What parents need to know about Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).
Children who are on Medicaid have important rights when it comes to what services that Medicaid must cover. For Medicaid purposes, “children” means kids under age 21.
In the law, we call these rights “Early and Periodic Screening, Diagnostic, and Treatment” (EPSDT). EPSDT is just Medicaid for children.
What rights do children have when it comes to Medicaid coverage?
Medicaid must pay for health care and treatments that are “medically necessary.” “Medically necessary” means that the service is prescribed by a medical provider to improve or maintain a child’s health.
Are there services that Medicaid does not have to cover?
Medicaid does not have to cover services that are:
- Experimental or investigational;
- Unsafe or ineffective; or
- Not medical in nature.
There are some specialized services that are not covered under EPSDT. These services are covered under Medicaid Waiver programs like the CAP/C or Innovations Waivers.
View our Medicaid waiver page for more information about Medicaid Waiver Programs.
Can Medicaid limit the amount of a service that it covers?
No. If the amount of the service is medically necessary, Medicaid cannot limit:
- How much of a service it will cover; or
- How long it will cover a service.
Can Medicaid put my child on a waitlist for medically necessary services?
No. There cannot be a waitlist to schedule services. But there can be a wait if there are no providers available.
Does Medicaid have to cover Case Management for children?
Yes, Medicaid must cover Case Management for children.
Case managers help you find the services and providers your child needs. They can help you understand the difficult system for getting Medicaid services. They can also help you get the services your child needs.
Why am I getting communications about Medicaid from organizations that are not the State?
The State is responsible for the Medicaid program. But the State works with other groups (contractors), to run the Medicaid program. For example, a state contractor called CCME decides whether to authorize physical therapy.
If you are confused about whether a communication is about Medicaid or want to know about your child’s rights, contact us.
How do medically necessary services get covered by Medicaid?
The state pays for some services for all children every time, like annual check-ups.
Other services must be “pre-authorized.” This means that the State (or one of its contractors) must okay the payment before your child gets the service. Your child’s provider should know how to ask for authorization.
What happens if Medicaid refuses to pay for a medically necessary service?
When a request for a service is denied, the State must send you a written notice that says:
- What service was refused;
- Why it was refused; and
- How to appeal the decision if you disagree with it.
What can I do if I disagree with a Medicaid denial?
You can appeal the decision. The written notice you get from the State or its contractor will tell you how to appeal.
Appeals are resolved through a hearing (trial) at the State Office of Administrative Hearings (OAH).
Do I need a lawyer to appeal a denial?
No. A lawyer can represent you in an appeal. But you do not need a lawyer to appeal a decision. Sometimes DRNC represents people at OAH. It depends on the case and whether DRNC has available resources.
View printable brochure and fact sheets in English and Spanish