Our pediatric preventive health care program is designed to improve the health of members from birth up to age 21 who are enrolled in Medicaid by increasing adherence to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) guidelines through identification of growth and development needs and coordination of appropriate health care services.
All AmeriHealth Caritas Ohio-licensed practitioners, including registered nurses, physicians, or physician assistants; or a person with a master’s degree in health services, public health, or health care administration or another related field, and/or who is a certified professional in healthcare quality (CHCQ), are responsible to provide EPSDT/Healthchek services to AmeriHealth Caritas Ohio members from birth up to age 21 according to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule or upon request to evaluate the general physical and mental health, growth, development, and nutritional status of a member. The most current periodicity schedules are available on the Bright Futures website.
EPSDT services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 USC 1396d(a) to correct or ameliorate defects, and physical and mental illness and conditions discovered by a Healthchek screening. Such services and items, if approved through prior authorization, include those services and items listed at 42 USC 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults.
For the initial examination and assessment of a child, practitioners are required to perform the relevant EPSDT/Healthchek screenings and services, as well as any additional assessment, using the Ohio Department of Medicaid (ODM) developed, standardized, developmental screening tools to determine whether or not a child has special health care needs.
Periodic assessments must consist of the following components:
- Routine physical examinations as recommended by the AAP and “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents”
- Comprehensive health and developmental history that assesses for both physical and mental health, as well as for substance use disorders
- Screening for developmental delay at each visit through the fifth year using a validated screening tool
- Screening for autism spectrum disorders per AAP guidelines
- Comprehensive, unclothed physical examination
- All appropriate immunizations in accordance with the schedule established by the Advisory Committee on Immunization Practices
- Vision and hearing screening
- Dental screening and education
- Nutrition assessment and education
- Laboratory tests including blood lead screening
- Health education and anticipatory guidance for both the child and caregiver
- Referral for further diagnostic and treatment services, if needed
EPSDT/Healthchek providers (PCPs) are expected to provide written and verbal explanation of EPSDT services to AmeriHealth Caritas Ohio members including pregnant women, parents or guardians, child custodians and sui juris (of one’s own right) teenagers. This explanation of EPSDT/Healthchek services should occur on the member’s first visit and quarterly thereafter, and must include distribution of appropriate EPSDT/Healthchek educational tools and materials.
Screening time frames
Healthchek screening services are covered at the following frequency:
For immunizations, in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines established by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). Visit the CDC website to view the ACIP vaccine guidelines.
For other screening services, at ages and intervals in accordance with the Bright Futures guidelines.
For all screening services, at such other intervals indicated as medically necessary to determine the existence of physical or mental illnesses or conditions.
Plan practitioners are expected to assist members and parents or caregivers with accessing substance use disorder and mental health services as needed. The plan’s EPSDT Manager on the Rapid Response and Outreach Team is also available to members and providers to support the care coordination of EPSDT services. Members and providers may request the EPSDT Manager’s support by calling 1-833-464-7768.