The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is the key to ensuring that children and adolescents 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 reduce health problems found.
States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. 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 screening- 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)
- Health Education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)
When a screening examination indicates the need for further evaluation of an individual’s health, diagnostic services must be provided. Necessary referrals should be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation.
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.
If the screening provider is not licensed or equipped to render the necessary treatment or further diagnosis, the provider shall refer the individual to an appropriate practitioner or facility or to Healthy Communities at 303-602-6770 for assistance in finding a provider.
For information on how to refer EPSDT eligible members for in-network, out of network and wrap-around services contact the Utilization Management department at 303-602-2140 or visit our website: http://www.denverhealthmedicalplan.org/utilization-management-um
Colorado also provides these services through Healthy Communities 303-602-6770 and other programs:
- Information to all Medicaid-eligible individuals under age 21, 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 (directly or through referral) for corrective treatment as determined by child health screenings;
- Missed appointment follow-up; and
- Refer for transportation assistance.
Periodicity schedules for periodic screening, vision, and hearing services must be provided at intervals that meet reasonable standards of medical practice. Colorado uses a nationally recognized pediatric periodicity schedule (i.e., Bright Futures).
“Medical Necessity for EPSDT services” is defined as:
- A service that is found to be equally effective treatment among other less conservative or more costly treatment options.
- Meets one of the following criteria:
- The service is expected to prevent or diagnose the onset of an illness, condition, or disability.
- The service is expected to cure, correct, or reduce the physical, mental, cognitive, or developmental defects of an illness, injury, or disability.
- The service is expected to reduce or ameliorate the pain and suffering caused by an illness, injury, or disability.
- The service is expected to assist the individual to achieve or maintain maximum functional capacity in performing activities of daily living.
- May be a course of treatment that includes observation or no treatment at all.
- The contractor’s UM process provides for approval of healthcare services if the need for services is identified and meets the following requirements:
- The service is medically necessary.
- The service is in accordance with generally accepted standards of medical practice.
- The service is clinically appropriate in terms of type, frequency, extent, and duration.
- The service provides a safe environment or situation for the child.
- The service is not for the convenience of the caregiver.
- The service is not experimental and is generally accepted by the medical community for the purpose stated.
A child can get EPSDT services at Denver Health at no cost to the member. Services include:
- Well Child Checks
- Vision Screening/Eyeglasses
- Hearing Screening
EPSDT services that require a PCP referral and/or prior authorization (PAR):
- Speech (PCP referral)
- Physical Therapy/Occupational Therapy (PCP referral)
- Home Health (PCP referral and PAR)
- Substance Use Disorders Treatment (PCP referral and PAR)
Wrap-Around benefits are additional treatments or services that are not part of the Denver Health Medicaid Choice covered benefits, but are covered by Medicaid and payable by the State’s fiscal agent when medically necessary.
Wrap-Around benefits associated with EPSDT:
- Hearing devices and auditory training
- Dental/hygienist care and treatment
- Orthodontia for severe, handicapping malocclusions
- Transportation for non-emergency medical, dental, or behavioral/mental health care
- Family planning with a non DH provider such as Planned Parenthood
- Hospice services
- Skilled nursing facility care
- Intestinal transplants
- Private duty nursing
- Expanded benefits; benefits that the state chooses to provide a child that are above and beyond the EPSDT benefit package. Examples are: chiropractic care and extraordinary home care
Wrap-Around benefits associated with EPSDT:
Denver Health providers can obtain assistance with Wrap-Around services from their ACS RN Coordinator and should contact them with any questions.
For more information on the Healthy Communities Program or to be connected with a local outreach coordinator, please call 1-844-511-KIDS (5437).
For EPSDT related problems or questions please contact DHMP Health Plan Services at 303-602-2116.