Understanding EPSDT and How it Affects Health Care Services

Many Nebraska mental health care providers are asking “What is EPSDT, and how can it serve my clients?” It is not a new program; rather it is something that was established by Medicaid in about 1967. It is the child health component, known as the Early and Periodic Screening, Diagnosis and Treatment program. Quoting from the Health Resources and Services Administration, “Federal law – including statutes, regulations and guidelines – requires that Medicaid cover a very comprehensive set of benefits and services for children, different from adult benefits. Since one in three U.S. children under age six is eligible for Medicaid,  EPSDT offers a very important way to ensure that young children receive appropriate health,  mental health, and developmental services.”

The Centers for Medicare and Medicaid Services state that the EPSDT service is “Medicaid’s comprehensive and preventive child health program for individuals under age 21.”  The CMS continues, “In addition, Section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at Section 1905(a) of The Act be provided to an EPSDT recipient even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population.”

On March 18, 2011, NAMI National hosted a teleconference with guest speaker Jane Perkins, legal director of the National Health Law Center. Jane is considered the leading expert on EPSDT. Ms. Perkins stated that “States must apply the federal definition of “medical necessity” and that this broad definition cannot be narrowed by state rules. The federal definition of medical necessity is defined in the federal statute which states “If a practitioner of the healing arts deems that a treatment is medically necessary to correct or ameliorate a condition, the state must provide it, whether or not it is covered under any other state plan.”  

Ms. Perkins listed services not covered under EPSDT, which include respite, habilitative care, and home modification. She defined habilitative treatment as ‘to teach a skill they never had.”  This is an important delineation when formally requesting services under the EPSDT provision, continued Ms. Perkins, as the law does include rehabilitative care. Ms. Perkins stressed the importance of wording when requesting services under EPSDT. Such wordings include EPSDT and correct or ameliorate.

Toni Hoy, author of  “Second Time Foster Child,” has used EPSDT as the basis for the Hoy Family federal lawsuit against the state of Illinois, filed in November, 2010.  The suit is pending in the Northern District Federal Court.

Jane Perkins is hosting a 16-month workgroup on EPSDT; The Kim Foundation urges readers to visit her website at www.healthlaw.org. Her email is perkins@healthlaw.org.