Wellness Visits, and Diagnostic and Treatment Services

Wellness Visits (Early and Periodic Screening or Health Check)

Wellness visits are an essential part of children’s health. Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit covers a program of regular wellness visits called Health Check.

Wellness visits allow health care providers to carefully monitor a child’s overall health and development, so that health concerns are identified and addressed early. These visits include services recommended by the American Academy of Pediatrics.

The required components of a Health Check visit are:

• Comprehensive health and developmental history that assesses for both physical and mental health, as well as for substance use disorders
• Comprehensive, unclothed physical examination
• Appropriate immunizations, in accordance with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices
• Laboratory testing (including blood lead screening appropriate for age and risk factors)
• Health education and anticipatory guidance for both the child and caregiver

Diagnostic and Treatment Services

If a problem is found during a wellness visit, providers make appropriate referrals to necessary diagnostic and treatment services. Prior approval from the Division of Health Benefits may be required for specialized care.

EPSDT benefit requires that requested services meet all of the following conditions:

• Must be medical in nature
• Must be coverable under §1905(a) of the Social Security Act
• Must not be experimental or investigational
• Must be generally recognized as an accepted method of medical practice or treatment
• Must be safe
• Must be effective

CMS 416 Participation Reports, Early Periodic Screening

• Federal Fiscal Year 2020 Report by State and Age Group
• Federal Fiscal Year 2019 Report by State and Age Group
• Federal Fiscal Year 2018 Report by State and Age Group
• Federal Fiscal Year 2017 Report by County and Age Group
• Federal Fiscal Year 2017 (Oct. 12, 2016 - Sept. 30, 2017)
• Federal Fiscal Year 2016 Report by County and Age Group
• Federal Fiscal Year 2016 (Oct. 1, 2015 -Sept. 30, 2016)
• Federal Fiscal Year 2015 (Oct. 1, 2014 -Sept. 30, 2015)
• Federal Fiscal Year 2014 (Oct. 1, 2013 -Sept. 30, 2014)
• Federal Fiscal Year 2013 (Oct. 1, 2012 -Sept. 30, 2013)
• Federal Fiscal Year 2012 (Oct. 1, 2011 -Sept. 30, 2012)

Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) Policy Description

EPSDT Policy Description - Updated December 2024

More Information

American Academy of Pediatrics Schedule of Well-Child Visits

American Academy of Pediatrics “Bright Futures” Guidelines

Health Check Program Guide (available under Provider Policies, Manuals and Guidelines on NCTracks) 

Health Check Coordinator Directory

Oral Health Periodicity Schedule

2016 NCIP/VFC Vaccine Codes

Contact

NC Medicaid Operations Section
Phone: 919-855-4350
Fax: 919-715-8548