The benefit package includes the delivery of the federally
mandated EPSDT services ( 42 CFR Part 441, Subpart B) provided by a primary
care provider (PCP) as detailed in 8.320.2 NMAC. The MCO shall provide access
to early intervention programs and services for a member identified in an EPSDT
screen as being at-risk for developing or having a severe emotional, behavioral
or neurobiological disorder. Unless otherwise specified in a service rule,
EPSDT services are for a member under 21 years of age. For detailed description
of each service, see 8.320.2 NMAC. EPSDT behavioral health services are
included in
8.308.9.19 NMAC.
A.
EPSDT nutritional counseling and
services: The benefit package includes nutritional services furnished to
a pregnant member and a member under 21 years of age as detailed in
8.310.2
NMAC.
B.
EPSDT personal
care: The benefit package includes personal care services for a
member.
C.
EPSDT private duty
nursing: The benefit package includes private duty nursing for a member
and the services shall be delivered in either his or her home or school
setting.
D.
EPSDT
rehabilitation services: A member under 21 years of age who is eligible
for home and community based waiver services receives medically necessary
rehabilitation services through the EPSDT program; see
8.320.2 NMAC for a
detailed description. The home and community-based waiver program provides
rehabilitation services only for the purpose of community
integration.
E.
Services
provided in schools: The benefit package includes services to a member
provided in a school, excluding those specified in their individual education
plan (IEP) or the individualized family service plan (IFSP); see
8.320.6
NMAC.
F.
Tot-to-teen health
checks:
(1) The MCO shall adhere to the
MAD periodicity schedule and ensure that each eligible member receives
age-appropriate EPSDT screens (tot-to-teen health checks), referrals, and
appropriate services and follow-up care. See
8.320.2 NMAC for detailed
description of the benefits. The services include, but are not limited to:
(a) education of and outreach to a member or
the member's family regarding the importance of regular screens and health
checks;
(b) development of a
proactive approach to ensure that the member receives the services;
(c) facilitation of appropriate coordination
with school-based providers;
(d)
development of a systematic communication process with MCO network providers
regarding screens and treatment coordination;
(e) processes to document, measure and assure
compliance with MAD's periodicity schedule; and
(f) development of a proactive process to
insure the appropriate follow-up evaluation, referral and treatment, including
early intervention for developmental delay, vision and hearing screening,
dental examinations and immunizations.
(2) The MCO will facilitate appropriate
referral for possible or identified behavioral health conditions. See
8.321.2
NMAC for EPSDT behavioral health services descriptions.
