EPSDT From a Parents' Standpoint

8/8/2019 EPSDT From a Parents' Standpoint

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An article published in 2004 by the Southern Disability Law Centerstates:

EPSDT has always been part of the Medicaid regulations, however,many states were slow to implement these provisions. To correct thisproblem, Congress amended the Medicaid Act in 1989 to makeEPSDT a statutory requirement. See, Omnibus Budget ReconciliationAct of 1989 (OBRA 89). Today, EPSDT is the most comprehensivechild health program in either the public or private sector.

So EPSDT is a statutory requirement. Every state has to have anEPSDT program.

EPSDT is defined under federal law by 42 USC 1396d(r)(5):

(r) Early and periodic screening, diagnostic, and treatment services

The term early and periodic screening, diagnostic, and treatmentservices means the following items and services:

(5) Such other necessary health care, diagnostic services, treatment,and other measures described in subsection (a) of this section tocorrect or ameliorate defects and physical and mental illnesses andconditions discovered by the screening services, whether or not such

services are covered under the State plan.

CMS has spent the past year and a half updating and revisingMedicaid regulations to reflect the requirements of CHIPRA. CMSpublished the following in the Federal Register on April 30, 2010:

Children must be provided access to the full range of EPSDTservices, as defined in section 1905(r). While section 1905(r) of theAct specifically requires that States provide children necessary healthcare, diagnostic services, treatment and other measures described insection 1905(a) related to conditions discovered by a screeningservice, we believe that any encounter with a health professionalpracticing within the scope of his or her practice should be consideredto be a screening service for the purpose of the EPSDT requirement.


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receive the supports and services they need.

This letter also defines the concept that has become known as the"full EPSDT benefit":

The second purpose of EPSDT services is to ensure that childrenreceive the services they need to treat identified health problems.When a periodic or inter-periodic screening reveals the existence of aproblem, EPSDT requires that Medicaid-eligible children receivecoverage of all services necessary to diagnose, treat, or amelioratedefects identified by an EPSDT screen, as long as the service iswithin the scope of section 1905(a) of the Social Security ActThatis, under EPSDT requirements, a State must cover any medicallynecessary services that could be part of the basic Medicaid benefit if

the State elected the broadest benefits permitted under federal law(not including HCBS services, which are not a basic Medicaidbenefit). Therefore, EPSDT must include access to casemanagement, home health, and personal care services to the extentcoverable under federal law.

Semantically, I find it interesting that federal language refers inmultiple places to the concept of "EPSDT-eligible children", and thatthese eligible children have the same right to EPSDT services asMedicaid children. Again, the January 2001 letter states " Statesmay notlimit medically necessary services needed by a child who iseligible for EPSDT that otherwise could be covered under Medicaid."

In the April 30, 2010 Federal Register, CMS writes:

We agree that States should be required to inform families of theirrights under EPSDT. The commenter is correct that children enrolledin benchmark or benchmark-equivalent plans may be entitled to

additional services. It should be noted that CHIPRA underscored thatfull EPSDT services must be provided. Therefore, we are clarifyingthat States must ensure that information is provided to all EPSDTeligibles and/or their families about the benefits of preventive healthcare, what services are available under the EPSDT benefit, whereand how to access those services, that transportation and schedulingassistance are available, and that services are available at no cost.


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This is consistent with the requirements of section 1902(a)(43)(A) ofthe Act and current policy outlined in Section 5121 of the StateMedicaid Manual. Information must be given to individuals no laterthan within 60 days of the individual's initial Medicaid eligibilitydetermination, and annually thereafter if they have not utilizedEPSDT services.

What this means to parents is simple: if our childs doctor prescribessomething as medically necessary then the states Medicaidapparatus cannot deny, limit or reduce it.

If its medically necessary for your child to have 24/7 skilled nursing athome (which is about $200,000 cheaper than providing it in ahospital), then that is what Medicaid should provide you.

If your child needs their gastric tube changed once a month so theskin doesnt have a chance to attach to the plastic, creating a bloodywound when its removed, then that is what your child should bereceiving.

If your child has a chance to communicate using specializedtechnology, then that technology along with the appropriate training,is due them.

Any time your child has to be prescribed a diet to take through afeeding tube because they cant eat by mouth, that diet should bepaid for by Medicaid, even if its just pediasure.

If your childs care requires the use of needleless syringes, then youare entitled to one for every day of the month. Have you ever seen ahospital wash out a syringe and use it for a week or two at a time?Yet that is exactly what state Medicaid offices force parents to do,with their stingy policies for home medical supplies.

Another issue which seems to keep coming up in discussions aboutEPSDT is the idea that states can impose caps or limits on EPSDTservices

In a document from CMS to Idaho written in August 2009, CMSwrites:


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Any service requested which is covered under Title XIX of the SocialSecurity Act that is not identified in applicable Department rulesspecifically as a covered benefit or service will requirepreauthorization for medical necessity prior to payment for thatservice. Any service required as a result of an EPSDT screen andwhich is currently covered under the scope of the EnhancedBenchmark Benefit Package will not be subject to amount, scope,and duration limitations, but will be subject to prior-authorization.

The idea that the state can issue prior authorization but cannot limitthe amount, scope or duration of services prescribed by the child'sdoctor as medically necessary was supported by two federal courtdecisions in Georgia in December 2009. In Moore v. Medows,December 9, 2009, the judge wrote of

the clear statutory intent that the 1989 amendment adding 1396d(r)(5) took away a states discretion not to provide necessarytreatment for individuals under the age of twenty-one.

This case specifically dealt with a child whose physician had ordereda certain number of home nursing hours and who was then notifiedthe state was going to reduce them.

Georgia published a comprehensive guide for physicians on whatEPSDT services are and how to obtain them for their patients. Theguide tells doctors that

As long as you have completed any necessary prior approvalpaperwork which includes current information from primaryphysician, other licensed clinicians, requesting qualified providers andfamily members or legal representative, the request for the service orpayment for the service SHOULD NOT BE DENIED. [emphasis inoriginal] ... The court found that EPSDT required the state to provide

for the amount of treatment which the childs treating physiciandeems necessary to correct or ameliorate her condition. The onlycriterion that the state can consider is whether the care requested isnecessary to correct or ameliorate the childs condition [myemphasis].

EPSDT From a Parents' Standpoint

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