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A Parent's Guide to Medicaid Screening (EPSDT Benefits)

Authored By: Legal Services Alabama LSC Funded

Information

What is EPSDT? Who can get EPSDT? How can I get EPSDT services for my child? What is an EPSDT screening? What kinds of services does EPSDT provide? This document answers these questions and many more.

What is EPSDT?

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is Medicaid's program to screen children for health problems and then make sure they receive the health care they need.

Who can get EPSDT?

Children under age 21 on Medicaid. Once they get a screening, they are on EPSDT.

How can I get EPSDT services for my child?

  • First, ask if your child's doctor can do a screening. If not, have the doctor refer you to one who can. You can also go to your county health department.
  • Ask the doctor who sees your child whether your child has any health problems and, if so, what care your child needs.
  • If the doctor who sees your child cannot meet your child's needs, ask that doctor to refer you to one who can.

What is an EPSDT screening?

  • An examination that sees how your child is growing and eating
  • A check for problems hearing and seeing
  • A check for low blood and sugar diabetes
  • A check for sickle cell anemia
  • A check for worms
  • A dental checkup
  • Shots that your child needs

How often should my child get screened?

  • Up to 9 times before your child is 2. You should get them at 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months and 2 years.
  • Once a year after that

What kinds of services does EPSDT provide?

  • First, EPSDT provides checkups for your child, which Medicaid calls screenings.
  • Once a screening shows your child has a health problem, EPSDT can cover almost any kind of medical service for that problem. This includes services that Medicaid would not provide for adults. It also includes more thorough, comprehensive services than adults can get. Your child can get unlimited visits to the doctor for some problems found during a screening.
  • A long list of EPSDT services is at the end of this article.

Where can my child get EPSDT services?

In your home, in an outpatient or inpatient facility, in school, at daycare, in a foster home or at a shelter.

May Alabama Medicaid put limits and caps on EPSDT services?

Yes, but only based on what is medically necessary. EPSDT is supposed to give a child as much care as the child needs.

How does Alabama Medicaid decide what is "medically necessary"?

  • Federal law makes Alabama Medicaid programs cover health care needed to correct a health problem, improve the problem, prevent it from getting worse or help the child make up for it.
  • Alabama Medicaid looks to see whether a doctor says care is "medically necessary". The agency can disagree with a doctor, but only if it has a very good reason for disagreeing.

A partial list of EPSDT services:

  • Ambulance
  • Artificial arms and legs
  • Audiology (hearing)
  • Body braces
  • Certified nurse midwife
  • Chiropractic services
  • Dental care, including preventative, restorative and emergency care
  • Diabetic supplies
  • Doctor visits for primary care, second opinions and comprehensive health exams
  • Doctors visits to specialists
  • Durable medical equipment, like hearing aids and batteries, wheelchairs, eyeglasses
  • Emergency room
  • Enteral/Parenteral nutritional formula
  • Eye exams
  • Eyeglasses
  • Family planning (birth control)
  • Formula for PKU
  • Gynecologist (women's health care)
  • Healthy babies program
  • Hearing aids
  • Hospice care
  • Immunizations
  • Inpatient hospital
  • Inpatient rehabilitation
  • Lab tests and screenings
  • Maternity care
  • Medical supplies
  • Nutrition and dietician services
  • Occupational therapy
  • Organ transplants
  • Outpatient hospital care
  • Over-the-counter drugs
  • Pediatric specialists in neurology, cardiology, urology and so on
  • Podiatry
  • Prescription drugs
  • Psychological services
  • Respiratory therapy
  • Service coordination
  • Skilled nursing facility
  • Speech therapy
  • Substance abuse treatment
  • Surgery
  • Transportation to and from medical appointments
  • Well-child visits

Some very ill children need and can get intensive medical services such as:

  • Case management
  • Home health nursing or private duty nursing
  • Home health aide
  • Personal care services

What can I do if Alabama Medicaid denies my child services or does not give enough of a service my child needs?

In either case, you have a right to request a fair hearing to appeal that decision.

Reviewed May 2012


AlabamaLegalHelp.org offers legal information, not legal advice. We try hard to make sure this website accurately explains your rights and options. However, the site does not apply the law to your personal facts. For this sort of legal advice, you should call a lawyer. To apply for free legal services in Alabama, call the Legal Services Alabama office that is closest to where you live OR call toll-free 1-866-456-4995. You can also apply online at intake.alsp.org.

Last Review and Update: May 24, 2012