The Early Periodic Screening Diagnosis and Treatment (EPSDT) provision in the Medicaid Act spells out what is expected of states. For adults, Medicaid allows for states to compose their own definition of medical necessity. For children however, EPSDT requires states to provide any “necessary health care, diagnostic services, treatment and other measures…to correct or ameliorate defects and physical and mental illnesses and conditions as covered by the Medicaid Act.”2 This means that services meeting these criteria, such as therapies, skilled nursing care, behavioral supports, vision or dental services must be provided even if they are something that a state does not cover for adults. A child should be provided with services based on their individual needs, as determined by their doctor or other healthcare professional, not by predetermined limits or caps established in the state plan or Medicaid state policy.

Since EPSDT is a part of Medicaid law, the guidelines that apply to Medicaid also apply to EPSDT. Medicaid recipients have a right to  receive prompt medical services “without delay caused by administrative procedures.”2 This means that if a child requires services under EPSDT they must receive those services promptly.

142 U.S.C. § 1396(r)(5)
242 C.F.R. §435.930

The following list (EPSDT Scope of Benefits) is provided in the EPSDT section of the Medicaid act (see 42 U.S.C. § 1396d(a). These are broad categories of service covered under the Medicaid Act, and do not represent an exhaustive list.

• Inpatient hospital services (other than services in an institution for mental disease)
• Outpatient hospital services
• Rural health clinic services (including home visits for homebound individuals)
• Federally-qualified health center services
• Other laboratory and X-ray services (in an office or similar facility)
• EPSDT services
• Family planning services and supplies
• Physician services (in office, patient’s home, hospital, nursing facility, or elsewhere)
• Medical and surgical services furnished by a dentist
• Home health care services, including nursing services, home health aides, medical supplies and equipment, physical therapy, occupation therapy, speech pathology, audiology services
• Private duty nursing services (in the home, hospital, and/or skilled nursing facility)
• Clinic services (including services outside of clinic for eligible homeless individuals)
• Dental services
• Physical therapy and related services (includes occupational therapy and services for individuals with speech, hearing, and language disorders)
• Prescribed drugs
• Dentures
• Prosthetic devices
• Eyeglasses
• Other diagnostic, screening, preventive, and rehabilitative services, including medical or remedial services recommended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level (in facility, home, or other setting)
• Services in an intermediate care facility for the mentally retarded (ICF-MR) Inpatient psychiatric hospital services for individuals under age 21
• Services furnished by a midwife, which the nurse-midwife is legally authorized to perform under state law, without regard to whether or not the services are performed in the area of management of the care of mothers and babies throughout the maternity cycle
• Hospice care
• Case-management services
• TB-related services
• Respiratory care services
• Services furnished by a certified pediatric nurse practitioner or certified family nurse practitioner, which the practitioner is legally authorized to perform under state law
• Personal care services (in a home or other location) furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease
• Primary care case management services
• Any other medical care, and any other type of remedial care recognized under state law, specified by the secretary (includes transportation and personal care services)

Clinicians can prescribe services and treatments based on the individual needs of the child, even if the services needed are not included in Georgia’s Medicaid State Plan. Services need to be medical in nature, generally recognized as an accepted method of medical practice, not experimental or investigative, and safe and effective in order to be covered.

• Prescribed services must be medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening.”
• Ameliorate means to “improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.”
• Treatment need not ameliorate the child’s condition as a whole, but need only be medically necessary to ameliorate one of the child’s diagnoses or medical conditions.
• There is no waiting list for EPSDT services.
• There is no monetary cap on the total cost of EPSDT services.
• There is no limit on the number of hours under EPSDT.
• There is no limit of the number of ESPDT visits to a physician, therapist, dentist or other licensed clinician.
• There is no set list that specifies what EPSDT services / equipment may be covered.
• Case management is an EPSDT service and must be provided to a Medicaid-eligible child if medically necessary to correct or ameliorate a child’s condition(s).

For many services, prior authorization is required. You are required to submit full documentation for medical necessity for the service or procedure. For therapies, Senate Bill 507 extended the time for prior authorization to 6 months rather than 3 months. Requests for EPSDT services do NOT have to be requested as such. Any proper request for services for a recipient under 21 years old is a request for ESPDT services.

In the event that DCH or its contractors (such as GMCF) denies a request for services for a Medicaid- eligible child, or if services are reduced in frequency (fewer days per month), duration (less time in therapy), or intensity, the parent must receive a notice in the mail explaining why the treatment or service has been denied or reduced. SB 507 (now state law) requires that the denial letter include a description of:

1.  the exact treatment/services being denied, described in words and codes;
2. any additional information needed from the you as the provider that could change DCH’s or their contractors’ decision;
3. the specific reason, including the facts relevant to the individual case, that DCH or their providers used to determine that the service is not medically necessary for that Medicaid-eligible child.

Parents can make claims against the state for violation of the denial and appeal process. These have been explained in a separate parent publication. Generally speaking, the state has 90 days within which to make a final determination on the appeal. For children enrolled in a CMO, this time frame may be extended by any time the parent takes to appeal the CMO’s decision to the state.

DCH must send the request for a hearing to Office of State Administrative Hearings (OSAH) promptly so a hearing can be scheduled within that 90 day time frame.

We urge health care professionals to support the appeals for denials for services they have prescribed based on the individual needs of the child. As long as you have completed any necessary prior approval paperwork which includes current information from primary physician, other licensed clinicians, requesting qualified providers and family members or legal representative, the request for the service or payment for the service SHOULD NOT BE DENIED.

EPSDT is the most comprehensive child health program in either the public or private sector. EPSDT is a powerful tool for getting children what they need when they need it. All children who are eligible to receive Medicaid are guaranteed by law screening and all medically necessary diagnostic and treatment services for their physical and mental illnesses or conditions whether or not the services are regularly covered under the state Medicaid plan. CMOs (care management organizations) must provide these services to all enrolled children under their contracts with the state. DCH is ultimately responsible for EPSDT, but the contracts with the CMOs require them to provide the EPSDT services for eligible children. Parents and children have many protections under EPSDT. We are hoping this information will encourage physicians to write the necessary orders, submit the claims to Medicaid and support the appeals for denials of service if they occur. Together we can make Medicaid more responsive to the children it serves.

A separate publication has been prepared for parents which describes the basic coverage of EPSDT, and where to file appeals.

The Georgia legislature enacted SB 507 in 2008, which defines “Medically necessary services” a “services or treatments that are prescribed by a physician or other licensed practitioner, and which, pursuant to the EPSDT Program, diagnose or correct or ameliorate defects, physical and mental illnesses, and health conditions, whether or not such services are in the state plan.” The new law further defines the key terms “correct or ameliorate” to mean “to improve or maintain a child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, prevent the development of additional health problems, or improve or maintain a child’s overall health, even if treatment or services will not cure the recipient’s overall health.” SB 507 also sets a 15 day time frame for prior approval decisions and enforces the notice provisions as described on pg. 3. O.C.G.A. § 49-4-169.1 (1) and (4).

In 2008, a federal court ruled in favor of a Georgia child whose doctor said she needed 94 hours of nursing care per week, but who had received notice from DCH that her approved hours were being reduced. The court found that EPSDT required the state to provide for the amount of treatment which the child’s treating physician deems necessary to correct or ameliorate her condition. The only criterion that the state can consider is whether the care requested is necessary to correct or ameliorate the child’s condition. Moore v. Medows, Civil Action File No 1:07-CV-631-TWT