EPSDT: A Primer on Medicaid’s Pediatric Benefit

Children enrolled in Medicaid are entitled to a comprehensive array of preventive and ameliorative care through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Beyond the indecipherable acronym, EPSDT is a critically important benefit that is broadly recognized as the definitive standard for children. We’ve broken down the acronym in this fact sheet, and we’re continuing to investigate how it’s working for kids, so stay tuned for more!

But before we explore what EPSDT is and how it’s helping kids today, let’s take a look back at how we got here. The American Academy of Pediatrics described the origins of EPSDT in a news article commemorating Medicaid’s 50th anniversary earlier this year:

“The program’s origin can be traced to a government study…titled ‘One Third of a Nation: A Report on Young Men Found Unqualified for Military Service.’ The report revealed that half of the young men drafted into military service in 1962 were rejected due to preventable and treatable physical, mental and developmental health conditions. This discovery demonstrated the need for children and adolescents’ access to preventive medical services starting from an early age, eventually leading up to one of the hallmarks of the Medicaid program, the EPSDT benefit.”

Under EPSDT, states are required to provide comprehensive services by covering all appropriate and medically necessary services needed to correct and ameliorate health conditions, even if such services are not included in the Medicaid state plan. Additionally, states are required to inform all Medicaid-eligible individuals under age 21 that EPSDT services are available and of the need for age-appropriate immunizations.

As Say Ahhh! readers know, we have previously echoed the concerns raised by the HHS Office of the Inspector General that children are not receiving all of the required well child visits and screenings. Without the required screenings, conditions are more likely to go undiagnosed and untreated, potentially resulting in poorer health status throughout childhood and into adulthood. Early intervention is critical to ensuring that children start school ready to learn, rather than behind the curve. Gavin’s story below highlights the importance of early screening and intervention.

“Consistent with the state mandate for infant hearing screening, Gavin received a newborn hearing screening test in the hospital 48 hours after he was born. The newborn hearing screening indicated a possible hearing loss, and according to the state protocol, he was referred for a repeat outpatient hearing screening. The results of the outpatient screening indicated the need for further testing; therefore, he was referred to a pediatric audiologist for a comprehensive diagnostic evaluation. The results of the evaluation confirmed a moderate sensorineural hearing loss in both ears. The family chose an auditory/oral approach for speech and language development for Gavin. He was fitted with binaural hearing aids at three months of age and referred to the state Early Intervention program. The initial recommendations were biweekly early intervention services provided by an audiologist and speech-language pathologist (SLP) in the home, beginning at four months of age that focused on parent education, auditory/listening skills, and language development. After three years of consistent hearing aid use and regular habilitation treatment services, Gavin entered preschool with normal receptive and expressive language, on par with his normal hearing peers.”

Source: American Speech-Language-Hearing Association

In addition to the state requirements to inform beneficiaries about the EPSDT benefit and provide related services, HHS is required to set annual participation goals to make sure the benefit reaches all eligible children. While states and HHS have worked to improve the number of eligible children receiving these screenings, more could be done. In 1990, HHS set a goal for each state to achieve an 80% EPSDT participation rate (showing the percentage of eligible children who received at least one initial or periodic screening) by 1995. But in 2014, nearly 25 years after the target date, the national average participation rate is just 59%. Participation rates vary widely by age range, exceeding 80% for infants in most states. In contrast, older youth have the lowest participation rates, with the percentage of 19 and 20 year olds receiving scheduled screenings in the single digits in many states. This series on EPSDT will identify ways that states and advocates can help fulfill the promise of EPSDT for all kids – helping children reach their full potential through early intervention.

Kelly Whitener is an Associate Professor of the Practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.