Medicaid for Children: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s comprehensive and preventive child health program for individuals under age 21.
What is EPSDT?*
- EPSDT stands for Early and Periodic Screening, Diagnosis, and Treatment.
- EPSDT is a complete benefit package that provides periodic check-ups (screenings) and necessary treatment to children enrolled in Medicaid.
- EPSDT offers four types of screens: medical, vision, hearing, and dental.
- These screens are scheduled at appropriate age intervals to meet current pediatric, adolescent, and dental practices so that children receive services necessary to maintain their health.
Who is eligible for EPSDT?
All Medicaid-eligible children under the age of 21 qualify for EPSDT. For information about who is eligible for Medicaid, contact the SC Department of Health and Human Services at (888) 549-0820.
What services does EPSDT cover?
EPSDT must include screening, diagnostic services, treatment, and education. More information is available from the United States Department of Health and Human Services.
Medical Screening Services:*
- Complete health and developmental history, including physical and mental health assessment
- Unclothed physical exam
- Appropriate immunizations
- Certain laboratory tests, including lead poisoning prevention/screening
If screening services indicate there is a need for a more complete evaluation of the child’s health or some specific condition, that evaluation and diagnosis should be provided without delay.
- EPSDT requires that state Medicaid agencies arrange for, directly or through referrals, treatment or other measures “to correct or ameliorate defects and physical and mental illnesses and conditions” discovered by the screenings.
- Examples: mental health services, vision services, hearing services, speech therapy, occupational therapy, physical therapy, dental services, health education, nursing services, and attendant care
- Health education and counseling for both parents (or guardians) and children is required. It should assist them in understanding the child’s development and provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention;
A child’s individual needs should determine what care the child receives:
- If a health care provider determines that a service is medically necessary to correct or improve a health problem, then EPSDT should cover the service.
- Even if the state places a limit on the particular service or does not cover the service for adults, states may not set limits on the number of services or place monetary caps on children’s EPSDT services.
- If a treatment or service is denied, you have the right to appeal the decision at a legal hearing called a “fair hearing.” See DHHS’s website for Appeals and Hearings FAQs.
To appeal the denial of services, you must send a letter to the following address within 30 days of the decision:
Department of Health and Human Services
Attn: Division of Appeals and Hearings
Post Office Box 8206
Columbia, South Carolina 29202-8206
Their toll-free number is 1-800-763-9087.
See Disability Rights South Carolina’s publication on “Medicaid Fair Hearings.”
EPSDT services have some restrictions:
- EPSDT services are available only to Medicaid-eligible children.
- The services or items requested must be medical in nature.
- Treatment services may require pre-authorization.
- EPSDT may not provide services that are considered unsafe or experimental.
- States may choose to provide services in the most economical way possible.
Getting EPSDT Services:
- Parents or guardians of children who have Medicaid should ask the child’s doctor and service providers about getting EPSDT services. Since Medicaid does not have a list of all services covered by EPSDT, healthcare providers must be careful to explain why the service is needed.
- Free transportation to EPSDT appointments can be arranged by contacting the “Medicaid Transportation Broker” for your county. You can get the number by calling the SC Department of Health and Human Services (HHS) at 1-888-549-0820 or visiting their website.
- If a child has a caseworker, the parents or guardians can request help from the caseworker in scheduling appointments or transportation for EPSDT services.
- If the family has difficulty communicating in English, then EPSDT information must be given in the language the family can understand, including sign language.
- 42 U.S.C. § 1396d(r). This is the section of the US Code of Laws (“U.S.C.”), where you can find the rules that describe EPSDT.
- 42 C.F.R. § 441.56(b). This is the section of the Code of Federal Regulations (“C.F.R.”), where you can find the rules about EPSDT.
- 42 C.F.R. § 441.56(c), (e).
- 42 U.S.C. § 1396d(r)(5).
This publication provides legal information, but is not intended to be legal advice. As the law may change, please contact Disability Rights South Carolina for updates. Please let us know if you would like this information in an alternative format.
The Protection and Advocacy System for South Carolina. This publication was made possible by funding, in part, by SAMHSA. These contents are solely the responsibility of the grantee and do not necessarily represent the official views of SAMHSA.
Last updated: 2020