Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federally mandated Medicaid benefit that every state must provide to Medicaid-enrolled children and youth under age 21. The purpose is to identify child health problems early and provide assurance that they will be addressed. Screening is a key part and can be provided through special programs (like school screening programs) or incorporated into regular well child visits. Under the EPSDT benefit, states are required to provide all medically necessary services to correct or ameliorate physical or behavioral health conditions, even if the service is not part of the state plan. EPSDT is a required benefit regardless of how children qualify for Medicaid or the form of service delivery utilized by a state (e.g., managed care). This is a foundational principle in Medicaid law and there are no exceptions.

Medicaid is required to inform all Medicaid-eligible individuals under age 21 that EPSDT services are available and help them access care by providing services such as transportation, assistance with scheduling appointments, and connections to other supports. Many Title V programs work in partnership with Medicaid to ensure children have access to EPSDT, including providing outreach and education to families and providers to ensure EPSDT services are covered and to encourage EPSDT screenings. For state Children’s Health Insurance Programs (CHIP) administered separately, EPSDT is an optional benefit.

System Surveillance

The CYSHCN program in Arkansas collects information from families about services that Medicaid has denied and advocates for those services to be covered under the EPSDT benefit. In Vermont, the Title V CYSHCN program developed a system for tracking coverage denials based on family report. They noticed that particular services were repeatedly denied. They reached out to their state’s Medicaid staff focused on EPSDT and informed them of this trend. The Medicaid agency affirmed that the services should have been covered under EPSDT and implemented agency change to prevent future denials.

Medicaid Managed Care, Provider, and Family Education

Michigan’s Title V CYSHCN program employs a Billing Resolution Specialist, who works with Local Health Departments, families, and healthcare providers to explain prior authorization processes and ensure that CYSHCN have access to medically necessary services.

Kansas Title V collaborates with local public health programs to share information about EPSDT updates and best practices. The Title V program also supports training programs for local health departments related to developmental screenings. In 2019, the Title V program purchased a statewide license for the online Bright Futures Tool and Resource Kit, which eliminated cost barriers to accessing education on updated guidelines for annual well visits and screenings.

Strategies to Facilitate Screening

As part care coordination services provided by the CYSHCN program in Kansas, families are reminded about the need for their child’s yearly EPSDT appointment and assisted in scheduling the appointment if necessary. This is monitored as part of the client’s Action Plan.

Quality improvement initiatives in DC include well visit and EPSDT documentation in School Based Health Center Electronic Health Records.

Title V - Medicaid Partnerships Focused on EPSDT

Idaho CYSHCN staff are working with Idaho Medicaid/EPSDT staff to ensure that all newborns covered by Idaho Medicaid who have presumptive positive newborn screening result can receive recommended diagnostic tests to confirm diagnosis without the requirement of a prior authorization. The Idaho Medicaid Provider Handbook and fee schedule will be updated once this project is completed and shared with other private insurance companies with the goal to promote similar changes within private insurance companies’ policies and procedures surrounding prior authorizations that impact newborn screening conditions.

The Title V agency in West Virginia works closely with Medicaid to implement EPSDT and provides administrative support for EPSDT outreach. While West Virginia’s EPSDT outreach and education program, called HealthCheck, is funded by the state’s Medicaid agency, West Virginia’s CSHCN Program provides services in alignment with EPSDT guidelines.

The Utah Department of Health and Human Services houses the state Medicaid agency and maintains a strong relationship with Title V. Together, they work closely on EPSDT and other Medicaid-administered programs that serve mothers and children.