Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a comprehensive health program for Medicaid/NJ FamilyCare beneficiaries from birth through 20 years of age. 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 or diagnosed and treated at the earliest possible time.
(b) For the certification criteria that a physician must meet in providing services to children under 21 years of age, see 10:54-1.5, concerning certification of physician services.
(c) 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.
(d) EPSDT services shall include the following:
1. Screening services;
2. Vision services;
3. Dental services;
4. Hearing services; and
5. Other medically necessary health care, diagnostic services and treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.
(e) EPSDT screening services, vision services, dental services, and hearing services shall be provided at defined intervals as required by the standards contained in N.J.A.C. 10:58-3.
(f) EPSDT screening services shall include the following components:
1. A comprehensive health and developmental history including an assessment of both physical and mental health development;
2. Developmental assessment shall be culturally sensitive and valid. The parameters used in assessing the beneficiary's developmental level and behavior shall be appropriate for the age. While no specific test instrument is endorsed, it is expected that an evaluation of a young child shall, at a minimum, address the 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 shall include school performance; peer relationships; social activity and/or behavior; physical and/or athletic aptitude; and sexual maturation.
3. A comprehensive unclothed physical examination, including vision and hearing screening, dental inspection and nutritional assessment;
4. Appropriate immunizations according to age and health history;
5. Appropriate laboratory tests, including:
i. Hemoglobin or hematocrit;
ii. Urinalysis;
iii. Tuberculin skin test (Mantoux), intradermal, administered annually and when medically indicated;
iv. Lead screening using blood lead level determinations between six and 12 months, at two years of age, and annually up to six years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level testing, as indicated;
v. Additional laboratory tests which may be appropriate and medically indicated (for example, for ova and parasites) shall be obtained, as necessary;
6. Health education, including anticipatory guidance;
7. 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
8. 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.
(g) EPSDT screening services shall be provided periodically according to the following schedule which reflects the age of the child:
1. Under six weeks; two months; four months; six months; nine months; 12 months; 15 months; 18 months; 24 months; and annually through age 20 years.
(h) Vision screening shall include the following:
1. A newborn examination, including general inspection of the eyes, visualization of the red reflex and evaluation of ocular motility;
2. A medical and family history which is appropriate for the individual patient;
3. An evaluation, by age six months, of eye fixation preference, muscle imbalance, and pupillary light reflex;
4. A third examination with visual acuity testing by age three or four years; and
5. Periodicity testing for school aged children, as follows:
i. Kindergarten or first grade (five or six years);
ii. Second grade (seven years);
iii. Fifth grade (10/11 years);
iv. Eighth grade (13/14 years); and
v. Tenth or eleventh grades (15/17 years).
(i) Children shall be referred for further vision testing if they:
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.
(j) Dental screening shall include the following:
1. An intraoral examination which is an integral part of a general physical examination, meaning observation of tooth eruption, occlusion pattern, and presence of caries or oral infection;
2. A formal referral to a dentist, which is recommended at one year of age; and is mandatory for children three years of age and older; and
3. Dental inspection and prophylaxis, which should be carried out every six months until 17 years of age, then annually.
(k) Hearing screening requirements shall include the following:
1. An individual hearing screening shall be administered annually to all children through age eight, and to all children who are at risk of hearing impairment;
2. In addition to what is required in (k)1 above, after eight years of age, children shall be screened every other year; and
3. Hearing screening shall include, at a minimum, an observation of an infant's response to auditory stimuli. Speech and hearing assessment shall be part of each preventive visit for an older child. An objective audiometric test, such as a pure tone screening test, if performed as part of an EPSDT screening examination, is eligible for separate reimbursement.
