What is EPSDT?
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a Medicaid benefit for individuals under 21, providing comprehensive and preventive healthcare services.
Key Elements:
- Early: Identifying issues early
- Periodic: Regular age-appropriate checks
- Screening: Physical, developmental, dental, hearing, and vision screenings
- Diagnostic: Tests following screening results
- Treatment: Address and manage identified health issues
EPSDT is what most people think of when they think of Medicaid for kids. EPSDT is only for those under 21. This is the Medicaid benefit that provides comprehensive and preventive health care services for children.
● Early: Assessing and identifying problems early
● Periodic: Checking children’s health at periodic, age-appropriate intervals
● Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
● Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and
● Treatment: Control, correct or reduce health problems found.
EPSDT Private Duty Nursing (PDN)
- Child must be under 21 and Medicaid eligible
- A physician must prescribe PDN
- Requires at least 4 consecutive hours of skilled nursing care
- Nursing services must be prescribed by a physician. Specialists should work with the EPSDT physician (pediatrician) when needs arise since orders for private duty nursing typically involve specialty care.
If Not on Medicaid Waiver:
- PDN can still be accessed via EPSDT if prescribed
Additional Considerations:
- Temporary Illness: Up to 90 days of PDN
- Sleep Needs: Up to 8 hours/night
- Work/School Hours of Caregiver: Includes travel time (with documentation if over 1 hour)
Additional Considerations
● Temporary Illness: Private duty nursing hours may be provided for up to 90 days if the primary caregiver is incapacitated due to personal illness or illness of another family member who is dependent upon the caregiver and there is no other trained caregiver available in the home.
● Sleep: Private duty nursing hours may be provided up to eight hours per day for caregiver sleep.
● Work: Private duty nursing hours will be up to the number of hours that the primary caregiver is at work plus one hour travel time. If additional travel time is needed beyond one hour, documentation must be provided to justify the increase.
● School: Private duty nursing hours will be up to the number of hours the primary caregiver is attending class plus one hour travel time.
Criteria for High-Technology need Non-Ventilator Recipients
Must meet:
- One Primary Requisite, or
- Two Secondary Requisites
Primary Requisites Examples:
- Tracheostomy with oxygen/cough assist
- Total Parenteral Nutrition (TPN)
- IV therapy >4 continuous hours
Secondary Requisites Examples:
- Stage 3 or 4 pressure ulcers
- New/problematic G/NG/J tube, colostomy, etc.
- Unstable health conditions requiring skilled observation
More details:
● Any one of the primary requisites OR two or more secondary requisites are present.
● Primary requisites include, but may not be limited to, the following:
○ Tracheotomy –Coverage for a functioning tracheotomy requiring oxygen supplementation; and nebulizer treatments or cough assist-in/exsufflator devices.
○ Total Parenteral Nutrition (TPN) – Coverage up to two months for acute phase with additional certification based upon the need for continuing therapy
○ Intravenous Therapy infusions exceeding 4 continuous hours and require monitoring and treatment of a skilled nurse – Coverage up to two months for a single episode.
● Two or more secondary requisites include, but may not be limited to, the following:
○ Decubitus ulcers – coverage for stage three or four ulcers
○ Colostomy or ileostomy care – coverage for new or problematic cases
○ Suprapubic catheter care – coverage for new or problematic cases
○ NG, G, or GJ tube feedings – coverage for new or problematic cases
○ Tracheotomy
○ A documented illness or disability, which requires ongoing skilled observation, monitoring and judgment to maintain or improve health status of a medically fragile or complex condition to include at least one (1) of the following:
■ An unstable seizure disorder
■ Unstable respiratory function
■ Unstable vital signs
■ Cardiac pacemaker
■ Unstable shunted hydrocephalus or otherwise unstable neurological
status and delayed skilled intervention is expected to result in:
● Deterioration of a chronic condition
● Loss of function
● Imminent risk to health status due to medical fragility
● Extensive or complete assistance with activities of daily living in a child of an age normally expected to perform ADLs such as eating, bathing, dressing, and mobility, bowel and bladder control.
Criteria for Ventilator-Dependent Recipients
- Ventilator ≥6 hours/day
- Oxygen FiO2 ≤ 0.40
- Regular ventilator setting changes and monitoring
More details:
Any one of, but not limited to, the following requisites are present.
● Mechanical ventilator support is necessary for at least six hours per day and appropriate weaning steps are in progress on a continuing basis.
● Frequent ventilator checks are necessary.
● Frequent ventilator checks are defined as daytime versus nighttime setting changes, weaning in progress, or parameter checks a minimum of every eight hours with subsequent ventilator setting changes.
● Oxygen supplementation for ventilator dependent recipients is at or below an inspired fraction of 40 percent (Fi02 of 0.40).
For assistance navigating this system in Alabama, please reach out to Disability Advocacy Solutions.
Disability Advocacy Solutions LLC 