Sec. 10.67.06.20. Benefits — EPSDT Services

A. An MCO shall provide, to enrollees younger than 21 years old, medically necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, including:

(1) EPSDT comprehensive well-child services provided in accordance with the EPSDT periodicity schedule and performed by an EPSDT-certified provider, including:

(a) A comprehensive health and developmental history, including an evaluation of both physical and mental health development;

(b) A comprehensive unclothed physical exam;

(c) Immunizations appropriate to age and health history;

(d) Laboratory tests, including blood lead level assessment, as appropriate to age and risk;

(e) Health education, including anticipatory guidance; and

(f) Vision, hearing, and dental screening;

(2) EPSDT partial or interperiodic well-child services; and

(3) Health care services that are:

(a) Necessary to prevent, treat, or ameliorate physical, mental, or developmental problems or conditions identified by an EPSDT-certified provider or other health professional;

(b) Sufficient in amount, duration, and scope to treat the identified condition; and

(c) Subject to limitation only on the basis of medical necessity.

B. The health care services described in §A(3) of this regulation shall include, at a minimum, all services described in this chapter, and the following:

(1) Chiropractic services;

(2) Nutrition counseling services;

(3) Private duty nursing services including:

(a) An initial assessment and development of a plan of care by a registered nurse; and

(b) On-going private duty nursing services delivered by a licensed practical nurse or a registered nurse; and

(4) Durable medical equipment.

C. An MCO shall provide referrals for services not covered by Medicaid, but which are furnished at little or no cost to recipients, including appropriate referrals to:

(1) The Head Start Program;

(2) The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC);

(3) School Health-Related Special Education Services;

(4) Vocational Rehabilitation; and

(5) Maternal and Child Health Services located at local health departments.