N.J. Admin. Code § 10:58A-2.11 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a Federally mandated comprehensive child health program for Medicaid/NJ FamilyCare-Plan A beneficiaries under 21 years of age. The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) codified EPSDT. The term "EPSDT Services" means a preventive and comprehensive health program: for Medicaid and NJ FamilyCare--Plan A beneficiaries under 21 years of age for the purpose of assessing a beneficiary's health needs through initial and periodic examinations, health education and guidance and identification, diagnosis and treatment of health problems; for eligible NJ FamilyCare B and C enrollees, covering early and periodic screening and diagnostic medical examinations, dental, vision, hearing and lead screening services, and those treatment services identified through the examination that are available under the MCO contractor's benefit package or specified services under the FFS program (see N.J.A.C. 10:49-5.6). EPSDT service shall include, at a minimum, the following:

1. EPSDT Screening Services;

2. Vision Services;

3. Dental Services;

4. Hearing Services; and

5. Such necessary health care diagnostic services, treatment and other measures to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services. (See 42 CFR 441 Subpart B.)

(b) An APN who is certified in the advanced practice category of pediatrics or family health may provide EPSDT screening services.

(c) An EPSDT examination shall include the following:

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

2. A comprehensive unclothed physical exam including vision and hearing screening, dental inspection, and nutritional assessment;

3. Appropriate immunizations according to age and health history;

4. Appropriate laboratory tests, including, but not limited to:

i. Hemoglobin/hematocrit;

ii. Urinalysis;

iii. Tuberculin test (Mantoux);

iv. Lead screening using blood lead level determinations between 9 and 18 months of age, preferably at 1 year of age, once between 18 and 26 months of age, preferably at 2 years of age and for any child between 2 and 6 years of age not previously tested or at 6 months of age or younger, if indicated. At all other visits, screening shall consist of verbal risk assessment and additional blood lead level testing, if indicated; and

v. Other appropriate medically necessary procedures.

5. Health education, including anticipatory guidance;

6. Vision screening:

i. A newborn examination including general inspection of the eyes, visualization of the red reflex, and evaluation of ocular motility;

ii. An appropriate medical and family history;

iii. An evaluation, by age six months, of eye fixation preference, muscle imbalance, and pupillary light reflex; and

iv. A repeat eye examination and visual screening with visual acuity testing by age three or four years.

v. Periodic vision testing for school aged children:

(1) Kindergarten or first grade (five or six years);

(2) Second grade (seven years);

(3) Fifth grade (10/11 years);

(4) Eighth grade (13/14 years); and

(5) Tenth or eleventh grades (15/17 years).

vi. Referral for vision screening by an optometrist or ophthalmologist if the child:

(1) Cannot read the majority of the 20/40 line before their fifth birthday;

(2) Have a two-line difference of visual acuity between the eyes;

(3) Have suspected strabismus; or

(4) Have an abnormal light or red reflex.

7. Hearing screening:

i. Newborn hearing screening, including risk assessment;

ii. Individual hearing screenings shall be included in all EPSDT periodic examinations.

iii. Audiometric testing shall be administered annually to all children between three and eight years of age. At age eight, children shall be tested every other year.

8. Dental screening:

i. Intraoral examination included as an integral part of a general physical examination;

ii. A formal referral to a dentist at one year of age (recommended) and mandatory for children three years of age and older;

iii. Dental inspection and prophylaxis every six months until 17 years of age, then annually.

9. Referral for further diagnosis and treatment or follow up of all correctable abnormalities, uncovered or suspected. Referral may be to the provider conducting the screening examination, or to another provider, as appropriate.

(d) Children two years of age and older are provided preventive health care services through the EPSDT program while under 21 years of age. In addition, Medicaid/NJ FamilyCare fee-for-service providers who have not been certified as HealthStart Pediatric Providers use the EPSDT procedure codes for preventive health care services for children from birth through age two when the requirements for the EPSDT examination have been met. The following schedule reflects the ages at which children shall be provided EPSDT screening:

1. Under six weeks;

2. Two months;

3. Four months;

4. Six months;

5. Nine months;

6. 12 months;

7. 15 months;

8. 18 months;

9. 24 months; and

10. Annually through age 20.

(e) Reimbursement policy for EPSDT services:

1. Each periodic EPSDT screening shall be billed only once for the same patient by the same clinical practitioner(s) sharing a common record.

2. Reimbursement for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) examination is contingent upon the submission of a completed "Report and Claim for EPSDT/HealthStart Screening and Related Procedures (MC-19)" within 30 days of the date of service.

3. Laboratory, other diagnostic procedures and immunizations shall be eligible for separate reimbursement. (See N.J.A.C. 10:58A-4)

Notes

N.J. Admin. Code § 10:58A-2.11

Recodified from N.J.A.C. 10:58A-2.10 by R.1999 d.232, effective 7/19/1999 (operative September 1, 1999).
See: 31 N.J.R. 245(a), 31 N.J.R. 1956(a).
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
In (a), substituted a reference to Medicaid and NJ KidCare-Plan A beneficiaries for a reference to Medicaid recipients; and in (d), inserted a reference to NJ KidCare fee-for-service providers in the introductory paragraph.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Rewrote (b).
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
In (b), changed "pediatric" to "pediatrics"; in (e)1, added "clinical" preceding "practitioner(s)."
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Section was "Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)". Rewrote the introductory paragraph of (a); in (b), substituted "APN" for "advanced practice nurse"; in the introductory paragraph of (c)4, inserted ", but not limited to"; in (c)4iii, deleted ", annually" from the end; rewrote (c)4iv; in the introductory paragraph of (c)6, substituted "screening" for "services"; in (c)6iv, substituted "repeat eye" for "second" and inserted "and visual screening"; in (c)6vi, substituted "by an optometrist or ophthalmologist if the child" for "of children who"; in the introductory paragraph of (c)7, substituted "screening" for "Services"; rewrote (c)7ii and (c)7iii; in the introductory paragraph of (c)8, substituted "screening" for "Services"; in the introductory paragraph of (d), inserted "while under 21 years of age"; and in (e)3, deleted a comma following "procedures" and updated the N.J.A.C. reference.