New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES
Section 10:52-2.4 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Universal Citation: NJ Admin Code 10:52-2.4

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a Federally-mandated comprehensive and preventive child health program for Medicaid/NJ FamilyCare-Children's Program fee-for-service beneficiaries from birth through 20 years of age (see 42 CFR 441 Subpart B). The goal of the program is to assess the beneficiary's health needs through initial and periodic examinations (screenings); to provide health education and guidance; and to assure that health problems are prevented, diagnosed, and treated at the earliest possible time.

1. As a condition of participation in Medicaid/NJ FamilyCare, all ambulatory care facilities (including hospital outpatient departments) providing primary care to children and adolescents from birth through 20 years of age, shall participate in the EPSDT program and shall provide, at a minimum, the required EPSDT screening services.

(b) The required EPSDT services shall include the following:

1. Screening services, the components of which are described below:
i. A comprehensive health and developmental history, including an assessment of both physical and mental health development;

ii. A culturally-sensitive and valid developmental assessment. The parameters used in assessing the child's developmental level and behavior shall be appropriate for the child's age. While no specific test instrument is endorsed, it is expected that an evaluation of a young child would, at a minimum, address the child's gross and fine motor coordination, language/vocabulary and adaptive behavior, including self-help and self-care skills and social emotional development. An assessment of a school-age child should include school performance, peer relationships, social activity and behavior, physical and athletic aptitude and sexual maturation;

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

iv. Appropriate immunizations according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines, incorporated herein by reference, as amended and supplemented. The schedule can be found on the Centers for Disease Control (CDC) website at http://www.cdc.gov/ or can be requested from the Centers for Disease Control and Prevention, National Immunization Program, Division of Epidemiology and Surveillance, Mail Stop E61, 1600 Clifton Road, NE Atlanta, Georgia 30333;

v. Age-appropriate laboratory and other diagnostic tests, including:
(1) Hemoglobin or hematocrit;

(2) Lead screening, using blood lead level determinations, once between nine and 18 months (preferably at 12 months), once between 18 and 26 months (preferably at 24 months) and, for any child who has not been previously tested between 27 months and 72 months;

(3) Urinalysis;

(4) Tuberculin skin test (Mantoux), intradermal, administered annually and when medically indicated; and

(5) Additional laboratory tests which may be appropriate and medically indicated shall be obtained, as necessary;

vi. Health education, including anticipatory guidance;

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

viii. Referral to the Special Supplemental Food Program for Women, Infants and Children (WIC) for children under five years of age and for pregnant or lactating women.

2. Vision services as follows:
i. Vision screening, which shall include the following:
(1) If a newborn, the examination shall include general inspection of the eyes, visualization of the red reflex and evaluation of ocular motility;

(2) An appropriate medical and family history;

(3) An evaluation, by age six months, of eye fixation preference, muscle imbalance and papillary light reflex; and

(4) A third examination with visual acuity testing by age three or four years;

ii. Vision testing for school-aged children, which shall be performed at the following grades and ages:
(1) Kindergarten or first grade (five or six years);

(2) Second grade (seven years);

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

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

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

iii. Referral for vision testing if a child:
(1) Cannot read the majority of the 20/40 line before his or her fifth birthday;

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

(3) Has suspected strabismus; or

(4) Has an abnormal light or red reflex.

3. Dental services as follows:
i. Dental screening, which shall include the following:
(1) An intraoral examination, including observation of tooth eruption, occlusion pattern and presence of caries or oral infection;

ii. A recommended referral to a dentist at one year of age;

iii. A mandatory referral for a child three years of age or older; and

iv. Dental inspection and prophylaxis, which shall be performed every six months until a child is 17 years of age and annually for any beneficiary 18 years of age or older who is eligible for EPSDT services.

4. Hearing services including the following:
i. A hearing screening for infants that shall include, at a minimum, an observation of an infant's response to auditory stimuli;

ii. A speech and hearing assessment, which shall be part of each preventive visit for an older child;

iii. An individual hearing screening, which shall be administered annually to all children through the age of eight and to all children at risk of hearing impairment;

iv. An individual hearing screening of each child every other year after the age of eight; and

v. An objective audiometric test, such as a pure-tone screening test, if performed as part of an EPSDT screening examination, shall be eligible for separate reimbursement.

5. Other medically 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.
i. For requirements regarding community private duty nursing services for EPSDT beneficiaries, see N.J.A.C. 10:60-5.

(c) EPSDT screening services shall be provided periodically according to the following schedule, based on the age of the child:

1. Under six weeks;

2. Two months;

3. Four months;

4. Six months;

5. Nine months;

6. Twelve months;

7. Fifteen months;

8. Eighteen months;

9. Twenty-four months; and

10. Annually through 20 years of age.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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