What’s covered?

EPSDT services are available at no cost to Medicaid members from birth through the end of the month in which their 21st birthday occurs.

Benefits include well-child check-ups performed throughout a child’s development that include services such as preventative physical exams, hearing and vision screenings, mental health care, as well as access to all

necessary immunizations. If there are additional medical concerns, EPSDT

works with the doctor to ensure the child is given appropriate and necessary care. EPSDT dental provides preventive, as well as restorative dental care.

These regular checkups make sure enrolled children and adolescents are developing in optimal ways and getting the health care services they need during this period of rapid growth and development.

It is very important that children attend these checkups. Your child may look and feel well but still have a health problem. Your doctor can help find health concerns before they become larger problems. These exams are important to make sure children are healthy and are developing physically and mentally in expected ways.

When should members get care?

Mothers should have prenatal exams and children should have checkups at birth, 3-5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18, 24 and 30 months of age. After that, children should have at least one checkup per year.

The American Academy of Pediatrics has published a helpful periodicity schedule that can be used to plan your child’s well child exams. The Periodicity Schedule includes recommendations for Preventative Pediatric

Health Care and provides important screenings and assessments your child should get at each well child visit.

What do I need to do?

Make an appointment for a well-child checkup!

If you are on Medicaid, call your child’s primary care doctor to find out who your child should see for the well-child checkup (sometimes called a screening). Sometimes it will be your child’s doctor. Other times it may be a physician assistant or nurse with special training.

Additional covered services

Medicaid also provides access to additional treatment and services for members through the end of the month in which their 21st birthday occurs; some of the tests and treatment may require pre-approval. Your primary care doctor can assist you in determining what additional services are necessary and help you contact the appropriate clinic for these services.

The following services are covered when medically necessary:

• Health screens
• Physical exams
• Vaccines (shots)
• Lab tests, including blood lead level
• Teaching about health topics
• Hearing tests
• Dental screenings and preventative care
• Vision screenings
• Mental health screenings and services
• Durable medical equipment and medical supplies
• Physical, occupational, and speech therapy
• Interpretive services
• Medical transportation

What if my child requires a service not covered by Medicaid?

If your health care professional determines your child needs extra care, they may receive the necessary treatment, tests, or therapy even if it is not a covered Medicaid benefit. Any additional care your child needs that is medically necessary can be covered by Medicaid through the EPSDT program. To receive approval for non-covered services, members and their families should work with their medical provider to submit a prior authorization request.

Create a member brochure with the following information:

What is the EPSDT program?

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services are available at no cost to Medicaid members from birth through the month of their 21st birthday.

Benefits include well-child check-ups performed throughout a child’s development that include services such as preventative physical exams, hearing and vision screenings, mental health care, as well as all necessary immunizations. If there are additional medical concerns, the services covered through the EPSDT benefit enables the doctor to ensure the child is given appropriate and necessary care. EPSDT dental services provides preventive as well as restorative dental care.

Why it’s important for your child to have well-child visits

Your child may look and feel well but still have a health problem. Your doctor can help find health concerns before they become larger problems. These exams are important to make sure children are healthy and are developing physically and mentally in expected ways.

What do I need to get a checkup?

If you are on Medicaid, call your child’s primary care doctor that is enrolled with Medicaid to find

out who your child should see for the well-child checkup (sometimes called a screening).

When should I schedule a checkup?

Getting a checkup at the right time is the best way to make sure your child gets the medical care your child needs

Babies need checkups at:

• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months (1 year)

Toddlers need checkups at:

• 15 months
• 18 months
• 24 months (2 years)

Young children need checkups at:

• 3 years (36 months)
• 4 years
• 5 years
• 6 years

Older children and teenagers need:

• a checkup every year

Who needs a well-child checkup? Checkups are for all children!

1. Checkups are FREE!

If your child is on Medicaid, your child can get well-child checkups at no charge.

Well-child checkups provide screenings, assessments, and treatments that will help your child stay healthy or, if your child has any problems, provide treatment right away.

Checkups are also a time for you to ask questions about any health concerns you have about your child.

2. Your child needs checkups at certain times

There are certain times your child needs a well-child checkup. For example, because babies change a lot in a short period of time, they need 9 different checkups before age 2.

Well-child checkups are sometimes called screenings or EPSDT visits. Attending these regular well-child checkups will help your child receive the medical care he or she needs to be healthy.

3. Your child gets a complete exam

When your child has a well-child checkup, the doctor will give your child a complete exam. He or she will check:

• if your child is growing as he or she should,
• for ear or eye problems,
• dental concerns,
• for the presence of disease, such as diabetes,
• for low blood cell counts or sickle cell disease,
• for stomach problems,
• for any mental, emotional, or substance abuse problems
• if any immunizations or laboratory tests are needed, and
• any additional medical problems your child

4. Your child can get extra visits and care

Medicaid will cover different types of care. Medical, dental, vision, hearing, behavior screenings, and follow-up care are covered. If medically necessary, Medicaid also covers services to treat mental and emotional health issues and substance abuse. If an issue is found during a checkup or screening visit, your doctor can refer you to a specialist or for more testing.

Note: If your health care professional determines your child needs extra care, they may receive the necessary treatment, tests, or therapy even if it is not a covered Medicaid benefit. Any additional care your child needs that is medically necessary can be covered by Medicaid through the EPSDT program. To receive approval for non-covered services, members and their families should work with their medical provider to submit a prior authorization request.