California Code of Regulations
Title 22 - Social Security
Division 3 - Health Care Services
Subdivision 1 - California Medical Assistance Program
Chapter 3 - Health Care Services
Article 4 - Scope and Duration of Benefits
Section 51340 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services and EPSDT Supplemental Services
Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) EPSDT screening services as defined in Section 51184(a)(1) are a program benefit when provided through the Child Health and Disability Prevention program in accordance with Title 17, California Code of Regulations, Sections 6800 et seq. EPSDT screening services as defined in Sections 51184(a)(2) and (a)(3) are covered when provided by a certified Medi-Cal provider meeting the requirements of this chapter, if such services are otherwise reimbursable under the program.
(b) EPSDT diagnosis and treatment services as defined in Section 51184(b) are covered subject to the provisions of this chapter.
(c) Unless otherwise specified in this Chapter, EPSDT supplemental services are covered subject to prior authorization if the requirements of subsections (e) or (f), as appropriate, are met. The Department shall review requests for services resulting from EPSDT screening services for compliance with this section whether the screen was performed by a Medi-Cal provider or a non-Medi-Cal provider.
(d) Requests for prior authorization for EPSDT supplemental services pursuant to subsection (c) shall state explicitly that the request is for EPSDT supplemental services, and shall be accompanied by the following information:
(e) EPSDT supplemental services must meet one of the following standards, as determined by the Department:
(f)
(g) If reimbursement is being sought on a "by report" basis, a description of the service, the proposed unit of service, and the requested dollar amount shall be included with the request for authorization. A "by report" service or item is any service for which a maximum allowance has not been established because the item is rarely billed to the Medi-Cal program or because the service is unusual, variable or new.
(h) EPSDT supplemental services requested as a result of EPSDT screening services are exempt from the benefit limitations in Section 51304, and may be covered subject to prior authorization as defined in Section 51003 if the requirements of subsection (e) of this section are met.
(i) Regardless of the source of the referral for the service, requests for EPSDT diagnostic and treatment services and EPSDT supplemental services pursuant to the requirements of this chapter shall be reviewed pursuant to this section.
(j)
(k) For members of Medi-Cal managed care plans, the Medi-Cal managed care plan shall determine whether EPSDT case management services are medically necessary based on subsection (f). If the plan determines EPSDT case management services are medically necessary, the plan shall refer the members to an appropriate EPSDT case manager described in paragraph (h)(1) or (h)(2) of Section 51184. Services shall first be sought pursuant to paragraph (j)(1). If services are not available pursuant to paragraph (j)(1), the plan shall provide, or arrange and pay for, the EPSDT case management services. For purposes of this subsection, Medi-Cal managed care plan means any entity that has entered into a contract with the Department to provide, or arrange for, comprehensive health care to enrolled Medi-Cal beneficiaries pursuant to Chapter 8 or Articles 2.7, 2.8, 2.9 and 2.91 of Chapter 7 of Part 3, Division 9, of the Welfare and Institutions Code.
(l) The Department shall not approve an EPSDT supplemental service pursuant to this section if the Department determines that the service to be provided is accessible and available in an appropriate and timely manner as an EPSDT diagnostic and treatment service.
(m) The Department shall not approve a request for EPSDT diagnostic and treatment services or EPSDT supplemental services in home and community-based settings if the Department determines that the total cost incurred by the Medi-Cal program for providing such services to the beneficiary is greater than the total costs incurred by the Medi-Cal program in providing medically equivalent services at the beneficiary's otherwise appropriate institutional level of care, where medically equivalent services at the appropriate level are available in a timely manner.
1. New
section filed 2-27-75; effective thirtieth day thereafter (Register 75, No.
9).
2. Change without regulatory effect of NOTE (Register 86, No.
49).
3. Amendment of section heading, text, and NOTE filed 4-4-94 as
an emergency; operative 4-4-94 (Register 94, No. 14). A Certificate of
Compliance must be transmitted to OAL by 8-2-94 or emergency language will be
repealed by operation of law on the following day.
4. Amendment of
section heading, text and NOTE refiled 8-1-94 as an emergency; operative 8-1-94
(Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL
by 11-29-94 or emergency language will be repealed by operation of law on the
following day.
5. Editorial correction of printing errors in
subsections (d)(1), (e) and (i) (Register 94, No. 31).
6. Amendment
of section heading, text and NOTE refiled 10-24-94 as an emergency; operative
10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted
to OAL by 2-21-95 or emergency language will be repealed by operation of law on
the following day.
7. Amendment of section heading, text and NOTE
refiled 2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of
Compliance must be transmitted to OAL by 6-22-95 or emergency language will be
repealed by operation of law on the following day.
8. Certificate of
Compliance as to 2-22-95 order including amendment of section heading and
section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No.
17).
9. Amendment of subsection (c) and amendment of NOTE filed
4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate
of Compliance must be transmitted to OAL by 8-11-99 or emergency language will
be repealed by operation of law on the following day.
10. Amendment
of subsection (c) and amendment of NOTE refiled 8-5-99 as an emergency;
operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be
transmitted to OAL by 12-3-99 or emergency language will be repealed by
operation of law on the following day.
11. Certificate of Compliance
as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register
2000, No. 2).
Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14059 and 14132, Welfare and Institutions Code; Sections 306- 309, Health and Safety Code; and 42 U.S.C. 1396d(r).