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.