2930 EPSDT Services | Medicaid

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides coverage for a comprehensive array of preventive, diagnostic, and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit 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 the EPSDT benefit is to assure that individual children get the health care they need when they need it. When a preventive health examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnostic and treatment services without delay. States are required to arrange for and cover under the EPSDT benefit any Medicaid covered service listed in Section 1905(a) of the Act if that treatment or service is determined to be medically necessary to correct or ameliorate defects and physical and mental illnesses or conditions. This includes physician, nurse practitioner and hospital services; physical, speech/language, and occupational therapies; home health services, including medical equipment, supplies, and appliances; treatment for mental health and substance use disorders; treatment for vision, hearing and dental diseases and disorders, and much more. This broad coverage requirement results in a comprehensive, high quality health benefit for children under age 21 enrolled in Medicaid.

The EPSDT benefit is available for Medicaid-eligible children from birth up to twenty-one (21) years of age and PeachCare for Kids®-eligible children from birth up to nineteen (19) years of age.

The EPSDT benefit allows for: an assessment of a child’s health at key points in his/her life so that potential diseases can be prevented or detected early enough to allow for treatment, thus assuring continued healthy development and; tests, procedures and treatments when needed to correct or ameliorate diseases and conditions.

EPSDT providers include Physicians (pediatricians, family practitioners, general practitioners, etc.), Nurse Practitioners, Physicians' Assistants, Rural Health Clinics, Federally Qualified Health Clinics and Public Health Departments that are enrolled in the Health Check program.

The EPSDT program provides reimbursement for preventive and primary health services, immunization administration, vision, hearing and dental screenings, and developmental screenings. Other Medicaid program areas reimburse providers for services provided under the EPSDT benefit.

EPSDT preventive health services align with the AAP’s Bright Futures Periodicity Schedule and include, but are not limited to the following:

Inform the applicant about the program verbally and in writing at the time of application for Family Medicaid.

Document in the system how the member was informed of the services available under the EPSDT benefit (i.e., face to face, telephone, brochure, or video).

Upon approval, a description of the EPSDT program and contact information is sent to A/R via the GA Gateway approval notice.

Explain the benefits of preventive health care services and the services offered under the program including the following: