Early and Periodic Screening, Diagnostic, and Treatment

Transcript available here.

EPSDT is part of the federal Medicaid Act. The Act entitles children under age 21 who have Medicaid to all services that are medically necessary to make or keep them physically and mentally healthy. State Medicaid programs must cover any service that is medically necessary to correct or ameliorate a child’s physical or mental condition.

A service is medically necessary when it corrects or ameliorates a condition. A service or treatment ameliorates a condition if it does one or more of the following:

  • Improves or maintains the recipient’s health in the best condition possible;
  • Compensates for a health problem;
  • Prevents a health problem from getting worse; or
  • Prevents the development of additional health problems.

The State must cover medically necessary services even if those services are not otherwise covered under the State Medicaid Plan.

EPSDT Services

EPSDT includes both short-term and long-term services. It also includes durable medical equipment, prosthetics, wheelchairs, oxygen equipment, communication aides, and other equipment—as long as they are medically necessary.

Under the federal Medicaid law, there are mandatory services, which states must provide to Medicaid recipients, and optional services, which states may provide. EPSDT requires that the State Medicaid program provide all mandatory and optional services to children who have Medicaid, if those services are medically necessary.

There is no set list that specifies what EPSDT services or equipment are covered. However, a service will only be covered if it falls within the scope of those services listed in the Medicaid Act. For example, neither autism services (such as applied behavioral analysis) nor equine therapy is listed in the Act. However, both can be covered under EPSDT because they fall within the scope of at least one of the services listed in the Act.

Here is the list of services found in the Medicaid Act:

  • Inpatient and outpatient hospital services
  • Physician services
  • Clinic and rural health clinic services
  • Health center services
  • Laboratory and x-ray services
  • Family planning services and supplies
  • Dental services, medical/surgical services from a dentist, and dentures
  • Home health care services
  • Private-duty nursing
  • Physical and occupational therapy
  • Services for speech, language, and hearing disorders
  • Prescribed drugs
  • Prosthetic devices
  • Eyeglasses
  • Intermediate care facility services
  • Medical and remedial care
  • Diagnostic, screening, preventive, and rehabilitative services
  • Inpatient psychiatric hospital services
  • Midwife services
  • Hospice care
  • Case management
  • TB-related services
  • Respiratory care
  • Pediatric or family nurse practitioner services
  • Personal care service

EPSDT also requires the State to cover transportation to or from medical appointments. It even covers out-of-state travel, lodging, and meals, if the travel is medically necessary. Contact your local Department of Social Services to arrange for reimbursement before you travel.

EPSDT is limited to rehabilitative services and does not include habilitative services. In general, rehabilitative services involve re-teaching a skill that has been lost, while habilitative services involve teaching new skills. However, the distinction between the two types of services is often blurred, and a service that is habilitative in one instance may be considered rehabilitative in another.

For details, read North Carolina’s EPSDT Policy Instructions Update, available at https://www2.ncdhhs.gov/dma/epsdt/epsdtpolicyinstructions.pdf.

Limits Do Not Apply

North Carolina’s Clinical Coverage Policies explain the limits on scope, amount, duration, frequency, location of service, and other specific criteria for all covered services. However, under EPSDT, these limits may be exceeded or may not apply at all. Your child can receive more hours or visits of the requested service than are allowed under the Clinical Coverage Policies if it is medically necessary.

Other restrictions that do not apply under EPSDT include the location of the service (for example, the Policies say Personal Care Services should only happen in the home) and prohibitions on receiving multiple services on the same day or at the same time. The provider of the service should document how the service, product, or procedure meets all EPSDT criteria and why it is medically necessary to exceed the limits outlined in the Clinical Coverage Policies.

You can find all of North Carolina’s Clinical Coverage Policies at https://dma.ncdhhs.gov/providers/clinical-coverage-policies.

Screenings and Diagnostic Services under EPSDT

A good example of a screening service is a child’s regular check-up with a pediatrician. EPSDT requires that Medicaid cover screenings for physical health, dental health, vision, and hearing. Medicaid must also cover periodic developmental and behavioral screenings in order to identify any intellectual or developmental delay or disability.

If any screening identifies a possible health issue or disability, the state must provide whatever services or assessments are necessary to diagnose the condition.

Treatment under EPSDT

The State must provide medically necessary treatment for a child who has Medicaid and has been diagnosed with a health condition or a physical or mental disability. Even if the condition existed before the child started to receive Medicaid, it must be covered.

In addition to being medically necessary, EPSDT policy requires that a service or treatment meet the following criteria:

  • It is medical in nature;
  • It is safe and effective;
  • It is generally recognized as accepted medical practice or treatment; and
  • It is not experimental or investigational.

There is no co-payment or other cost to the recipient for services covered by EPSDT. Also, there is no waiting list for EPSDT services. However, doctors or other practitioners may have waiting lists to schedule appointments or procedures.

Requesting Services

You do not need to say you are requesting EPSDT services. However, if you have trouble getting your provider to prescribe a needed service for your child, or if Medicaid refuses to pay for the service, citing EPSDT policies may help you make your case to receive services.

The recipient’s physician, therapist, or clinician must request the service and be able to show that the service is medically necessary. Documentation showing the medical need for the service is the most compelling evidence you can have to convince Medicaid to cover the service. The courts have held that states should give deference to the medical opinions of treating physicians and therapists.

Waiver Programs and EPSDT

North Carolina has three Medicaid waiver programs—the Innovations Waiver for people with intellectual and developmental disabilities, CAP-C for children with complex medical needs, and CAP-DA for people age 18 and older with significant medical needs. Even if your child receives services through a waiver, he or she is also eligible for EPSDT services.

The Importance of Case Management

You might not think of Case Management as a medical service. However, for many families, Case Management is medically necessary to connect children to appropriate services and supports. Case Managers advocate for recipients and help families navigate the complex systems of services for mental health, substance abuse and intellectual/developmental disabilities. They may also interact with schools and the juvenile justice system on the recipient’s behalf.

You should ask for Case Management if you feel that your child is “slipping through the cracks” and you need help making sure your child gets the services he or she needs.

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