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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Federal Link: www.cms.hhs.gov/m edicaid/epsdt/default.asp
What is it: EPSDT is intended to remove financial barriers to health care for children and ensure access to the comprehensive preventive services necessary for healthy growth and development. EPSDT is one of the Medicaid services that states are required to provide. Periodic examinations or screenings delivered according to a set schedule (referred to as the periodicity schedule) through infancy, early childhood, late childhood and adolescence assure that health problems are diagnosed and treated early, before they become more complex and treatment becomes more costly.
Who qualifies: All Medicaid-eligible persons under age 21.
States who do not choose the full range of services for their Medicaid plan must make the full range of services available for children enrolled in the EPSDT program (OBRA 89 § 1905 (r) Social Security Act).
States must use a combination of written and oral methods to effectively inform eligible individuals about:
- the benefits of preventive health care;
- the services available through EPSDT;
- that services are without charge, except for premiums for certain families; and
- that support services, specifically transportation and appointment scheduling assistance, are available on request.
- LANGUAGE - If the child/family has difficulty reading or understanding English, then the information needs to be conveyed in a format that can be understood.
- TRANSPORATION – States must offer both transportation and appointment scheduling assistance "prior to each due date of a child's periodic examination."
What it covers: The EPSDT benefit, in accordance with section 1905(r) of the Act, must include the services noted below. The American Academy of Pediatrics recommends twenty health screens during the first twenty-one years of a person's life.
SCREENING SERVICES -- Screening services must include all of the following services:
- Comprehensive health and developmental history - (including assessment of both physical and mental health development);
- Comprehensive unclothed physical exam;
- Appropriate immunizations - (according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines);
- Laboratory tests - Identify as statewide screening requirements the minimum laboratory tests or analyses to be performed by medical providers for particular age or population groups;
- Health Education - Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and/or dental screening provides the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention;
- Vision Services - At a minimum, include diagnosis and treatment for defects in vision, including eyeglasses. Vision services must be provided according to a distinct periodicity schedule developed by the state and at other intervals as medically necessary;
- Dental Services - At a minimum, include relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services. Although an oral screening may be part of a physical examination, it does not substitute for examination through direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule developed by the state and at other intervals as medically necessary. The law as amended by OBRA 1989 requires that dental services (including initial direct referral to a dentist) conform to the state periodicity schedule which must be established after consultation with recognized dental organizations involved in child health care;
- Hearing Services - At a minimum, include diagnosis and treatment for defects in hearing, including hearing aids; and
- Other Necessary Health Care - Provide other necessary health care, diagnosis services, treatment, and other measure described in section 1905(a) of the Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services.
DIAGNOSIS -- When a screening examination indicates the need for further evaluation of an individual's health, provide diagnostic services. The referral should be made without delay and follow-up to make sure that the recipient receives a complete diagnostic evaluation. If the recipient is receiving care from a continuing care provider, diagnosis may be part of the screening and examination process. States should develop quality assurance procedures to assure comprehensive care for the individual.
TREATMENT -- Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services.
Lead Poisoning Prevention - Screening for lead poisoning is a required component of an EPSDT screen. A blood lead test must be used when screening Medicaid-eligible children. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (fingerstick) must be confirmed using a venous blood sample.
Current CMS policy requires a screening blood lead test for all Medicaid-eligible children at 12- and 24-months of age.
- Children over the age of 24 months, up to 72 months of age, should receive a screening blood lead test if there is no record of a previous test.
- Any additional diagnostic and treatment services determined to be medically necessary must also be provided to a child diagnosed with an elevated blood lead level.
What it costs: EPSDT provides for FREE preventative and health care services to individuals under age 21.
Impact for YOUTH: The EPSDT program provides continued health services and screening for any youth under 21. It is especially helpful for those youth who:
- Age out of family’s private insurance coverage at 18 or 19, and who may become eligible for Medicaid.
- It insures that youth will get the treatment they need even if their state Medicaid policy does not cover a specific service. If it is identified as part of an EPSDT examination, it will be covered.
How to Apply: Youth receiving Medicaid are automatically eligible. Contact State Medicaid Office. www.cms.hhs.gov/medicaid/consumer.asp
Guides:
NATIONAL HEALTH LAW PROJECT
Medicaid Managed Care and Children with Special Needs:
An EPSDT Checklist
www.healthlaw.org/pubs/mc1997checklist-epsdt.html
EPSDT is Medicaid's mandatory benefit package for children under age 21. It includes well-child screening and a broad treatment package. As children eligible for SSI are increasingly being required to enroll in Medicaid managed care, it is critical to ensure that these children receive all of the EPSDT services to the same extent that they are entitled to such services under fee-for-service. Unfortunately, many managed care organizations do not know what they are getting into, and they might not be familiar with the services included under EPSDT.
MINNESOTA DEPARTMENT OF HEALTH
Early and Periodic Screening Diagnosis and Treatment (EPSDT)
and Child and Teen Checkups (C&TC) Online Training
www.health.state.mn.us /divs/fh/mch/webcourse/intro/toc.html
Minnesota 's EPSDT program is called the Child and Teen Checkups (C&TC) Program . While this on-line training course was developed for providers in Minnesota , others can gain knowledge testing through the interactive module design.
THE SPECIAL EDUCATION & MEDICAID KNOWLEDGEBASE
Quality Assurance Checklist for Medicaid Providers
www.helpforschools.com/medicaid/checklists/quality_assurance_checklist.shtml
This document was prepared by the Oklahoma Health Care Authority for the use by public schools in the state of Oklahoma . School districts in other states should address specific questions to their State Medicaid Agency. Quality assurance efforts should be built into districts’ EPSDT School-Based Services program. Records may be subject to both State and Federal audit.
- School-Based Medicaid EPSDT Services
Subcontracting With A Third Party Billing Or Service Agent:
A Compliance Checklist For Schools
www.helpforschools.com/medicaid/checklists/school_checklist.shtml
Pursuant to its contract with the Oklahoma Health Care Authority (OHCA) for Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT) School-Based Services, school districts or cooperatives retain responsibility for ensuring that program requirements are met, regardless of whether the services are provided by employees or subcontractors.
Resources:
NATIONAL HEALTH LAW PROGRAM
Early and Periodic Screening, Diagnosis and Treatment
www.healthlaw.org /pubs/19990323epsdtfact.html
Fact Sheet
EPSDT service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. These components enable Medicaid agencies to manage a comprehensive child health program of prevention and treatment, to seek out eligibles and inform them of the benefits of prevention and the health services and assistance available and to help them and their families use health resources, including their own talents and knowledge, effectively and efficiently.
The Packard Foundation's Journal, The Future of Children (Spring 2003)
www.futureofchil dren.org/homepage28 24/index.htm
The spring issue of The Future of Children, called Health Insurance for Children, contains numerous articles on many aspects of providing health coverage for children. Topics covered include a historical overview of children's health coverage, why some children are still uninsured, access to health care for special populations of children (including children with special health care needs), reducing health disparities among children, and express lane eligibility.
NATIONAL CENTER FOR EDUCATION IN MATERNAL & CHLD HEALTH (NCEMCH)
Knowledge Path: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
www.mchlibrary.info/ KnowledgePaths/kp_EPSDT.html
Fact sheets and information about the EPSDT Program
NATIONAL GOVERNORS’ ASSOCIATION
Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)
www.nga.org/center/divisions/1,1188,C_ISSUE_BRI EF%5ED_1655,00.html
Guidelines from the American Academy of Pediatrics (AAP) exist for frequency, timing, and content of well-child care services, including general health indicator screenings, immunizations, and developmental screenings.
NAHIC - State Children's Health Insurance Program (SCHIP) Subsequent to the release of Adolescents and the State Children's Health Insurance Program (CHIP): Healthy Options for Meeting the Needs of Adolescents,
youth.ucsf.edu/policycenter/projects.html
NAHIC continues to examine questions related to the coverage of adolescents under SCHIP. Curricula Assessment for America 's Schools of Public Health. In Fall 2000, the Policy Center began a project to assess training and education related to the adolescent and middle childhood populations within the country's Schools of Public Health (SPH). Policy Center staff have reviewed SPH catalogues and are interviewing key SPH faculty and staff designed to learn more about (1) courses that cover issues related to the middle childhood and adolescent populations; (2) specialized tracks or plans of study related to these populations; and (3) faculty research and policy projects related to these populations. We will produce a monograph summarizing key findings. This project will lay the groundwork for initiatives by the Maternal and Child Health Bureau, and other institutions interested in the public health workforce, to strengthen teaching in U.S. Schools of Public Health related to middle childhood and adolescence. After gathering the information, we will prepare a state-of-the-art monograph summarizing key findings.
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