Adult Medicaid Manual MA-2905- MEDICAID COVERED SERVICES

REVISED 08/01/11 – CHANGE NO. 16-11

I. Introduction

This section contains information on Medicaid covered services. Each service may have certain limitations, including the need for a prior approval. The guidelines and restrictions for each service are outlined in this section. Refer to the DMA website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for specific clinical coverage criteria and requirements.

A. EPSDT for Recipients Under 21 Years of Age

Although Medicaid covered services have strict limitations on scope, amount, duration, and/or frequency, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that mandates state Medicaid agencies to provide services, products, or procedures requested by physicians and licensed clinicians for Medicaid recipients under 21 years of age if the services are medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified by a screening examination. EPSDT or Medicaid for children is administered under the name Health Check in North Carolina and is jointly overseen by Clinical Policy and Programs and Managed Care. Services provided under EPSDT include periodic screening, vision, dental, and hearing services. There is no requirement that the requested service, product, or procedure be included in the state Medicaid plan. However, the requested service, product, or procedure must be within the scope of the services listed in the Social Security Act (the Act) at 1905(a). A listing of federal Medicaid covered services can be found at http://www.ncdhhs.gov/dma/epsdt/on DMA’s website.

Service limitations on scope, amount, duration, and/or frequency described in this manual or in the clinical coverage policies may be excluded or may not apply provided documentation supports that the requested service is medically necessary to correct or ameliorate a defect, physical and mental illness, or a condition identified by a licensed clinician. In accordance with EPSDT requirements, health care services shall be provided in a frequency and amount to reasonably achieve their purpose and shall be consistent with the recipient’s medical needs.

B. When providing Medical services to recipients under 21 years of age, it is important to adhere to the following:

1. There are no recipient co-payments.

2. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval.

REVISED 08/01/11 – CHANGE NO. 16-11

(I.B)

3. All requests for services, products, or procedures that are not covered in the North Carolina State Medicaid Plan MUST be approved before the service is rendered. To request a service, product, or procedure not covered under the North Carolina State Medicaid Plan for a recipient under 21 years of age, the recipient’s physician or other licensed clinician should submit an EPSDT request on behalf of the recipient to:

Director

c/o Assistant Director for Clinical Policy and Programs

Division of Medical Assistance

EPSDT Request

2501 Mail Service Center

Raleigh, NC 27699-2501

FAX 919-715-7679

Recipients should be advised to consult with their medical provider or the Medicaid ombudsman at the state office, for further information regarding covered services, including EPSDT services. For Medicare covered services, please refer to the Medicare website at http://www.medicare.gov/Coverage/Home.asp.

For additional information regarding EPSDT and Health Check, refer to the website at http://www.ncdhhs.gov/dma/healthcheck/. Also, see XXXVIII. of this manual section.