PURPOSE: This rule establishes the basis and criteria for payment of screenings and related services resulting from the Early Periodic Screening, Diagnosis and Treatment Program.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

1. (1) The Department of Social Services shall administer an Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program. In Missouri, the EPSDT Program is administered as the Healthy Children and Youth
2. (HCY) Program. The EPSDT/HCY Program provides for thorough physical and dental examinations for Medicaid-eligible persons under the age of twenty-one (21) years, for persons under the age of twenty-one (21) years who are eligible for General Relief benefits and for all persons under the age of twenty-one (21) years in the legal custody of the Department of Social Services or any division of the department at no cost to the child or to the parents or guardians if they accept the offer of this service. Funding for EPSDT services is through Title XIX of the federal Social Security Act (Medicaid) and Missouri.
3. (2) EPSDT services are available to recipients under the age of twenty-one (21) years who are eligible to receive medical assistance benefits under the provisions of sections 208.151, 208.162 and 208.204, RSMo.

4. (3) The EPSDT Program shall make a general physical examination available to eligible recipients under the age of twenty-one (21) years. The components of the general physical examination shall include a health history, an unclothed physical examination, appropriate laboratory tests, immunizations, a developmental/mental health screen, a vision screen and a dental screen. These screens will be made available at the frequency recommended by the American Academy of Pediatrics and the American Academy of Pediatric Dentists.

   1. (A) Interperiodic screenings outside the recommendations of the American Academy of Pediatrics or the American Academy of Pediatric Dentists are available when medically indicated.
   2. (B) Partial screens for vision, hearing, dental, unclothed physical examination, an interval history and appropriate laboratory tests and immunizations, developmental/mental health assessment and anticipatory guidance shall be reimbursable services.
5. (4) Providers of the screening services must be enrolled Medicaid providers. 13 CSR 70-25
6. (5) Reimbursement for medically necessary treatment services identified as a result of a screening shall be provided by the Department of Social Services, Division of Medical Services, if the services are available under Section 1905(a) of the Social Security Act. These services shall be limited by medical necessity. Experimental services are not covered. Any service authorized must be effective in addressing the recipient’s need. Services may be prior-authorized to assure medical necessity.
7. (6) Medical and dental services which Section 1905(a) of the Social Security Act permits to be covered under Medicaid and which are necessary to treat or ameliorate defects, physical and mental illness or conditions identified by an EPSDT screen are covered regardless of whether or not the services are covered under the Medicaid state plan. Services provided under this program will be sufficient in amount, duration and scope to reasonably achieve their purpose. The services are limited due to medical necessity. Services identified as needed as the result of a screening which are beyond the scope of the Medicaid state plan require a plan of care identifying the treatment needs of the child in regard to amount, scope and prognosis. Prior authorization of services may be required for these services needs and for services of extended duration unless otherwise noted in the benefits and limitations section of the provider manual of the appropriate provider of the service. Examples of services beyond the scope of the state Medicaid Plan are— orthodontic services; physical, occupational and speech therapy evaluations and services; psychology and counseling services; private duty nursing services; and medical supplies. Services may be made available on an inpatient, outpatient office or home setting depending upon the medical condition of the recipient and availability of services.
8. (7) Services must be provided by enrolled Medicaid providers operating within their legal scope of practice.

AUTHORITY: sections 208.152, RSMo Supp. 1990, 208.153, RSMo Supp. 1991 and 208.201, RSMo Supp. 1987.* This rule was previously filed as 13 CSR 40-81.015. Original rule filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed Jan. 13, 1992, effective Sept. 6, 1992. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; and 208.201, RSMo 1987.