What is EPSDT? And Why Is It Important?

     About the Authorjanetblog[1]

Janet Shouse is a parent of a young adult with autism, and she is passionate about inclusion, employment of people with disabilities, medical issues related to developmental disabilities, supports and services, public policy, legislative initiatives, advocacy, and the intersection of faith and disability. She wears many hats at the Vanderbilt Kennedy Center, including one as a disability employment specialist for TennesseeWorks.

Our hope is that this weekly blog will offer information you want to know, so if you have a question you want answered about employment for people with disabilities or other mysteries of the world of work, please email me at janet.shouse@vumc.org.

By Janet Shouse

While the primary focus of this blog is on employment-related topics for people with disabilities, today I want to share information that may help some on the path to employment. If you have friends with younger children with disabilities or suspected disabilities, you may want to share.

If you have a child who is under 21 and is on TennCare, this one’s for you.

EPSDT stands for Early Periodic Screening, Diagnosis and Treatment. EPSDT is a program of checkups and health care services for children from birth until age 21 to detect and treat health problems. EPSDT checkups are free for all children who have TennCare. And while many families may not qualify financially for TennCare when their children are young, you will find when your son or daughter turns 18, and he or she applies for Supplemental Security Income (SSI) and is found eligible, he or she now qualifies for TennCare. So EPSDT may become important for your child from ages 18 to 21.

Early: Identifying problems early, starting at birth.

Periodic: Checking children’s health at periodic, age-appropriate intervals.

Screening: Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems.

Diagnosis: Performing diagnostic tests to follow up when a risk is identified.

Treatment: Treating the problems found.

The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. Through the EPSDT benefit, children’s health problems should be addressed before they become advanced and treatment is more difficult and costly.

EPSDT entitles enrolled children and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service “is necessary to correct or ameliorate defects and physical and mental illnesses or conditions.” (Ameliorate means “make more tolerable.”) This includes:

  • Physician, nurse practitioner and hospital services.
  • Physical, speech/language, and occupational therapies.
  • Home health services, including medical equipment, supplies, and appliances.
  • Treatment for mental health and substance use disorders.
  • Treatment for vision, hearing and dental diseases and disorders.
  • And much more.

This broad coverage requirement results in a comprehensive, high-quality health benefit for children under age 21 enrolled in Medicaid.

However, while children enrolled in Medicaid are entitled to a broad scope of treatment services, no such service is covered under Medicaid unless medically necessary for that particular child. Also, a state may not deny medically necessary treatment to a child based on cost alone, but may consider the relative cost effectiveness of alternatives as part of the prior authorization process.

For more in-depth information, see EPSDT – A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents.

Some of you may also be interested in information specific to autism spectrum disorders and Medicaid. See Autism Services at Medicaid.gov.

So how does all this Early Periodic Screening, Diagnosis and Treatment information help pave the path to employment? If your son or daughter has significant communication difficulties, early diagnosis and therapy and possibly an augmentative communication device may help him or her be better able to communicate in the workplace. If your son or daughter has fine-motor issues, such as grasping a pencil or typing or buttoning a button, these skills can be addressed by an occupational therapist, again to boost functioning in a work setting. And behavioral therapy can often help a child or an adolescent be better equipped to engage with employers, colleagues and customers.

While school personnel often address these same concerns through an individual education plan (IEP) under the Individuals with Disabilities Education Improvement Act, there may be difficulties in fitting all these therapies and treatments into the school day, and you may find that EPSDT can help in that regard.

If your child has a TennCare provider, and you have concerns about your child’s physical or mental/behavioral health, please inquire about EPSDT. Addressing a child’s health concerns early can sometimes change the trajectory of that child’s life and is likely to be more cost-effective for everyone in the long run.

If you have questions about EPSDT, please email me at janet.shouse@vumc.org.

1 Comment

  • Felicia KBurk says:

    It would be nice if DIDD were compliant. I filed an appeal today because DIDD doesn’t get it. Or that school Special Ed doesn’t provide medically necessary services.

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