Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Texas as Texas Health Steps (THSteps), refers to Medicaid’s obligation to provide a comprehensive array of prevention, diagnostic and treatment services for infants, children and adolescents in the program. EPSDT is designed to ensure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible.

THSteps Comprehensive Care Program (CCP) is an expansion of the EPSDT service as mandated by the Omnibus Budget Reconciliation Act of 1989. This act requires states to provide all medically necessary treatment for correction of physical or mental health conditions to members eligible for THSteps (birth through 20 years of age) when Federal Financial Participation (FFP) is available. THSteps and THSteps CCP do not apply to CHIP.

Exceptions include:

  • Experimental or investigational treatment.
  • Services or items not generally accepted as effective and/or not within the normal course and duration of treatment.
  • Services for the caregiver or provider convenience.

Extended Ophthalmoscopy 

According to the American Academy of Pediatrics (AAP)’s 2018 guidance Screening Examination of Premature Infants for Retinopathy of Prematurity, infants born premature or with low birth weight are at risk for developing retinopathy of prematurity (ROP). Because of the usually predictable and sequential nature of ROP progression, and the proven benefits of timely treatment in reducing the risk of vision loss, efficacious care now requires that infants who are at risk receive carefully timed retinal examinations to identify treatment-requiring ROP in time for that treatment to be effective.

Texas Medicaid Vision Services policy currently limits coverage of ophthalmoscopy (procedure codes 92201 and 92202) to two services per year. With evidence of medical necessity, additional screening examinations of premature infants for retinopathy of prematurity must be considered through the Texas Health Steps-Comprehensive Care Program (CCP).

Resources:

Additional information on Texas Health Steps-CCP is available in the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Section 2, “Medicaid Children’s Services Comprehensive Care Program (CCP).”

For more information, call the TMHP at 800-925-9126.