Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Vaya Health Medicaid members under age 21 have access to a broad menu of federal health care benefits referred to as Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT). The “EPSDT guarantee” covers wellness visits and treatment services.
Early and Periodic Screening and Diagnosis
These “screening” visits are wellness care. They are free for members under age 21. These visits include a complete exam, free vaccines, and vision and hearing tests. Your provider will also watch your child’s physical and emotional growth and well-being at every visit and diagnose any conditions that may exist. At these visits, you will get referrals to any treatment services your child needs to get well and to stay healthy.
The “T” in EPSDT: Treatment for Members under age 21
Sometimes children need medical treatment for a health problem. Vaya might not offer every service covered by the federal Medicaid program. When a child needs treatment, we will pay for any service that the federal government’s Medicaid plan covers.
The proposed treatment must be evaluated on its ability to treat, fix, or improve your child’s health problem or condition. This decision is made specifically for your child. Vaya cannot deny your child’s service just because of a policy limit. Also, we cannot deny a service just because that service is not included in our coverage policies. We must complete a special EPSDT review in these cases.
When Vaya approves services for children, important rules apply:
- There are no copays for Medicaid covered services to members under age 21.
- There are no limits on how often a service or treatment is given.
- There is no limit on how many services the member can get on the same day.
- Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.
You will find the entire menu of Medicaid-covered services in the Social Security Act. The federal Medicaid program covers a broad menu of medical care, including:
- Dental services
- Comprehensive health screening services (well-child checks, developmental screenings, and immunizations)
- Health education
- Hearing services
- 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
- Any other necessary health services to treat, fix or improve a health problem
If you have questions about EPSDT services, talk with your child’s primary care provider (PCP). You can also find out more about the federal EPSDT guarantee online on the NC Medicaid EPSDT webpage.