The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit entitles Medicaid beneficiaries under the age of 21 to receive medically necessary screening, diagnostic and treatment services within the scope of the Social Security Act that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether the requested service is covered in the NC State Plan for Medical Assistance. This means that children under 21 years of age can receive services in excess of benefit limits or even if the service is no longer covered under the State Plan. To request a service that is not covered by the State Plan but that is covered under 1905(a) of the Social Security Act, please email the Non-Covered State Medicaid Plan Services Request Form for Recipients Under the Age of 21 to the Alliance Health Utilization Management Department at [email protected].
According to CMS, “ameliorate” means to improve or maintain the beneficiary’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Basic EPSDT criteria are that the service must be covered under 1905(a) of the Social Security Act, and that it must be safe, effective, generally recognized as an accepted method of medical practice or treatment, and cannot be experimental or investigational. (This means that most clinical trials cannot be covered).
Requests for MH/IDD/SUD services for Medicaid-eligible children under the age of 21 will be reviewed using EPSDT criteria. Requests for NC Innovations Waiver services will be reviewed under EPSDT if the request is both a waiver and an EPSDT service. Most NC Innovations Waiver services (i.e. respite, home modifications and all habilitative services) are not covered under the Social Security Act.