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.
|Assessing and identifying problems early
|Checking children's health at periodic, age-appropriate intervals
|Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
|Performing diagnostic tests to follow up when a risk is identified
|Controlling, correcting, or reducing health problems found
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:
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).
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.
EPSDT services are required to be provided. However, some states may demonstrate violations to the mandate. Examples of violations may include the following:
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.
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.
Contact ASHA staff at email@example.com.