Section 107.22. Early and periodic screening, diagnosis and treatment (EPSDT) services.

 

(1)   Covered services. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defects shall be covered services for all recipients under 21 years of age when provided by an EPSDT clinic, a physician, a private clinic, an HMO or a hospital certified under s. DHS 105.37 .

(2)   EPSDT health assessment and evaluation package. The EPSDT health assessment and evaluation package shall include at least those procedures and tests required by 42 CFR 441.56 . The package shall include the following:

(a) A comprehensive health and developmental history;

(b) A comprehensive unclothed physical examination;

(c) A vision test appropriate for the person being assessed;

(d) A hearing test appropriate for the person being assessed;

(e) Dental assessment and evaluation services furnished by direct referral to a dentist for children beginning at 3 years of age;

(f) Appropriate immunizations; and

(g) Appropriate laboratory tests.

(3)   Supplemental tests. Selection of additional tests to supplement the health assessment and evaluation package shall be based on the health needs of the target population. Consideration shall be given to the prevalence of specific diseases and conditions, the specific racial and ethnic characteristics of the population, and the existence of treatment programs for each condition for which assessment and evaluation is provided.

(4)   Other needed services. In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of "medical assistance" under federal law, 42 USC 1396d (a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed. Prior authorization under s. DHS 107.02 (3) is required for coverage of services under this subsection.

(5)   Reasonable standards of practice. Services under this section shall be provided in accordance with reasonable standards of medical and dental practice determined by the department after consultation with the medical society of Wisconsin and the Wisconsin dental association.

(6)   Referral. When EPSDT assessment and evaluation indicates that a recipient needs a treatment service not available under MA, the department shall refer the recipient to a provider willing to perform the service at little or no expense to the recipient's family.

(7)   No charge for services. EPSDT services shall be provided without charge to recipients under 18 years of age.

Cr. Register, February, 1986, No. 362 , eff. 3-1-86; emerg. am. (4) (intro.), r. (4) (a) and (b) eff. 4-30-07; CR 07-041 : am. (4) (intro.), r. (4) (a) and (b) Register December 2007 No. 624 , eff. 1-1-08; correction in (1) made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 .