Medicaid EPSDT Case Docket

Medicaid EPSDT Case Docket

Executive Summary

The Early and Periodic Screening, Diagnostic and Treatment service (EPSDT) is a mandatory Medicaid service for children and youth under age 21. Screening forms the foundation of EPSDT. Four separate screens are required: vision (including eyeglasses), hearing (including hearing aids), dental (including restoration of teeth), and medical. The medical screen has five required components: a comprehensive health and developmental history, unclothed physical exam, immunizations, laboratory testing, and health education and anticipatory guidance. Screening services must be provided according to “periodicity schedules,” set by the state in consultation with child health experts, and at other times to determine whether a child has a condition that needs further care. Id.at § 1396d(r)(1)-(4). State Medicaid agencies must effectively inform all Medicaid-eligible persons in the state who are under age 21 of the availability of EPSDT. Id. at § 1396a(a)(43)(A).

Overview of EPSDT [1]
The Early and Periodic Screening, Diagnostic and Treatment service (EPSDT) is a mandatory Medicaid service for children and youth under age 21. Screening forms the foundation of EPSDT. Four separate screens are required: vision (including eyeglasses), hearing (including hearing aids), dental (including restoration of teeth), and medical. The medical screen has five required components: a comprehensive health and developmental history, unclothed physical exam, immunizations, laboratory testing, and health education and anticipatory guidance. Screening services must be provided according to ?periodicity schedules,? set by the state in consultation with child health experts, and at other times to determine whether a child has a condition that needs further care. Id.at § 1396d(r)(1)-(4). State Medicaid agencies must effectively inform all Medicaid-eligible persons in the state who are under age 21 of the availability of EPSDT. Id. at § 1396a(a)(43)(A).
The Medicaid Act requires the state Medicaid agency to ?arrange for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment.? Id. at § 1396a(a)(43)(C). The Act prescribes a comprehensive Treatment package and the medical necessity standard that must be applied on an individual basis to determine a child?s treatment needs:
Scope of benefits: Covered services include all mandatory and optional services that the state can cover under Medicaid, whether or not such services are covered for adults, see Id. at § 1396d(a) (listing services).
Medical necessity: The Medicaid Act requires coverage of ?necessary health care, diagnostic services, treatment, and other measures? to correct or ameliorate defects and physical and mental illnesses and conditions[.]?

Id. at § 1396d(r)(5). In sum, if a health care provider determines that an EPSDT Treatment service is needed, it should be covered to the extent needed and allowed under the federal Medicaid Act. For example, if a child needs personal care services to ameliorate a behavioral health problem, EPSDT should cover these services to the extent the child needs them? even if the state places a quantitative limit on personal care services or does not cover them at all for adults.

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1 This document was prepared with the support of The Atlantic Philanthropies, a limited life foundation dedicated to bringing about lasting changes in the lives of disadvantaged and vulnerable people.

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