What is EPSDT?
EPSDT stands for Early and Periodic Screening, Diagnostic and Treatment services. EPSDT is a child health program in Medicaid. It is designed to meet the physical, mental and developmental health needs of children. The purpose of EPSDT is to find and treat health problems early so that children can have the best health and development possible. In Ohio, the EPSDT program is called Healthchek.
Who is covered by Healthchek/EPSDT?
Any child younger than age 21 who has Medicaid is covered by Healthchek/EPSDT. Children who are covered by a Medicaid waiver, children who have a Medicaid card, and children who are in a Medicaid managed care plan are all eligible for Healthchek/EPSDT. Medicaid-eligible children are automatically eligible for Healthchek/EPSDT. No separate enrollment is necessary.
What does Healthchek/EPSDT provide?
Healthchek provides screening services at certain times throughout a child’s development to look for physical and mental illnesses and conditions. The program also provides services to diagnose and treat any illnesses and conditions that are found. These services are provided to all children, including children who have special conditions or disabilities that require medical attention.
What is Healthchek/EPSDT screening?
Multiple screenings are provided in a child’s first two years of life and then one screening per year until the child turns 21. The screenings look at the child’s growth and development, including physical and behavioral health, vision and hearing.
What treatment services are available?
Any service that is available through Medicaid under federal law is available through Healthchek/EPSDT for children. This includes some services that may not be available to adults in Ohio. Examples of services include:
- physician and clinic services
- inpatient and outpatient hospital services
- laboratory and x-ray services
- home health services
- private duty nursing
- personal care services
- care coordination or case management services
- physical therapy
- occupational therapy
- speech therapy
- durable medical equipment
- dental services
- respiratory care services
- nursing facilities
- psychiatric hospitals
- certified pediatric nurse practitioner services
Are there limits on treatment services for children?
Under EPSDT/Healthchek, a child can receive medically necessary services or equipment that federal Medicaid law allows states to offer, whether or not the service is covered by Ohio’s Medicaid plan. Children can get more of a service or treatment than an adult can get. For example, a child can get more physical therapy or dental care than an adult can get. This means that children can get the type and amount of a service for as long as they need it, if it is “medically necessary.” Types of services include things like therapy, nursing care or personal care.
What does “medically necessary” mean?
Under EPSDT/Healthchek, children can have procedures and get items or services that prevent, diagnose, evaluate, correct, ameliorate or treat an adverse health condition. A health condition could be any one of the following:
- an illness
- an injury
- a disease or its symptoms
- an emotional or behavioral dysfunction
- an intellectual disability
- a cognitive impairment, or
- a developmental disability.
Any Medicaid provider can make a recommendation for what is medically necessary for a child. Medicaid providers include doctors, nurses, dentists, physical therapists, occupational therapists, speech therapists, psychologists, psychiatrists and other health care professionals.
What does “ameliorate” mean?
To improve or maintain the child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
How does a child get medically necessary services?
Your child’s doctor/health care professional will help your child get the services they need. Some services must be approved by the Ohio Department of Medicaid or your managed care plan before your child can receive them. This is called “prior authorization.” If your child needs a service that must be pre-approved, the child’s doctor or health care professional will submit a request for the service. Only a Medicaid provider can make the request for medically necessary treatment or services. If a child is enrolled in a Medicaid managed care plan, the provider should contact the plan’s prior authorization department to request treatment or services ahead of time. If a child is not enrolled in a Medicaid managed care plan, the Medicaid provider should submit a request for the treatment or services to the Ohio Department of Medicaid.
What happens if a request for prior authorization is denied?
If Medicaid denies a service or equipment recommended by your child’s doctor or health care professional, you should receive a notice in the mail. If you disagree with their decision, you can appeal. The appeal process you should use depends on whether the decision was made by a managed care plan or a different agency. Your denial notice will explain how to appeal and the timeline for asking for an appeal.
Is there a list of Medicaid providers?
If your child is in a Medicaid managed care plan, the managed care plan will have a list of Medicaid providers. If your child is not enrolled in a Medicaid managed care plan, contact your county department of job and family services. Each county department has a Healthchek Coordinator. The Healthchek Coordinator will give you a list of available Medicaid providers in the county.
Is transportation available under Healthchek/EPSDT?
Yes. Healthchek/EPSDT will help with scheduling medical appointments and getting transportation to those appointments. How the transportation is provided may vary by county. Contact either your child’s Medicaid managed care plan or the Healthchek Coordinator at your county department of job and family services for help with scheduling appointments and transportation.
Where can I get more information about Healthchek/EPSDT?
Any of the following resources can provide you with more information about Healthchek/EPSDT:
- Your county Healthchek Coordinator - http://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/countycoordinators.pdf
- Ohio Medicaid’s Consumer Hotline - 1-800-324-8680
- Your child’s Medicaid managed care plan - http://medicaid.ohio.gov/FOROHIOANS/Programs/ManagedCareforOhioans.aspx
- The Ohio Medicaid Healthchek web page - http://medicaid.ohio.gov/FOROHIOANS/Programs/Healthchek.aspx
- EPSDT – A Guide to States: Coverage in the Medicaid Benefit for Children and Adolescents - https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf
You can also call Disability Rights Ohio at 800-282-9181 and select option 2 for intake.
Reviewed December 2018