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EPSDT Video Transcript

One goal of Medicaid is to make sure children get the healthcare they need. That care includes treatment for any disability or health condition.

The right to that care is guaranteed under part of the federal Medicaid Act called EPSDT – Early and Periodic Screening, Diagnostic, and Treatment. It applies to children under the age of 21 who have Medicaid.

EPSDT says children are entitled to all rehabilitative services that are medically necessary to make or keep them physically and mentally healthy.

So, what are rehabilitative services? Those are services that re-teach a skill that has been lost. EPSDT does not include habilitative services, which teach a new skill. However, the difference between the two is often blurred.

And what does that term “medically necessary” mean? A service is medically necessary if it corrects or ameliorates a condition.

Ameliorates means

  • The service improves or maintains the child’s health in the best condition possible.
  • It compensates for a health problem.
  • It prevents a health problem from getting worse.
  • Or it prevents the development of additional health problems.

So, if a service, treatment, or piece of equipment corrects or ameliorates a condition for your child, it is medically necessary and Medicaid must cover it. EPSDT even requires Medicaid to pay for transportation to and from medical appointments.

There is a list of services in the Medicaid Act. But just because a service is not on the list, that doesn’t mean it is not covered under EPSDT. The service only needs to fall within the scope of a service that is on the list. For example, mobile crisis teams, intensive outpatient therapy, and medication management are not on the list. But they fall within the scope of rehabilitative services, which is on the list.

EPSDT also applies to services that you may not think of as being medical services. For example, case management! A case manager can advocate for your child and make sure she gets what she needs. This service is essential for parents who are having difficulty navigating the multiple systems that affect their children’s lives. For some families, case management is medically necessary, so Medicaid has to cover it under EPSDT.

We hope you’re beginning to understand how powerful EPSDT is! It requires that children get all of the services they need – in whatever amount they need them! That means the limits North Carolina places on Medicaid services for adults do not apply to children. As long as it’s medically necessary, your child can receive as much of a service as she needs.

To get a service under EPSDT, first you have to ask your child’s doctor or other provider to prescribe it. You do not have to say that you are requesting EPSDT services. However, if you have trouble getting your provider to prescribe a service your child needs, or if your request to have a service covered is denied, it might help you make your case if you mention that EPSDT requires that children receive all services that are necessary in a timely manner.

Remember, showing that a service is medically necessary is the key to unlocking Medicaid coverage under EPSDT. You should work with your child’s doctor, therapist, or other provider to make sure they can document the need for the service you are requesting.

Learn more about EPSDT by reading our fact sheet. You may want to share it with your child’s providers.

Disability Rights North Carolina. Dedicated to protecting and advocating for the rights of people with disabilities throughout North Carolina. Learn about our legally based services and find more self-advocacy tools on our website – disability rights nc dot org.

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