Early Periodic Screening, Diagnostic and Treatment (EPSDT)

EPSDT is available to all Medicaid eligible children and adolescents under 21 years of age.

The Components of EPSDT

The components that make up EPSDT include:

Early- Assess and identify conditions early. Refer with reasonable promptness.

Periodic- Provide a well child visit at specific ages.

Screening- Detect potential health conditions.

Diagnosis- Further testing to confirm any positive screenings or identified risks.

Treatment- Control, correct, ameliorate, or reduce health conditions that are discovered.                             

Overview of the EPSDT Benefit

The goal of EPSDT is to provide medically necessary health care and preventive services to children through screening, diagnosis, and treatment services.

What Does “Medically Necessary” Mean for EPSDT?

Michigan recognizes the American Academy of Pediatrics (AAP) definition of “medically necessary" which is:

“Health care interventions that are evidence based, evidence informed, or based on consensus advisory opinion and that are recommended by recognized health care professionals to promote optimal growth and development in a child and to prevent, detect, diagnose, treat, ameliorate, or palliate the effects of physical, genetic, congenital, developmental, behavioral, or mental conditions, injuries, or disabilities.”

What Types of Services are Covered Under EPSDT?

Examples of EPSDT services include:

•        Physician office visits
•        Physical exams
•        Measurements, including, but not limited to length/height, weight, head circumference, body mass index (BMI) and blood pressure
•        Nutritional assessments
•        Developmental screenings (e.g. autism)
•        Mental, behavioral health (e.g. autism), and counseling services
•        Growth and development checks
•        Lab tests and x-rays
•        Blood lead testing
•        Hearing services
•        Vision services
•        Therapy services (i.e. physical therapy, occupational therapy, speech therapy)
•        Habilitative and rehabilitative services
•        Medical equipment and supplies
•        Private duty nursing
•        Personal care services
•        Home health
•        Tobacco, alcohol and drug use assessments
•        Prescriptions / Medications
•        Anticipatory guidance
•        Referrals for medically necessary treatment services
•        Dental services
•        Immunizations / vaccinations
•        Transportation to and from medical appointments if needed

What Types of Services are NOT Covered Under EPSDT?

Examples of services not covered under EPSDT include:

•        Experimental or unproven care
•        Care that is not safe or is ineffective
•        High-cost services or items if a less expensive item will work just as well
•        Services that are not medically necessary
•        Respite services (i.e. a temporary break to relieve the caregiver)
•        Cosmetic procedures
•        Services for adults

The Importance of an EPSDT or Well Child Visit Benefit Includes:

•        Identifying illnesses and potentially life-threatening health conditions early.
•        Preventing any health conditions from getting worse later.
•        Providing recommended preventive screenings.
•        Tracking growth and development.
•        Providing education and other support services.
•        Providing referrals to manage any health conditions.

Well Child Visits Schedule Per The AAP Bright Futures Periodicity Schedule

EPSDT visits are to be performed in accordance with the Bright Futures American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care periodicity schedule, its components, and medical guidelines.

Primary care providers (e.g. pediatricians) are expected to complete all testing components at the ages indicated on the AAP periodicity schedule. Well child visits may be performed more frequently than what the AAP periodicity schedule indicates if required by court order, foster care standards, or if considered medically necessary.

The AAP indicates a child should receive a well child visit at the following ages:

•        Newborn
•        3-5 days
•        By 1 month
•        2 months
•        4 months
•        6 months
•        9 months
•        12 months
•        15 months
•        18 months
•        24 months
•        30 months
•        Once a year beginning at 3 years of age until turning 21 years of age

Dental Visits Per The AAPD Periodicity Schedule

Under EPSDT, dental services are to be provided at intervals which meet reasonable standards of dental practice. Primary care providers should provide an oral health screening and caries risk assessment for beneficiaries at each well child visit as recommended by the AAP periodicity schedule.

The Dental Periodicity Schedule follows the American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling schedule.

EPSDT services are typically accessed through a well child visit with a primary care "medical home" or pediatrician. MDHHS supports the concept of a medical home for each Medicaid beneficiary. A medical home is a primary care provider (PCP) who assumes responsibility for assuring the overall care of a beneficiary, and for the maintenance and updating of a beneficiary’s medical record. When a PCP accepts a child in a primary care relationship, the provider takes responsibility for arranging or providing EPSDT well child visits.

If a medical issue is determined or suspected during a well child visit, the (suspected) issue must be diagnosed and treated as appropriate. This determination may result in further diagnosis and/or treatment by the PCP, or it may result in a referral to another provider or specialist for further diagnosis and treatment.

EPSDT entitles enrolled infants, children and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions. This includes physician, nurse practitioner and hospital services; physical, speech/language, and occupational therapies; home health services, including medical equipment, supplies, and appliances; treatment for mental health and substance use disorders; treatment for vision, hearing and dental diseases and disorders, and much more.

How To Apply For Medicaid Or Other Healthcare Assistance

To enroll in Medicaid or to learn about other programs and resources, visit the Medicaid Beneficiary webpage.

You can apply online faster through http://healthcare4mi.com or you can also call your local Michigan Department of Health and Human Services (MDHHS) office for more information. 

The Michigan Medicaid Provider Manual addresses all health insurance programs administered by MDHHS. MDHHS also issues periodic bulletins and changes are implemented to the policies and/or processes described in the manual.

MDHHS Medicaid Provider Resources

Bright Futures American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care Periodicity Schedule

Dental Periodicity Schedule

Mandatory and Optional Services

Vaccines for Children (VFC) Providers Resources

MDHHS Division of Immunization

Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that provides health coverage to more than 160 million individuals through Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace. CMS works in partnership with the entire health care community to improve quality, equity and outcomes in the health care system.

For more information visit the CMS EPSDT webpage.

See also the EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents. This guide is intended to help states, health care providers and others to understand the scope of services that are covered under EPSDT so that they may realize EPSDT’s goals and provide the best possible child and adolescent health benefit through their Medicaid programs.

CMS-416 Form: Annual EPSDT Participation Report

The annual EPSDT report (Form CMS-416) provides basic information on participation in the Medicaid child health program. The data is used to assess the effectiveness of state Medicaid programs in reaching EPSDT eligible children in terms of the number of individuals under 21 years of age who are provided child health screening services, referred for corrective treatment, and receiving dental services.

For more information visit Annual Reporting Data Files to access the CMS-416 Reports. The Form CMS-416 is used by CMS to collect basic information on State Medicaid and CHIP programs to assess the effectiveness of EPSDT services.

Provider Support

•        Email: Providersupport@Michigan.gov
•        Phone: 1-800-292-2550

Monday through Friday 8:00 am to 5:00 pm EST. Closed on all State of Michigan and major holidays.

When contacting Provider Support, please have the necessary information available to receive adequate assistance.

For further information visit Contact Provider Support.

Medicaid Beneficiary Webpage

Apply for Healthcare Assistance

Medicaid Health Plan (MHP) Non-Emergency Medical Transportation (NEMT)

Healthy Michigan Plan, MIChild & Fee-for-Service Medicaid Handbook

Brochures

• Michigan Free Health Check-ups

• Vaccines for Children

• Healthy Kids Dental (HKD)

• Non-Emergency Medical Transportation (NEMT)

Important Contact Information For Beneficiaries, Parents, And / Or Caregivers

•        Medicaid questions and/or problems: Beneficiary Help Line: 1-800-642-3195
•        mihealth card questions, and if you need a card replacement: 1-800-642-3195
•        To enroll in a Medicaid Health Plan: MICHIGAN ENROLLS 1-800-975-7630
•        For further information visit Beneficiary Support.

The following EPSDT Video Presentation provides an overview and brief history of EPSDT, as well as a discussion of the services required and the limits of the EPSDT benefit.

EPSDT Video Presentation