Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

(This is a federal Medicaid benefit, not a waiver)

Overview

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.

  • Early: Assessing and identifying problems early.
  • Periodic: Checking children’s health at periodic, age-appropriate intervals.
  • Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems.
  • Diagnostic: Performing diagnostic tests to follow up when a risk is identified.
  • Treatment: Control, correct, or reduce health problems found.

Eligibility

Criteria

Process

  • Once eligible for Medicaid, your doctor (primary care physician, physician’s assistant, or nurse practitioner) will need to complete a DMAS-7 (See a sample DMAS-7 here).
    • Make an appointment with your doctor to discuss this form.
    • The DMAS-7 requires information on medical necessity to include:
      • Medical diagnoses
      • Activities of daily living (ADLs/IADLs)
        • Bathing, dressing, transferring, eating/feeding, continence/toileting, ambulation, meal preperation, house cleaning, grocery shopping, and transportation.
          • EPSDT requires 3 out of 10 ADL tasks based on the member’s impairment as it applies to the member’s ability to perform these tasks and the level of support required.
      • Behavioral support
        • Based on the member’s impairment, as it applies to the frequency of the member’s behaviors and the level of intervention required by caregivers to minimize impact.
      • Additional supports
        • Medical support
          • Self-administration of medications
          • Accompanying member to medical appointments
          • Assistance with skilled tasks
            • Monitoring of vital signs, dressing changes, glucose monitoring, etc.
        • Support services
          • Home health. skilled nursing (if ID/DD), school-based services, or private duty nursing.
        • Assistive devices
          • Sensory, mobility, communication, etc.

Coverage

    • Assistive technology
    • Hearing Aids
    • Private Duty Nursing
    • Behavioral Therapy (including ABA)
    • Personal Care
    • Medical Formula & Nutritional Supplements

EPSDT Services

Virginia’s Department of Medical Assistance Services is required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services:

  • Screening:
    • Health and development history
    • Physical exam
    • Immunizations
    • Lab tests
    • Health education
  • Vision/Hearing
  • Dental
  • Diagnostic
  • Treatment

Developmental and Behavioral Screening

Periodic developmental and behavioral screening during early childhood is essential to identify possible delays in growth and development, when steps to address deficits can be most effective. These screenings are required for children enrolled in Medicaid, and are also covered for children enrolled in CHIP.

Consumer-Directed Model

Individuals choosing to receive services through the Consumer-Directed (CD) model may do so by choosing a SF to provide the training and guidance needed to be an Employer of Record (EOR). As the EOR, the individual is responsible for hiring, training, supervising, and firing attendants. The individual may choose to designate a person to serve as the EOR on his/her behalf. If the individual is under 18 years of age the parent or responsible adult must serve as the EOR. A person serving as the EOR cannot be the paid caregiver, attendant, or Service Facilitator (SF). An EOR can only serve on behalf of one individual. The only exception to this is that EORs can serve on behalf of multiple individuals only if the individuals reside at the same address. All CD services must be authorized by the service authorization contractor and require the services of an SF. Specific duties of the individual or EOR, as the employer of the CD personal care attendant, include the following:

  • Checking references
  • Determining that the employee meets basic qualifications
  • Submitting required hiring documentation to the fiscal employer agent (F/EA)
  • Training, supervising performance, and submitting time sheets to the F/EA on a consistent and timely basis

CD attendants are not eligible for Worker’s Compensation, overtime, or holiday pay.

Initial visit with Service Facilitator (Intake)

  • Visit conducted in the home with the individual present.
  • Consumer-Directed services and process are explained.
  • Employer of Record (EOR) is identified and established.
  • Support needs of the individual are identified and developed in the Plan of Care (POC).
  • Signatures are collected on all DMAS-required documentation, including the EOR’s contract with the SF.
  • Electronic Visit Verification (EVV) requirement is discussed with the EOR.
  • SF and EOR schedule next visit date.
  • After the intake, the following will occur:
    • Level of Care (LOC) determined and prior-authorization for hours are requested from the Managed Care Organization (MCO).
    • Fiscal Agent Request Form (FARF) sent to FA to establish individual and EOR with the FA.

Routine on-site visits (Monthly)

  • Visit conducted in the home with the individual present.
  • EOR may receive Management Training (MT) on hiring responsibilities and any changes implemented by DMAS.
  • SF and EOR discuss any updates needed for the individual’s POC or any changes that have occurred since the last visit. Examples of this may include:
    • Health of the individual
    • Medication changes
    • Recent hospitalizations
  • SF and EOR discuss any changes to the MCO health plan of the individual, FA issues, and attendant issues (hiring/onboarding/etc.).
  • Signatures are collected on all DMAS-required documentation.
  • SF and EOR schedule next visit date.

Useful Links

Federal Sites

Virginia Sites

Additional Resources

Contact Information

For general inquiries:

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