Medicaid

Medicaid, also known as Medical Assistance, is a program that is administered by both the federal government and the individual state governments. Federal and state governments share the cost of Medicaid programs. If a disabled person meets the eligibility requirements, Medicaid can provide medical care from any doctor, hospital or health care provider that participates in the Medicaid program. You need to contact the state agency that administers the Medicaid program to obtain an application.

Eligibility for Medicaid is based on income and the financial resources of the person and family applying. There are two levels of eligibility for Medicaid: (1) categorically needed and (2) medically needed.

To be categorically needed, individuals or families must receive some type of supplement benefit such as Supplemental Security Income (SSI), Aid for Families with Dependent Children (AFDC), or general medical assistance. If you qualify for Medicaid, the program will pay for skilled nursing home care and home health care if you need skilled nursing services.

The Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)

Medicaid’s child health component—the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program—has been shaped to fit the standards of pediatric care and to meet the special physical, emotional, and developmental needs of low-income children. Since 1967, the purpose of the EPSDT program has been to discover, as early as possible, our children and to provide continuing follow-up and treatment so that such conditions are not neglected.

Federal law—including statutes, regulations, and guidelines—requires that Medicaid cover a very comprehensive set of benefits and services for children, different from adult benefits. Since one in three U.S. children under age six (6) is eligible for Medicaid, EPSDT offers a very important way to ensure that young children receive appropriate health, mental health, and developmental services. To remember the elements of EPSDT, use the name of the program:

• Early (Identifying problems early, starting at birth)
• Periodic (Checking children’s health at periodic, age-appropriate intervals)
• Screening (Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems)
• Diagnosis (Performing diagnostic tests to follow up when a risk is identified), and
• Treatment (Treating the problems found)

EPSDT is a mandatory set of services and benefits for all individuals under age 21 who are enrolled in Medicaid. Think of it as the child health coverage package of Medicaid.

Screening services to detect physical and mental conditions must be covered at established, periodic intervals (periodic screens) and whenever a problem is suspected (inter-periodic screens). Screening includes a comprehensive health and developmental history, an unclothed physical exam, appropriate immunizations, laboratory tests, and health education.

In addition, dental, vision, and hearing services are required, including appropriate screening, diagnostic, and treatment. The treatment component of EPSDT is broadly defined. Federal law states that treatment must include any “necessary health care, diagnostic services, treatment, and other measures” that fall within the federal definition of “medical assistance” (as described in Section 1905(a) of the Social Security Act) that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.”

All medically necessary diagnostic and treatment services within the federal definition of Medicaid medical assistance must be covered, regardless of whether or not such services are otherwise covered under the state Medicaid plan for adults ages 21 and older.

EPSDT is designed to help ensure access to needed services, including assistance in scheduling appointments and transportation assistance to keep appointments. As described in federal program rules, The EPSDT program consists of two, mutually supportive, operational components: assuring the availability and accessibility of required health care resources and helping Medicaid recipients and their parents or guardians effectively use them.