What Is EPSDT?
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law that says Medicaid must provide all medically necessary health care services to Medicaid-eligible children. Even if a service is not covered under the North Carolina Medicaid State Plan, it can be covered for members under age 21 if the service is listed at 1905(a) of the Social Security Act and if all EPSDT criteria are met.
Trillium is committed to providing preventive health screenings and improving the overall health of children enrolled in our health plans. Trillium will cover services, products, or procedures for a Medicaid member under age 21 if the service is medically necessary to correct or ameliorate a defect, physical or mental illness, or a condition or health problem identified through a screening examination.
Developmental and Behavioral Screening
Periodic developmental and behavioral screening during early childhood is essential to identify possible delays in growth and development, when steps to address deficits can be most effective. These screenings are required for children enrolled in Medicaid.
EPSDT Required Services and Coverage
The assigned primary care provider (PCP) is responsible for EPSDT services, including screening, diagnosis and treatment.
Screening services include:
- Routine physical examinations as recommended and updated by the American Academy of Pediatrics (AAP) “Guidelines for Health Supervision III” and described in “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents”
- Screening for developmental delay at each visit through the 5th year
- Screening for Autism Spectrum Disorders per AAP guidelines
- Health and development history
- Unclothed physical exam
- Development assessment and behavioral health screening
- Assessment and provision of immunizations as appropriate for age and health history, in accordance with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices
- Assessment of nutrition status
- Vision testing
- Hearing testing
- Laboratory procedures appropriate for age and population groups, including blood lead screening
- Oral health assessments, evaluations, prophylaxis and oral hygiene counseling for all children at preventive visits at regular intervals and in accordance with state Oral Health Periodicity Schedule.
- Infant members under the age of 1 must be referred to a dentist or dental professional working under the supervision of a dentist as part of the Medicaid Fee-for-Service program
- Anticipatory guidance and health education
- Referral for additional services if indicated for further diagnosis and treatment
services.
Trillium will ensure and verify that network Behavioral Health providers coordinate with Primary Care Providers and specialists conducting EPSDT screenings. Trillium will not make an adverse benefit determination on a service authorization request for a child until the request is reviewed. For more information, please view our EPSDT Policy.
Treatment Services
EPSDT provides for treatment and services that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether the requested service is covered in the State Plan. This means that children under age 21 can receive services in excess of benefit limits, even if the service is no longer covered or not covered under the State Plan.
According to CMS, “ameliorate” means to improve or maintain the beneficiary’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT criteria include:
- the service must be covered under 1905(a) of the Social Security Act
- it must be safe, effective, generally recognized as an accepted method of medical practice or treatment,
- cannot be experimental or investigational (which means that most clinical trials cannot be covered).
Resources:
- Health Check and EPSDT
- EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents
- Paving the Road to Good Health: Strategies for Increasing Medicaid Adolescent Well-Care Visits
- Making Connections: Strategies for Strengthening Care Coordination in the Medicaid Benefit for Children & Adolescents
Requesting EPSDT Services
All requests for services for Medicaid-eligible children under age 21 are reviewed using EPSDT criteria. Requests for NC Innovations Waiver services are reviewed under EPSDT when requested services are both on the Innovaions Waiver and are also a covered service in SSA 1905a. Most NC Innovations Waiver services are not covered under the Social Security Act (i.e. respite, home modifications and all habilitative services).
To request a service that is not covered by the State Plan but is covered under 1905(a) of the Social Security Act, please submit the completed form below using secure email to the Trillium Health Resources UM Department, at UM@TrilliumNC.org. You may use additional sheets to supply any other information you think would be helpful. Include evidence-based literature, if available.
EPSDT Prior Approval Request Form
EPSDT Resources for Providers
- NC Medicaid Provider EPSDT Training PPT
- NC Division of Health Benefits Resource Page - EPSDT for Providers
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