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

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federal law requiring health care services for Medicaid beneficiaries under 21 years of age. EPSDT ensures that children and adolescents receive appropriate preventative, developmental, dental, mental health, and specialty services—including speech, language, and hearing services. Although EPSDT services are required to be provided under federal law, ASHA is aware that some state Medicaid programs have violated this mandate. Therefore, ASHA advocates that states ensure that EPSDT coverage in state plans includes services provided by audiologists and speech-language pathologists (SLPs) for both evaluation and treatment and that state Medicaid programs act in compliance with the federal law.

The following information from Medicaid.gov describes EPSDT.

Impact on Everyday Practice for Audiologists and SLPs

EPSDT mandates coverage for all medically necessary services that a child needs—including audiology and speech-language pathology services—in all settings. Children with impairments that fall under audiology and speech-language pathology scopes of practice (e.g., speech, language, hearing, swallowing, cognition, balance) are covered and may include:

• referral for medical or other professional attention necessary for rehabilitation and habilitation;
• identification, screening, and diagnostics;
• treatment/management;
• counseling and guidance for parents, children, and teachers; and
• durable medical equipment and/or device(s) (e.g., hearing aids, augmentative and alternative communication equipment), when medically necessary.

State Medicaid agencies and health care plans may vary in their determination of medical necessity. As such, providers should apply the medical necessity definition associated with their state Medicaid agencies, health care plans, and practice setting(s).

Navigating State Medicaid Agencies

Medically necessary services for children must be covered under the federal EPSDT mandate; adult coverage may vary by state. States can set medical necessity and other criteria that may restrict coverage and reimbursement; criteria may vary by state and by health care plan. Knowledge of the state's medical necessity criteria and documentation requirements is essential to maximizing coverage of services. States should develop quality assurance procedures to ensure that comprehensive care is provided.

Recognizing Violations

EPSDT services are required to be provided. However, some states may demonstrate violations to the mandate. Examples of violations may include the following:

• Limiting services under Medicaid Managed Care Plans and overstepping utilization management
  • Example: Setting hard limits/caps on services (e.g., ST limited to 12 x 45-minute visits per year, no requests for extensions or additional visits accepted) is not permissible under EPSDT; however, soft limits like prior authorization (e.g., prior authorization for 12 x 45 minute visits for 6 months, requests to extend visits beyond that will require new plan of care [POC] submission) are permissible.
• Preventing access to care
• Example: Not ensuring that infants identified with hearing loss under the Early Hearing Detection and Intervention (EHDI) program continue treatment and intervention; also known as Loss to Follow Up. This is a significant challenge across most states. If the state does not demonstrate an effort to address Loss to Follow Up, the state is in violation of EPSDT.
• Using the Medicaid waiver program to exempt provision of all but the core medical services
  • Example: Oregon’s Section 1115 waiver formerly allowed a “prioritized list of services” for children over the age of 1. This exclusion of medically necessary services, such as—speech-language pathology and audiology services (as defined by the state Medicaid program)—was a violation of EPSDT. As a result of advocacy on the part of practitioners and professional associations, this practice was reversed.

Unfortunately, enforcement and oversight of state Medicaid programs following the EPSDT mandate are limited and patients and/or providers must litigate denials at the Fair Hearing level.

Get Involved: Member Advocacy for EPSDT  

Audiologists and SLPs can take steps to advocate for EPSDT compliance at the state level. Here are some resources to ensure that Medicaid beneficiaries under age 21 have access to the medically necessary services that they are entitled to under law.

• If you have any questions or concerns, contact ASHA staff at reimbursement@asha.org
• Know your state Medicaid plan policies and the health care plan policies. Your state’s Medicaid office may have more current information available. 
• If you receive a denial from a health care plan (e.g., prior authorization, coverage, medical necessity), carefully review or request the reason for denial. If you do not agree with the decision, review the plan’s appeals process and consider appealing the denial. 
• Communicate with and monitor changes associated with your state Medicaid office and health care plan representative.
• Monitor coding and billing changes. 
• Communicate with your state association and/or State Advocates for Reimbursement (STARs) to:
  • identify patterns of noncompliance and/or
  • participate in state advocacy and communicate with your state Medicaid office.
• Utilize ASHA resources such as our EPSDT flyer [PDF] to answer common questions about EPSDT
• Health Resources and Services Administration Overview  
• EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents [PDF]  
• Centers for Medicare & Medicaid Services EPSDT Information  
• American Academy of Pediatrics Bright Futures Toolkit  
• Read in-depth policy analysis articles
  • The ASHA Leader and ASHA Leader Live
  • Avoid Prior Authorization Pitfalls (ASHA Leader article)

ASHA’s Advocacy on EPSDT Compliance

• ASHA's advocacy efforts ensured that EPSDT coverage in state plans includes services provided by audiologists and SLPs for both evaluation and treatment. 
• ASHA’s advocacy efforts ensured passage of the Bipartisan Safer Communities Act—with new provisions for EPSDT enforcement.
• ASHA advocacy efforts ensured of the Bipartisan Safer Communities Act— with new provisions for EPSDT enforcement
• ASHA’s Medicaid Committee met with CMS regarding EPSDT mandate enforcement on August 23, 2022

Questions?  

Contact ASHA staff at reimbursement@asha.org.