EPSDT Law

The following is the text of the Federal Law governing EPSDT services in all 50 states that has existed since 1989.

USC Title 42 Chapter 7 Subchapter XIX (The Social Security Act) §1396a-d (Selected Text regarding EPSDT services in the USA; essential text in bold.)

(a) Medical assistance

The term “medical assistance” means payment of part or all of the cost of the following care and services (if provided in or after the third month before the month in which the recipient makes application for assistance or, in the case of medicare cost-sharing with respect to a qualified medicare beneficiary described in subsection (p)(1) of this section, if provided after the month in which the individual becomes such a beneficiary) for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals (other than individuals with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in section 1396a (a)(10)(A) of this title) not receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter, and with respect to whom supplemental security income benefits are not being paid under subchapter XVI of this chapter, who are—

(i) under the age of 21, or, at the option of the State, under the age of 20, 19, or 18 as the State may choose, …

(xiii) individuals described in section 1396a (aa) [2] of this title, but whose income and resources are insufficient to meet all of such cost— Note: this refers to the child’s income, not the parent’s or family’s income. Few children earn enough income to be disqualified under this rule….

(13) other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level; Note: If a licensed physician, psychiatrist or psychologist prescribes it, the child is entitled to receive it, whether or not it is “part of any State plan” and the services can be delivered anywhere, including a facility or the child’s home.

(24) personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are:

(A) authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State,

(B) provided by an individual who is qualified to provide such services and who is not a member of the individual’s family, and

(C) furnished in a home or other location;

(r) Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services

The term “early and periodic screening, diagnostic, and treatment services” means the following items and services: Note: Section 5 below describes mental health and behavioral support services; EPSDT services are not limited to just “medical” screening, diagnosis or treatment services.

(1) Screening services

(A) which are provided—

at intervals which meet reasonable standards of medical and dental practice, as determined by the State after consultation with recognized medical and dental organizations involved in child health care and, with respect to immunizations under subparagraph (B)(iii), in accordance with the schedule referred to in section 1396s (c)(2)(B)(i) of this title for pediatric vaccines, and at such other intervals, indicated as medically necessary, to determine the existence of certain physical or mental illnesses or conditions; and

(B) which shall at a minimum include—

· a comprehensive health and developmental history (including assessment of both physical and mental health development),

· a comprehensive unclothed physical exam,

· appropriate immunizations (according to the schedule referred to in section 1396s (c)(2)(B)(i) of this title for pediatric vaccines) according to age and health history,

· laboratory tests (including lead blood level assessment appropriate for age and risk factors),

· and health education (including anticipatory guidance).

(2) Vision services—

(A) which are provided

at intervals which meet reasonable standards of medical practice, as determined by the State after consultation with recognized medical organizations involved in child health care, and at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and

(B) which shall at a minimum include

diagnosis and treatment for defects in vision, including eyeglasses.

(3) Dental services—

(A) which are provided—

at intervals which meet reasonable standards of dental practice, as determined by the State after consultation with recognized dental organizations involved in child health care, and at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and

(B) which shall at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health.

(4) Hearing services—

(A) which are provided—

at intervals which meet reasonable standards of medical practice, as determined by the State after consultation with recognized medical organizations involved in child health care, and at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and

(B) which shall at a minimum include diagnosis and treatment for defects in hearing, including hearing aids.

(5) Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.

Nothing in this subchapter shall be construed as limiting providers of early and periodic screening, diagnostic, and treatment services to providers who are qualified to provide all of the items and services described in the previous sentence or as preventing a provider that is qualified under the plan to furnish one or more (but not all) of such items or services from being qualified to provide such items and services as part of early and periodic screening, diagnostic, and treatment services. The Secretary shall, not later than July 1, 1990, and every 12 months thereafter, develop and set annual participation goals for each State for participation of individuals who are covered under the State plan under this subchapter in early and periodic screening, diagnostic, and treatment services.

Note: A licensed psychologist (who delivers only outpatient mental health treatment without prescribing any medication) can supervise the delivery of EPSDT services by those under his/her supervision in accordance with State law governing the practice of psychology without having to deliver any other services.

Commentary

EPSDT services (“Early and Periodic Screening, Diagnosis and Treatment”) are often confused with a treatment philosophy called “wrap-around” services. They are not the same.

· EPSDT services are mandated by the Federal government for disabled children in all 50 states.

· They are not “time limited” (except by the child’s attaining the age of 21 years).

· They do not need to be “titrated” according to some preordained schedule (as if any mortal professional could possibly predict the future of a child’s need for services months in advance),

· They can be delivered anywhere (a doctor’s office, at school, at home, or anywhere else),

· They can be delivered whether or not the skills and expertise of the professionals providing treatment are “transferred” to the child, his or her parents, teachers or other adults.

· They are, after all, treatment services that are necessary, as defined by the licensed professional who prescribes them, and cannot be denied to a child just because the “state plan” doesn’t include them.

· They’re Federal Statutes; part of Federal law.  To keep getting Federal funds, every State must comply….

On the other hand, the “wrap-around” philosophy, while a worthy ideal for treatment providers to aspire to (replacing professional service providers with no-cost “naturally occurring supports” to whom the professional’s skills “transfer” in as short a period of time as possible, for example), can be misapplied to create inappropriate barriers to treatment and impose unnecessary restrictions and limitations on access to the EPSDT services that all children under the age of 21 who have a disability are entitled to under Federal law.

Although each state has created its own version of the EPSDT mandate, obedience or fidelity to the wrap-around philosophy, while it may be admirable, is not mandated anywhere, although some will argue quite forcefully as if that were the case. Fidelity to the CASSP principles, on the other hand, is required in Pennsylvania (treatment must be child-centered, family-focused, culturally competent, minimally intrusive and minimally restrictive, involve multiple systems and be community-based).

At the Institute for Behavior Change, we are dedicated to the encouragement of responsible professionals, practicing in the mental health field to better the lives of children and their families, to explore the opportunities provided by the EPSDT system to deliver state-of-the-art and evidence-based treatment services to children in their homes, schools and communities. No other treatment modality has shown such promise in the treatment of children with developmental delays, behavioral disorders or mental illnesses. Fidelity to the CASSP principles and wrap-around philosophy are worthy goals for any treatment provider to aspire to.

Click here to watch a video that comprehensively describes EPSDT, BHRS and Defending the Civil Rights of Children with Disabilities

Leave a Reply

You must be logged in to post a comment.