Within the revised EPSDT/PPHSD regulations (130 CMR 450.140 through 450.150), MassHealth requires primary-care providers (PCPs) to offer to EPSDT and PPHSD screens for members under the age of 21 according to the EPSDT Services Medical Protocol and Periodicity Schedule found in Appendix W of the MassHealth provider manuals, and provide or refer members to assessment, diagnosis, and treatment services, as necessary. These screens include behavioral-health screening. Behavioral-health screening must be conducted using one of the standardized screening tools listed in Appendix W of the MassHealth provider manuals. Providers choose a clinically appropriate tool from the list, based on the age of the child.
Collectively, EPSDT and PPHSD services are the preventive care and treatment services that MassHealth covers for members under the age of 21. MassHealth pays for these members to see their PCPs on a periodic schedule (at least once every year and more often when they are under the age of two). At these visits, PCPs perform a series of health screens. If the screens show that there might be a problem, MassHealth pays for certain further assessment, diagnosis, and treatment services.
Periodic Visits
Periodic visits are visits to assess a child's health at key points in life to ensure continued healthy development. Appendix W recommends a schedule of visits at the following ages:
- 1-2 weeks;
- at 1, 2, 4, 6, 9, 12, 18, and 24 months; and
- every year afterward until the member turns 21
Interperiodic Visits
Interperiodic visits are medically necessary visits between the ages for a periodic visit to determine if a child has an illness or condition or if a child is experiencing a change in a preexisting condition. Interperiodic visits are medically necessary whenever a parent, guardian, PCP, or other clinician (such as a school nurse) thinks that there might be something wrong. These visits may include the full range of components for a periodic visit or a portion of the components that are indicated by the suspected illness, condition, or change in preexisting condition.