Early and Periodic Screening, Diagnostic, 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 North Carolina State Plan for Medical Assistance or a state Medicaid 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. They must meet all the following criteria:
- Must fall within a category of services listed at Section 1905(a) of the Social Security Act (this means EPSDT does not cover most NC Innovations Waiver services)
- 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 any prior authorization requirements also apply to services approved under EPSDT.
In addition to coverage of services that Vaya does not traditionally cover, the EPSDT benefit also means 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 a child or adolescent you are serving would benefit from a service that is not covered under the State Plan for Medical Assistance or the Innovations Waiver, you can complete and submit a Non-Covered Services Request Form for Medicaid Beneficiaries under Age 21. For more information, call Vaya’s Utilization Management Team at 1-800-893-6246, ext. 1515 (behavioral health) or ext. 1526 (physical health). You can also visit the Wellness Visits and Diagnostic and Treatment Services webpage of the North Carolina Department of Health and Human Services.