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The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for Health First Colorado (Colorado's Medicaid Program) 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 earlyPeriodic: Checking children's health at periodic, age-appropriate intervalsScreening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problemsDiagnostic: Performing diagnostic tests to follow up when a risk is identified, andTreatment: Control, correct or ameliorate health problems found.
EPSDT is made up of the following screening, diagnostic, and treatment services:
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.
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:
Colorado has adopted the American Academy of Pediatrics Bright Futures Periodicity schedule.
Lead screening is a requirement for all Health First Colorado-eligible children at 12 and 24 months or between the ages of 36 and 72 months if not previously tested.
All Health First Colorado coverable, medically necessary, services must be provided even if the service is not available under the State plan to other Health First Colorado 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.
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, in-home support services, and home modifications are examples of waiver services.
Colorado is required to report specific matrix to the federal government on the EPSDT CMS-416 which include but are not limited to:
For more information about the EPSDT Program contact: