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MEDICAID and EPSDT

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening, vision, dental, and hearing services. 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.

The EPSDT program consist of two mutually supportive, operational components:
(1) assuring the availability and accessibility of required health care resources; and (2) helping Medicaid recipients and their parents or guardians effectively use these resources. These components enable Medicaid agencies to manage a comprehensive child health program of prevention and treatment, to seek out eligibles and inform them of the benefits of prevention and the health services and assistance available and to help them and their families use health resources, including their own talents and knowledge, effectively and efficiently. It also enables them to assess the child's health needs through initial and periodic examinations and evaluations, and also to assure that the health problems found are diagnosed and treated early, before they become more complex and their treatment more costly.

Periodicity Schedule

Periodicity schedules for Periodic Screening, Vision, and Hearing services must be provided at intervals that meet reasonable standards of medical practice. States must consult with recognized medical organizations involved in child health care in developing reasonable standards.

Dental services must be provided at intervals determined to meet reasonable standards of dental practice. States must consult with recognized dental organizations involved in child health care to establish those intervals. A direct dental referral is required for every child in accordance with each states periodicity schedule and at other intervals as medically necessary. The periodicity schedule for other EPSDT services may not govern the schedule for dental services. It is expected that older children may require dental services more frequently than physical examinations.

The EPSDT benefit, in accordance with section 1905(r) of the Act, must include the following services:

Screening Services -- Screening services must include all of the following services:

• Comprehensive health and developmental history -- (including assessment of both physical and mental health development);
• Comprehensive unclothed physical exam;
• Appropriate immunizations -- (according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines);
• Laboratory tests -- Identify as statewide screening requirements the minimum laboratory tests or analyses to be performed by medical providers for particular age or population groups;

  Lead Toxicity Screening - All children are considered at risk and must be screened for lead poisoning. CMS requires that all children receive a screening blood lead test at 12 months and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test must be used when screening Medicaid-eligible children. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (fingerstick) must be confirmed using a venous blood sample.

  At this time, States may not adopt a statewide plan for screening children for lead poisoning that does not require lead screening for all Medicaid-eligible children.

• Health Education -- Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and/or dental screening provides the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention;
• Vision Services -- At a minimum, include diagnosis and treatment for defects in vision, including eyeglasses. Vision services must be provided according to a distinct periodicity schedule developed by the state and at other intervals as medically necessary;
• Dental Services -- At a minimum, include relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services. Although an oral screening may be part of a physical examination, it does not substitute for examination through direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule developed by the state and at other intervals as medically necessary. The law as amended by OBRA 1989 requires that dental services (including initial direct referral to a dentist) conform to the state periodicity schedule which must be established after consultation with recognized dental organizations involved in child health care;
• Hearing Services -- At a minimum, include diagnosis and treatment for defects in hearing, including hearing aids; and
• Other Necessary Health Care -- Provide other necessary health care, diagnosis services, treatment, and other measure described in section 1905(a) of the Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services.

-- When a screening examination indicates the need for further evaluation of an individual's health, provide diagnostic services. The referral should be made without delay and follow-up to make sure that the recipient receives a complete diagnostic evaluation. If the recipient is receiving care from a continuing care provider, diagnosis may be part of the screening and examination process. States should develop quality assurance procedures to assure comprehensive care for the individual.

Treatment -- Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services.

Lead Poisoning Prevention -- Screening for lead poisoning is a required component of an EPSDT screen. Current CMS policy requires a screening blood lead test for all Medicaid-eligible children at 12- and 24-months of age. In addition, children over the age of 24 months, up to 72 months of age, should receive a screening blood lead test if there is no record of a previous test. Any additional diagnostic and treatment services determined to be medically necessary must also be provided to a child diagnosed with an elevated blood lead level.

State Medicaid Agency required activities --

• States must inform all Medicaid-eligible persons under age 21 that EPSDT services are available.
• States must set distinct periodicity schedules for screening, dental, vision, and hearing services.
• States must report EPSDT performance information annually (CMS Form-416). The authority for requiring states to submit the annual report is section 1902(a)(43) of the Social Security Act (the Act). Each state must report annually for each Federal fiscal year if they administer or supervise the administration of an approved plan for a Federally aided title XIX program. The statute requires that states provide us with the following: (1) the number of children provided child health screening services, (2) the number of children referred for corrective treatment, (3) the number of children receiving dental services, and (4) the state's results in attaining goals set for the state under section 1905(r) of the Act. The form CMS-416 was developed to collect this information.

provides basic information on participation in the Medicaid child health program. The information is used to assess the effectiveness of State EPSDT programs in terms of the number of children (by age group and basis of Medicaid eligibility), who are provided child health screening services, are referred for corrective treatment, and the number receiving dental services. Child health screening services are defined for purposes of reporting on this form as initial or periodic screens required to be provided according to a state's screening periodicity schedule.

We have changed the CMS Form-416

In 1997, an EPSDT workgroup was convened to re-evaluate and revise the form and instructions. The EPSDT workgroup was composed of staff from state Medicaid programs, Maternal and Child Health programs, the American Academy of Pediatrics, and CMS regional and central office staff. It was the goal of the workgroup to clarify and simplify reporting requirements wherever possible, while assuring that the information collected is the most relevant and useful data currently available for assessing delivery of appropriate services.

The workgroup identified data which it believes are less burdensome for states to collect and will result in more consistent data being reported especially from states with a large population of children receiving EPSDT services through managed care arrangements. The changes to the CMS-416 will eliminate confusion the state may have had understanding CMS formulas used on the instructions section of the report. In the past we have had to meet with states to answer their questions concerning our reporting requirements and our methodology for capturing data. We believe that states will save reporting burden hours by having a thorough understanding of the instructions and that these changes will also provide CMS with more accurate and consistent data.

EPSDT CMS-Form-416 published national data is now available through this web site!

• The new CMS Form-416 and instructions
• The FY 2000 individual State reports (PDF - 473K)
• The FY 1999 individual State reports (PDF - 439K)
  (Note: The following states are not included: Texas, Maine, Kansas & Washington State)
• The FY 1998 individual State reports (PDF - 477K)
• The FY 1998 national summary report (PDF - 17K)
• The FY 1997 individual State reports (PDF - 457K)
• The FY 1997 national summary report (PDF - 18K)
• The FY 1996 individual State reports (PDF - 459K)
• The FY 1996 national summary report (PDF - 18K)
• The FY 1995 individual State reports (PDF - 459K)
• The FY 1995 national summary report (PDF - 18K)

Contacts:

Cindy Ruff, 410-786-5916, E-mail cruff@cms.hhs.gov
Teresa Brocato, 410-786-3289, E-mail tbrocato@cms.hhs.gov
Dr. Jerry Zelinger, 410-786-5929, E-mail gzelinger@cms.hhs.gov