What is EPSDT?

​​​​Federal Medicaid law at 42 U.S.C.§ 1396d(r) [1905(r) of the Social Security Act] requires state Medicaid programs to provide Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) for recipients under 21 years of age. Within the scope of EPSDT benefits under the federal Medicaid law, states are required to cover any service that is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,” whether or not the service is covered under the North Carolina State Medicaid Plan. The services covered under EPSDT are limited to those within the scope of the category of services listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act].

When can services be covered under EPSDT?

  1. EPSDT services must be coverable services within the scope of those listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act]. For example, “rehabilitative services” are a covered EPSDT service, even if the particular rehabilitative service requested is not listed in DMA clinical policies or service definitions.
  2. The service must be medically necessary to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] diagnosed by the recipient’s physician, therapist, or other licensed practitioner. By requiring coverage of services needed to correct or ameliorate a defect, physical or mental illness, or a condition [health problem], EPSDT requires payment of services that are medically necessary to sustain or support rather than cure or eliminate health problems to the extent that the service is needed to correct or ameliorate a defect, physical or mental illness, or condition [health problem].
  3. The requested service must be determined to be medical in nature.
  4. The service must be safe.
  5. The service must be effective.
  6. The service must be generally recognized as an accepted method of medical practice or treatment.
  7. The service must not be experimental/investigational.
Additionally, services can only be covered if they are provided by a North Carolina Medicaid enrolled
provider for the specific service type. This may include an out-of-state provider who is willing to enroll if
an in-state provider is not available.

How do I request services under EPSDT?

All Medicaid service requests submitted to Cardinal Innovations for recipients under 21 are automatically considered under EPSDT criteria when unable to be approved under the standard limits and/or service definition requirements. For requests for non-covered Services, a form must be completed by a physician, licensed clinician, or other provider and submitted to Cardinal Innovations. This form can be found at the link below:

 


  
Where can I find more information about EPSDT?

Additional information related to EPSDT can be located on the North Carolina Division of Medical Assistance (DMA) website. www2.ncdhhs.gov/dma/epsdt/​