Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is the children's health component of Medicaid. Federal statutes and regulations state that children under age 21 who are enrolled in Medicaid are entitled to EPSDT benefits and that States must cover a broad array of preventive and treatment services.
Unlike private insurance, EPSDT is designed to address problems early, ameliorate conditions, and intervene as early as possible.Federal Medicaid EPSDT page , December 2012Centers for Medicare and Medicaid Services. Chapter 5 Early and Periodic Screening manual. EPSDT Services in Medicaid Knowledge Path. Maternal and Child Health Library at Georgetown University. For the 25 million children enrolled in Medicaid and entitled to EPSDT in 2012, the program is a vital source of coverage and a means to improve the health and well-being of beneficiaries.
While a small number of cases and anecdotes regarding high EPSDT costs have garnered public attention, spending per child is low compared with worker-age adults and seniors covered by Medicaid. This is true despite the breadth of coverage provided to children through EPSDT. Children account for approximately half of Medicaid beneficiaries but only roughly 20-25 percent of the costs of the program overall.
With Medicaid and EPSDT, however, poor children's access to health care is similar to that of non-poor, privately insured children and child Medicaid beneficiaries use care in approximately the same pattern as their privately insured counterparts. On average, Medicaid costs per child are less than private insurance.
History EPSDT was enacted in 1967 as part of Medicaid as the child health component of Medicaid, with a deliberate focus on prevention and early intervention to reduce health problems among poor children and offer them equal opportunity to succeed in life. The design of EPSDT encompasses the vision of President Johnson and the Congress in order "to discover, as early as possible, the ills that handicap our children" and to provide "continuing follow up and treatment so that handicaps do not go neglected."Rosenbaum S, Johnson K. Providing health care for low-income children: reconciling child health goals with child health financing realities. Milbank Quarterly. 1986; 64(3):442-78Foltz AM. An Ounce of Prevention: Child health politics under Medicaid. MIT Press, Cambridge, MA, 1981.Children’s Defense Fund. EPSDT: Does it spell health care for poor children? Washington, DC: Children’s Defense Fund. 1977. While children were eligible for Medicaid from its original enactment in 1965, no specific standards related to child health coverage were included.
Within two years, however, policymakers would focus on the range and depth of Medicaid coverage for infants, children, and adolescents.The Social Security Act Amendments of 1967, added the EPSDT benefit. Sec. 1905(a)(4)(B), added by sec. 302(a), P.L. 90-248. President Johnson’s concern for the well-being of poor children was one political force. In 1967, as he transmitted his program for America’s children and youth, President Johnson said: “Recent studies confirm what we have long suspected. In education, in health, in all of human development, the early years are the critical years. Ignorance, ill health, personality disorder--these are disabilities often contracted in childhood: afflictions which linger to cripple the man and damage the next generation. Our nation must rid itself of this bitter inheritance. Our goal must be clear--to give every child the chance to fulfill his promise.” Lyndon B. Johnson. Special Message to the Congress Recommending a 12-Point Program for America’s Children and Youth, February 8, 1967. Transcript available at: Another set of arguments in support of EPSDT was in a report on young men found unqualified for military service, which concluded that the majority of those rejected for service in the early 1960s failed as a result of physical and mental health conditions which might have been prevented or treated in childhood.Rosenbaum S, Mauery DR, Shin P, Hildalgo. National Security and US Child Health Policy: The origins and continuing role of Medicaid and EPSDT. George Washington University. 2005.
Over the past 40 years, federal EPSDT law has been amended and state efforts have evolved to match changes in standards of pediatric care, structures in the health care system, and our understanding of the physical, emotional, and developmental needs of low-income children.Rosenbaum S, Wise PH. Crossing the Medicaid-private insurance divide: the case of EPSDT. Health Affairs. 2007; 26(2):382-93. Rosenbaum S, Wilensky S, Allen K. EPSDT at 40: Modernizing a Pediatric Health Policy to Reflect a Changing Health Care System. Center for Health Care Strategies. 2008.Olson K, Perkins J, Pate T. Children Health under Medicaid: A national review of Early Periodic Screening, Diagnosis, and Treatment. National Health Law Program. Important modifications were made in 1972 and 1981 to add requirements for outreach and family support.Social Security Amendments of 1972. October 30, 1972. Pub. L. 92-603. The amendments of 1989 clarified and broadened coverage to include all necessary diagnostic and treatment services approved under federal law.Rosenbaum S, Mauery DR, Shin P, Hildalgo. National Security and US Child Health Policy: The origins and continuing role of Medicaid and EPSDT. George Washington University. 2005.
The politics of EPSDT remain controversial. Some view the program as well designed and structured to meet child health needs, fitting professional guidelines and standards and focusing on prevention and optimal development. Others view the sweeping coverage as too generous for public coverage. As a result, the EPSDT benefit is guaranteed only for children with Medicaid coverage and not under other federal programs (see discussion below of CHIP).Sardell A, Johnson K. The Politics of EPSDT in the 1990s: Policy entrepreneurs, political streams, and children’s health benefits. The Milbank Quarterly. 1998;76(2):175-205).Rosenbaum S, Sonosky CA. Medicaid Reforms and SCHIP: Health care coverage and the changing policy environment. In CJ DeVita and R Mosher-Willisams (Eds), Who Speaks for America’s Children” The Role of Child Advocates in Public Policy (pp.81-104). Washington DC: Urban Institute Press.Foltz AM and Brown D. State response to federal policy: children, EPSDT, and the Medicaid muddle. Medical Care. 1977; 13(8):630-42.
Design of EPSDT Benefit EPSDT, as a set of benefits, offers a comprehensive approach to medical, dental, and mental health care for children which emphasizes prevention and early intervention. The core of the EPSDT benefit is a comprehensive, well-child visit known as an EPSDT screen. It must include: a comprehensive health and developmental history, comprehensive physical exam, appropriate immunizations, laboratory tests, and health education. The general design and content of the EPSDT screen is based on the Bright Futures guidelines Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics. 2008. for well child visits developed by the American Academy of Pediatrics and federal Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services.
Periodicity Schedule The schedules for periodic well-child visits in EPSDT are known as periodicity schedules. States are required to develop schedules for periodic screening, vision, and hearing services at intervals that meet reasonable standards of medical practice. Federal law requires that states consult with recognized medical organizations involved in child health care in the development of their states’ EPSDT periodicity schedules. Alternatively, states may elect to use a nationally recognized pediatric periodicity schedule such as Bright Futures .American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. A separate children’s dental periodicity schedule is also required. One has been developed by the American Academy of Pediatric Dentistry.Schneider D, Crall JJ. EPSDT Periodicity Schedules and their Relation to Pediatric Oral Health Standards in Health Start and Early Head Start. Oral Health Policy Center. State Dental Periodicity Schedules. American Academy of Pediatric Dentistry. Improving periodicity schedules can improve access to and utilization of child health services.Kaye N, Johnson K, May J. Improving EPSDT Periodicity Schedules to Promote Healthy Development.
Treatment and Medical Necessity EPSDT also provides coverage for treatment. All types of child health conditions — medical, dental, mental, developmental, acute, and chronic — must be treated, including pre-existing conditions or those detected outside of an EPSDT comprehensive well-child “screening” visit. EPSDT coverage is set by a federal standard and goes beyond what states may cover for adults in Medicaid. Specifically, states are required by federal law to provide any additional health care services that are covered under the federal Medicaid program and found to be medically necessary regardless of whether the service is covered in a state’s Medicaid plan.
Some common EPSDT treatment and intervention services beyond what is typically covered for adults include: eyeglasses, hearing aids, orthodontia, wheelchairs and prosthetic devices, occupational and physical therapy, prescribed medical formula foods, assistive communication devices, personal care, therapeutic behavioral services, and substance abuse treatment Johnson K. Managing the "T" in EPSDT. National Academy for State Health Policy. 2010 . Medicaid, as well as private insurers, will not pay for treatment for a covered individual unless they consider it to be medically necessary. In most private health plans, this means the service must be justified as reasonable, necessary, and/or appropriate, using evidence-based clinical standards of care.
For children, federal Medicaid law requires coverage of “necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions.” 42 USC § 1396d(r)(5) Thus, the EPSDT medical necessity standard assures a level of coverage sufficient not only to treat an already-existing illness or injury but also to prevent the development or worsening of conditions, illnesses, and disabilities.American Academy of Pediatrics (AAP) Committee on Child Health Financing Model Contractual Language for Medical Necessity. Pediatrics. 2005b 116(1): 261-262.
Dental Dental services must meet standards of dental practice. These standards should be determined by the state following discussion regarding the health of the child. Minimum services should include pain relief, restoration of teeth and maintenance for dental health. EPSDT individuals below the age of 21 are not to be limited emergency services. Medical care providers should provide direct referral to a dentist as part of a comprehensive EPSDT screening visit. If a condition requiring treatment is discovered for a child, EPSDT provides financing for nearly all medically necessary dental services.Medicaid Dental Coverage. Centers for Medicare and Medicaid Services. Centers for Medicare & Medicaid Services Centers for Medicare and Medicaid. Guide to Children’s Dental Care in Medicaid.
Vision Vision services, at a minimum, include diagnosis and treatment for defects in vision and eyeglasses when appropriate. Vision services must be provided according to a distinct, separate periodicity schedule developed by the state and at other intervals as medically necessary.
Hearing