The Medicaid Act, the federal law governing California’s Medi-Cal Program, has long contained specific benefit requirements for covering children and youth under the age of 21 through the Early and Periodic Screening, Diagnostic and Treatment – or “EPSDT” – services mandate. Despite its unmemorable name, this federal mandate critically identifies that children and adolescents are undergoing and experiencing rapid developmental and behavioral changes that require identification and treatment of health related problems or conditions at the earliest point possible, and that their health care needs differ from those of adults. The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. EPSDT is specifically targeted to meet the needs of low-income children, who are disproportionately affected by numerous health problems such as vision, hearing and speech problems; obesity; untreated tooth decay; elevated lead blood levels; asthma; behavioral health problems; and trauma.
One key element of EPSDT that states sometimes don’t get right is the “T” – or treatment obligation. This has often resulted in litigation on behalf of Medicaid eligible children to address the problem. The federal law makes clear that states have an obligation to make sure these children and youth receive the physical, behavioral health, vision, hearing, and dental services they need to treat health problems or conditions. Through this benefit, children’s health problems should be addressed before they become advanced and treatment is more difficult (and costly). The standard that states must follow to provide these Medicaid services – commonly referred to as “medical necessity” – is broader for children than adults. Under EPSDT, services must be provided to a child whenever they are necessary to correct or ameliorate the individual child’s physical or mental condition. This means services to maintain or improve a child’s health or condition must be covered, not just to correct the problem.
California is currently in a three way tie with Florida and Louisiana for highest poverty rate, with roughly 7.5 million Californians — about 19 percent of the state population — living in poverty. Medi-Cal covers more than 13 million people, and EPSDT plays a critical role for the approximately 5.5 million children and youth on the program. While California has had its own long and sorted history with EPSDT compliance, recently enacted legislation (SB 1287) will finally bring state law into compliance with the federal EPSDT treatment mandate standard starting in 2019. This legal change is certainly necessary, as there is ongoing evidence that children on Medi-Cal are having difficulty accessing needed care and compliance with EPSDT in California remains a concern.
There will still be more to do over the next few years to get the state into full compliance with EPSDT, including changes to state regulations, guidance, and other key manuals and bulletins. But this change is an important first step to raise awareness among advocates, providers, health plans, and other stakeholders and to educate Medi-Cal recipients and their families/caregivers about the availability of EPSDT benefits so children and youth can get the health care services they need to thrive.