EPSDT: Medicaid's Guarantee that Children Get All the Health Care They Need When They Need It

Any caregiver or guardian for a child or adolescent on Medicaid should know about EPSDT-  the Early and Periodic Screening, Diagnostic and Treatment benefit.  EPSDT provides comprehensive health preventive and treatment services for all children under age 21 who are enrolled in Medicaid.  It is a guarantee that children and adolescents receive all of the physical and mental health care that they need when they need it. 

In West Virginia, the Medicaid EPSDT program is called “HealthCheck.” More information about HealthCheck is online here.

Here is what that hard-to-remember benefit stand for:

Early – EPSDT benefit covers a range of testing to identify any health problems early. 

Periodic – The benefit provides a systematic approach to check the child’s overall health at periodic, age-appropriate intervals. 

Screening – EPSDT provides physical, mental, developmental, dental, hearing, vision, and other screening tests to detect any potential health-related problems.  Screening services include:

  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate immunizations
  • Laboratory tests
  • Health education (guidance including child development, healthy lifestyles, and accident and disease prevention)
  • Vision services
  • Dental services
  • Hearing services

Diagnosis – Based on screening findings, EPSDT covers diagnostic tests to follow up whenever a health risk is identified.  When a screening examination indicates the need for further evaluation of a child’s health, then  diagnostic services must be provided.  Necessary referrals are expected to be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation.

Treatment – When a screening examination indicates the need for further evaluation of a child’s health, then diagnostic services must be provided. The Medicaid program must cover services necessary to control, correct or reduce any health problems found in children and youth in the screening and diagnostic process, by financing a very broad range of appropriate and necessary pediatric services.

There are few limits to the EPSDT benefit.  Services need to be deemed “medically necessary” by a qualified health practitioner. The concept of medical necessity in EPSDT is intentionally expansive, consistent with promoting children’s healthy development and maximizing their health and function.  Service limits that state Medicaid programs may impose on adults, such as a limit on therapy sessions, or a maximum number of prescriptions per month, cannot be applied to children. 

If requested, states must also offer the enrolled youth or family assistance with scheduling appointments, or with transportation, to access the services to which the child is entitled.  Furthermore -- for very young children, for example -- services may be provided directly to the parent or caregiver, on behalf of the enrolled child, to address the identified healthcare need of that child, without regard to the Medicaid eligibility status of that parent or caregiver.

The EPSDT provisions in the Medicaid program require West Virginia to: 

  • Inform all Medicaid-eligible individuals under age 21 that EPSDT services are available;
  • Inform them of the need for age-appropriate immunizations;
  • Provide or arrange for the provision of screening services for all children;
  • Arrange (directly or through referral) for corrective treatment as determined by child health screenings; and
  • Report EPSDT performance information to CMS annually.

Assistance Finding a Doctor or Other Provider.  The West Virginia Medicaid programs must provide Medicaid enrolled children or their parents/guardian with referral assistance for any treatment services their providers might not cover, that are found to be needed because of conditions identified or disclosed during the screening and diagnostic processes.  Specifically, such referral assistance must include giving the family or recipient the names, addresses, and telephone numbers of providers who will furnish services at little or no expense to the family. 

EPSDT rules also require West Virginia to make available a variety of individual and group providers qualified and willing to provide EPSDT services in all areas of the state. West Virginia must also make appropriate use of state health, vocational rehabilitation and maternal and child health programs, as well as other public health, mental health, and education programs and related programs, such as Head Start, Title XX (Social Services) programs, and the Special Supplemental Food Program for Women, Infants and Children (WIC), to provide an effective and comprehensive child health program.

 

West Virginians Together for Medicaid