 13, 1993 (Supp. 93-4). Amended effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 13 A.A.R. 3272, effective September 11, 2007 (Supp. 07-3). Amended by final rulemaking at 20 A.A.R. 1949, effective 9/6/2014.