Well-Child Care Toolkit

EPSDT Requirements: A Summary

The Centers for Medicare & Medicaid Services (CMS) requires states to ensure that all Medicaid-eligible children and youth receive comprehensive health services, especially early and periodic screening, diagnostic, and treatment (EPSDT) services.

In general, EPSDT services include:

Early
and comprehensive health care to assess a child's health status, identify risks or concerns, and intervene promptly
Periodic
well-child visits at recommended age-appropriate intervals (periodicity).
Screening
services including health history, physical exam, tests and assessments, immunizations, and health guidance.
Diagnostic
services to determine the nature and cause of identified health problems and evaluate treatment options.
Treatment
services, including early intervention, to correct or improve physical, developmental, and mental health conditions.

The following preventive care services (broadly defined as "screening services") must be provided at well-child visits:

Screening Services

  • Comprehensive health and developmental history -- includes assessment of physical and mental health development.
  • Comprehensive unclothed physical exam.
  • Appropriate immunizations -- according to the Advisory Committee on Immunization Practices (ACIP) schedule for pediatric vaccines.
  • Laboratory tests -- based on approved statewide screening requirements for minimum laboratory tests or analyses for particular ages or population groups.
  • Lead toxicity screening -- requires a blood lead test for all Medicaid-eligible children at 12 months and 24 months of age. Children ages 36 to 72 months should be tested if not previously screened. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (fingerstick) must be confirmed using a venous blood sample.
  • Health education and anticipatory guidance -- parents (or guardians) and children must receive health education and counseling on what to expect in the child's development, the benefits of healthy lifestyles and practices, and how to prevent illness and injury.
  • Vision services* -- minimum services include diagnosis and treatment for defects in vision, including eyeglasses.
  • Hearing services* -- minimum services include diagnosis and treatment for defects in hearing, including hearing aids.
  • Dental services* -- minimum services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services. Oral screening during the physical exam does not substitute for direct referral to a dentist. A direct dental referral is required for every child, in accord with a state's approved dental periodicity schedule or as medically necessary.
  • Other necessary health care. States must provide other necessary health care, diagnosis services, treatment, and other measure described in section 1905(a) of the Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services.

    * Distinct periodicity schedules for vision, hearing, and dental services must be developed by each state, in consultation with recognized medical and dental organizations involved in child health care. Services must also be provided at other intervals as medically necessary.

 

Diagnostic Services

When screening indicates the need for further evaluation, diagnostic services should be provided. Referrals and follow-up should be made without delay to ensure a complete diagnostic evaluation. If the child has a continuing care provider, diagnosis may be part of the screening and examination process. States should develop quality assurance procedures to ensure comprehensive care.

 

Treatment Services

Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services. Children diagnosed with elevated blood lead levels should receive any additional diagnostic and treatment services that are medically necessary.



Source:

EPSDT Benefits. Available online at http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp#TopOfPage
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