Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
If a child (up to the age of 21), needs medically necessary services that exceed the limitations of the Medicaid State Plan, additional services through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit can be approved. EPSDT prior authorization requests may be submitted by a child’s primary care provider (PCP) who determines the child needs additional treatment for a primary health condition. In this instance, the PCP orders the services for the child. If the services can’t be provided by the PCP, the PCP will make an appropriate referral.
EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents
The Medicaid program’s benefit for children and adolescents is known as Early and Periodic Screening, Diagnostic and Treatment services, or EPSDT. EPSDT provides a comprehensive array of prevention, diagnostic, and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). 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.
In response to increased interest and activity with respect to services available to children with autism spectrum disorder (ASD), The Center for Medicaid and Chip Services (CMS) is providing information on approaches available under the federal Medicaid program for providing services to eligible individuals with ASD. See artical here.