Medicaid’s child health component, known as the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, children has been shaped to fit the standards of pediatric care and to meet the special physical, emotional, and developmental needs of low-income children. Since 1967, the purpose of the EPSDT program has been "to discover, as early as possible, the ills that handicap our children" and to provide "continuing follow up and treatment so that handicaps do not go neglected."
Federal law – including statutes, regulations, and guidelines – requires that Medicaid cover a very comprehensive set of benefits and services for children, different from adult benefits. Since one in three U.S. children under age six is eligible for Medicaid, EPSDT offers a very important way to ensure that young children receive appropriate health, mental health, and developmental services.
To remember the elements of EPSDT, use the name of the program:
|Early||Identifying problems early, starting at birth|
|Periodic||Checking children's health at periodic, age-appropriate intervals|
|Screening||Doing 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, and|
|Treatment||Treating the problems found.|
Under the Deficit Reduction Act of 2005 (DRA, enacted February 2006), states were given the option to modify the approach to delivery of services to children enrolled in Medicaid. Two DRA changes Medicaid law may have direct impact on EPSDT .
The DRA gives states the option to restructure their approach to benefits under Medicaid without a federal waiver, using the state plan amendment process. Under this option, states may enroll certain groups (mainly those in optional eligibility groups) in benchmark or benchmark equivalent benefit packages and wrap-around benefits consisting of EPSDT benefits for any child under age 19 covered under a state plan.
The DRA also includes a more specific definition of case management and places limits on use of targeted case management and administrative case management and. Since State Medicaid agencies use both EPSDT case management and targeted case management for infants, children, and adolescents, such programs may be affected by the DRA provisions.
EPSDT is a mandatory set of services and benefits for all individuals under age 21 who are enrolled in Medicaid. Think of it as the child health coverage package of Medicaid.
Screening services "to detect physical and mental conditions must be covered at established, periodic intervals (periodic screens) and whenever a problem is suspected (inter-periodic screens).
Screening includes a comprehensive health and developmental history, an unclothed physical exam, appropriate immunizations, laboratory tests, and health education.
In addition, dental, vision, and hearing services are required, including appropriate screening, diagnostic, and treatment. The treatment component of EPSDT is broadly defined. Federal law states that treatment must include any "necessary health care, diagnostic services, treatment, and other measures" that fall within the federal definition of medical assistance (as described in Section 1905(a) of the Social Security Act that are needed to "correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services."
All medically necessary diagnostic and treatment services within the federal definition of Medicaid medical assistance must be covered, regardless of whether or not such services are otherwise covered under the state Medicaid plan for adults ages 21 and older.
EPSDT is designed to help ensure access to needed services, including assistance in scheduling appointments and transportation assistance to keep appointments. As described in federal program rules: The EPSDT program consists of two, mutually supportive, operational components:
Much has been written about EPSDT over the past 40 years of the
programs existence. The selected titles and links below will guide you to some key resources and references.
GWU Center for Health Services Research and Policy
Federal Oversight Reports