Current through Register Vol. 35, No. 6, March 26, 2024
MAD developed the tot to teen healthcheck, the screening
segment of EPSDT services. The tot to teen healthcheck includes periodic
screening and regularly scheduled assessments of the MAP eligible recipient's
general physical growth and development as well as behavioral health and social
emotional development.
A. Primary care
providers (PCP), dentists, psychologists, IHS public health clinics, federally
qualified health center (FQHC), rural health clinic (RHC), community mental
health centers (CMHC), hospitals, school-based clinics, independent certified
or licensed nurse practitioners and other health care providers may perform tot
to teen healthcheck screens or partial health screenings. A provider must meet
the participation requirements specified in applicable sections of NMAC rules.
Tot to teen healthcheck screens must be furnished within the scope of the
provider's practice, as defined by law.
B. Screening services are furnished to a MAP
eligible recipient under 21 years of age. Referrals or treatment for conditions
detected during a complete or a partial screen which require further treatment
are then covered as part of MAD's EPSDT services. A tot to teen healthcheck can
be performed during an office visit for an acute illness as long as the illness
does not affect the results or the screening process.
(1) Screening schedule for medical
components:
(a) The MAD tot to teen
healthcheck periodicity schedule allows for a total of 25 screens. Screenings
are encouraged at the following intervals:
(i)
under age one: six screenings (birth, one, two, four, six and nine
months)
(ii) ages one-two: four
screenings (12, 15, 18 and 24 months)
(iii) ages three-five: three screenings
(three, four and five years)
(iv)
ages six-nine: two screenings (six and eight years)
(v) ages 10-14: four screenings (10, 12, 13
and 14 years)
(vi) ages 15-18: four
screenings (15, 16, 17 and 18 years)
(vii) ages 19-20: two screenings (19 and 20
years).
(b) Screenings
may be performed at intervals other than as described on the periodicity
schedule or in addition to those on the periodicity schedule if a MAP eligible
recipient receives care at a time not listed on the periodicity schedule or if
any components of the screen were not completed at the scheduled ages.
Additional screenings can help bring the MAP eligible recipient up to date with
the periodicity schedule.
(c) The
established schedule must be followed unless the MAP eligible recipient's
medical condition is such that a brief deviation is warranted.
(2) Complete medical screens
include the following components:
(a) a
comprehensive health and developmental history, including an assessment of both
physical and behavioral health or social emotional development;
(b) a comprehensive unclothed physical
exam;
(c) appropriate
immunizations, according to age and health history, unless medically
contraindicated at the time;
(d)
laboratory tests, including an appropriate blood lead level
assessment;
(e) health education,
including the MAD anticipatory guidance; and
(f) vision and hearing screenings at the ages
indicated in the MAD EPSDT preventative health guidelines.
(3) MAD pays for partial medical screens to a
MAP eligible recipient. Partial medical screens are defined as screens where
all the required components of a complete medical screen are not completed for
medical reasons.
(4) MAD covers
additional medical screens as listed below.
(a) Behavioral health screenings are
performed at intervals which meet reasonable standards or at other intervals as
medically necessary for the diagnosis or treatment of a behavioral health
disorders or conditions.
(b) Dental
examinations are performed at intervals which meet reasonable dental standards.
Usually these examinations are furnished every six months. However,
examinations can be furnished at other intervals as medically
necessary.
(c) Hearing testing is
performed at intervals which meet reasonable standards or at other intervals as
medically necessary for the diagnosis or treatment of defects in hearing. A
hearing test using an audiogram should be given to a MAP eligible recipient at
five years of age or prior to him or her to entering school. Annual
examinations should be furnished if abnormalities are identified.
(d) Interperiodic screens can be performed at
intervals beyond those specified in the periodicity schedule. Reimbursement for
the performance of interperiodic screens is made only to a MAD provider.
Interperiodic screens are screening encounters with health care, developmental,
or educational professionals to determine the existence of suspected physical
or behavioral health disorders or conditions.
(e) Vision examinations are performed at
intervals which meet reasonable vision standards or at other intervals as
medically necessary. A vision examination should be furnished before the MAP
eligible recipient reaches three years of age and again prior to five years of
age or prior to entering school. If no abnormalities are found, screenings
should be furnished every two years with a complete examination furnished if
indicated.
(f) Other necessary
health care or diagnostic services are performed when medically necessary.
C. MAD
covers services considered medically necessary for the treatment or
amelioration of conditions identified as a result of a complete tot to teen
healthcheck screen, partial medical screen, or interperiodic screen. Diagnostic
or evaluation services furnished during the screening cannot be duplicated as
part of the follow-up treatment. If appropriate, treatment is furnished by the
screening provider at the time of the tot to teen healthcheck.
(1) A MAP eligible recipient can be referred
for treatment as a result of a tot to teen healthcheck, regardless of whether
the provider making the referral is a participating MAD provider. If it is
inappropriate for a screening provider to furnish treatment needed by the MAP
eligible recipient, referrals must be made only to a qualified MAD
provider.
(2) A MAP eligible
recipient may be identified through a tot to teen healthcheck, self referral,
or referral from an agency (such as a public school, child care provider, Part
B or Part C provider) when he or she is experiencing behavioral health
concerns. For a MAP eligible recipient requiring extensive or long term
treatment, he or she must be referred to a MAD behavioral health professional
for further evaluation, and if medically necessary, treatment.
(a) The receiving provider of a MAP eligible
recipient must develop an individualized treatment plan.
(b) The plan must consider the total
behavioral health needs of the MAP eligible recipient, including any medical
conditions that may impact his or her behavioral health services.
(c) The plan must be developed in cooperation
with the MAP eligible recipient, his or her parents, or guardians, and other
health care professionals, as appropriate. In the case of a MAP eligible
recipient under 21 years of age who is placed in the custody of the children,
youth and families department (CYFD), its assigned social worker, and those
appropriate from CYFD's juvenile justice system (JJS) are to be included in the
development of the plan.
(d) See to
8.321.2 NMAC for additional information regarding specialized behavioral health
services for an ESPDT MAP eligible recipient.
(3) A MAP eligible recipient, when allowed
under state law, has the right to refuse proposed medical and behavioral health
treatment. He or she has the freedom to select among enrolled MAD providers.
Information in this section does not restrict or limit a MAP eligible
recipient's rights or choice.
