EPSDT: The Medicaid health benefit for members under 21 years old
Members under 21 years old (excluding NC Health Choice members) have a broad menu of health care benefits. Medicaid calls this benefit Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT).
The guarantee covers wellness visits and treatment services.
Early and periodic screening and diagnosis
These "screening" visits are wellness care. They are free for plan members under age 21. These visits include a complete exam, no-cost vaccines, and vision and hearing tests. Your provider will also watch your child's physical and emotional growth and well-being at every visit, and "diagnose" any conditions that may exist. At these visits you will get referrals to any treatment services your child needs to get well and to stay healthy.
The "T" in EPSDT: treatment for members under 21 years old
Sometimes children need medical "treatment" for a health problem. Your plan may not offer every service covered by the federal Medicaid program. When a child needs treatment, your plan will pay for any service that the federal government's Medicaid plan covers. The plan must use a set of special rules that apply only to children. These rules are called EPSDT "medical necessity criteria."
A plan cannot deny your child's service just because of a policy limit. Also, a plan cannot deny a service just because that service is not covered in the plan's policies. Your plan must complete a special "EPSDT review" in these cases.
When your plan approves services for children, important rules apply:
- There are no copays for Medicaid-covered services to members under 21 years old.
- There are no limits on how often a service or treatment is given.
- There is no limit on how many services the member can get on the same day.
- Services may be delivered in the best setting for the child's health. This might include a school or a community setting.
You will find the entire menu of Medicaid-covered services in the Social Security Act. The federal Medicaid program covers a broad menu of medical care, including:
- Dental services
- Comprehensive health screening services (well-child checks, developmental screenings and immunizations)
- Health education
- Hearing services
- Home health services
- Hospice services
- Inpatient and outpatient hospital services
- Lab and X-ray services
- Mental health services
- Personal care services
- Physical and occupational therapy
- Prescription medicines
- Rehabilitative services for speech, hearing and language disorders
- Transportation to and from medical appointments
- Vision services
- Any other necessary health services to treat, fix or improve a health problem
If you have questions about EPSDT services, talk with your PCP. You can also find out more about the federal EPSDT guarantee online. Visit the NC Medicaid EPSDT webpage.
If you have questions or want to find out more about this program, call AmeriHealth Caritas North Carolina Member Services, at 1-855-375-8811 (TTY 1-866-209-6421), 24 hours a day, seven days a week.