The Medicaid Act provides a variety of both services and protections for people with disabilities. One of the populations that benefits the most from Medicaid services is children. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) is a Medicaid benefit designed to increase the duration and scope of treatment provided to children. In doing so, EPSDT requires states to provide nearly any “medically necessary” service to children. From Medicaid.gov:
The EPSDT benefit is more robust than the Medicaid benefit for adults and 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 EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.
Under EPSDT, states are required to provide a schedule of recommended screenings for medical, vision, hearing and dental. Medical screenings include health and developmental history for both physical and mental health (including substance use disorders), comprehensive unclothed physical exams, immunizations, lab testing, and health education/anticipatory guidance for both children and their caregivers. While states are free to design their periodicity schedule, EPSDT also includes access to screenings that might not fit within that schedule if there is an indication of medical need.
Scope of Services
As stated above, EPSDT is a crucial resource for children with disabilities, providing services that are greater in scope and duration than those provided to all other Medicaid recipients. From Medicaid.gov:
The Act provides for coverage of all medically necessary services that are included within the categories of mandatory and optional services listed in section 1905(a), regardless of whether such services are covered under the State Plan. These include physician and hospital services, private duty nursing, personal care services, home health and medical equipment and supplies, rehabilitative services, and vision, hearing, and dental services.
Further, EPSDT covers “any other medical care, and any other type of remedial care recognized under state law[…]” While the state is free to develop a “State Plan” that describes the services it will commit to cover to its population of Medicaid recipients, that plan does not limit the services a child can receive. Further, any limits to the duration of those services equally do not apply to children, as long as those services are “medically necessary.”
If a child requires twelve sessions of physical therapy, and it is shown that twelve sessions are medically necessary to ameliorate the effects of the child’s disability, then it does not matter whether the state has capped physical therapy services to six sessions. EPSDT requires the state to provide the service to the extent it is medically necessary, regardless of its State Plan limitations.
What do I need to do to get access to EPSDT?
EPSDT is not a waiver program, it is not a specific service, and should not be something that needs to be applied for and approved. It is a Medicaid benefit that is automatically extended to children. That said, your state might require a specific form to request benefits that would only be available because of EPSDT. You should ask your county DHS office for any form they might require to process or approve a specific service, or extension of the duration of a service.
If you are denied a medically necessary service for a child who receives Medicaid, in any form, please call Disability Rights Arkansas at (501) 492-5776.
Thomas Nichols is the Director of Legal and Advocacy Services at Disability Rights Arkansas. Email him at email@example.com.