[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR441.56]



[Page 273-274]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 441_SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC 

 

Subpart B_Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 

                       of Individuals Under Age 21

 

Sec.  441.56  Required activities.



    (a) Informing. The agency must--

    (1) Provide for a combination of written and oral methods designed 

to inform effectively all EPSDT eligible individuals (or their families) 

about the EPSDT program.

    (2) Using clear and nontechnical language, provide information about 

the following--

    (i) The benefits of preventive health care;

    (ii) The services available under the EPSDT program and where and 

how to obtain those services;

    (iii) That the services provided under the EPSDT program are without 

cost to eligible individuals under 18 years of age, and if the agency 

chooses, to those 18 or older, up to age 21, except for any enrollment 

fee, premium, or similar charge that may be imposed on medically needy 

recipients; and

    (iv) That necessary transportation and scheduling assistance 

described in Sec.  441.62 of this subpart is available to the EPSDT 

eligible individual upon request.

    (3) Effectively inform those individuals who are blind or deaf, or 

who cannot read or understand the English language.

    (4) Provide assurance to CMS that processes are in place to 

effectively inform individuals as required under this paragraph, 

generally, within 60 days of the individual's initial Medicaid 

eligibility determination and in the case of families which have not 

utilized EPSDT services, annually thereafter.

    (b) Screening. (1) The agency must provide to eligible EPSDT 

recipients who request it, screening (periodic comprehensive child 

health assessments); that is, regularly scheduled examinations and 

evaluations of the general physical and mental health, growth, 

development, and nutritional status of infants, children, and youth. 

(See paragraph (c)(3) of this section for requirements relating to 

provision of immunization at the time of screening.) As a minimum, these 

screenings must include, but are not limited to:

    (i) Comprehensive health and developmental history.

    (ii) Comprehensive unclothed physical examination.

    (iii) Appropriate vision testing.

    (iv) Appropriate hearing testing.

    (v) Appropriate laboratory tests.

    (vi) Dental screening services furnished by direct referral to a 

dentist for children beginning at 3 years of age. An agency may request 

from CMS an exception from this age requirement



[[Page 274]]



(within an outer limit of age 5) for a two year period and may request 

additional two year exceptions. If an agency requests an exception, it 

must demonstrate to CMS's satisfaction that there is a shortage of 

dentists that prevents the agency from meeting the age 3 requirement.

    (2) Screening services in paragraph (b)(1) of this section must be 

provided in accordance with reasonable standards of medical and dental 

practice determined by the agency after consultation with recognized 

medical and dental organizations involved in child health care.

    (c) Diagnosis and treatment. In addition to any diagnostic and 

treatment services included in the plan, the agency must provide to 

eligible EPSDT recipients, the following services, the need for which is 

indicated by screening, even if the services are not included in the 

plan--

    (1) Diagnosis of and treatment for defects in vision and hearing, 

including eyeglasses and hearing aids;

    (2) Dental care, at as early an age as necessary, needed for relief 

of pain and infections, restoration of teeth and maintenance of dental 

health; and

    (3) Appropriate immunizations. (If it is determined at the time of 

screening that immunization is needed and appropriate to provide at the 

time of screening, then immunization treatment must be provided at that 

time.)

    (d) Accountability. The agency must maintain as required by 

Sec. Sec.  431.17 and 431.18--

    (1) Records and program manuals;

    (2) A description of its screening package under paragraph (b) of 

this section; and

    (3) Copies of rules and policies describing the methods used to 

assure that the informing requirement of paragraph (a)(1) of this 

section is met.

    (e) Timeliness. With the exception of the informing requirements 

specified in paragraph (a) of this section, the agency must set 

standards for the timely provision of EPSDT services which meet 

reasonable standards of medical and dental practice, as determined by 

the agency after consultation with recognized medical and dental 

organizations involved in child health care, and must employ processes 

to ensure timely initiation of treatment, if required, generally within 

an outer limit of 6 months after the request for screening services.



[49 FR 43666, Oct. 31, 1984; 49 FR 45431, Nov. 16, 1984]