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| EPSDT
Program Background |
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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
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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
Requirements
Top |
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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.
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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: |
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assuring the availability and accessibility
of required health care resources; and
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helping Medicaid recipients and their parents
or guardians effectively use them."
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| EPSDT
Resources
Top |
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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
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| Federal
Oversight Reports |
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| National
Health Law Program (NHeLP) |
- Toward
a Healthy Future: Medicaid Early and Periodic
Screening, Diagnostic and Treatment Services
for Poor Children and Youth (April 2003).
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| National
Academy for State Health Policy |
- VanLandeghem
Karen, Curtis Debra, and Abrams Melinda. Reasons
and Strategies for Strengthening Childhood
Development Services in the Healthcare System.
(October 2002).
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| Milbank
Quarterly |
- Gavin
et al, The Use of EPSDT and Other Health Care
Services by Children Enrolled in Medicaid:
The impact of OBRA 89. 1998;76:236-47. (June)
-
Sardell and Johnson. The Politics of EPSDT
Policy in the 1990s: Policy entrepreneurs,
political streams, and children's health benefits.
1998;76:186-89. (June)
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