Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

What is EPSDT?

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid’s Managed Care or FAMIS Plus program. EPSDT is key to ensuring that children and adolescents receive appropriate screenings, preventive, dental, mental health, developmental, and any medically necessary services, and that services are provided early before health problems become complex or impact growth and development.

Early: Assessing and identifying problems early

Periodic: Checking children's health at periodic, age-appropriate intervals

Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and Treatment: Control, correct or ameliorate health problems found.
Treatment: Timely treatment services to control, correct or ameliorate health conditions.

EPSDT Benefit Overview

Services covered under EPSDT are not limited to services listed in a state’s Medicaid state plan (although the services must be allowed under federal Medicaid rules outlined in the Social Security Act). EPSDT rules require Medicaid programs to provide comprehensive health screenings, furnish all necessary health care, diagnostic services, treatments and other measures to correct or ameliorate (to make better or more tolerable) health conditions – within limits as allowed under federal law. In deciding if a service is needed, programs must consider the specific needs and circumstances of the individual child. Also, services that help the child maintain functioning, or prevent a condition from worsening are allowed.

The EPSDT benefit applies to all children under age 21 who are enrolled Medicaid, including those enrolled in one of DMAS’ Home and Community Based Waiver Programs, including the Commonwealth Coordinated Care (CCC) Plus Waiver, the Community Living (CL) Waiver and the Family and Individual Support (FIS) Waiver.

EPSDT Training and Answers to Frequently Asked Questions

How EPSDT is Operationalized in Virginia Medicaid
How EPSDT is Operationalized in Virginia Medicaid Q & A

Medically Necessary Services Accessed Under EPSDT

Medically Necessary services require a service authorization, and a decision is made on a case-by-case- basis as to whether the services is medically necessary. These are medically necessary treatment services for children that are not routinely covered by Medicaid.