Rosie D.
Reforming the Mental Health System in Massachusetts


EPSDT Overview

The Medicaid program, authorized and regulated pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396a, is a joint federal-state medical assistance program for low-income persons.  Provisions of federal Medicaid law known as Early Periodic Screening, Diagnosis and Treatment (EPSDT) describe a comprehensive entitlement to medical assistance for eligible children under 21 years of age. 


For information and a detailed description of Medicaid’s EPSDT program, the Advocates Guide to the Medicaid Program is available for purchase through the National Health Law Program.


Basic EPSDT Requirements

States must have a program for all Medicaid-eligible children under the age of 21 that provides screening, diagnosis and treatment of all physical and mental health conditions.  The program must have the following elements:

Early: be available from birth, and be designed to intervene early so that medical problems and illnesses are prevented; 

Periodic Screening: beginning at birth, and every six months or year thereafter, the child should be screened by a health care professional to determine if there are any conditions that might require correction or treatment.  Screening must address hearing, sight, developmental, dental, and behavioral conditions, and include appropriate immunizations;  

Diagnosis: if a screening identifies a potential issue, the condition must be promptly assessed and diagnosed, so that appropriate treatment can be provided; and

Treatment: if an assessment or diagnosis indicates that treatment is needed, it must be provided promptly.

States also have an obligation to develop outreach programs and to inform families of all eligible persons about the availability of early and periodic screening, diagnostic and treatment services.  States have a federal duty to provide or arrange for the treatment needed to correct or ameliorate physical or mental health conditions revealed through screening or diagnostic services. 

For more information about the EPSDT provisions of the Medicaid Act, see:

42 U.S.C. ' 1396a(a)(43), 42 U.S.C. ' 1396d(a)(4), and 42 U.S.C. ' 1396d(r). 


Medicaid Covered Services

States must provide all of the services covered by the Medicaid program, as listed in 42 U.S.C. ' 1396d(a).  Covered services clearly include behavioral support services, psychiatric and clinical services, professionally acceptable assessments, crisis services, case management, and intensive home-based services.  Even when a particular service or treatment for children is not included in the State's Medicaid Plan for adults, the State must nevertheless provide that service or treatment for children if it is otherwise covered and reimbursed by the federal Medicaid program. 

Home-based services are generally considered to be a form of rehabilitative services, which are defined very broadly to include:

Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.


Case management, a core element of home-based services, can be provided for all Medicaid eligible individuals under 42 U.S.C. § 1396d(a)(13), or for specific subgroups, like children with disabilities under 42 U.S.C. § 1396n(g).

Other Relevant Provisions of the Medicaid Act

States must provide Medicaid benefits to all eligible individuals with reasonable promptness.  42 U.S.C. ' 1396a(a)(8); 42 C.F.R. ' 435.930(a).  EPSDT treatment services must be initiated in a timely manner, as the individual needs of the child require and consistent with accepted medical standards, generally within an outer limit six months from the date of request.  42 C.F.R. ' 441.56(e).

Medical Necessity

Medicaid services must be provided when they are medically necessary to treat a particular condition.  While federal EPSDT law does not specifically define medical necessity, it sets broad limits on State’s discretion to establish these standards, requiring they be reasonable (42 U.S.C. § 1396a(a)(17)(A)) and consistent with the purpose of the Medicaid benefit (42 C.F.R. § 440.230).

Click here for a list of EPSTD cases and resources under Medical Necessity.

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