Medicaid Toolkit

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The early and periodic screening, diagnosis, and treatment (EPSDT) benefit provides comprehensive and preventative health care services for children under the age of 21 who are enrolled in Medicaid. EPSDT ensures that children and adolescents receive appropriate preventative, developmental, dental, mental health, and specialty services. EPSDT's rules support the health needs of low-­income children and those with special health needs who meet the criteria for assistance. Although states may decide whether they want to cover services for adults, medically necessary services for children must be covered under the federal EPSDT mandate. States are able to set medical necessity and other criteria that may affect coverage and reimbursement restrictions.

The following information from Medicaid.gov provides an overview of services covered under EPSDT.

 Early Assessing and identifying problems early
 Periodic Checking children's health at periodic, age­-appropriate intervals
 Screening Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
 Diagnosis Performing diagnostic tests to follow up when a risk is identified
 Treatment Controlling, correcting, or reducing health problems found

Considerations

  • When a screening examination indicates the need for further evaluation of an individual's health, diagnostic services must be provided. Necessary referrals should be made without delay, and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation. States should develop quality assurance procedures to ensure that comprehensive care is provided.
  • Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.
  • At a minimum, hearing services include diagnosis and treatment for defects in hearing, including hearing aids and cochlear implants.

The service delivery setting will affect implementation of the EPSDT benefit. For example, audiologists and speech-language pathologists may provide diagnostic and treatment services in the medical home service delivery model. Alternatively, many EPSDT services are provided within the school setting.

Knowledge of the state's medical necessity criteria and documentation requirements is essential to maximizing reimbursement.

Advocacy

Professionals and state associations can advocate to ensure EPSDT coverage in state plans, including services of audiologists and speech-language pathologists for both evaluation and treatment under EPSDT coverage.

Resources

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