Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ALL-137 March 2006 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: All Provider Manuals (Updated Appendix W: EPSDT Schedule) This letter transmits a revised Appendix W for all MassHealth provider manuals. This appendix contains the medical protocol and periodicity schedule for the Early and Periodic Screening, Diagnosis, and Treatment Program. MassHealth has updated the appendix to reflect current standards of care. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. This transmittal letter is also available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. The Provider Library contains most provider publications issued by MassHealth, including transmittal letters and bulletins. From this page, you can also sign up to receive e-mail notification when new transmittal letters and bulletins are posted to the Web site. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages W-1 through W-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Medical Protocol and Periodicity Schedule The EPSDT Medical Protocol and Periodicity Schedule consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. See 130 CMR 450.140 through 450.150 for more information about EPSDT. Pediatric preventive health-care visits – Pediatric preventive health-care visits must: * contain the components explained in the descriptions in the EPSDT Medical Protocol and Periodicity Schedule; and * occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday. Initial or Interval Health History * Initial – An initial history must be taken at the first EPSDT visit delivered to a member by a provider. The initial health history includes the family health history and baseline data on the member, including but not limited to: (a) growth and developmental history; (b) immunization history; (c) known reactions to medications and allergies; and (d) pertinent information about previous illnesses and hospitalizations, risk-taking behaviors, such as drug, alcohol, and tobacco use, sexual activity, and other medical and psychosocial problems. * Interval – An interval history must be taken at each periodic EPSDT visit. The interval history includes an update of the member’s medical history, including but not limited to: (a) a review of all systems and any illnesses, diseases, or medical problems experienced by the member since the last visit; and (b) an updated assessment of lifestyle, risk behavior, sexual activity, and psychosocial concerns. Comprehensive Physical Examination – Each EPSDT visit must include an unclothed physical examination, including: * assessment of growth parameters using height and weight. Include head-circumference measurements until the age of two years. Measurements must be plotted on appropriate growth charts. Screen for overweight using the Centers for Disease Control and Prevention (CDC) body mass index (BMI) charts for members aged two through 20 years; * blood pressure at age three years and older; * sensory screening, including vision and hearing; * oral-health assessment; and * pelvic examination within three years after the first sexual intercourse and thereafter every one to three years based on risk factors, at the clinician’s discretion, but no later than age 21. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule Page W-2 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 Nutritional Assessment * Each EPSDT visit must include an evaluation of the member's nutritional health, including: (a) medical history; (b) diet history; (c) physical examination; (d) height, weight, and BMI; (e) head-circumference measurements, as appropriate; and (f) laboratory tests to screen for iron deficiency and elevated cholesterol, if indicated. * Providers must make every effort to inform the member or his or her parent or guardian about the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), if the provider believes that the child may be eligible for WIC. A referral to WIC should be made using the WIC Medical Referral Form (MRF) from the Massachusetts WIC Program. * The member, parent, or guardian may also be referred to the Food Stamp Program, which is administered by the Department of Transitional Assistance. Developmental and Behavioral Assessment At each EPSDT visit, the provider must screen the member for delays or differences in functioning in the following areas, as appropriate to the member's age: (a) physical development, including gross motor development (strength, balance, and locomotion), fine motor development (hand-eye coordination), and sexual development; (b) cognitive development, including self-help and self-care skills and cognitive skills (problem-solving and reasoning abilities); (c) language development, including expression, comprehension, and articulation; and (d) psychosocial and behavioral development, including an assessment of social integration and peer relations, behavioral difficulties, such as sleep disturbances and aggression, psychological problems, such as depression, risk-taking behavior, and school performance. Essential components of the screening process include, but are not limited to: (a) sensitive attention to parent or guardian concerns about the member; (b) thoughtful inquiry about parent or guardian observations; (c) observation by the provider and the member’s parent or guardian about the member’s behaviors; (d) examination of specific developmental attainments; and (e) observation of member and parent or guardian interaction. * In performing the developmental and behavioral screening, the provider may utilize specific developmental and behavioral screening instruments including, but not limited to the: (a) Denver Prescreening Developmental Questionnaire; (b) Denver Developmental Screening Test II; (c) Early Language Milestone Scale; (d) Ages and Stages Questionnaire; (e) BRIGANCE screens; (f) Child Development Inventories; (g) Parents Evaluation of Developmental Status; and (h) Pediatric Symptom Checklist. * Providers must make every effort to inform the member’s parent or guardian about the availability of Early Intervention services, if the provider believes the member may be eligible for an early intervention program. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule Page W-3 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 The member or parent or guardian may also be referred to the Massachusetts Department of Education for special education services. * Providers should inform the member or the member’s parent or guardian about the availability of behavioral health treatment services for any child who may require behavioral health treatment. Hearing Screening – An objective hearing screening must be performed using an audiometer at the following frequencies: 1,000 Hz, 2,000 Hz, and 4,000 Hz tones at 20 dB HL, at the following ages: four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. * If the objective hearing screen is performed in another setting, such as a school, the screening does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Conduct a subjective hearing assessment at all other routine checkups. Conduct audiologic monitoring every six months until the age of three years if there is a language delay or risk of hearing loss. * If the provider receives notification of a missed or failed newborn hearing screen, then the provider should ensure that a new screening or diagnostic follow-up takes place. Providers should contact the Massachusetts Department of Public Health’s Universal Newborn Hearing Screening Program for additional information about the newborn hearing screening. Vision Screening * Assess newborns before discharge or at least by the age of two weeks, including corneal light reflex and red reflex. * Evaluate fixation preference, alignment, and eye disease by the age of six months and at each subsequent well-child visit. * Screen for strabismus between the ages of three years and five years. An objective vision acuity screening must be performed at the following ages: three years, four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. * Screen children at entry to kindergarten if they have not been screened during the previous 12-month period (2004 MA law) using the Massachusetts Preschool Vision Screening Protocol. Children who fail to pass the vision screening and children with neurodevelopmental delay must be referred to a licensed optometrist or ophthalmologist. * If the objective vision screen is performed in another setting, such as a school, the screen does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Dental Assessment and Referral – The screening provider must encourage members to seek regular dental care from a dental provider, beginning at the age of three years, or earlier, if indicated, including examinations once every six months, preventive services, and treatment, as necessary. Intraoral assessments should identify obvious dental problems and ensure that regular visits to a dental provider are occurring by three years of age. * Assess oral health at each visit. * Assess the need for fluoride supplementation starting at the age of six months continuing through four years of age. Counsel on good dental-hygiene habits, fluoride supplementation, and prevention of infant caries, including avoidance of bottle-propping. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule Page W-4 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 Cancer Screening and Examination * Perform a Pap smear within three years after the first sexual intercourse and thereafter every one to three years based on risk factors, at the clinician’s discretion, but no later than the age of 21 years. * Perform a clinical breast exam and provide breast self-exam instruction at every visit for female members beginning at the age of 18 years. * Perform a clinical testicular exam and provide self-exam instruction for male members annually beginning at the age of 15 years. * Screen all members for the presence of other cancers as indicated by member or family history. Health Education and Anticipatory Guidance * At every EPSDT visit, age-specific and appropriate counseling must be delivered to parents or guardians and members, if age-appropriate, about common and expected developmental advancements and common physical problems. * Effective discussion includes assessment and teaching based on a family-centered, culturally competent approach. Discussion topics should include, but not be limited to: (a) concerns of the member, parent(s), or guardian(s); (b) developmental expectations and sound parenting practices; (c) behavioral risks, such as substance use and violence, sexuality, HIV/AIDS and other communicable diseases, depression, injury prevention, and nutrition; and (d) safety measures, including car seats, bike helmets, poison prevention, gun safety, and other age-appropriate counseling. * Educational activities and resources (such as printed brochures, audiovisual materials, class instruction, and health-risk questionnaires) can enhance comprehensive child and adolescent health supervision, but should not replace interaction between the provider and the member. * The American Medical Association's Guidelines for Adolescent Preventive Services, the American Academy of Pediatrics' Guidelines for Health Supervision III, and Bright Futures provide lists of topics that may be discussed at periodic visits. Immunization Assessment and Administration – At every EPSDT visit, the provider must assess the member’s immunization status and administer all immunizations for which the member is due in accordance with the recommendations of the Department of Public Health’s Immunization Program. Lead Toxicity Screening * Providers must screen every member for lead toxicity according to the requirements for lead toxicity screening set forth by the Massachusetts Childhood Lead Poisoning Prevention Program (MCLPPP). These requirements can be found at 105 CMR 460.050 et seq. * If a child is found to have a blood lead level equal to or greater than 10 micrograms per deciliter, providers should use their professional judgment, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines about patient management and treatment, as well as follow-up blood tests. * Physicians and other health-care providers must report all cases of childhood lead poisoning (equal to or greater than 10 micrograms per deciliter) known to them to the Director of the MCLPPP within three working days of identification, unless that episode has been previously reported. (a) When a child has multiple episodes of lead poisoning, each episode must be reported. (b) Initiation of investigations to determine the source of lead in the child’s environment is provided by the MCLPPP. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule Page W-5 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 Tuberculin Test – The screening provider must assess a child’s risk at every periodic visit and administer a Mantoux test to children determined to be at high risk for contracting tuberculosis. Hematocrit or Hemoglobin Test * The screening provider must obtain the hematocrit/hemoglobin test for iron deficiency according to the following: (a) once between nine months and 12 months of age; (b) as needed, at the clinician’s discretion for members aged one year through 10 years; and (c) annually, at the clinician’s discretion for members aged 11 years through 17 years. Cholesterol Screening – Screen children aged two years through 17 years at least once if they have a family history of premature cardiovascular disease or a parent with known lipid disorder and/or a parent with BMI greater than the 85th percentile. Screen once between the ages of 18 years and 21 years, if not screened previously. Urinalysis – Conduct once at about five years of age at the clinician’s discretion. Hepatitis C – Obtain anti-Hepatitis C virus test after the age of 12 months in children with mothers infected with hepatitis C virus. Sexually Transmitted Infections – Test all sexually active adolescents and young adults annually for gonorrhea and chlamydia, and according to the member’s risk and the provider's professional judgment for syphilis and any other sexually transmitted infections. Screen for syphilis, gonorrhea, and chlamydia during pregnancy, if at risk, at the first prenatal visit and in the third trimester. HIV – Screen all pregnant members. Routinely test males and females at high risk. Advise about risk factors for HIV infection. Other Laboratory Testing – Obtain other laboratory tests according to the member’s risk, the provider's professional judgment, and applicable state requirements for newborn screening tests. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule Page W-6 All Provider Manuals Transmittal Letter ALL-137 Date 03/01/06 This page is reserved.