Section R9-22-213. Early and Periodic Screening, Diagnosis, and Treatment Services (E.P.S.D.T.)

A.      The following E.P.S.D.T. services are covered for a member less than 21 years of age:

1.        Screening services including:

a.         Comprehensive health and developmental history;

b.        Comprehensive unclothed physical examination;

c.         Appropriate  immunizations  according  to  age  and health history;

d.        Laboratory tests; and

e.         Health education, including anticipatory guidance;

2.        Vision services including:

a.         Diagnosis and treatment for defects in vision;

b.        Eye examinations for the provision of prescriptive lenses;

c.         Prescriptive lenses; and

d.        Frames.

3.        Hearing services including:

a.         Diagnosis and treatment for defects in hearing;

b.        Testing to determine hearing impairment; and

c.         Hearing aids;

4.        Dental services including:

a.         Emergency dental services as specified in R9-22- 207;

b.        Preventive services including screening, diagnosis, and treatment of dental disease; and

c.         Therapeutic   dental   services   including   fillings, crowns, dentures, and other prosthetic devices;

5.        Orthognathic surgery;

6.        Medically necessary, nutritional assessment and nutri- tional therapy as specified in contract to provide complete daily dietary requirements or  supplement a member’s daily nutritional and caloric intake;

7.        Behavioral health services under 9 A.A.C. 22, Article 12;

8.        Hospice services do not include home-delivered meals or services provided and covered through Medicare. The following hospice services are covered:

a.         Hospice services are covered only for a member who is in the final stages of a terminal illness and has a prognosis of death within six months;

b.        Services available to a member receiving hospice care are limited to those allowable under 42 CFR 418.202, October 1, 2006, incorporated by reference and on file with the Administration. This incorpora- tion by reference contains no future editions or amendments;

9.        Incontinence briefs as specified under R9-22-212; and

10.     Other necessary health care, diagnostic services, treat- ment, and measures required by 42 U.S.C. 1396d(r)(5).

B.       Providers of E.P.S.D.T. services shall meet the following stan- dards:

1.        Ensure that services are provided by or under the direc- tion of the member’s primary care provider, attending physician, practitioner, or dentist.

2.        Perform tests and examinations under 42 CFR 441 Sub- part B, October 1, 2006, which is incorporated by refer- ence and on file with the Administration. This incorporation by reference contains no future editions or amendments.

3.        Refer a member as necessary for dental diagnosis and treatment and necessary specialty care.

4.        Refer a member as necessary for behavioral health evalu- ation and treatment services.

C.      Contractors shall meet other E.P.S.D.T. requirements as speci- fied in contract.

D.      A primary care provider, attending physician, or practitioner shall refer a member with special health care needs under R9- 7-301 to CRS.

Historical Note

Adopted as an emergency effective May 20, 1982 pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-213 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22- 213 repealed, new Section R9-22-213 adopted effective October 1, 1983 (Supp. 83-5). Amended effective Octo-

ber 1, 1985 (Supp. 85-5). Amended effective December

13, 1993 (Supp. 93-4). Amended effective September 22,

1997 (Supp. 97-3). Amended by final rulemaking at 6

A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking

at 13 A.A.R. 3272, effective September 11, 2007 (Supp. 07-3). Amended by final rulemaking at 20 A.A.R.

1949, effective September 6, 2014 (Supp. 14-3).