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Child and Teen Checkups (C&TC)

Revised: 07-01-2014



Overview
Child and Teen Checkups (C&TC) is the name for Minnesota’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, a required service under Title XIX of the Social Security Act. C&TC is a comprehensive child health program provided to children and teens (newborn through the age of 20) enrolled in Medical Assistance (MA) or MinnesotaCare. The purpose of the program is to reduce the impact of childhood health problems by identifying, diagnosing, and treating health problems early, and encourage the development of good health habits.

The federal Centers for Medicare and Medicaid Services (CMS) has set a goal for states to have an 80% participation rate in C&TC screening services. Federal law requires states to maintain an 80% participation rate in the C&TC screenings. This participation rate is based on eligible children receiving a C&TC screening service during the reporting year. As Minnesota works toward reaching the 80% participation rate goal, accurate billing/coding is critical in documenting the screenings that have been provided.

States are also required to follow-up on referrals made as a result of a C&TC screening to assure that children/families receive the necessary services to correct or improve health problems. It is important that providers report all referrals on C&TC claims using one of the four HIPAA Required Referral Codes.

Coordination of Preventive Health Care
The C&TC program emphasizes the need to avoid fragmentation of care and the importance of continuity of care in comprehensive health supervision. Providers can assist in reducing duplication of services by substituting a C&TC screening service (when appropriate) for other preventive health care visits, such as:

• Newborn/well-baby checkups
• School
• Camp or athletic physicals
• Routine well-child care
• Family planning visits
• Special Supplemental Food Program for Women Infants and Children (WIC)
• Head Start physicals
• Immunizations
• Initial prenatal visits
• Early childhood screening

Eligible Providers
To be reimbursed for C&TC screening services, fee-for-service C&TC screening providers must either be enrolled as:

• An MHCP C&TC provider and sign a C&TC agreement; or
• A C&TC clinic or a facility which is supervised by a physician, that provides screening according to EPSDT (Minnesota Rules 9505.1693-9505.1748)

Individual Providers
• Nurse practitioners
• Physicians
• Physician assistants
• Public Health Nurses approved by MDH after completing the 2-3-day C&TC screening component training
• Dentists

Staff eligible to provide some components under supervision of a physician or dentist includes:

• Public Health Nurses
• Registered Nurses
• Other staff through delegation by a licensed health professional within their scope of practice

Facility Types
• Clinics
• C&TC
• Community Health
• Dental
• Physicians
• Public Health
• Public Health Nursing
• Rural Health
• School (clinics)
• Family Planning Agencies
• Federally Qualified Health Centers
• Head Start
• Hospitals
• Indian Health Services
• WIC

Some providers listed can only complete certain components that are within their scope of practice as a licensed professional. For more information about enrolling as an MHCP provider, refer to Requirements for Providers. Use this MHCP Provider Manual in conjunction with the DHS C&TC Provider Guide (DHS-4212).
Eligible Recipients
• Children and teens, newborn through the age of 20 years, enrolled in Medical Assistance (MA) or MinnesotaCare. Children enrolled in MA or MinnesotaCare through a Managed Care Organization (MCO) must receive screening services from their Prepaid Minnesota Healthcare Program provider
• Use MN–ITS Interactive Eligibility Request to verify a recipient’s eligibility for this service

Covered Services
Medical Screenings
The C&TC medical screening components include:
• Health Education (Anticipatory Guidance)
• Physical Growth and Measurement (height, weight, head circumference and BMI at appropriate ages)
• Health History (including mental health, nutrition and chemical use)
• Developmental Health
• Mental Health
• Physical Examination (includes but not limited to: pulse, respiration, blood pressure, exam of head, eyes, ears, nose, mouth, pharynx, neck, chest, heart, lungs, abdomen, spine, genitals, extremities, joints, muscle tone, skin and neurological condition)
• Immunizations and Review of Immunizations
• Newborn Metabolic Screening
• Laboratory Tests including:
• Blood Lead Test
• Hemoglobin/hematocrit
• Urinalysis is no longer required
• Other tests as indicated
• Vision Screening
• Hearing Screening
• Verbal referral to a dentist for Dental Services

Refer to the Schedule of Age-Related Screening Standards (C&TC Screening Component Periodicity Schedule) (DHS-3379) for Minnesota’s age-related screening standards schedule details. Refer to the DHS C&TC Provider Guide (DHS-4212) for more information on screening components.

Dental Service Components for C&TC
The C&TC dental screening components include:

• Oral health history
• Clinical oral examination
• Assessments/screening
• Oral growth and development
• Caries risk
• Radiographic
• Prophylaxis and topical fluoride (as indicated by clinical findings)
• Fluoride supplementation (as indicated by clinical findings)
• Anticipatory guidance/counseling
• Counseling
• Oral hygiene
• Dietary
• Injury prevention
• Nonnutritive habits
• Speech/language development
• Substance abuse
• Intraoral/perioral piercing
• Assessment and treatment of developing malocclusion
• Assessment for sealants
• Assessment and /or removal of third molars
• Transition to adult care

Refer to the Schedule of Age-Related Dental Standards (C&TC Dental Periodicity Schedule) (DHS- 5544) for Minnesota’s age-related dental standards schedule details.

For details on dental benefit coverage policy, refer to the Dental Services section of this manual.

Blood Lead Test
A blood lead test at ages 12 and 24 months is a federally required component of C&TC. Research indicates that MA/MinnesotaCare children are at greater risk of lead poisoning. Lead testing can occur at other times within the ranges that are indicated on the Schedule of Age-Related Screening Standards (C&TC Screening Component Periodicity Schedule) (DHS-3379) and when medically indicated. A blood lead test done between 9 and 15 months can fulfill the 12-month screening requirement. A blood lead test completed for a child between 16 months and 30 months of age can fulfill the 24-month screening requirement.

When billing a blood lead test use the correct CPT code for the lead test. Venipuncture and capillary specimen collection and handling are covered services.

Lab services must be performed and billed by a CLIA certified lab.

Blood Lead Resources:


Tuberculosis (TB) Testing
All children/adolescents should be evaluated for their risk of exposure to TB. High-risk children include:

• Recent close contacts of persons with infectious TB disease;
• Foreign-born children and children with foreign-born parents from high prevalence areas;
• Foreign travel to areas with endemic TB;
• Children with (or those children in households with) socioeconomic risk factors such as homelessness, living in shelters, or incarceration. Any high-risk individual who has not received TB testing previously should be screened.

TB testing is recommended for high-risk children/adolescents only, either by tuberculin skin test (TST) or TB blood test. TB testing is not mandatory but is a covered service if clinical documentation supports the medical need for the test. When TB testing is performed during a C&TC screening, bill with the appropriate CPT code on the C&TC screening claim. For more information, review the C&TC TB Screening FACT Sheet.

Developmental and Mental Health Screenings
Developmental and mental health surveillance/screenings are a C&TC screening component. To receive additional reimbursement for a developmental and/or mental health screening, providers must use a standardized screening instrument. Without the use of a standardize screening instrument, reimbursement for developmental and/or mental health surveillance/screening is included in the payment of the E&M code used for a C&TC visit.

To use a standardized instrument, providers need to meet the instrument-specific criteria, as outlined by the publisher. Providers that may use the standardized instruments could include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.

Currently, no recommended standardized instrument adequately covers both developmental and mental health screening domains. Two separate screening instruments are needed to adequately screen for potential developmental and mental health concerns.

Required documentation must be maintained in the child’s health record and at a minimum includes the name of the screening instrument used, the score and the anticipatory guidance related to the screening results. If the screening results are abnormal, documentation must include how this is being addressed such as referral to Help Me Grow, other appropriate medical specialist(s), follow-up plan of care, and when appropriate, a referral to local community service agency.

Refer to Developmental and Social-Emotional Screening of Young Children (0-6 years of age) in Minnesota for instruments recommended by the Minnesota Interagency Developmental Screening Task Force, including a list of All Instruments at a Glance (PDF). The Task Force no longer recommends the Denver II and thus MHCP will no longer reimburse providers when this tool is used.

Refer to the Mental Health Screening (6-21 years) FACT Sheet (PDF) for a list of instruments recommended by the DHS Children’s Mental Health Division and MDH.

For more information on developmental and social-emotional screening and recommended instruments, refer to the DHS Children’s Mental Health Division Screening website

For more information on recommended mental health and substance abuse, screening tools refer to Bulletin #12-53-01.

Bill the developmental and/or mental health screening on the same claim as other C&TC services. Use:

• CPT code 96110 for a developmental screening with a standardized instrument
• CPT code 96110 and modifier UC for a mental health screening with a standardized instrument

You may bill for both a developmental and a mental health screening on the same date of service, on the same claim.

When a developmental and mental health screening is provided at other pediatric visits, bill the developmental and mental health screening on the same claim as the other pediatric services.

Screening for Autism in Toddlers
A standardized screening instrument must be used for autism screening. Without the use of a standardized screening instrument, reimbursement for autism screening is included in the payment of the E&M code used for the C&TC visit.

• When an autism screening is completed in addition to another developmental screening using two separate standardized screening instruments, bill for the autism screening on the C&TC claim using CPT code 96110 with 2 units.
• If only the autism screening is performed with a standardized screening instrument, bill using CPT 96110 with one unit.
• Required documentation must be maintained in the child’s health record and at a minimum, must include the name of the screening instrument(s) used, the score(s) and the anticipatory guidance related to the results.

Immunization and Vaccinations
The immunization status of a child must be reviewed and compared to the current Recommended Childhood and Adolescent Immunization Schedule from the Advisory Committee on Immunization Practices (ACIP). ACIP is part of the Centers for Disease Control and Prevention (CDC) and provides current recommendations for vaccine administration, schedules of periodicity, and appropriate dosage and contraindications. The Minnesota Department of Health (MDH) Recommended Immunization Schedule, for Children and Adolescents, which is revised annually, may be used as it incorporates the ACIP schedule.

State law requires all MHCP enrolled providers who administer pediatric vaccines to enroll in the MnVFC program. MDH administers the Minnesota Vaccines for Children Program (MnVFC) to provide most pediatric vaccines to participating providers at no cost. Providers must obtain vaccines through MnVFC whenever available.

When billing for immunizations or vaccinations administered during a C&TC screening enter the correct immunization or vaccination code(s) with the SL modifier when applicable, and add the correct administration code(s) to the C&TC claim. Refer to the MHCP Provider Manual – Immunizations and Vaccinations Section for details on coding and billing criteria.

Immunization and Vaccinations Resources:


Health Education/Anticipatory Guidance
Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and dental screening, gives you the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child’s development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention.

Reimbursement for health education and anticipatory guidance is included in the payment of the E&M code used for a C&TC screening.

For more information on Health Education/Anticipatory Guidance, refer to the Anticipatory Guidance (0-5 years), (6-12 years), and (13-21 years) FACT Sheets

Preventive counseling is included in the preventive medicine E&M service; do not report preventive counseling separately. Report CPT Codes 99401-99404 if patient visit is for counseling only.

Screening Exceptions
MHCP recognizes that for some situations it is not possible or appropriate to require C&TC providers to complete certain components of the C&TC screening as outlined in the Schedule of Age-Related Screening Standards. According to the Administrative Uniformity Committee (AUC) recommendations, use the following billing guidelines for the situations listed below when screening component(s) cannot be performed or an initial screening is not appropriate.

Claims submitted using the following guidelines for an exception identified below will be recognized as completed C&TC claims.

• Follow all billing policy requirements for submitting a C&TC screening claim
• Report one of the HIPAA compliant referral codes (ST, NU, AV S2)
• Use the claim reporting and medical documentation for the exception reasons as appropriate

Exception Reason Situation Claim Reporting and Medical Documentation
Medical contraindication Out of provider’s control:
• Child has a diagnosis of a hearing or visual impairment
• Child wears has new glasses (identified visual impairment)
• Completing a vision screening may not be indicated at this time
• Refer child/parent for ongoing monitoring or treatment
• Child has been diagnosed as having autism or developmental delay
• Completing a developmental screening may not be indicated
• Refer child/parent for on-going treatment and/or services for the condition
• Maintain specific documentation of the diagnosis in the medical record of the child
• Report the correct CPT code for the screening component on the claim
• Enter an additional diagnosis code identifying the condition
• Enter $0.00 or $0.01 as the submitted charge
Contraindication (Service recently performed elsewhere) Out of provider’s control:
• Lead screening was performed at a different agency, clinic or location
• Hearing, vision screening performed at school
• Request and review test results at the time of the visit. If results are within acceptable limits, add specific documentation and maintain a copy of the test results in the medical record of the child
• Report the correct CPT code for the screening component on the claim
• Enter $0.00 or $0.01 as the submitted charge
Parent refusal Out of provider’s control:
• Rescheduling for a later date is not feasible
• Against personal or religious belief of the parent or family
• Provide specific documentation of the parent refusal
• Report the correct CPT code for the screening component on the claim
• Enter $0.00 or $0.01 as the submitted charge
Parent refusal Within the provider’s control:
• Rescheduling for later date is feasible (parent is willing)
• Parent indicates they do not want the component completed because of time constraints or mood of the child
• Re-attempt the screen component within 30 days
• If re-attempting to screen, wait to bill the C&TC screening until all components are completed
• Bill using the two separate dates if within the same month
• If the second screening attempt crosses over to a new month, use the date the C&TC screening was finally completed
Unsuccessful attempt (Child uncooperative)
• Rescheduling for a later date is not feasible
• A valid attempt was made to complete the service
• Provider specific documentation of the unsuccessful attempt
• Report the correct CPT code for the screening component on the claim
• Add the modifier 52 to the claim
• Enter your usual and customary charge
Unsuccessful attempt (Child uncooperative)
• Rescheduling for later date is feasible
• The child is not cooperating to allow component to be completed at that time
• Child is emotional and or stressed
• A diagnosis has been found to justify that performing the component would further upset the child. (i.e. child has ear infection, pink eye)
• Re-attempt the screen component within 30 days
• If re-attempting to screen wait to bill the C&TC screening until all components are completed
• Bill using the two separate dates if within the same month
• If the screening crosses over to a new month, use the date the C&TC screening was finally completed
Screening Instrument not reviewed A developmental screening instrument was sent to parents but not returned for review at the time of the C&TC screening
• Do not report the developmental screening code as a separate line item on the claim
∼∼ or∼∼
• Wait to bill the completed screening until the parent-report is received and reviewed
• Bill using the two separate dates, if within the same month. The date the C^TC screening was started, and the date the completed screening instrument was reviewed.
• If the review of the screening instrument, crosses over to a new month, use the date the C&TC screening was finally completed

Other Covered Services

• Interperiodic or interim screenings may be done as indicated and are reimbursable as a C&TC screening if all component requirements are met.
• Additional screening services and/or specific screening components may be provided at other intervals as medically indicated.
• Diagnosis and treatment of health conditions determined to be medically necessary are covered services through C&TC.

C&TC Screening With an E&M Service
If a significant, separately identifiable E&M service is provided at the time of the C&TC screening, that E&M code must be billed with the modifier 25. Documentation in the health record must support key components of billed E&M services. Follow CPT instructions for appropriate coding.

Fluoride Varnish Application (FVA)
FVA may be performed at all locations where C&TC services are rendered. Upon successful completion of an approved training course, the following providers may perform the FVA procedure:

• Nurse practitioners
• Nurses
• Physicians
• Physician assistants
• Other licensed or certified health care professionals under the direct supervision of a treating physician or dentist

Obtain a signed consent form from a parent or legal guardian before providing the FVA. Keep the signed consent form with the child’s health records. In addition to a signed consent form, documentation of primary caries preventive services should be in the health record. It is not necessary to get a new parental consent form each time you apply the FVA if there is a signed consent form in the child’s record. Refer to the DHS C&TC Provider Guide for more information.

It is recommended that high risk infants and young children receive FVA at 3-6 month intervals, beginning when the first tooth erupts or by 12 months of age. Apply fluoride varnish to a child’s teeth as often as every three to six months. Medical providers may bill FVA up to four times per year, per child, as indicated by risk/susceptibility.

Bill the FVA using the CDT code D1206 on the same claim as the other C&TC services. MHCP reimbursement rate is per procedure (not per tooth).

When FVA is provided at other pediatric visits, bill FVA on the same claim as the other pediatric services.

For more information on FVA, refer to the National Maternal and Child Oral Health Resource Center and the DHS C&TC Provider Guide (DHS-4212).

Maternal Depression Screening
Maternal depression screening is covered as a C&TC service or at other pediatric visits as follows:

• Screen any time within the child’s first year (suggested screening times are at the 1-month visit and either the 4-month or one other subsequent visit before the child’s first birthday).
• Use one of the following standardized screening instruments:

Providers that meet the instrument-specific criteria for administering the screening tool, as outlined by the publisher, may perform maternal depression screenings. Depending on the tool, this may include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.

MHCP allows up to three maternal depression screenings for a mother per child less than one year of age. For documenting maternal depression screening service, record the name of the completed screening instrument and that the screening was performed as a “risk assessment” in the child’s medical record.

You are not required to include the screening score results or a copy of the screening instrument in the child’s record. You may give the mother a paper copy of the screening instrument to bring with her to a referral appointment or destroy it if she does not want it. For more information on maternal depression screening, refer to the DHS C&TC Provider Guide (DHS-4212).

Bill for the maternal depression screening only when one of the standardized screening instruments is used. When billing for a maternal depression screening:

• Use CPT code 99420 with modifier UC
• Use the child’s MHCP recipient ID number
• Bill it on the same claim as the C&TC screening or other pediatric visit.

May be billed on the same date as a child’s developmental screening (96110), and or a mental health screening (96110 UC


Non-Covered C&TC Screening Services
• Clinic visits or well child screenings that do not meet C&TC screening requirements may be covered through other MHCP services such as physician services
• Services provided by a non-C&TC provider
• Counseling and risk factor reduction E&M codes cannot be billed with comprehensive preventive medicine E&M codes. These codes already include counseling, anticipatory guidance and risk factor reduction as part of the comprehensive exam.

Authorization
C&TC screening services and screening components do not require authorization. For diagnosis and treatment services that may require authorization refer to the MHCP Provider Manual - Authorization Section. For clinic or physician services provided to a child not included in the C&TC screening benefit, refer to the MHCP Provider Manual – Physician Services Section.


Billing
Use the 837P claim to bill for C&TC services. Refer to the MN–ITS User Guide for Child and Teen Checkups when submitting claims via MN–ITS Interactive. If billing X12 Batch, follow HIPAA electronic data interchange (EDI) as outline in the X12 implementation guides and follow the standards as outline in the Minnesota Uniform Companion Guides.

C&TC billing processes include complying with HIPAA, AUC and MHCP system and data requirements. Billing C&TC screening services accurately is necessary to:

• Identify the claim as a C&TC screening
• Ensure appropriate provider reimbursement
• Provide public health and Tribal health staff the necessary information to follow-up with families, such as assisting them to access referral services
• Collect federally required data

Follow the Schedule of Age-Related Screening Standards (C&TC Screening Component Periodicity Schedule) (DHS-3379) to identify required C&TC screening components for the periodic visit including a referral to a dentist. Enter the appropriate CPT/HCPCS codes for each age-related component provided in MN-ITS-837P claim form. On claims for C&TC screening services, include:

• The most appropriate C&TC E&M code
• One of the four HIPAA compliant referral condition codes

Refer to the Schedule of Age-Related Dental Standards (C&TC Dental Periodicity Schedule) (DHS- 5544) for dental screening components.

For policy and billing dental screening components, refer to the Dental Service section of this manual.

Definition of a Referral
A referral for C&TC reporting purposes indicates that the child needs to be seen again for further assessment, diagnosis or treatment of a problem or a concern which was identified during the C&TC screening. The referral can be made to the screening provider or to another provider.

C&TC HIPAA Compliant Referral Condition Codes
C&TC HIPAA compliant referral condition codes (also called referral codes) indicate if a referral was made as a result of the C&TC screening. C&TC claims must list the most appropriate HIPAA compliant referral condition code: NU, ST, S2 or AV. MHCP C&TC screening payment requires one of the four HIPAA compliant referral condition codes to be entered at the claim (header) level.

Two-Character C&TC HIPAA Compliant Referral Condition Codes and Definitions
Use the most appropriate referral code from the table below:

HIPAA Compliant Referral Condition Code Use this referral condition code for billing when a C&TC screening results in:
NU
(no referral – not used)
No referral(s) given (“NU”) If only a verbal dental referral was made for preventive dental health care
ST
(new diagnosis or treatment service requested)
One or more referrals were made (“ST”)
Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR

Patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
AV – refused referral
(referral recommended but it was refused)
One or more referrals were made and the patient refused one or more of the referrals (“AV”),
S2
(continue current services/treatment)
The patient is currently under treatment for a diagnostic or corrective health problem(s)

HCPCS Code S0302
MHCP does not require the use of HCPCS code S0302 and considers this code as informational only. If a submitted charge is entered on the same line as the HCPCS Code S0302, MHCP will deduct that amount from the total charges on the claim.

If the HCPCS code S0302 is reported without a HIPAA compliant referral condition code on that claim, the claim will deny.

DHS will only recognize a claim, as a C&TC screening when a HIPAA compliant referral condition code is entered on the claim.

Reference and Outside Lab Services
Effective for dates of service October 1, 2014, and forward, in conjunction with Section 1902(a)(32) of the Social Security Act, MHCP must only reimburse the provider who personally performed a service. MHCP will no longer reimburse providers for lab tests they did not complete or tests sent to a reference or outside lab provider; therefore, modifier 90 will no longer be allowed. Do not include lab services you did not complete on your claim. When a specimen is sent to a reference or outside lab provider, the ordering provider must also send all necessary information required for the reference or outside lab provider to claim for the service. For policy and billing lab services, refer to Reference and Outside Lab Services in the Laboratory/Pathology Services section of this manual.

For dates of services before October 1, 2014, providers may choose to bill for lab tests or services sent to another provider by indicating the reference lab’s NPI as the rendering provider on the 837P. Use modifier 90 and place of service 81 (independent lab).


Resources
For additional C&TC Information, refer to the DHS C&TC Provider Guide (DHS-4212), designed to offer providers and clinic staff basic information about the C&TC Program, component standards, and documentation requirements. Use the DHS C&TC Provider Guide in conjunction with the MHCP Provider Manual. Additional resources available from the Minnesota Department of Human Services (DHS) include:


C&TC FACT Sheets - (provided through a DHS contract with MDH
• Anticipatory Guidance, Birth to 5 Years
• Anticipatory Guidance, 6-12 Years
• Anticipatory Guidance, 13-21 Years
• Dental Checkup
• Developmental Screening
• Health History
• Hearing Screening
• Hematocrit or Hemoglobin
• Immunizations and Review
• Lead Screening
• Mental Health Screening, 6-21 Years
• Newborn Screening – Blood Spot
• Physical Examination
• Physical Growth and Measurements
• Sexually Transmitted Infection Screening
• Social-Emotional Screening, 0-5 Years
• Tuberculosis (TB) Screening
• Vision

C&TC Provider Training and E-Learning Modules

• C&TC DHS/MDH Trainings (provided through a DHS contract with MDH) – These trainings provide the standards/component requirements, and training of skills needed to perform various components including basic hearing and vision screening.
• C&TCMDH/DHS E-Learning Training Modules (provided through a DHS contract with MDH) –These online training programs are designed to provide knowledge and information needed to provide Minnesota children eligible for Child and Teen Checkups with quality health care.

Fluoride Varnish Web-Based Training

Other Related Websites
Centers for Medicare & Medicaid (CMS) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program


Legal References
MS 256B.04 (Subd. 1b)
MS 256B.0625 (Subd. 14)
– preventative and screening services
MS 256B.0
625
, subd.39 (immunizations)
Minnesota Rules 9505.0275
, 9505.1693 to 9505.1748 (C&TC)
42 CFR 440.40(b); 42 CFR 441.50-441.62 (C&TC) - “The terminology used to describe people with developmental disabilities has changed over time. While DHS supports the use of “people first” language within its documents, certain outdated terms may still be found within historical and official documents, such as statutes and reports, and other documents created by third parties.”
Title XIX, Sections 1902(a)(43), 1905(a)(4)(B), 1905(r) of the Social Security Act (C&TC)


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