The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit allows a child under 21 to receive medically necessary services that exceed the limits of the Idaho Medicaid plan. The EPSDT benefit is provided to ensure physical conditions or mental illnesses, which can affect a child’s growth or development are found and treated early.
If you are eligible for Children's Medicaid or CHIP, you can qualify for services under EPSDT. There are not different income limits for this program. Children enrolled in Medicaid are eligible for medically necessary screenings, diagnosis, and treatment for physical conditions or mental illnesses. If Idaho Medicaid doesn’t usually cover a service under basic plans, but it is listed in the federal Medicaid law, then it is coverable under EPSDT. Companies who provide these services to children enrolled in Idaho Medicaid must use EPSDT as a guide.
- Screening services (well child checks, immunizations and lead and developmental screenings)
- Lab tests
- Health education
- Vision services
- Dental services
- Hearing services
- Rehabilitative services
- Personal care services
- Diagnostic Services
- Treatment (physical or mental illnesses or conditions)
- Transportation to and from medical appointments
- Psychiatric Residential Treatment Services
Before Medicaid can approve or deny the request for treatment or service:
- The EPSDT Request Form must be completed and signed by the parents/guardians (or a participant over 18)
- The primary care provider MUST complete and sign the form
The parents/guardians (or the participant) will receive a Notice of Decision from the Department telling them if the request was approved or denied. The Notice of Decision may list alternative services that are available.
Requests for services covered by the Idaho Medicaid State Plan and provided by a provider enrolled with Idaho Medicaid will usually be decided within 15 business days. Requests for services not covered under the State Plan, may take longer to secure, enroll a provider, and to determine medical necessity for the service. No request for services for a recipient (through the month of their 21st birthday) will be denied, formally or informally, until it is evaluated under EPSDT.
Reasons to apply for an appeal:
- Your request for services is denied.
- The amount of your child’s services is reduced (for example, 5 therapy sessions instead of 8).
- The length of time your child receives services is reduced (for example, therapy approved for 8 weeks instead of 12 weeks).
- The intensity of your child’s services is reduced (fewer sessions per week/month).