Rules on EPSDT and Medicaid 

EPSDT stands for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). It is a Medicaid benefit that provides all enrollees under age 21 with a comprehensive set of prevention, screening, diagnostic, and treatment services. EPSDT covers items such as vision and hearing screening and treatment (e.g., glasses or hearing aids), basic dental, medical, mental health, and developmental services. 

While states have both mandatory and optional benefits under the Medicaid statute, the EPSDT benefit means that states are required to provide any health care services covered under the federal Medicaid program that are medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state's Medicaid plan. Some states have shown interest in waiving this benefit, particularly for those over the age of 18 in the Medicaid expansion population, although no waivers have been approved to date.
 

Arguments for keeping EPSDT in Medicaid 

EPSDT works to make children healthier.

  • Low-income children have distinct needs: Congress designed Medicaid with the EPSDT requirement because low-income children and young adults have a distinct need for comprehensive care in order to lead healthy lives.
  • There is a health benefit to extending EPSDT to age 21: The brain does not develop fully until children reach about age 25. As a result, young adults benefit from frequent screenings and access to comprehensive treatment as their medical needs, particularly mental health needs, continue to change.

States with an EPSDT Element

New Mexico
New Mexico*
 

Utah
Utah*
 

*Waiver Pending Approval

EPSDT is cost-effective

  • EPSDT is not high-cost: EPSDT provides sweeping benefits for all Medicaid enrollees under age 21, but it is not a high-cost service. Children have the lowest per-enrollee costs of any group covered by the Medicaid program, even though all children receive EPSDT services. Removing the EPSDT benefit for 19- and 20-year-olds would not produce large savings, but would make it more difficult for these young adults to receive the care they need.
     

If your state is insisting on omitting EPSDT from the Medicaid expansion

Advocates and consumers should strongly oppose EPSDT waivers as contrary to the objectives of the Medicaid statute and the health and well-being of children.Commenters on EPSDT waiver proposals have an important opportunity state their reasons in detail for fearing the impact of EPSDT cutbacks on older adolescents.

Suggestions for Minimizing Consumer Impact: Depending on the environment in their state, advocates and consumers may also want to mitigate the impact of an EPSDT waiver. The following are potential mitigation approaches.

Keep demonstrations to a year 

  • EPSDT is a vital benefit, and problems must be caught early: Because EPSDT is critical in catching and preventing serious illness, it is important that any state trial at waiving EPSDT be short before an evaluation is preformed and any adverse consequences identified. 

Ensure a robust monitoring and evaluation process

  • Make frequent, ongoing and objective evaluation is a part of the program. It is important to understand how loss of EPSDT impacts affected children and adolescents. In addition to any state evaluations, evaluations from sources that are widely trusted in the state (such as universities or state research organizations) can be helpful. 

Start Making the case to change the program

  • Collect evidence on the impact on enrollees. Legislation and waivers can be modified. Document the impact of a waiver of EPSDT on childrens’ access to care, as well as any other consequences like increased program or hospital costs. Use stories from children, adolescents and their families to help build your case for the reinstatement of EPSDT. 
  • Build a campaign with a broad coalition: Reach out to other groups like pediatric provider groups, children’s disease groups and children’s health and poverty advocacy organization in your state and nationally. Build a collation and advocate for program changes.