The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit stands as a cornerstone of Medicaid, ensuring comprehensive and preventive healthcare services for children and adolescents under the age of 21 enrolled in the program. EPSDT is vital in guaranteeing that young individuals receive the necessary preventive, dental, mental health, and specialized services to thrive.
EPSDT operates on five key principles:
- Early Intervention: Identifying and addressing potential health issues as early as possible in a child’s life.
- Periodicity: Regular health check-ups at age-appropriate intervals throughout childhood and adolescence.
- Screening: Providing a range of physical, mental, developmental, dental, hearing, vision, and other screenings to detect potential health concerns proactively.
- Diagnosis: Conducting thorough diagnostic tests to investigate any risks or issues identified during screenings.
- Treatment: Providing necessary care to control, correct, or mitigate any health problems that are diagnosed.
Comprehensive EPSDT Services
States participating in Medicaid are mandated to provide all services coverable under section 1905(a) of the Social Security Act that are deemed appropriate, medically necessary, and aimed at correcting or improving health conditions based on federal guidelines. EPSDT encompasses a broad spectrum of screening, diagnostic, and treatment services, ensuring holistic care for young beneficiaries.
Screening Services: Proactive Health Assessments
EPSDT screening services are designed to proactively identify potential health issues. These services include:
- Comprehensive Health and Developmental History: Gathering detailed information about the child’s health history and developmental milestones.
- Comprehensive Unclothed Physical Exam: A thorough physical examination to assess the child’s overall health status.
- Appropriate Immunizations: Administering vaccines according to the schedules recommended by the Advisory Committee on Immunization Practices (ACIP) to protect against preventable diseases.
- Laboratory Tests including Lead Toxicity Screening: Conducting necessary lab tests, including screenings for lead exposure, which is crucial for children’s health.
- Health Education (Anticipatory Guidance): Providing guidance on child development, healthy lifestyles, accident prevention, and disease prevention to empower families to make informed health decisions.
Alt: A healthcare provider takes a comprehensive health and developmental history from a young child and their parent during an EPSDT screening, focusing on developmental milestones and past illnesses.
Schedules for periodic screening services are established based on reasonable standards of medical practice. States are required to consult with recognized medical organizations specializing in child health care when developing these schedules. Alternatively, states have the option to adopt a nationally recognized pediatric periodicity schedule, such as Bright Futures. A separate dental periodicity schedule is also a mandatory component of EPSDT.
Vision & Hearing Services: Ensuring Sensory Health
EPSDT emphasizes the importance of vision and hearing health by including comprehensive services. At a minimum, these services cover screening, diagnosis, and treatment for vision and hearing impairments, including the provision of hearing aids and eyeglasses when necessary. Vision services are provided according to a periodicity schedule and at any other intervals when deemed medically necessary to ensure timely intervention and care.
Alt: A young child undergoes a vision screening test as part of EPSDT vision and hearing services, ensuring early detection of potential vision problems.
For more detailed information, resources are available on the Vision and Hearing Screening Services for Children & Adolescents page.
Dental Services: Promoting Oral Health from an Early Age
Dental health is a critical component of overall well-being, and EPSDT mandates comprehensive dental services. Covered services must include, at a minimum, dental care necessary for pain relief, infection control, tooth restoration, and maintaining dental health, starting as early as necessary. Medically necessary orthodontic services are also included. Each state must develop a dental periodicity schedule in consultation with recognized dental organizations specializing in child dental health. Services beyond the periodicity schedule are covered when medically necessary for an individual child, ensuring tailored dental care. Further details can be found on the Dental page.
Alt: A dentist performs a dental exam on a child as part of EPSDT dental services, focusing on preventive care and early identification of dental health issues.
Lead Screening: Protecting Children from Lead Exposure
Recognizing the dangers of lead exposure, EPSDT requires all Medicaid-enrolled children to receive blood lead screening tests at 12 and 24 months of age. Furthermore, children between 24 and 72 months without a prior record of blood lead screening must also be tested. This universal screening requirement is crucial for identifying and addressing lead exposure in young children. Additional information on Medicaid’s universal blood lead screening requirement is available on the Lead Screening page.
Immunizations/Vaccines for Children (VFC) Program: Ensuring Vaccination Coverage
EPSDT ensures that all children under 21 eligible for the benefit receive all age-appropriate vaccines recommended by the Advisory Committee on Immunization Practices. The Vaccines for Children (VFC) program plays a vital role by providing federally purchased vaccines to children enrolled in Medicaid, as well as those who are uninsured, underinsured, or American Indian/Alaska Native. More information is available on the Quality of Care Vaccines page.
Other Necessary Health Care Services: Addressing Comprehensive Needs
States are obligated to provide any additional services listed under section 1905(a) that are covered by the Federal Medicaid program and are deemed medically necessary to treat, correct, or reduce illnesses and conditions discovered through EPSDT, regardless of whether these services are explicitly covered in a state’s Medicaid plan. The determination of medical necessity is made by states on a case-by-case basis, ensuring flexibility in addressing individual health needs.
Diagnostic Services: Following Up on Screening Findings
When a screening examination indicates the need for further evaluation, EPSDT mandates the provision of diagnostic services. Necessary referrals should be made promptly, and follow-up is essential to ensure that the child receives a complete diagnostic evaluation. States are expected to develop quality assurance procedures to guarantee that comprehensive care is provided, bridging the gap between screening and definitive diagnosis.
Treatment: Addressing Identified Health Conditions
EPSDT ensures that necessary healthcare services are available for the treatment of all physical and mental illnesses or conditions identified through screening and diagnostic procedures. This comprehensive treatment component is crucial for improving health outcomes and ensuring that children receive the care they need to thrive.
State Program Guidelines: Implementing EPSDT Effectively
State Medicaid agencies play a vital role in implementing EPSDT effectively. They are required to:
- Inform eligible individuals: Notify all Medicaid-eligible individuals under age 21 about the availability of EPSDT services and the importance of age-appropriate immunizations.
- Provide screening services: Ensure the provision of screening services for all eligible children.
- Arrange for corrective treatment: Facilitate or arrange for necessary corrective treatment as determined by child health screenings, ensuring access to follow-up care.
- Report EPSDT performance: Submit annual reports on EPSDT performance information via Form CMS-416 to monitor program effectiveness and identify areas for improvement.
EPSDT Strategy Guides: Supporting State Program Enhancement
The Centers for Medicare & Medicaid Services (CMS) has developed a series of strategy guides to assist states and their partners in implementing the EPSDT benefit effectively. These guides offer practical approaches to enhance access, utilization, and quality of care for children and adolescents enrolled in Medicaid. They include examples of successful state initiatives and links to valuable resources and tools. These strategy guides are valuable resources for states seeking to optimize their EPSDT programs.
EPSDT Data: Monitoring Program Effectiveness
Form CMS-416 serves as the primary tool for CMS to collect essential data on State Medicaid and CHIP programs to evaluate the effectiveness of EPSDT services. Annually, states are required to report data on:
- Number of children provided child health screening services.
- Number of children referred for corrective treatment.
- Number of children receiving dental services.
- State’s progress in achieving goals set under section 1905(r) of the Social Security Act, focusing on continuous improvement in child health outcomes.
Form CMS-416 and instructions are publicly available. For data reports prior to FFY 2020 or to request a 508-compliant version of the form, please contact [email protected]. Additional reporting resources, including the FFY 2019 Form CMS-416 Data Quality Checklist for States, are also available to support accurate and comprehensive data submission.
