Rule 5160:1-2-15 | Medicaid: healthchek (early and periodic screening, diagnostic and treatment services).
(A) This rule explains the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit that is mandatory for an individual under twenty-one years of age who is enrolled in medicaid.
(1) The healthchek benefit provides comprehensive preventative, diagnostic, and treatment services for an eligible individual as specified in Section 1905(r) of the Social Security Act (as in effect October 1, 2024).
(2) There is no separate enrollment for healthchek. When an individual is eligible for medical assistance and is under twenty-one years of age, the individual automatically qualifies for healthchek services.
(3) Each county department of job and family services (CDJFS) is required to have a healthchek coordinator.
(4) The Ohio department of medicaid (ODM) will cover all medically necessary state plan services for a healthchek eligible individual when a need is identified during the course of an EPSDT exam, even when the service is not covered under ODM's state plan.
(B) Definitions. For the purposes of this rule, the following terms have the following meanings:
(1) "Administrative agency," for the purpose of this rule, means the CDJFS.
(2) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment benefit for all medicaid eligible individuals under twenty-one years of age.
(3) "Healthchek coordinator" is the CDJFS employee who is responsible for the implementation of healthchek services.
(4) "Healthchek services" are periodic screening services (including a comprehensive medical exam, vision, dental, and hearing screenings) and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. section 1396d(a) (as in effect October 1, 2024) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. Healthchek services are identical to "EPSDT services" as defined at 42 U.S.C. section 1396d(r) (as in effect October 1, 2024).
(5) "Healthchek Services Implementation Plan" (HSIP), ODM 03517, means the document submitted by a CDJFS describing how it delivers healthchek services to individuals in its county and who in the agency is responsible for ensuring the delivery of healthchek services.
(6) "Individual," for the purpose of this rule, means an individual under twenty-one years of age who is eligible for medical assistance.
(a) An individual under twenty-one years of age who receives medical assistance via presumptive eligibility, as described in rule 5160:1-2-13 of the Administrative Code, is entitled to the healthchek benefit.
(b) An individual under twenty-one years of age who receives medical assistance for coverage of the treatment of an emergency medical condition, as described in rule 5160:1-5-06 of the Administrative Code, is not entitled to the healthchek benefit.
(7) "Medically necessary," otherwise known as "medical necessity," as used in this chapter, is the same as defined in paragraph (A) of rule 5160-1-01 of the Administrative Code.
(8) "Prior authorization" for a member of a medicaid managed care organization (MCO) is the process outlined in rule 5160-26-03.1 of the Administrative Code. For all other individuals, prior authorization is the process outlined in rule 5160-1-31 of the Administrative Code.
(9) "Support services" are non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community agencies and other social services. Support services shall be coordinated with the individual's medicaid-contracting MCO, where applicable.
(C) The individual (or the individual's parent, guardian, or legal custodian, as applicable) may:
(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" to verify receipt and understanding of information about healthchek;
(2) Complete, sign, and return the ODM 03528 to identify service needs; and
(3) Request and attend scheduled appointments for healthchek services.
(D) CDJFS responsibilities. Each CDJFS shall:
(1) Inform. The CDJFS shall use a combination of written and oral methods (including telephone calls, office visits, or home visits) to inform the individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county about healthchek.
(a) Inform in writing.
(i) Ensure each eligible individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county receives the ODM 03528 within sixty days after the individual is determined eligible for medical assistance and at least once each year thereafter. For newborns, ensure the parent, guardian, or legal custodian receives the ODM 03528 as soon as the agency learns of the child's birth.
(ii) Document that each individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county has received the ODM 03528.
(iii) When written healthchek information that is mailed to an individual (or such individual's parent, guardian, or legal custodian, as applicable) is returned as undeliverable, the CDJFS shall make a second attempt to contact the individual by alternate means. All attempts to contact an individual (or such individual's parent, guardian, or legal custodian, as applicable) shall be documented in the electronic information system.
(iv) Upon completion of the ODM 03528, ask the individual (or such individual's parent, guardian, or legal custodian, as applicable) to sign the ODM 03528 to acknowledge receipt of healthchek information and to verify understanding of the healthchek services available. When the individual (or such individual's parent, guardian, or legal custodian, as applicable) needs additional information in order to understand healthchek services, the CDJFS shall immediately provide the necessary information.
(v) Enter data regarding the individual into the electronic information system, as directed by ODM. Such information shall include information from the completed ODM 03528, record of contact with the individual and any requests and referrals made or services provided.
(vi) Prominently display a notice that complies with the methods of providing information about healthchek as established by section 5164.26 of the Revised Code. All entities that distribute or accept applications for medical assistance must display a notice about healthchek.
(vii) Distribute written materials as directed by ODM. ODM may develop additional written materials containing information about healthchek. Any written materials developed by a CDJFS to inform individuals about healthchek shall be submitted to ODM for review and approval.
(b) Inform orally. The CDJFS shall ensure that each individual (or such individual's parent, guardian, or legal custodian, as applicable), who has an in-person meeting or telephone call with CDJFS staff to apply for medical assistance, is orally informed about healthchek using clear and non-technical language about the following:
(i) The benefits of preventive health care, including:
(a) Increased well-being;
(b) Reduced risk to the individual's health;
(c) Identification and treatment of health problems early to reduce the possibility of an increase in severity and cost of treatment; and
(d) Education of the family to promote optimal health.
(ii) The services covered by healthchek.
(iii) Where and how to obtain healthchek services.
(iv) That services covered by healthchek are without cost to eligible individuals.
(v) The individual's ability to request and schedule dental, vision, and hearing services separately from the healthchek screening visit.
(vi) The availability of medically necessary diagnostic and follow-up treatment services, including referrals, for problems discovered during the healthchek screening service.
(vii) The prior authorization process, including:
(a) The process, whether fee-for-service or managed care, must be started by the individual's medical assistance provider;
(b) The prior authorization requirement for some services, products, or procedures applies even when the individual is under twenty-one years of age;
(c) The prior authorization process may enable an individual under twenty-one years of age to receive services not available to adults, including services that are limited in number for adults; and
(d) Certain services require prior authorization, which must be requested by a provider and approved by ODM before the service is provided.
(viii) Effectively describe to an individual the services that are available under the healthchek benefit, including an explanation that necessary transportation and scheduling assistance are available in accordance with Chapter 5160-15 of the Administrative Code, including the following:
(a) Transportation is provided to any medicaid reimbursable service;
(b) How to request transportation and the timeframes for requesting transportation;
(c) Verification requirements for transportation, if any; and
(d) For an individual who is a member of an MCO, transportation is available through the individual's MCO.
(c) Use appropriate methods to inform an individual with a visual or hearing impairment or who cannot read or understand the English language (or such individual's parent, guardian, or legal custodian, as applicable) about the healthchek benefit. Information provided to individuals with visual or hearing impairments or who cannot read or understand the English language shall meet the requirements of paragraphs (D)(1) and (D)(2) of this rule.
(d) Informing a pregnant woman. Any time the administrative agency becomes aware of an individual's pregnancy, the ODM 03528 shall be utilized to document the informing of a pregnant woman about healthchek services. After an infant's birth, the ODM 03528 shall again be used to document the informing of the individual about healthchek.
(e) Use electronic means to track a pregnant woman and the birth of her infant to accomplish the following:
(i) Identify newborn and the infant's parent, guardian, or legal custodian, as applicable;
(ii) Ensure that any infant born to an individual eligible for medical assistance is added to the medicaid case, in accordance with rule 5160:1-4-02 of the Administrative Code;
(iii) Ensure the infant's parent, guardian, or legal custodian, as applicable, is informed about healthchek services within sixty days of the infant's birth;
(iv) Contact the infant's parent, guardian, or legal custodian, as applicable, to assist with securing an ongoing primary care provider for the newborn; and
(v) Coordinate the activity in paragraphs (C)(1) to (C)(3) of this rule with the individual's MCO, other agencies, and programs where applicable.
(2) Provide support services.
(a) Refer the individual (or the individual's parent, guardian, or legal custodian, as applicable) to entities listed on the ODM 03528 and/or other community supportive services as requested. The CDJFS will ensure:
(i) That referrals are made, as needed, for both medical and other services such as help me grow (HMG); the special supplemental nutrition program for women, infants, and children (WIC); maternal, child and family health (MCFH) clinics; local health departments; head start (HS); child care; clothing and/or other community social services, where applicable.
(ii) Coordination between the individual and the entity where the referral is made.
(iii) Coordination between the individual and the individual's MCO by forwarding a copy of the ODM 03528 to the individual's MCO, when applicable.
(iv) The individual enrolled in an MCO (or the individual's parent, guardian, or legal custodian, as applicable) is advised to contact the individual's MCO for medical care options and/or referrals.
(v) Assistance is provided with scheduling medical appointments as requested by the individual or the individual's parent, guardian, or legal custodian, as applicable.
(vi) Requests for support services available in the individual's county of residence received by the individual's MCO and forwarded to the CDJFS are acted upon and the requested service(s) provided.
(b) Provide the individual with necessary assistance in obtaining transportation to medicaid reimbursable services as requested by the individual or the individual's parent, guardian, or legal custodian, as applicable.
(c) Refer each individual in a household who requests or is in need of services not covered by medicaid, as indicated on the ODM 03528 or through other verbal or written communication, to community, medical, or other social services, as needed, including providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the family. Community and medical service requests will be documented and forwarded to the appropriate community provider, medical provider, and/or MCO.
(d) When notified, provide services for an individual identified as having elevated blood lead levels, including the following:
(i) Referral of the individual to the Ohio department of health (ODH) for an environmental assessment.
(ii) Verification of the individual's medical assistance eligibility at the time the environmental assessment is conducted and the ODH agent is informed of such eligibility. Verification shall only be provided upon receipt of proper verification of the identity of the ODH agent who is requesting the information.
(iii) Education of the family about the purpose of the environmental assessment by:
(a) Informing the family of the need to remove the source of lead or removing the individual from the contaminated environment;
(b) Explaining the family's responsibility to inform the health department staff who conduct the environmental assessment of places the individual visits regularly; and
(c) Assisting the family with securing lead-free housing by making any necessary referrals when the source of lead cannot or will not be removed from the environment.
(iv) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by ODH and any action taken as a result of those recommendations. When, as a result of CDJFS efforts, a family relocates, the CDJFS must inform ODH of the family's new address.
(v) In geographic areas with local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.
(3) The HSIP. The CDJFS is required to have a healthchek services implementation plan on file with ODM. The plan shall be signed by the agency director or the director's designee.
(a) The CDJFS shall complete and sign the HSIP to describe how EPSDT services are delivered to eligible individuals.
(b) The CDJFS shall provide a description in the HSIP of the electronic and/or hard-copy methods for ensuring permanent records and documentation are maintained in a case file for each individual. The case file shall contain the following information, when appropriate:
(i) Copy of the ODM 03528;
(ii) Copies of all correspondence received and sent;
(iii) Documentation of attempted and successful contacts with the individual (or such individual's parent, guardian, or legal custodian, as applicable);
(iv) Documentation of the MCO in which the individual is enrolled, when applicable;
(v) Documentation of contacts with or forms provided by the medical provider;
(vi) Information received from other counties when an individual's case is an inter-county transfer; and
(vii) Documentation of support services requested and/or provided and referrals made on an individual's behalf, and the CDJFS' efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:
(a) Steps taken by the CDJFS to ensure the requested support services are provided, and whether or not the individual received the requested support services;
(b) A copy of all documentation of services requested by an individual (or such individual's parent, guardian, or legal custodian, as applicable) and provided or facilitated by the CDJFS;
(c) Records of transportation requested and provided; and
(d) Any communication or forms provided by the medical provider.
(c) The CDJFS shall identify, when applicable, any services or functions required in this rule which are contracted out to other entities. A copy of the contract shall be provided to ODM. The CDJFS shall also describe accountability and monitoring measures, along with timeframes when monitoring takes place to ensure the contracted entities are completing all required functions and that these functions are in accordance with applicable state and federal rules.
(d) The CDJFS shall submit a new or amended HSIP to ODM when there has been a change, including but not limited to, agency address, CDJFS director, Healthchek coordinator, or where the responsibility for healthchek is organizationally located within the agency. The HSIP shall be submitted to ODM within ten business days of the change.
(4) Release of information. The CDJFS shall, when necessary, obtain a HIPAA-compliant signed authorization for release of information that is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" shall be used when the CDJFS needs additional medical information from the individual or the individual's provider.
(5) Provider recruitment. The CDJFS is required to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of healthchek eligible individuals. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.
(6) Mandatory training. The CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend available annual and other pertinent healthchek trainings offered by ODM. For video conferences or other training delivered electronically, verification shall consist of proof of the individual's attendance and submission of an evaluation form to the appropriate state monitored e-mail box within three days of the training. Verification of attendance at in-person training shall be documented by the healthchek coordinator, or such coordinator's designee(s), by signing the attendance log.
Last updated March 4, 2025 at 7:54 AM
Supplemental Information
Amplifies: 5162.03, 5164.26
Five Year Review Date: 3/1/2030
Prior Effective Dates: 1/14/1983, 3/20/1983, 3/21/1983, 11/1/1985 (Emer.), 1/1/1986, 1/29/1986 (Emer.), 1/31/1986, 4/1/1986 (Emer.), 1/1/1987, 3/20/1987, 9/28/1987 (Emer.), 12/23/1987 (Emer.), 3/15/1988, 7/1/1988 (Emer.), 9/1/1988, 1/1/1989, 10/1/1990, 7/1/1992, 9/1/1993, 6/1/1997, 3/18/1999 (Emer.), 6/17/1999, 4/1/2001, 12/1/2001, 9/19/2005, 3/1/2006, 10/1/2009, 12/31/2010, 2/14/2011, 9/12/2016