Early Periodic Screening, Diagnosis and Treatment Services (EPSDT)

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is federally mandated Medicaid program for children. In Kentucky, it is divided into two components: EPSDT Screenings and EPSDT Special Services.

EPSDT Screenings

The EPSDT Screening Program provides routine physicals or well-child check ups for Medicaid eligible children at certain specified ages. It is considered preventive care. Children are checked for medical problems early. Specific tests and treatments are recommended as children grow older.

The areas of health care that are checked include: preventive check-ups; growth and development assessments; vision; hearing; teeth; immunizations; and laboratory tests.

Children should receive health check-ups regularly or before the following ages: 1 month; 2 months; 4 months; 6 months; 9 months; 12 months; 15 months; 18 months; 24 months; 3 years; 4 years; 5 years; 6 years; 8 years; and once a year for ages 10-20.

EPSDT Special Services Program

The EPSDT Special Services Program allows coverage for items or services which are medically necessary and which are not covered somewhere else in Medicaid. It is considered treatment. 

All EPSDT special services require prior authorization.

EPSDT Special Services may be preventive, diagnostic or treatment, or rehabilitative.  Examples of services covered through the EPSDT Special Services include:

• additional pairs of eyeglasses after the Medicaid Vision Program has paid for the first two pair in a year,
• additional dental cleanings after the Medicaid Dental Program has paid for one cleaning,
• nitrous oxide when used in dental treatment,
• nutritional products when they are used as a supplement rather than as the child’s total nutrition,
• speech therapy, occupational therapy or physical therapy when the therapy does not meet the criteria for the Medicaid Home Health Program, and substance abuse treatment.

Note: Children who pay the KCHIP III Premium are not eligible for EPSDT Special Services or non-emergency transportation.

Some services that the EPSDT Special Services does not cover include:

• respite care
• environmental
• educational
• vocational
• cosmetic
• convenience
• experimental
• over the counter items

Who is eligible for EPSDT services?

Any Medicaid eligible child is eligible for EPSDT screenings. Additionally, any Medicaid eligible child may receive EPSDT Special Services as long as the services are medically necessary and not covered in another Medicaid program area.

EPSDT Special Services may only be provided to individuals under age 21. 

Services may be provided through the last day of the month in which the individual turns 21. For example, if someone is receiving services through the EPSDT Special Services Program, and their 21st birthday is March 16, they may continue to receive services through EPSDT Special Services through March 31 (if they are still eligible for Medicaid.)

How do I verify eligibility?

Once eligibility has been obtained, you may verify continued eligibility by one of the following methods:

• by contacting the Automated Voice Response System at (800) 807-1301,
• by using the Web-based KYHealth-Net System 
• by purchasing and using a swipe card reader

Provider information for EPSDT Screenings:
EPSDT Screenings may be performed by physicians or ARNPs in either individual or group practices, physicians in primary care or rural health centers, physicians or nurses in the local health departments or EPSDT screening clinics.  The EPSDT screening clinics must have separate provider number. Physicians, ARNPs, primary care centers, rural health centers and local health departments do not have to have a separate provider number to do EPSDT screenings.

Provider Information for EPSDT Special Services
EPSDT Special Services may only be provided by individuals or agencies that may enroll in the regular Medicaid program. EPSDT Special Services providers must have a separate provider number.

How do providers enroll as EPSDT Special Services Providers?
If a provider is already enrolled in the Medicaid program and wants to also become an EPSDT Special Services provider, they must complete the one page EPSDT Special Services Short Form (MAP-814).  If a provider is not currently enrolled in the Medicaid program and does not wish to become a regular Medicaid provider but does want to be an EPSDT Special Services provider (and could enroll as a regular Medicaid provider if they chose to do so), they must complete the full Medicaid Provider Application (MAP-811).

For more information on enrollment,  visit either the DMS Provider Enrolment page on the left or the First Health Web site.   You may also call Provider Enrollment at (877) 838-5085. 

Can individual practitioners such as occupational therapists and physical therapists enroll as EPSDT Special Services Providers?
No, individual practitioners such as occupational therapists, physical therapists, speech pathologists, psychologists, etc. may not enroll as EPSDT Special Services providers, since they may not enroll in the regular Medicaid program (except as QMB Only providers).