Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law that says Medicaid must provide all medically necessary health care services to Medicaid-eligible children.
Even if a service is not covered under the NC Medicaid State Plan, it can be covered for recipients under 21 years of age if the service is listed at 1905(a) of the Social Security Act and if all EPSDT criteria are met.
Health Check and EPSDT provide for the complete care of children and youth in Medicaid.
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Fact Sheet - July 5, 2023
- Listing of EPSDT Service Found in U.S. Social Security Act (42 U.S.C. § 1396d(a) - 1905(a) of the U.S. Social Security Act]
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years of Age
Covered Treatment Services
Services must be ordered by the child's physician or another licensed clinician. Prior approval from the Division of Health Benefits (DHB) may be required to verify medical necessity for some services.
The services must:
- Be medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination
- Be listed in section 1905(a) of the Social Security Act
- Not be experimental/investigational, unsafe or considered ineffective
Requests for Non-Covered Services
NCTracks will process all prior approval requests for services coverable under the scope of Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit for beneficiaries under 21 years of age. Before to this date, prior approval requests for many EPSDT coverable services were being processed by DHB.