EPSDT - Facts YOU need!

What is EPSDT?

The Early and Periodic Screening, Diagnostic, and Treatment service is Medicaid’s comprehensive and preventative child health program.

A part of the federal Medicaid Act, made a statutory requirement in the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989)

The MOST COMPRENSIVE child health care program in either the public or private sector.

Who is eligible?

Any child from birth to age 21 who is eligible for Medicaid is entitled to EPSDT services

(all eligibility categories, including Katie Beckett)

What are states’ requirements?

E - early and

P - periodic exams and

S - screenings,

D - diagnosis and ALL

T - treatment that is medically necessary.

The determination of medical necessity lies primarily with the child’s treating physician or other licensed healthcare professionals

Additionally, states must provide outreach and timely treatment, and they may not place arbitrary limits on services.

What is covered?

EPSDT requires state Medicaid programs to pay for all medically necessary services authorized by the federal Medicaid Act, even if the service is not available under the State’s Medicaid plan to adults.

(examples below)

EPSDT services are paid for with Medicaid dollars (40% state and 60% federal funds).

What is covered?

EPSDT requires state Medicaid programs to pay for all medically necessary services authorized by the federal Medicaid Act, even if the service is not available under the State’s Medicaid Plan to adults.

Here are just a few examples of the services EPSDT requires Georgia to provide for children:

√ Augmentative communication devices √ Case Management

√ Diapers for children over age 3 √ Enteral/Parenteral Formula

√ Home Health Aides √ Over-the-counter drugs

√ Private Duty Nurses √ Medical Supplies (e.g. trach ties)

Is your child getting the EPSDT services he/she needs?

NO? Have your child’s physician, home health agency, therapist, or other health care provider request Medicaid payment for services.

HOW? Use the Prior Authorization Form (DMA-80) to request EPSDT services and send to GMCF, 57 Executive Park South, NE, Suite 200, Atlanta, GA 30329-2224. Include:

1) physician’s order and 2) letter of medical necessity (include patient history, diagnosis and prognosis, medical justification, description of benefit to the patient, and length of time service will be needed).

GMCF has 90 days to reply.

DENIAL/NO RESPONSE? You have a right to appeal the decision or lack of response by asking for a fair hearing (30 day limit from notice). For assistance, call Atlanta Legal Aid (404) 524-5811, Georgia Legal Services (800) 498-9469, or Georgia Advocacy Office (800) 537-2329.