Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
(This is a federal Medicaid benefit, not a waiver)
Useful Links & Additional Resources
- Medicaid: EPSDT
- Cover VA: Applying for Medicaid
- Consumer-Directed Waiver Services EOR Manual (Arabic)
- Consumer-Directed Waiver Services EOR Manual (English)
- Consumer-Directed Waiver Services EOR Manual (Nepalese)
- Consumer-Directed Waiver Services EOR Manual (Spanish)
- EPSDT Brochure (English)
- EPSDT Brochure (Spanish)
- EPSDT Manual: Chapter 4 – Covered Services
- Fact Sheet
For general inquiries:
Quick Facts
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.
Must be under 21 years old.
Must be already eligible for Medicaid
Parents cannot be attendants until the child turns 18 years of age – Parents cannot be attendants under appendix K
EPSDT individual does not qualify for RespiteShort-term care for a child or adult that allows the primary caregiver relief. More
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
- Must be under 21 years old.
- Must be eligible for Medicaid.
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 livingPersonal care tasks such as bathing, dressing, toileting, transferring, and eating/feeding. A person’s degree of independence in performing these activities is a part of determining appropriate level of care and service needs. More (ADLs/IADLs)
- Bathing, dressing, transferring, eating/feeding, continence/toileting, ambulation, meal preparation, 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.
- Bathing, dressing, transferring, eating/feeding, continence/toileting, ambulation, meal preparation, house cleaning, grocery shopping, and transportation.
- 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 nursingCare that is provided by a registered nurse or a licensed practical nurse and which may be provided in a skilled nursing facility or in the patient’s home. Skilled nursing care is often necessary as a patient rehabilitates from an illness or injury, but the care provided is above and beyond that which can be provided by certified nursing assistants (CNAs) or home health aides. (if ID/DD), school-based services, or private duty nursingHourly, skilled nursing care provided in a patient’s home. Private duty nursing provides more individual and continuous skilled care than can be provided in a skilled nurse visit through a home health agency..
- Assistive devices
- Sensory, mobility, communication, etc.
- Medical support
Additional Benefits
- Assistive TechnologyProducts, equipment, and systems that enhance learning, working, and daily living for persons with disabilities. More
- Durable Medical Equipment
- Hearing Aids
- Private Duty Nursing
- Behavioral Therapy (including ABA)
- Personal Care Services
- 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
People choosing to receive services through the Consumer-DirectedServices where the person using them is allowed to select, hire, fire, and train their particular caregiver(s). More (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 person is responsible for hiring, training, supervising, and firing attendants. The person may choose to designate a person to serve as the EOR on his/her behalf. If the person 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 FacilitatorA Medicaid-enrolled provider who supports eligible people, and sometimes their families, in properly using consumer-directed services. More (SF). An EOR can only serve on behalf of one person. The only exception to this is that EORs can serve on behalf of multiple people only if the people 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 person 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 person present.
- Consumer-Directed services and processes are explained.
- Employer of Record (EOR) is identified and established.
- Support needs of the person 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) is determined and prior authorization for hours are requested from the Managed Care Organization (MCO).
- Fiscal Agent Request Form (FARF) sent to FA to establish person and EOR with the FA.
Routine on-site visits
- Visit conducted in the home with the person 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 person’s POC or any changes that have occurred since the last visit. Examples of this may include:
- Health of the person
- Medication changes
- Recent hospitalizations
- SF and EOR discuss any changes to the MCO health plan of the person, FA issues, and attendant issues (hiring/onboarding/etc.).
- Signatures are collected on all DMAS-required documentation.
- SF and EOR schedule next visit date.