42 C.F.R. § 441.56

Required activities

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(a) Informing. The agency must—

(1) Provide for a combination of written and oral methods designed to inform effectively all EPSDT eligible individuals (or their families) about the EPSDT program.

(2) Using clear and nontechnical language, provide information about the following—

(i) The benefits of preventive health care;

(ii) The services available under the EPSDT program and where and how to obtain those services;

(iii) That the services provided under the EPSDT program are without cost to eligible individuals under 18 years of age, and if the agency chooses, to those 18 or older, up to age 21, except for any enrollment fee, premium, or similar charge that may be imposed on medically needy beneficiaries; and

(iv) That necessary transportation and scheduling assistance described in § 441.62 of this subpart is available to the EPSDT eligible individual upon request.

(3) Effectively inform those individuals who are blind or deaf, or who cannot read or understand the English language.

(4) Provide assurance to CMS that processes are in place to effectively inform individuals as required under this paragraph, generally, within 60 days of the individual's initial Medicaid eligibility determination and in the case of families which have not utilized EPSDT services, annually thereafter.

(b) Screening. (1) The agency must provide to eligible EPSDT beneficiaries who request it, screening (periodic comprehensive child health assessments); that is, regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth. (See paragraph (c)(3) of this section for requirements relating to provision of immunization at the time of screening.) As a minimum, these screenings must include, but are not limited to:

(i) Comprehensive health and developmental history.

(ii) Comprehensive unclothed physical examination.

(iii) Appropriate vision testing.

(iv) Appropriate hearing testing.

(v) Appropriate laboratory tests.

(vi) Dental screening services furnished by direct referral to a dentist for children beginning at 3 years of age. An agency may request from CMS an exception from this age requirement (within an outer limit of age 5) for a two year period and may request additional two year exceptions. If an agency requests an exception, it must demonstrate to CMS's satisfaction that there is a shortage of dentists that prevents the agency from meeting the age 3 requirement.

(2) Screening services in paragraph (b)(1) of this section must be provided in accordance with reasonable standards of medical and dental practice determined by the agency after consultation with recognized medical and dental organizations involved in child health care.

(c) Diagnosis and treatment. In addition to any diagnostic and treatment services included in the plan, the agency must provide to eligible EPSDT beneficiaries, the following services, the need for which is indicated by screening, even if the services are not included in the plan—

(1) Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and hearing aids;

(2) Dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health; and

(3) Appropriate immunizations. (If it is determined at the time of screening that immunization is needed and appropriate to provide at the time of screening, then immunization treatment must be provided at that time.)

(d) Accountability. The agency must maintain as required by §§ 431.17 and 431.18—

(1) Records and program manuals;

(2) A description of its screening package under paragraph (b) of this section; and

(3) Copies of rules and policies describing the methods used to assure that the informing requirement of paragraph (a)(1) of this section is met.

(e) Timeliness. With the exception of the informing requirements specified in paragraph (a) of this section, the agency must set standards for the timely provision of EPSDT services which meet reasonable standards of medical and dental practice, as determined by the agency after consultation with recognized medical and dental organizations involved in child health care, and must employ processes to ensure timely initiation of treatment, if required, generally within an outer limit of 6 months after the request for screening services.

[49 FR 43666, Oct. 31, 1984; 49 FR 45431, Nov. 16, 1984]

Notes of Decisions

Cited in 36 cases, 1981–2020 · leading case: Salazar v. Dist. of Columbia, 954 F. Supp. 278 (D.D.C. 1996).

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Salazar v. Dist. of Columbia, 954 F. Supp. 278 (D.D.C. 1996). · cites it 8× “42 C.F.R. § 441.56 (a)(3) (1996). 157. Several parents received decision notices on their Medicaid applications that were printed in English.”

Clark v. Richman, 339 F. Supp. 2d 631 (M.D. Penn. 2004). · cites it 4× “§ 1396a(43)(B)-(C); 42 C.F.R. § 441.56 (e). Plaintiffs’s Count V remains viable to the extent it rests on the medical assistance provision, § 1396a(a)(10)(A), for the reasons set forth in Sabree II and the reasons discussed supra Parts I.”

Persico v. Maher, 465 A.2d 308 (Conn. 1983). · cites it 3× “” 42 C.F.R. § 441.56 (b) (2). As the trial court below noted so aptly, “[tjhere is a wide divergence between that which is necessary for maintenance of dental health as required by federal standards and that which is necessary to alleviate a serious health problem under the…”

John B. Ex Rel. L.A. v. Menke, 176 F. Supp. 2d 786 (M.D. Tenn. 2001). · cites it 3× “42 C.F.R. § 441.56 (a)(2001). Hence, although there is no “right” way to conduct outreach, the federal code and regulations certainly set forth guidelines for effectively conducting outreach.”

Rosie D. v. Baker, 958 F.3d 51 (1st Cir. 2020). · cites it 6× “To implement both requirements, federal Medicaid regulation, 42 C.F.R. § 441.56 (e), requires the following: [T]he [Commonwealth] must set standards for the timely provision of EPSDT services which meet reasonable standards of medical and dental practice, as determined by the…”

Rosie D. v. Romney, 410 F. Supp. 2d 18 (D. Mass. 2006). · cites it 2× “See § 1396a(a)(43); see also 42 C.F.R. § 441.56 (a)(1), -.61, -.62 (2005).”

Westside Mothers v. Olszewski, 454 F.3d 532 (6th Cir. 2006). · cites it 3× “§ 1396a(a)(10)(A), see also 42 C.F.R. § 441.56 (mandatory language). Third, the provisions are not so vague and amorphous as to defeat judicial enforcement, as the statute and regulations carefully detail the specific services to be provided.”

Carr v. Wilson-Coker, 203 F.R.D. 66 (D. Conn. 2001). · cites it 4× “§ 1396a(a)(43) and 42 C.F.R. § 441.56 (a); 2) failed to provide or arrange for provision of periodic EPSDT program dental screening services to assess the plaintiffs’ dental health, diagnostic dental services and treatment identified during the dental screenings, in violation of…”

New York City Coalition to End Lead Poisoning v. Koch, 138 Misc. 2d 188 (N.Y. Sup. Ct. 1987). · cites it 2× “It imposes an obligation on the municipal defendants both to ensure that certain medical screening services, including lead poisoning screening, are actually available to Medicaid-eligible children, and to take active and effective measures to inform eligible families of the…”

Westside Mothers v. Haveman, 133 F. Supp. 2d 549 (E.D. Mich. 2001). “§ 1396a(a)(43), 42 C.F.R. § 441.56 , and various HHS policy directives; (4) assistance in scheduling EPSDT services 5 as required by 42 U.”

Frew v. Gilbert, 109 F. Supp. 2d 579 (E.D. Tex. 2000). · cites it 2× “Defendants appear to suggest that the use of the phrase “effectively inform” in 42 C.F.R. § 441.56 (a) should inform the court as to the parties’ intended meaning of the phrase in the decree.”

Tallahassee Mem'l Reg'l Med. Ctr. v. Cook, 109 F.3d 693 (11th Cir. 1997). “§ 1396d(r); 42 C.F.R. § 441.56 (c). However, even when a state elects to provide an optional service, that service becomes part of the state Medicaid plan and is subject to the requirements of federal law.”

Show all 36 citing cases →

— 42 C.F.R. § 441.56(b)(2) — 2 cases

Mitchell v. Johnston, 701 F.2d 337 (5th Cir. 1983).

Stephanie Mitchell, on Behalf of Themselves & All Others Similarly Situated v. Marlin W. Johnston, in His Off. Capacity as Acting Comm'r of the Texas Dep't of Human Resources, Stephanie Mitchell, on Behalf of Themselves & All Others Similarly Situated, & Eddie Mae Benson, Intervenor-Appellant v. Marlin W. Johnston, in His Off. Capacity as Acting Comm'r of the Texas Dep't of Human Resources, 701 F.2d 337 (5th Cir. 1983).

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