Child Health Check-Up (formerly EPSDT) - Herman & Associates ...

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Child Health Check-Up Coverage and Limitations HandbookService Requirements, continuedMedicallyNecessaryChapter 59G-1.010 (166), Florida Administrative Code defines medicallynecessary as follows:(166) “Medically necessary” or “medical necessity” means that the medical orallied care, goods, or services furnished or ordered must:(a) Meet the following conditions:1. Be necessary to protect life, to prevent significant illness or significantdisability, or to alleviate severe pain;2. Be individualized, specific, and consistent with symptoms or confirmeddiagnosis of the illness or injury under treatment, and not in excess of thepatient’s needs;3. Be consistent with generally accepted professional medical standards asdetermined by the Medicaid program, and not experimental or investigational;4. Be reflective of the level of service that can be safely furnished, and forwhich no equally effective and more conservative or less costly treatment isavailable statewide; and5. Be furnished in a manner not primarily intended for the convenience of therecipient, the recipient's caretaker, or the provider.(b) “Medically necessary” or “medical necessity” for inpatient hospital servicesrequires that those services furnished in a hospital on an inpatient basis couldnot, consistent with the provisions of appropriate medical care, be effectivelyfurnished more economically on an outpatient basis or in an inpatient facility of adifferent type.(c) The fact that a provider has prescribed, recommended, or approved medicalor allied care, goods, or services does not, in itself, make such care, goods orservices medically necessary or a medical necessity or a covered service.Child Health Check-Up Periodicity ScheduleIntroductionTo receive Medicaid reimbursement for Child Health Check-Ups, providers mustfollow the Child Health Check-Up periodicity schedule. The schedule is basedon the American Academy of Pediatrics, “Recommendations for PreventivePediatric Health Care” and Florida Medicaid’s recommendation to include the 7and 9 year old recipients.2-4 October 2003
Child Health Check-Up Coverage and Limitations HandbookChild Health Check-Up Periodicity Schedule, continuedChild HealthCheck-UpPeriodicityScheduleThe Child Health Check-Up schedule is:• Birth or neonatal examination• 2-4 days for newborns discharged in less than 48 hours after delivery• By 1 month• 2 months• 4 months• 6 months• 9 months• 12 months• 15 months• 18 months• Once per year for 2 through 20 year olds*The child may enter the periodicity schedule at any time. For example, if a childhas an initial screening at age 4, then the next periodic screening is performedat age 5.* Florida Medicaid recommends check-ups at 7 and 9 years of age for thosechildren at risk.Note: See Appendix D, “Recommendations for Preventive Pediatric HealthCare.”Young AdultRecipients WhoAre 20 Years of AgeYoung adult recipients are eligible to receive a Child Health Check-Up throughage 20. However, in order to receive a Child Health Check-Up and necessarytreatment, young adult recipients should be screened at least 180 days beforethey turn 21 years old.Intermediate CareFacilities for theDevelopmentallyDisabled (ICF-DD)Medicaid children who reside in Intermediate Care Facilities for theDevelopmentally Disabled (ICF-DD) are not eligible for Child Health Check-Upservices. Federal regulations require ICF-DDs to provide routine medical andpreventive care for their residents.Interperiodic ChildHealth Check-UpsMedicaid reimburses interperiodic Child Health Check-Ups that are medicallynecessary or requested by the child or the child’s parent or caregiver. Thedetermination of whether an interperiodic Child Health Check-Up is medicallynecessary may be made by the provider or a health, developmental, oreducational professional that has contact with the child.Note: Children who are removed from their homes by DCF due to allegations ofabuse, abandonment or neglect are eligible for a Child Health Check-Up basedon medical necessity.October 2003 2-5
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