Medicaid Benefit for Children and Adolescents Under Age 21
Medicaid’s benefit for children and adolescents under age 21 in low-income families includes a broad selection of preventive, diagnostic and treatment services. Also known as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, its mandates and guarantees are listed in federal Medicaid law at 42 U.S.C. §1396a(a) (43) and 1396d(r) [1902(a) and 1905(a)(r) of the Social Security Act.
What This Benefit Provides
Medicaid’s benefit for children ensures that Medicaid beneficiaries under age 21 have access to the health care they need when they need it, and covers most health services needed to stay as healthy as possible. It ensures that eligible children and young adults can receive preventive services, early care and acute care, and ongoing, long-term treatment and services to prevent, diagnose and treat health problems as early as possible.
Medicaid’s benefit for children addresses potential or existing health problems before they begin, or before becoming advanced and life-limited, and treatment becomes more complex and costly. It often offers coverage without many of the restrictions in overall Medicaid or a Medicaid waiver for this age group.
Wellness Visits (Early and Periodic Screening or Health Check)
Wellness visits are an essential part of children’s health. Medicaid’s benefit for children covers child wellness visits, also known as Early and Periodic Screening or Health Check. Wellness visits ensure access to routine preventive care, including physical assessments, vision and hearing testing, developmental and mental health screenings, all vaccines recommended by the Advisory Committee on Immunization Practices, and family guidance and referrals to follow up care. Wellness visits are encouraged at intervals recommended by the American Academy of Pediatrics. Local Health Check program coordinators connect families with care providers and help them access these services.
Coverage of Treatments, Products or Services
Most coverable healthcare services are already included in clinical coverage policies of North Carolina’s Medicaid program. Your healthcare provider will order them for you, and there will never be a charge or a co-pay for them.
Sometimes, a need for service or treatment for children may exceed a policy limit, or may not be covered by policies within the state Medicaid Plan. When this happens, your request will be considered for coverage under the broader limits of the federal EPSDT benefit.
How to Request a Non-Covered Service for Children
There may be times when a health care provider recommends a medical product, treatment or service that is not covered under the North Carolina Medicaid program. In those circumstances, a review may be requested if the benefit Included as a federal Medicaid Act categories of services, but not included in the North Carolina Medicaid program clinical coverage policies, or exceeds North Carolina Medicaid program limits or restrictions.
In these situations, a Medical Necessity Review will be conducted to determine eligibility and coverage.
Carolina Medicaid’s prior approval vendors conduct most Medicaid’s benefit for children (EPSDT) eligibility and coverage reviews. LME/MCOs conduct behavioral health reviews. The Division of Medical Assistance reviews requests for hospice, private duty nursing, community alternatives program for children (CAP/C), out-of-state services and transplant services. In addition, a few services may require a provider to complete and submit a "Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years of Age," which can be found on the NCTracks Prior Approval web page. A family member may also submit a request. Follow the submission instructions on the form.
Requests for EPSDT coverable services are reviewed quickly by Medicaid (in most cases in less than 14 days, and sooner when medically urgent). Should Medicaid ever decide to not approve a request, the healthcare provider and the caregiver/parent are notified of the decision in a formal communication.
Appealing Medicaid’s Decision
If beneficiaries disagree with decisions made by Medicaid on their requests, they may appeal the decision to the state Medicaid Agency, using an “Appeal Request” form included with their decision letter. Medicaid beneficiaries are protected by a constitutional Right of Due Process.
- EPSDT Medical Necessity Review
- EPSDT: A Guide for States
- EPSDT Policy Instructions
- What is an EPSDT Service
- Medicaid Act 1905(a) Categories of Services
- Wellness Visits (Early and Periodic Screening or Health Check)
EPSDT Training Materials
- Introduction: Early and Periodic Screening, Diagnostic And Treatment Services
- The Medical Necessity Review and Early and Periodic Screening, Diagnostic And Treatment Services
- Important Operational Details: Early and Periodic Screening, Diagnostic And Treatment Services
NC Medicaid Operations Section