EPSDT is a federal entitlement that requires states and counties to provide comprehensive and preventative health care services to low-income children under 21 who are enrolled in Medicaid. In California, Medicaid is referred to as Medi-Cal. The EPSDT component of Medi-Cal aims to ensure that all children and adolescents have access to appropriate preventive, dental, mental health, and developmental, and specialty services. The federal government matches state dollars to fund these mandatory services.
Eligible Child or Adolescent Populations
Children under 21 who are enrolled in full-scope Medi-Cal are eligible for EPSDT. “Full-scope” is a benefit category that refers to applicants who meet the eligibility requirements and have access to the “full scope” of medical services under Medi-Cal. In contrast, there are other Medi-Cal benefit categories that have more limited medical services, for example, Emergency Medi-Cal.
Medi-Cal EPSDT providers offer two key benefits for all eligible children:
- Comprehensive Screening Services: Comprehensive health screenings that include, at a minimum, medical, dental, vision, and hearing; developmental history; physical exams including assessment of nutritional status, immunizations, laboratory tests, health education, lead screenings. Screenings must follow a pre-set periodicity schedule, as well as when needed.
- Medically Necessary Services: States are required to provide medical, diagnostic, and treatment services in order to “correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services” (42 USC § 1396d(r)(5)). These include dental services, prescription drugs, physical therapy, and medical equipment.
These benefits include supplemental specialty mental health services for eligible children under 21 through county Medi-Cal mental health plans. These services are provided by mental health specialists, such as psychiatrists, psychologists, licensed clinical social workers, and licensed marriage and family therapists and involve conditions not responsive to treatment by a physical health care provider. Services include mental health, rehabilitative, psychiatric inpatient hospital, and psychiatric nursing facility services. EPSDT requires that Medi-Cal programs engage in outreach and notification services for eligible children and families, as well as offer scheduling, transportation, referral, and appointment follow-up assistance.
Medi-Cal EPSDT funds a variety of practices that can include evidence-based practices such as:
- Aggression Replacement Training (ART)
- Cognitive Behavioral Therapy (CBT)
- Functional Family Therapy (FFT)
- Incredible Years (IY)
- Multisystemic Therapy (MST)
- Parent-Child Interaction Therapy (PCIT)
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
In 2012, California transferred oversight of a number of health and mental health programs, including EPSDT mental health services, to the counties. Prior to this realignment, EPSDT services were billable through Medi-Cal reimbursement and a combination of county, state, and federal funds, with the counties paying a 5 percent share of cost, the state paying 45 percent, and the federal government matching at 50 percent.
Under realignment, counties receive an annual allocation from the state based on historical spending and county demographics for EPSDT mental health services. County behavioral health departments are responsible for using this allocation to provide EPSDT mandated services. While there was concern that counties would be responsible for covering the costs of care above the allocation from the state, the state recently confirmed that, if counties spend above their allocation, the state would augment the realigned amount with additional funds.
All medically necessary diagnostic and treatment services (within the federal definition of Medicaid medical assistance) must be covered by EPSDT, regardless if these services are covered for adults 21 years or older through Medicaid.
EPSDT Overview – Health Resources and Services Administration (HRSA): Click here to visit website.
EPSDT Program – Medi-Cal Services for Children, National Health Law Program: Download a PDF with more information.