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A Parent's Guide to EPSDT Medicaid Benefits

Por: Georgia Legal Services Program® LSC Funded

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A Parent's Guide to EPSDT Medicaid Benefits

Linda Lowe
Georgia Legal Services Program
Last Revised: May 2005

What is EPSDT?

  • The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service is Medicaid's comprehensive child health program. EPSDT requires states to provide comprehensive preventive, acute, and chronic care services for Medicaid eligible children.
  • The federal Medicaid Act defines a comprehensive package of EPSDT benefits and sets forth the medical necessity standard that must be applied on an individual basis to each eligible child. The benefit package includes all services that the state can cover under Medicaid, whether or not such services are covered for adults.
  • EPSDT is the most comprehensive child health program in either the public or private sector.
  • Children from birth to age 21 who are eligible for Medicaid are entitled to EPSDT services.
  • EPSDT services are paid for with Medicaid dollars which, in Georgia, are 40% state funds and 60% federal dollars.

EPSDT covers many services, including:

  • Ambulance
  • Audiology
  • Augmentative communication devices
  • Certified nurse midwife
  • Chiropractic services
  • Dental care, including preventative, restorative and emergency care
  • Diabetic supplies
  • Doctor visits for primary care, comprehensive health exams
  • Doctors visits, specialists and second opinion
  • Durable medical equipment, like hearing aides and batteries, assistive technology, wheelchairs, AFO's monitors, eyeglasses, etc.
  • Emergency room
  • Enteral/Parenteral nutritional formula
  • Eye exams
  • Eyeglasses
  • Family planning (birth control)
  • Formula for PKU
  • Gynecologist (women's health care)
  • Healthy babies program
  • Hearing aides
  • Hospice care
  • Immunizations
  • Inpatient hospital
  • Inpatient rehabilitation
  • Lab tests and screenings
  • Maternity care
  • Medical supplies
  • Nutrition and dietician services
  • Occupational therapy
  • Organ transplants
  • Outpatient hospital care
  • Orthotics (braces for the body)
  • Over-the-counter drugs
  • Pediatric specialists including neurology cardiologists, urologists, etc.
  • Podiatry
  • Prescription drugs
  • Prosthetics (artificial replacements for external body parts or their functions)
  • Psychological services
  • Respiratory therapy
  • Service coordination
  • Skilled nursing facility
  • Speech therapy
  • Substance abuse treatment
  • Surgery
  • Transportation to and from medical appointments
  • Well child visits (1)

EPSDT services can be provided in the child's home, outpatient or inpatient facility, school, daycare, foster home, shelter, etc.

Some children with complex conditions, including those who use respirator or ventilator assistance, need intensive medical services such as:

  • Case management (coordination of services)
  • Home health nursing
  • Home health aid
  • Personal care services
  • Respite care

Are these services available through EPSDT?

Yes. EPSDT covers:

  1. Case management (coordination of services) (2)
  2. Home health nursing (3)
  3. Home health aid (4)
  4. Mental health services, including family counseling to help families learn how to care for special needs children (5)
  5. Personal care services, someone to assist, supervise and/or prompt a child who needs help with activities of daily living such as dressing, bathing and eating or someone to help consistently carry out a behavior modification plan, etc. (6)
  6. Private duty nursing (7)

Does EPSDT cover respite care?

No. EPSDT does not cover respite care. (8) Apparently, respite care is not covered because it is deemed to be a service provided to the parents rather than the children.

However, EPSDT does cover medically necessary personal care services, home health services, and home nursing care whether the parent is at home or away. (9) Thus, EPSDT can cover in-home medical services that, in effect, allow parents to get a "respite". (10)

May Georgia place arbitrary limits and hourly caps on EPSDT services?

No. EPSDT services must be sufficient in amount, scope and duration to reasonably achieve their purpose. Services may not be denied arbitrarily or reduced solely because of the child's diagnosis, type of illness, or condition. (11) Of course, appropriate limits may be placed on EPSDT services based upon medical necessity. (12)

One of the major problems with the Model Waiver and the Exceptional Children's programs is that they cap the number of hours of in-home nursing care children receive at 15 hours per day. (13) Children can get more hours of home nursing care through these two programs, but only for a period of 3 months or less. (14) Many, if not most, of the children on these two programs need more hours of nursing care.

A second problem with the Model Waiver is that its purpose is to teach parents how to care for their children without nursing help. The Waiver requires a "teaching plan" and uses in-home nurses to teach parents how to provide care with the goal of having the parent assume primary responsibility for the child's care. (15) The purpose of the "teaching plan" is to periodically reduce the number of hours of nursing care as the parents learn how to provide services. (16) The problem is that many children have severe, long term medical needs that require skilled nursing care. These children need on-going professional nursing care not short or medium-term educational services for their parents.

Under EPSDT, the state may not arbitrarily limit the maximum number of hours of in home nursing care as it does under the Model Waiver and Exceptional Children's program. (17) As with all other services for children under EPSDT, the "medical necessity" decision must be tied to the child's medical needs not the parent's educational plan.

How is medical necessity determined under EPSDT?

Under EPSDT state Medicaid programs must cover "necessary health care, diagnostic services, treatment and other measures...to correct or ameliorate defects and physical and mental illnesses and conditions." (18) Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening-even if the condition cannot be prevented or cured. (19)

Of course, services must be prescribed by a physician or other qualified medical care provider as medically necessary, and services must be provided by a Medicaid-qualified provider.

The state ultimately decides what it will cover under EPSDT as medically necessary, but this decision must be made on a case-by-case basis and cannot ignore the recommendations of the child's treating physician. (20)Moreover, states may not use arbitrary limits and hourly caps on EPSDT services. (21)

How does a parent request EPSDT treatment services for a child?

Simply have your child's physician, home health agency or other health care provider request Medicaid payment for services. Be sure to have the provider indicate that this is a request for "regular" EPSDT services and not a request for services under the Model Waiver or Exceptional Children's Program.

It is important to have proper documentation when making an application for any Medicaid service to avoid needless delays. The materials that should accompany your child's health care professional's request for EPSDT Medicaid services are:

1. A physician's order, and
2. A letter of medical necessity from the physician or other qualified person. This letter should include:

  • -a patient history
  • -a diagnosis and prognosis
  • -a medical justification for the services requested
  • -a description of the benefit to the patient (This is particularly important and should be very thorough.)

-the length of time the patient will need the services.

If your child's request for Medicaid EPSDT services is denied, you have a right to appeal that decision.

For more information or assistance call:

Georgia Advocacy Office
(404) 885-1234; 1-800-537-2329 or,
Your local office of Georgia Legal Services or Atlanta Legal Aid Society

 

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------------------------------Footnotes---------------------------

States must cover all services listed in 42 U.S.C. §1396d(a) "whether or not such services are covered under the State plan." 42 SU.S.C. §1396d(r)(5). 42 U.S.C. §1396a(a)(19). Case management is an EPSDT covered service because it is listed in 42 U.S.C. §1396a(a)(19). Letter from Christine Nye, HCFA Medicaid Director, to Lourdes Rivera and Sara Rosenbaum, CDF (May 21, 1992). Case management service may be used to reach out beyond the bounds of the Medicaid program to coordinate access to a broad range of medically necessary services. Services do not have to be medical in nature or reimbursable through Medicaid. Letter from Christine Nye, HCFA Medicaid Director, to Lourdes A. Rivera and Sara Rosenbaum, CDF (May 21, 1992). 42 U.S.C. §1396d(a), 42 C.F.R. §440.70 (home health services) and 440.80 (private duty nursing services). See, Letter from Lawrence L. McDonough, Associate Regional Admin. Region IX, to Ann Ronan, Arizona Center for Law in the Public Interest (Jan. 21, 1992) (Discussing skilled nursing services to ventilator dependent children. EPSDT definition of medical necessity applies, whether the parents are at home or at work is not relevant to the issue of medical necessity.) 42 U.S.C. §1396d(a), 42 C.F.R. §440.70. Jane Perkins, An Advocate's EPSDT Reference Manual, National Health Law Program, Appendix C (1993). 42 C.F.R. §440.167. 42 C.F.R. §440.80 (private duty nursing). See, Letter from Lawrence L. McDonough, Associate Regional Admin. Region IX, to Ann Ronan, Arizona Center for Law in the Public Interest (Jan. 21, 1992) (Discussing skilled nursing services to ventilator dependent children. EPSDT definition of medical necessity applies, whether the parents are at home or at work is not relevant to the issue of medical necessity.) Letter from Don Hearn, Chief Program Operations Branch, to Donald L. Kelly, Texas Medicaid Director (July 17, 1991). See, Letter from Lawrence L. McDonough, Associate Regional Admin. Region IX, to Ann Ronan, Arizona Center for Law in the Public Interest (Jan. 21, 1992) (Discussing skilled nursing services to ventilator dependent children. EPSDT definition of medical necessity applies, whether the parents are at home or at work is not relevant to the issue of medical necessity.) Services delivered to a family of an eligible child are covered if the "services are directed exclusively to the effective treatment of the Medicaid-eligible individual. The service must be aimed exclusively at the medical treatment of the Medicaid eligible patient, not at the treatment of someone other than the patient. In addition, the services must be medical in nature and cannot be social services." Letter from Christine Nye, Director, to Deborah A. Randa., Arent, Fox (Washington, D.C.) (1991). HCFA State Medicaid Manual, EPSDT Services, §5110. HCFA, State Medicaid Manual, EPSDT Services, §5110. DMA Provider Manual, Part II, Model Waiver Program, §905(D)(rev. 11/94). DMA Provider Manual, Part II, Model Wavier Program, §905 (D)(rev. 11/94). DMA Provider Manual, Part II, Model Waiver Program, §701.1 (rev. 11/94). DMA Provider Manual, Part II, Model Waiver Program, §900 (rev. 1/00). State may place "tentative" limits on services. Letter from Rozanne Abato, Acting Director Medicaid Bureau, to State Medicaid Directors (May 26, 1993). However, the state must have an expeditious process in place to allow children to obtain treatment services beyond the tentative limits. Jane Perkins, An Advocate's Medicaid EPSDT Reference Manual, National Health Law Program 7 (1993). 42 U.S.C. §1396d(r)(5). HCFA, Medicaid State Bulletin-231 (Sept. 10, 1992); HCFA, Letter to Region VIII (Oct. 29, 1991). See, e.g., Weaver v Reagen, 886 F.2d 194 (8th Cir. 1989); See, also, Hilburn by Hilburn v Maher, 795 F.2d 252 (2d Cir. 1986); See, S.Rep. No. 404, 89th Cong., 1 St Sess., reprinted in 1965 U.S.C.C.A.N. 1943, 1986 ("the physician is to be the key figure in determining utilization of heatlth services...it is the physician who is to decide upon admission to a hospital, order tests, drugs , and treatments[.]"). States may place "tentative" limits on services. Letter from Rozanne Abato, Acting Director Medicaid Bureau, to State Medicaid Directors (May 26, 1993). However, the state must have an expeditious process in place to allow children to obtain treatment services beyond the tentative limits. Jane Perkins, An Advocate's Medicaid EPSDT Reference Manual, National Health Law Program 7 (1993).

Prepared by: Sidney D. Watson 11/27/00; Adapted by Linda S. Lowe 05/20/02, reviewed 11/25/03

Linda Lowe
Georgia Legal Services Program
Last Revised: May 2005

Última revisión y actualización: May 16, 2005