Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Medicaid's Healthcare Plan for Beneficiaries under 21 Years of Age

Medicaid’s health insurance plan for its beneficiaries under 21 years of age features a broad menu of preventive, diagnostic and treatment services unmatched by any package offered by private insurers. Its mandates and guarantees are specified in federal Medicaid law at 42 U.S.C. §1396a(a)(43) and 1396d(r) [1902(a) and1905(r) of the Social Security Act] and are titled as Early and Periodic Screening, Diagnostic and Treatment or simply, EPSDT.

More comprehensive and less restrictive than the Medicaid benefit for adults, the EPSDT benefit is designed to assure that children receive the preventive services, early care, acute care and ongoing, long-term treatment and services they need so that health problems are averted, or diagnosed and treated as early as possible. The goal of EPSDT is to assure that Medicaid’s infants, children and adolescents 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 life-limiting, and before treatment becomes more complex, difficult and costly. This means that EPSDT covers most of the treatments a recipient under 21 years of age needs to stay as healthy as possible. EPSDT makes short-term and long-term services available to these recipients without many of the restrictions Medicaid imposes for services under a waiver OR for adults (recipients 21 years of age or older).

Requests for EPSDT Services

The EPSDT benefit "runs in the background" at all times, for all of Medicaid’s child beneficiaries. North Carolina’s prior approval vendors conduct most EPSDT reviews. Behavioral health EPSDT reviews are conducted by LME / MCO’s. DMA continues to review requests for Hospice, Private Duty Nursing, CAP/C, Out of State services and Transplant services. In addition, a small number of services may require a provider to complete and submit an EPSDT service request form. Follow the submission instructions on the form.

Contact

Medical Assistance Operations Section
Phone: 919-855-4260