Early Periodic Screening, Diagnosis, and Treatment

What is EPSDT?

EPSDT is a comprehensive and preventive health care benefit for Apple Health clients under the age of 21 years old. The EPSDT benefit requires periodic screening services, often referred to as well-child checkups, as one of the mandatory components to monitor healthy development and identify issues as early as possible. Medically necessary services, including those identified through well-child checkups, are covered under the EPSDT benefit.

The following are descriptions of the components of the program. Learn more about EPSDT at Medicaid.gov.

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).

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.

Who qualifies for EPSDT?

This benefit provides comprehensive services for anyone under 21 years of age who is eligible for Apple Health categorically needy (CN) or medically needy (MN) coverage. This benefit applies to both individuals enrolled in managed care and individuals without a managed care plan (a.k.a. fee-for-service).

EPSDT resources

Pediatric services and programs

• Early Supports for Infants & Toddlers (Early Intervention)
• Home Visiting
• Prenatal, child, and young adult behavioral health services
• Universal Developmental Screening

EPSDT updates

Subscribe to the Pediatric Health mailing list to get the latest bulletin updates.

Recent bulletins are linked below.