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;
"The Guide to
Chidren's Dental Care in Medicaid" is now available
through this web site. (PDF 691KB)
- 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.
Diagnosis
-- 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.
The annual EPSDT report (Form CMS-416)
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
Dr. Jerry Zelinger, 410-786-5929, E-mail gzelinger@cms.hhs.gov
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Last Modified on Monday, October 25, 2004
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