The EPSDT Program and Medicaid Coverage for Children

Keeping Our Children Healthy and Strong

Not every family can afford private health insurance for their children. In 2015, 39 percent of children between 0 and 18 years of age were covered by Medicaid and the Children's Insurance Health Program (CHIP). The numbers ranged as low as 21 percent of children in Utah to as high as 53 percent of children in Mississippi and West Virginia.

Altogether, nearly 30.5 million children required federal assistance in 2015 to keep them healthy and strong. As of February 2017, the number of children covered has skyrocketed to 35.9 million.

Each state sets its own rules on who and what will be covered, but the federal government sets a baseline standard for what care each covered child must receive. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program offered to children and young adults under 21 years of age who are covered by Medicaid. These are the key services that every state program must include for their youngest beneficiaries.

Dental Services

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Prevention: Poor dentition, whether from tooth decay or infections, can be a sign of malnutrition or improper hygiene. Untreated dental disease can cause pain, impairing a child’s ability to eat, sleep, and function at home or at school. Their self-esteem and social development can also be affected based on the appearance of their teeth.

Screening: Each state determines how often dental care will be provided, but it cannot limit that care to emergency services. The covered scheduling cannot be arbitrary either. It must fall in line with recommended guidelines by specialists in the field. At a minimum, EPDST dental care must include maintenance of dental health, restoration of teeth, and treatment of dental pain and infections. Each state will decide what to cover in these categories. 

Diagnosis: Every child is guaranteed a referral to a dentist in accordance with the state's recommended screening schedule. However, if an oral screening examination raises concern outside of that schedule, referral to a dental professional should be pursued sooner.

Treatment: A state is not off the hook if it does not pay for a specific treatment under its standard Medicaid plan. The federal government requires that any condition diagnosed during a routine EPSDT screening must also be treated. That means each state must pay for the necessary care.

Hearing Services

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Prevention: Hearing loss in children, whether inherited or acquired, can impact a child's ability to develop speech and language, to perform well at school, and to interact on a social level. Early detection and intervention can help these children meet their developmental milestones.

Screening: A newborn hearing screening is usually performed in the hospital when a child is born. However, not all children are born in hospitals, and many more children may develop hearing loss as they get older. EPSDT requires that children at risk for hearing loss (e.g., family history, ear infections, etc.) be screened according to a schedule set forth by each state, again with deference to professional guidelines. Children with signs of suspected hearing loss should be screened right away.

Diagnosis: If hearing loss is suspected, a formal audiological examination should be conducted by a professional in the field. A hearing aid evaluation will also be covered if indicated.

Treatment: Medicaid must pay for the cost of cochlear implants, hearing aids, and hearing aid supplies, if they are medically necessary, even if the does not offer those service for its adult beneficiaries.

Lead Screening

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Prevention: Exposure to lead occurs through paint ​chips or drinking water and can impact a child's neurologic and social development. Complications range from anemia and kidney disease to behavior issues and low IQ. The earlier lead toxicity can be detected, the sooner a child can be put on track to hopefully reverse any damage that may have been done and to guide them to better health.

Screening: All Medicaid-eligible children, regardless of risk for lead exposure, should be screened for lead at 12 months and 24 months of age. If screening is not completed between 24 and 72 months of age, it should be performed at that time. Screening is often performed using a simple fingerprick test in the office setting or at a local laboratory.

Diagnosis: A lead screening test that measures 10 mcg/dL or more on a fingerprick test needs to be confirmed using a venous blood sample. That means a full blood draw. The kids may not like it, but it is key to establishing a diagnosis.

Treatment: Treatment for lead toxicity relies on chelation therapy. This involves taking a pill that will bind up the lead and excrete it in the urine. The bad news is that not everyone can tolerate the medication's side effects. This may require the use of an injected chelation agent, EDTA, to treat the lead poisoning instead. Regardless of the method of chelation, Medicaid must cover the cost of treatment for any condition detected under EPSDT.

Vision Services

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Prevention: Defects in vision run the gamut. A child could have amblyopia, also known as lazy eye, where one eye is weaker than the other despite use of corrective lenses. Astigmatism is caused by a defect in the cornea that makes it harder to focus with the affected eye. Strabismus develops when the eye muscles are not equally strong, causing the eyes to deviate from one another so that they appear cross-eyed. Let's not forget about binocular vision and nearsightedness. Regardless of the cause of a child's vision impairment, failure to treat these conditions could result in long-term consequences.

Screening: Each state will perform vision screening on its own schedule, taking into consideration recommendations from pediatric organizations in the field. A screening test may include a simple eye chart. Any child that struggles with his vision should get screened sooner than later, regardless of the state's preferred schedule.

Diagnosis: A more extensive examination must be performed by a certified professional to establish the cause of a child's vision impairment. At this time, the most appropriate treatment options will come to light.

Treatment: Medicaid must pay for eyeglass frames and lenses if they are needed, but the program is not required to cover contact lenses. Some states, however, may include this as a benefit.

Other Services

Baby Girl getting a shot
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Preventive screening goes beyond the services mentioned above. They should include one-on-one time with a physician and routine well-child checks. In this regard, the EPSDT program also includes:

  • Health education, including accident avoidance, anticipatory guidance on child development, disease prevention, and encouragement of a healthy lifestyle
  • Health history, including birth history, developmental history, a mental health assessment, and a detailed review of medical illnesses and surgeries
  • Immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP)
  • Laboratory tests, including lead screening tests
  • Physical examination

Taken together, a child will have their best chance at a healthy future if we can prevent disease, catch it early, and treat it before it has a chance to do him harm.

A Word From Verywell

Tens of millions of children receive health care through Medicaid. That care includes state participation is a program called Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). With emphasis on screening and early treatment for common ailments, Medicaid can put our youngest generations on the path to healthy futures.

Source:

Early and Periodic Screening, Diagnostic, and Treatment. Medicaid.gov website. https://www.medicaid.gov/medicaid/benefits/epsdt/index.html.

Health Insurance Coverage of Children 0-18, 2015. The Henry J. Kaiser Family Foundation. http://kff.org/other/state-indicator/children-0-18/?dataView=1¤tTimeframe=0&sortModel=%7B%22colId%22:%22Medicaid%22,%22sort%22:%22asc%22%7D.

Medicaid Child and CHIP Total Enrollment in February 2017. Medicaid.gov website. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/child-and-chip-enrollment/index.html.

Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017. Centers for Disease Control and Prevention website. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. Updated March 6, 2017.

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