Extra Services for Children and Youth Under The Medi-Cal EPSDT Program

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#5526.01

This pub tells you about EPSDT. EPSDT stands for Early and Periodic Screening, Diagnosis, and Treatment. It is a Medi-Cal benefit. Medi-Cal gives health care to people with low income and limited ability to pay for health care. If you are under age 21 and have full-scope Medi-Cal, you get EPSDT. It gives you with a number of health care benefits. This pub tells you about those benefits. It tells you what to do if you are not happy with a Medi-Cal decision.

1. What services can I get from Medi-Cal1 under EPSDT?

EPSDT stands for Early and Periodic Screening, Diagnosis, and Treatment. EPSDT is a Medi-Cal benefit. If you are under age 21 and have full-scope Medi-Cal,2 you get the EPSDT benefit.3

EPSDT provides you with a number of health care benefits. 

Periodic screens—First, EPSDT says that Medi-Cal must provide you with periodic screenings to determine your health care needs.  This includes screens for hearing, vision, dental and mental health needs. It also includes screens for lead-based paint poisoning.

Diagnostic and treatment services—Second, once you have a health care need, EPSDT says that Medi-Cal must provide you with diagnostic and treatment services to “correct or ameliorate” your condition.

Any medical care service that can be paid for in the Medicaid program—EPSDT provides for a broad range of medical care services, including services that are not on the list of regular Medi-Cal services available to those 21 and older.  This is because California can choose to limit the services it offers to adults, but for children under 21, the State must offer any service that the Medicaid program could pay for, even if the State has chosen not to provide it to adults.

Examples include extra dental, vision, hearing, private duty nursing (shift nursing) services from a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN), Case Management, Pediatric Day Health Care, Nutritional Evaluations and Services, and Mental Health Evaluations and Services.  Mental health evaluations and services include therapeutic behavioral services (TBS), and in-home behavioral services (IHBS), and intensive care coordination (ICC).4

2. How is EPSDT different from Medi-Cal?

EPSDT is not different from Medi-Cal - it is a part of Medi-Cal. It is just an extra benefit that you get because you are under age 21. EPSDT has a reasonable, common sense medical necessity standard for getting services authorized. This means you can get more testing and services than you would if you were 21 or older if your doctor or treating professional recommends it. The State must agree that the services are "medically necessary."

3. What is the EPSDT medical necessity standard?

Services under EPSDT are medically necessary if they can be expected to “correct or ameliorate defects and physical and mental illnesses and conditions.5

4. Do I get EPSDT if I have MAGI Medi-Cal?

Yes, if you are below age 21. The Affordable Care Act expanded the number of people who could qualify for Medi-Cal. The Modified Adjusted Gross Income (MAGI) is the method by which financial eligibility is determined for this expanded group, as well as for premium tax credits and cost-sharing help through Covered California.6 People who are on the MAGI Medi-Cal program get the same benefits as those with regular Medi-Cal.7  

5. What if I have California Children’s Services (CCS)?

CCS is a state program for children under age 21 with certain disabilities.8 You can have CCS and Medi-Cal. You still have the right to EPSDT under Medi-Cal even if you have CCS. 

6. What is Medi-Cal managed care?

Most people with disabilities now receive their Medi-Cal through a managed care plan. A Medi-Cal managed care plan is a network of healthcare providers including hospital, doctors, therapists etc… that provide health services to its members. In a Medi-Cal managed care plan, you are generally limited to providers in the plan.9 You choose a primary care physician (PCP) who will coordinate your care and refer you to a specialist if needed. This is different from Fee-For Service Medi-Cal (sometimes called “traditional,”  “straight,” or “regular” Medi-Cal) where you can go to any provider who accepts Medi-Cal. 

7. Do I still get EPSDT if I am in Medi-Cal managed care?

Yes.  If you receive Medi-Cal through a Medi-Cal managed care plan you still receive EPSDT benefits. You have the same rights as you did when you were in fee-for-service Medi-Cal.

8. How does EPSDT work when I am in Medi-Cal managed care?

Medi-Cal managed care plans must provide you with EPSDT benefits in accordance with state and federal law. They must use the EPSDT medical necessity standard when deciding whether to authorize a service. Medi-Cal managed care plans must provide comprehensive case management, coordinate care, and are primarily responsible for providing all medically necessary services even if other programs such as schools, regional centers, or other programs can provide the service(s).  Children are not required to exhaust services in these programs before Medi-Cal managed care plans become responsible. There are services that are “carved out” of managed care and are not the Medi-Cal managed care plans’ responsibility to provide. These services include dental services covered by the Denti-Cal program and specialty mental health services. 10

9. I am dissatisfied with a decision of my managed care plan, what can I do?

Read the reason why the service was denied or reduced and the medical necessity standard your Medi-Cal managed care plan is using.  If your Medi-Cal managed care plan does not mention EPSDT in its reason for the denial, then it may be using the wrong medical necessity standard. If your Medi-Cal managed care plan says “no” because the service is not covered, that tells you it probably did not consider the extra benefits available through EPSDT. 

If you are dissatisfied with your Medi-Cal managed care plan’s decision you can file a grievance and/or appeal. Starting July 1, 2017, the rules for grievances and appeals changed. For information see: All Plan Letter 17-006 at:

http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2017/APL17-006.pdf.  You can also read our publication on this subject at https://www.disabilityrightsca.org/publications/medi-cal-managed-care-appeals-and-grievances.

Note: if you are in fee-for service Medi-Cal, you can file for a Medi-Cal fair hearing.11

 

 

1 Medicaid is known as Medi-Cal in California. – (Return to main document)

2 Full scope Medi-Cal means all services available under Medi-Cal.  Full-scope Medi-Cal does not include those who have only emergency Medi-Cal. – (Return to main document)

3 22 CCR § 51340; http://www.dhcs.ca.gov/services/Pages/EPSDT.aspx(Return to main document)

4 42 USC §1396d(r); 22 CCR §§ 51340, 51340.1, 51184; http://www.dhcs.ca.gov/services/MH/Documents/PPQA%20Pages/Katie%20A/Medi-Cal_Manual_Third_Edition.pdf(Return to main document)

5 42 USC § 1396d(r)(5); 22 CCR §§ 51340 and 51340.1 – (Return to main document)

6 For information on Covered California see: https://www.coveredca.com/  https://www.affordablecarecalifornia.org(Return to main document)

7 See DRC pub #555101 – “What is Adult Expansion/MAGI Medi-Cal?” at https://www.disabilityrightsca.org/publications/what-is-adult-expansion-magi-medi-cal(Return to main document)

8 See http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx(Return to main document)

9 For more information on Medi-Cal managed care, see DRC publication # 549501, at https://www.disabilityrightsca.org/publications/medi-cal-managed-care-health-plans-what-are-they-what-do-i-need-to-know-about-them and # 554501.  Also see - Medi-Cal Managed Care: "Continuity of Care"  at: https://www.disabilityrightsca.org/publications/medi-cal-managed-care-continuity-of-care   If you are already in a managed care plan and need to see an out-of-network provider see DRC publication #555901 at https://www.disabilityrightsca.org/publications/medi-cal-managed-care-out-of-network-services(Return to main document)

10 See All Plan Letter 14-017: Requirements for Coverage of Early and Periodic : Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One at: http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-017.pdf(Return to main document)

11 To request a Medi-Cal fair hearing review your Notice of Action for information on how to request a fair hearing and the deadlines for requesting a fair hearing and aid-paid-pending. Also go to: http://www.cdss.ca.gov/Hearing-Requests and http://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-CalFairHearing.aspx(Return to main document)