Children Services Policy

Early And Periodic Screening, Diagnosis And Treatment (EPSDT) Program Services 

Introduction

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, under section 1905(a) of the Social Security Act, applies to all children and youth under 21 years old who are enrolled in Medicaid. The goal of EPSDT is to assure that individual children and adolescents get the health care they need, when they need it.

The EPSDT benefit:

• includes all covered services and any other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate birth defects and physical and behavioral health conditions
• is more robust than the benefit for adults. It is designed to ensure that children and adolescents get timely care so that health problems are prevented or diagnosed and treated as early as possible
• allows for timely identification of problems that, if left undiagnosed or untreated, could create greater disabilities or diminish one’s likelihood of achieving future life goals
• supports treatment determinations that are made on a case-by-case basis taking into account the particular needs of the child or adolescent
• does not allow for ‘hard limits’ on services. This means services can be covered beyond any benefit limit and should be based solely on medical necessity

The EPSDT benefit includes all services that are permitted under federal Medicaid regulations and deemed medically necessary by a provider. Beneficiaries can access EPSDT benefits through consultation with a health care provider. Prior Authorization is required for all EPSDT services that are not in the normal scope of covered services.