Early Periodic Screening, Diagnosis and Treatment (EPSDT) is a part of the federal Medicaid law that requires state Medicaid programs to pay for regular screenings and certain services for children under age 21, even if the services are not included in the N.C. State Plan for Medical Assistance or the 1915(b)/(c) Waiver. Services approved under EPSDT must be medically necessary to correct or ameliorate a defect, physical or mental illness or condition identified through the screening and must meet all of the following criteria:
- Must fall within a category of services listed at Section 1905(a) of the Social Security Act. This means that most Innovations Waiver services are not covered under EPSDT.
- Must be medical in nature
- Must be generally recognized as an accepted method of medical practice or treatment
- Must not be experimental or investigational
- Must be safe and effective
Vaya Health reviews all requests submitted for Medicaid services for children under age 21 against these criteria. Please remember that all requirements for prior approval apply to EPSDT services.
In additional to coverage of behavioral health services that are not traditionally covered by Vaya, the EPSDT benefit also means that Waiver and Clinical Coverage Policy limits on hours, units and visits that apply to adults may not apply to children under age 21 if the request meets EPSDT criteria. However, the Innovations Waiver annual budget limit cannot be exceeded under EPSDT.
If you believe that a child you are serving would benefit from a behavioral health service that is not covered under the waiver, you can complete and submit an EPSDT Non-Covered Services Request Form. For more information, contact Utilization Management (UM) at 1-800-893-6246, ext. 1513, or visit the website of the N.C. Department of Health and Human Services.