Chapter 182-534 WAC
Last Update: 6/11/25EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)
WAC Sections
| HTMLPDF | 182-534-0010 | Purpose. |
| HTMLPDF | 182-534-0050 | Definitions. |
| HTMLPDF | 182-534-0100 | Standard for coverage. |
| HTMLPDF | 182-534-0200 | Enhanced payments for EPSDT well-child checkups for children in out-of-home placement. |
PDF182-534-0010
Purpose.
The purpose of the early periodic screening, diagnosis, and treatment program is to ensure that children and adolescents receive comprehensive preventive, diagnostic, and treatment services.
PDF182-534-0050
Definitions.
The following definitions and those found in chapter 182-500 WAC apply to this chapter:
"Early periodic screening, diagnosis, and treatment (EPSDT)" means the federally mandated health care benefit for clients from birth through age 20 that ensures access to medically necessary services. Federal statutes and rules govern EPSDT services; see, e.g., 42 U.S.C. § 1396d(r) and 42 C.F.R. Part 441, Subpart B.
"Well-child checkup" means the same as "screening" in 42 C.F.R. § 441.56(b).
PDF182-534-0100
Standard for coverage.
(1) People age 20 and younger who are enrolled in medicaid are eligible for coverage through the early periodic screening, diagnosis, and treatment (EPSDT) program. See WAC 182-501-0060, Health care coverage—Program benefit packages—Scope of service categories.
(2) Under the EPSDT program, the medicaid agency pays for health care services that fall under any of the categories listed in 42 C.F.R. Part 441, Subpart B, when they are:
(a) Medically necessary, as defined in WAC 182-500-0070;
(b) Safe and effective; and
(c) Not experimental.
(3) Services under the EPSDT program are exempt from specific coverage or service limitations, including amount, duration, and scope of services applicable to the Washington apple health categorically needy and medically needy programs.
(a) The agency may establish utilization controls to safeguard against unnecessary use of care and services. These limits may be exceeded through a process in which the agency reviews medical necessity in a manner consistent with federal EPSDT requirements.
(b) The agency conducts reviews of prior authorization requests on a case-by-case basis, evaluating each client's needs individually, so that delivery of needed treatment services is not delayed. The agency evaluates these requests using the process described in WAC 182-501-0165.
(c) Services not otherwise covered under the medicaid program, including optional services under 42 U.S.C. § 1396d, are available to children through EPSDT when the agency determines the services are medically necessary.
(4) Under the EPSDT program, the agency evaluates requests for noncovered services, as defined by WAC 182-500-0020 and 182-500-0075, under WAC 182-501-0165.
(5) Providers must document all EPSDT services furnished to each client as required by WAC 182-502-0020.
(6) To ensure clients have transportation to medically necessary services, the agency covers various modes of transportation under chapter 182-546 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0100, filed 6/11/25, effective 7/12/25. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-534-0100, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021 and section 1115 (a)(2) of the Social Security Act. WSR 12-22-046, § 182-534-0100, filed 11/2/12, effective 12/3/12. WSR 11-14-075, recodified as § 182-534-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-534-0100, filed 12/29/00, effective 1/29/01. WSR 00-11-183, recodified as § 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. WSR 90-12-061 (Order 3019), § 388-86-027, filed 5/31/90, effective 7/1/90; WSR 82-01-001 (Order 1725), § 388-86-027, filed 12/3/81; WSR 81-10-015 (Order 1647), § 388-86-027, filed 4/27/81; WSR 80-15-034 (Order 1554), § 388-86-027, filed 10/9/80; WSR 79-12-047 (Order 1457), § 388-86-027, filed 11/26/79; Order 1112, § 388-86-027, filed 4/15/76; Order 738, § 388-86-027, filed 11/22/72.]
PDF182-534-0200
Enhanced payments for EPSDT well-child checkups for children in out-of-home placement.
The medicaid agency covers early periodic screening, diagnosis, and treatment (EPSDT) services, as described in WAC 182-534-0100, for children in out-of-home placement to ensure medically necessary needs are promptly addressed.
(1) For the purposes of this section, out-of-home placement means temporary, 24 hour-per-day, substitute care for a child age 20 and younger:
(a) Placed away from the child's parents or guardians in licensed, paid, out-of-home care; and
(b) For whom the department of children, youth, and families or a tribe has placement and care authority.
(2) The agency pays an enhanced fee only for well-child checkups provided to children in out-of-home placement when the placement meets the federal requirements under 42 C.F.R. Part 441, Subpart B.
(3) For children in out-of-home placement, the agency exempts well-child checkups from coverage limitations, regardless of the periodicity schedule recommended by the American Academy of Pediatrics' Bright Futures guidelines or a comparable standard. The periodicity schedule is found in the agency's EPSDT well-child program billing guide.
(4) The agency pays for initial health screenings for children transitioning to out-of-home placement to identify and address immediate health needs.
(a) The agency pays for an initial health screening in addition to well-child checkups.
(b) Children must have an initial health screen within five days of entering out-of-home placement and a required well-child checkup within 30 days of entering out-of-home placement.
(c) The provider must document the initial health screening using the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Out-of-Home Placement Initial Health Screen Form (HCA 13-843).
(5) The agency evaluates client files and payments made under this program. The agency may recover the enhanced payment amount when:
(a) The child was not in out-of-home placement as defined in subsection (1) of this section when the EPSDT screen was provided; or
(b) Documentation was not in the child's medical file.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0200, filed 6/11/25, effective 7/12/25; WSR 24-21-163, s 182-534-0200, filed 10/23/24, effective 11/23/24; WSR 15-12-074, § 182-534-0200, filed 5/29/15, effective 7/1/15. WSR 11-14-075, recodified as § 182-534-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-534-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0200, filed 3/8/02, effective 4/8/02.]