Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for Medicaid members age 20 and under along with pregnant adults. EPSDT is key to ensuring that children and youth receive appropriate preventive, dental, mental health, developmental and specialty services.
Early: Assessing and identifying problems early
Periodic: Checking children's health at periodic, age-appropriate intervals
Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and
Treatment: Control, correct or ameliorate health problems found.
EPSDT is made up of the following screening, diagnostic, and treatment services:
- Comprehensive health and developmental history
- Comprehensive unclothed physical exam
- Appropriate immunizations (according to the Advisory Committee on Immunization Practices)
- Laboratory tests (including lead toxicity testing)
- Health Education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)
At a minimum, diagnosis and treatment for defects in vision, including eyeglasses.
At a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health, including examinations, cleanings and fluoride treatments.
At a minimum, diagnosis and treatment for defects in hearing, including hearing aids.
Other Necessary Health Care Services
Additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct or ameliorate illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis (see medical necessity below for more information).
When a screening indicates the need for further evaluation, diagnostic services must be provided.
Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.
Colorado also provides through Healthy Communities and other programs:
- Information to all Medicaid-eligible individuals under age 20 and under, including adults who are pregnant, that EPSDT services are available and of the need for age-appropriate screenings, well child visits and immunizations;
- Provide or arrange for the provision of screening services for all children;
- Arrange (through referral) for corrective treatment as determined by child health screenings;
- Missed appointment follow-up; and,
- Refer for transportation assistance.
Colorado has adopted the American Academy of Pediatrics Bright Futures Periodicity schedule.
Lead screening is a requirement for all Medicaid eligible children at 12 and 24 months or between the ages of 36 and 72 months if not previously tested.
All Medicaid coverable, medically necessary, services must be provided even if the service is not available under the State plan to other Medicaid eligibles. Benefits not listed are not considered to be a state plan benefit and therefore outside of EPSDT coverage and exceptions. No arbitrary limitations on services are allowed, e.g., one pair of eyeglasses or 10 physical therapy visits per year.
Colorado makes the final determination of medical necessity and it is determined on a case-by-case basis. Provider recommendations will be taken in to consideration, but are not the sole determining factor in coverage. Colorado determines which treatment it will cover among equally effective, available alternative treatments.
EPSDT Medical Necessity Does NOT include:
- Experimental or investigational treatments;
- Services or items not generally accepted as effective; and/or not within the normal course and duration of treatment;
- Services for caregiver or providers convenience.
Services for which Colorado has a waiver are also not considered to be state plan benefits, and therefore are not a benefit under EPSDT. Items such as respite, behavioral interventions, in-home support services, and home modifications are examples of waiver services.
EPSDT and Managed Care
- All EPSDT requirements must be adhered to for individuals who receive services under managed care arrangements.
- Colorado is responsible for medically necessary services not included in the managed care contract.
Centers for Medicare and Medicaid (CMS) EPSDT 416 Report
Colorado is required to report specific matrix to the federal government on the EPSDT CMS-416 which include but are not limited to:
- The number of children provided child health screening services;
- The number of children referred for corrective treatment;
- The number of children receiving dental services, broken down by type of service and type of provider; and
- The State’s results in attaining the participation goals set for the States under section 1905(r)
- Social Security Act, Section 1905(a)(4)(b) – list of services
- Social Security Act, Section 1905(r) of SS Act – definition of EPSDT benefit (OBRA 1989)
- Social Security Act, Section 1902(a)(43) of SS Act – administrative requirements
- Social Security Act, Section 1902(a)(10), following (G) – exception to comparability
- CMS, Part 5 of State Medicaid Manual – services
- CMS, Part 2 of State Medicaid Manual – data
For more information about the EPSDT Program contact: