Scope of care Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Revised date
Purpose statement

To describe Early and Periodic Screening, Diagnosis and Treatment (EPSDT) that is available to individuals under 21 years of age who are eligible for Apple Health CN or MN coverage.

WAC 182-534-0100 EPSDT

WAC 182-534-0100  EPSDT

Effective August 24, 2014

  1. Persons who are eligible for medicaid are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.
  2. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
    1. The standard for coverage for EPSDT is that the services, treatment or other measures are:
      1. Medically necessary;
      2. Safe and effective; and
      3. Not experimental.
    2. EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-200.
    3. Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:
      1. Nutritional counseling;
      2. Chiropractic care;
      3. Orthodontics; and
      4. Occupational therapy (not otherwise covered under the MN program).
    4. Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.
  3. Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

This program provides preventive and enhanced service coverage for anyone under 21 years of age who is eligible for Apple Health CN or MN coverage. Parents who are under 21 years of age and who are on CN or MN coverage are also eligible for EPSDT services. "Under 21" means through the day before their 21st birthday.

The significance of this program is that medically necessary services identified by medical service providers are covered even if the services are not otherwise covered services under the standard scope of care.

If you are an Apple Health client and/or a parent/caregiver of a child enrolled in Apple Health, visit the well-child checkups webpage or review the EPSDT well-child checkups for your child or teen brochure (HCA 19-0056).

If you are a provider or biller, please see the EPSDT billing guide for guidance on billing for these services.

Program overview

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federally mandated, comprehensive, and preventive health care benefit. The purpose of this program is to ensure children and adolescents age 20 and younger receive appropriate preventive, dental, mental health, developmental, and specialty services. Medically necessary treatment identified in the EPSDT well-child checkup is covered under the EPSDT benefit.

The following are descriptions of the components of the program:

Early: Assessing and monitoring a child's health and ongoing development early in life can help prevent, identify, and intervene, so potential diseases and disabilities can be addressed before they become more complex and are in their preliminary stages, when they are most effectively treated. This means as early as possible in a child's life in the case of a family already receiving medical benefits or as soon as a child's eligibility has been established.

Periodic: As children and adolescents grow, visits with their health care providers should occur at regular intervals to ensure continued healthy development and to monitor current or emerging needs. Section 1905 of the Social Security Act requires periodicity schedules sufficient to ensure that at least a minimum number of health examinations occur at critical points in a child’s life, and that medically necessary screenings are provided.

Screening: Providers use preventive services, including comprehensive interviews, medical examinations, and standardized tools, to identify children who require further diagnostic assessment or intervention for health and developmental issues. The five categories of screenings covered under this program are medical, vision, hearing, dental, and developmental. Screening services must be available both at established times and on an as-needed basis. When a screening indicates the need for further diagnostic assessment, a child and their family should be referred for diagnosis without delay.

Diagnosis: When there is an indication that a child or adolescent may have a health problem, a follow-up diagnostic assessment and additional evaluations must be provided. This includes recommendations and any necessary referrals to needed services when a diagnosis is determined.

Treatment: In response to an identified need, health care services needed to correct, ameliorate, or lessen health problems, including care coordination for chronic conditions, are offered and provided. Services provided to the child or adolescent must be considered medically necessary (see WAC 182-500-0070).

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