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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is required for all children and youth enrolled in Medicaid under age 21. This benefit requires Medicaid to cover any service that is deemed “medically necessary" for an enrollee regardless of whether it is a service covered by the state plan. The comprehensive and individualized nature of EPSDT is particularly important for CYSHCN, who require more health care services than their peers.
The EPSDT Benefit
The EPSDT benefit requires that Medicaid provide physical, mental, developmental, dental, hearing, vision, and other tests to screen for and identify potential health problems; perform follow-up diagnostic tests to rule out or confirm a health risk or diagnosis; and cover treatment to control, correct, or reduce the identified health problems. Medicaid-enrolled children are eligible for the EPSDT benefit regardless of how they qualify for Medicaid (i.e., whether they are eligible through income criteria, disability, or through a waiver program).
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E |
Early: Assess and identify problems as early as possible |
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P |
Periodic: Check children's health status at regular, periodic, age-appropriate intervals
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S |
Screening: Provide physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems. Screening services include:
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Diagnostic: Perform diagnostic tests to follow up (rule out or confirm) when screening identifies a risk or potential problem |
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T |
Treatment: Control, correct, or reduce health problems found |
Medicaid Mandates
State Medicaid agencies must provide education and enabling services to families of children enrolled in Medicaid. According to federal statute, state Medicaid agencies must:
- Provide information about the EPSDT benefit to families of eligible children within 60 days of an eligibility determination.
- Help families access care by providing services such as transportation, assistance with scheduling appointments, and connections to other supports, particularly services offered by state Women, Infants, and Children (WIC) programs and Title V.
States must also report EPSDT data annually using CMS Form 416.
Medical Necessity
Generally, medically necessary services are those that improve health or lessen the impact of a condition, prevent a condition, or cure or restore health. States have the ability to establish their own criteria for deciding if a service is medically necessary, as long as the definition is not more restrictive than what is written in federal law.
Prior authorization is the primary mechanism of applying medical necessity criteria in the EPSDT benefit. Many services do not require prior authorization. For those that do, typically, providers submit letters of medical necessity, and the state Medicaid agency or its designee reviews the request and makes a determination.
Prior Authorization
Prior authorization is used to determine medical necessity in both fee-for-service (FFS) Medicaid and Medicaid Managed Care (MMC). Understanding who is involved and how the prior authorization process works in both FFS and MMC contributes to a better understanding of opportunities to conduct data surveillance, potential areas of collaboration with state Medicaid agencies and other partners, and how to support families in navigating this process.
Learn More About Title V's Role in EPSDT
