§ 51184. Early and Periodic Screening, Diagnosis, and Treatment (Epsdt) Program Definitions.

(a) EPSDT Screening Services means:

(1) An initial, periodic, or additional health assessment of a Medi-Cal eligible individual under 21 years of age provided in accordance with the requirements of the Child Health and Disability Prevention (CHDP) program as set forth in Title 17, Sections 6800 et seq.; or

(2) A health assessment, examination, or evaluation of a Medi-Cal eligible individual under 21 years of age by a licensed health care professional acting within his or her scope of practice, at intervals other than those specified in paragraph (a)(1) to determine the existence of physical or mental illnesses or conditions; or

(3) Any other encounter with a licensed health care professional that results in the determination of the existence of a suspected illness or condition or a change or complication in a condition for a Medi-Cal eligible person under 21 years of age.

(b) EPSDT diagnosis and treatment services means only those services provided to persons under 21 years of age that:

(1) Are identified in section 1396d(r) of title 42 of the United States Code,

(2) Are available under this chapter without regard to the age of the recipient or that are provided to persons under 21 years of age pursuant to any provision of federal Medicaid law other than section 1396d(a)(4)(B) and section 1396a(a)(43) of title 42 of the United States Code, and

(3) Meet the standards and requirements of Sections 51003 and 51303, and any specific requirements applicable to a particular service that are based on the standards and requirements of those sections.

(c) EPSDT supplemental services means health care, diagnostic services, treatment, and other measures, that:

(1) Are identified in Section 1396d(r) of Title 42 of the United States Code.

(2) Are available only to persons under 21 years of age,

(3) Meet any one of the standards of medical necessity as set forth in paragraphs (1), (2), or (3) of Section 51340(e), and

(4) Are not EPSDT diagnosis and treatment services.

(d) EPSDT supplemental services include EPSDT case management services when provided by EPSDT case managers described in paragraph (h)(4).

(e) EPSDT diagnosis and treatment provider means any of the providers listed under Section 51051, other than EPSDT supplemental services providers.

(f) EPSDT Supplemental Services Provider means a person enrolled pursuant to Section 51242 to provide EPSDT supplemental services as defined in subsection (c).

(g) EPSDT case management services means services that will assist EPSDT-eligible individuals in gaining access to needed medical, social, educational, and other services.

(h) EPSDT case manager means:

(1) A targeted case management (TCM) provider under contract with a local governmental agency described in Section 14132.44 of the Welfare and Institutions Code.

(2) Entities and organizations, including Regional Centers, that provide TCM services to persons described in Section 14132.48 of the Welfare and Institutions Code.

(3) A unit within the Department designated by the Director.

(4) A child protection agency, other agency or entity serving children, or an individual provider, that the Department finds qualified by education, training, or experience, and that the Department enrolls pursuant to Section 51242 to provide EPSDT case management services.

(i) For purposes of the EPSDT program, excepting pediatric day health care EPSDT services provided as EPSDT supplemental services, the term “services” is deemed to include supplies, items, or equipment.

(j) EPSDT supplemental services include pediatric day health care EPSDT services when provided by a pediatric day health care facility.

(k) For purposes of pediatric day health care EPSDT services, the following definitions shall apply:

(1) “Pediatric day health care EPSDT services” means services that:

(A) Promote the physical, developmental and psychosocial well-being of individuals eligible for EPSDT services who are medically fragile as defined in Section 1760.2(b) of the Health and Safety Code and who live with their parent, foster parent, or legal guardian.

(B) Provide medically necessary skilled nursing care and therapeutic interventions which include occupational therapy, physical therapy, speech therapy and medical nutrition therapy provided by licensed or registered therapists and furnished in response to the attending physician's orders and in accordance with the individual's plan of treatment. These services do not include respite care pursuant to Section 14132.10(a), of the Welfare and Institutions Code.

(C) Are provided in a day program of less than 24 hours that is individualized and family-centered, with developmentally appropriate activities of play, learning and social interaction designed to optimize the individual's medical status and developmental functioning so that he or she can remain within the family.

(2) “Pediatric day health care facility” means a facility that is licensed pursuant to Section 1760 of the Health and Safety Code. For purposes of providing pediatric day health care EPSDT services, a pediatric day health care facility may also be referred to as the “facility”.

(3) “Pharmaceutical services” means medications, including prescription and nonprescription, and total parental nutrition supplied to eligible beneficiaries by licensed nursing personnel and administered upon orders of the attending physician.

(4) “Nutrition services” means a minimum of one meal per day, between meal nourishment, and consultation services by the facility's dietitian.

HISTORY

1. New section 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.

2. New section 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.

3. New section 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.

4. New section 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.

5. Certificate of Compliance as to 2-22-95 order including amendment of section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).

6. Amendment of subsection (i), new subsections (j)-(k)(4) and amendment of Note filed 11-10-99 as an emergency; operative 11-10-99 (Register 99, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-9-2000 or emergency language will be repealed by operation of law on the following day.

7. Certificate of Compliance as to 11-10-99 order, including further amendment of subsection (k)(1)(B) and (k)(4), transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No. 16).

Note

Note: Authority cited: Sections 10725, 14124.5 and 14195, Welfare and Institutions Code; and Sections 100275, 125000 and 125100, Health and Safety Code. Reference: Sections 14059, 14132 and 14132.10, Welfare and Institutions Code; Sections 125000 and 125100, Health and Safety Code; and 42 U.S.C. 1396d(r).