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Early and Periodic Screening, Diagnostic, and Treatment
ESPDT is the Medicaid program’s mandatory benefit for children is more robust than the Medicaid benefit for adults. It is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. Through EPSDT, eligible children under 21 can receive any Section 1905 service necessary to “correct or ameliorate” a condition, regardless of whether the service is covered under the state plan.
Because medical necessity decisions are individualized, flat limits or hard limits based on a monetary cap or budgetary constraints are not consistent with EPSDT requirements.
Providing Equitable Medical Care for Children at Home: Federal Law and State Policy
https://lpfch.org/wp-content/uploads/2024/05/Coleman-Grusin-Foster-Regulatory-Review-Final.pdf
Authors: Cara L. Coleman, JD, MPH, Sarah L. Grusin, JD, Carolyn C. Foster, MD, MS
Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements
EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents
This guide outlines:
EPSDT’s screening requirements, including when interperiodic screening should be provided;
Scope of services covered under EPSDT;
EPSDT’s requirements governing dental, vision, and hearing services;
Permissible limitations on service coverage under EPSDT;
States’ responsibilities to assure access to EPSDT services and providers;
Assistance to states as they work with managed care plans to provide the best child health benefit possible; and
Notice and appeal procedures required when services are denied, reduced or terminated.
Excerpt from the Guide:
Read the Guide Here:
https://www.medicaid.gov/medicaid/benefits/downloads/epsdt-coverage-guide.pdf
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