Under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), Vaya covers services, products, and procedures for Medicaid members under age 21 if the service is medically necessary to correct, prevent, treat, or improve a physical or mental illness, condition, or defect found through a screening examination.
What is EPSDT?
EPSDT is a Medicaid benefit that makes sure necessary health services are available for children and adolescents under age 21, even if NC Medicaid usually does not cover the service.
Early and Periodic Screening
The early years of a child’s life are an important time for lifelong physical, social, and emotional well-being. Regular health check-ups and screenings are important for children and adolescents. These preventive services are free and include a full exam, shots, and vision and hearing tests. At these visits, the doctor checks your child’s growth, physical health, and emotional health. If there are any issues, the doctor can refer your child to needed treatments.
Diagnostic services
If a screening finds something wrong, diagnostic services are available to figure out (diagnose) what the health issue is so it can be treated.
Treatment services
We may need to verify the treatment is medically necessary to help your child’s condition or overall health. This is called prior authorization. If the treatment is needed for your child’s health, Vaya won’t deny a service just because it’s not in our regular coverage policy.
What is covered under EPSDT?
- Comprehensive health screening services (well-child checks, developmental screenings, and immunizations)
- Dental services (dentist will bill directly to NC Medicaid)
- Health education
- Hearing services (including diagnosis and treatment for hearing defects, including hearing aids)
- Home health services
- Hospice services
- Inpatient and outpatient hospital services
- Lab and X-ray services
- Mental health services
- Personal care services
- Physical and occupational therapy
- Prescription drugs
- Prosthetics
- Rehabilitative and therapy services for speech, hearing, and language disorders
- Transportation to and from medical appointments
- Vision services (including eyeglasses)
EPSDT features include:
- No Copays: There are no copays for Medicaid members under age 21.
- Waiver of Service Limits: There are no limits on how often a service can be provided or how many services can be received in one day.
- Flexible Service Locations: Restrictions in clinical coverage policies, such as the location of the service (such as personal care services only in the home), prohibitions on multiple services on the same day or at the same time (such as day treatment and residential treatment) must also be waived under EPSDT as long as the services are medically necessary to correct or ameliorate a defect, physical or mental illness, or condition.
- Well-Child Website: NC Medicaid follows the American Academy of Pediatrics Bright Futures Periodicity Schedule but also recommends an enhanced schedule for developmental screenings. North Carolina’s enhanced developmental screening recommendations include developmental screenings at 6 months old, 12 months old, 18 months old, 24 months old, 36 months old, 48 months old, and 60 months old.
More EPSDT resources
- Early Periodic Screening, Diagnostic and Treatment Medicaid Services for Children information on the NC Medicaid website.
- Wellness Visits, and Diagnostic and Treatment Services information on the NC Medicaid website.
Need help or have questions?
If you have questions about EPSDT, talk with your child’s primary care provider. You can also learn on the NC Medicaid EPSDT webpage.
