Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

(This is a federal Medicaid benefit, not a waiver)

Overview

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.

  • Early: Assessing and identifying problems early.
  • Periodic: Checking children’s health at periodic, age-appropriate intervals.
  • Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems.
  • Diagnostic: Performing diagnostic tests to follow up when a risk is identified.
  • Treatment: Control, correct, or reduce health problems found.

Eligibility

Criteria:

Process:

  • Once eligible for Medicaid, your doctor (primary care physician, physician’s assistant, or nurse practitioner) will need to complete a DMAS-7 (See a sample DMAS-7 here).
    • Make an appointment with your doctor to discuss this form.
    • The DMAS-7 requires information on medical necessity to include:
      • Medical diagnoses
      • Activities of daily living (ADLs/IADLs)
        • Bathing, dressing, transferring, eating/feeding, continence/toileting, ambulation, meal preperation, house cleaning, grocery shopping, and transportation.
          • EPSDT requires 3 out of 10 ADL tasks based on the member’s impairment as it applies to the member’s ability to perform these tasks and the level of support required.
      • Behavioral support
        • Based on the member’s impairment, as it applies to the frequency of the member’s behaviors and the level of intervention required by caregivers to minimize impact.
      • Additional supports
        • Medical support
          • Self-administration of medications
          • Accompanying member to medical appointments
          • Assistance with skilled tasks
            • Monitoring of vital signs, dressing changes, glucose monitoring, etc.
        • Support services
          • Home health. skilled nursing (if ID/DD), school-based services, or private duty nursing.
        • Assistive devices
          • Sensory, mobility, communication, etc.

Coverage:

  • Assistive technology
  • Hearing Aids
  • Private Duty Nursing
  • Behavioral Therapy (including ABA)
  • Personal Care
  • Medical Formula & Nutritional Supplements

EPSDT Services

Virginia’s Department of Medical Assistance Services is required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services:

  • Screening:
    • Health and development history
    • Physical exam
    • Immunizations
    • Lab tests
    • Health education
  • Vision/Hearing
  • Dental
  • Diagnostic
  • Treatment

Developmental and Behavioral Screening:

Periodic developmental and behavioral screening during early childhood is essential to identify possible delays in growth and development, when steps to address deficits can be most effective. These screenings are required for children enrolled in Medicaid, and are also covered for children enrolled in CHIP.

Useful Links

Federal Sites

Virginia Sites

Additional Resources

Contact Information

For general inquiries:

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