Fact Sheet: Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
By: United Advocates for Children of California, California Mental Health Directors Association, California Alliance, California Mental Health Advocates for Children and Youth
Program History
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit has
been a requirement of the Medicaid program since its inception in 1966. The
federal Omnibus Budget Reconciliation Act of 1989 (OBRA '89) expanded the
benefit, requiring state EPSDT programs to provide diagnostic and treatment
services needed to "correct or ameliorate defects, physical and mental
illnesses, and conditions discovered by screening services, whether or not such
services were covered under the Medicaid State Plan." Under this program, states
are required to inform Medicaid-eligible beneficiaries from birth through age 21
of the services available to them. In 1993, a group of California-based
attorneys filed a lawsuit against the state Department of Health Services,
charging that the state was not sufficiently complying with the federal law. The
courts agreed, and the EPSDT mental health benefit implemented as a result of
this lawsuit increased the availability of State General Funds to finance
Medi-Cal specialty mental health services provided to eligible children and
adolescents. In its implementation of the expanded EPSDT benefit, DHS recognized
that county mental health departments had been the historic providers of mental
health services to children and youth with serious emotional disturbances (SED).
Accordingly, county mental health departments were determined to be the logical
choice to provide the expanded EPSDT benefit to the SED population. When
specialty mental health services were consolidated under a federal waiver in
1997-98, county mental health plans assumed the responsibility to provide the
expanded EPSDT benefit to all Medi-Cal children and youth meeting the medical
necessity criteria.
Program Funding
Medi-Cal specialty mental health services are funded with a mix of federal,
state, and county funds. The federal government pays approximately fifty percent
of the costs of Medi-Cal specialty mental health services. County mental health
pays the fifty percent match, pursuant to Realignment I, until it reaches its
adjusted fiscal-year 1994-95 baseline of expenditures for specialty mental
health services (i.e., the EPSDT baseline). The State Department of Mental
Health receives State General Funds to pay the fifty percent match for costs
that exceed the EPSDT baseline. In 2002, in an effort to ensure that counties
had an “incentive” to control costs, the Administration imposed an additional
10% county share of cost on growth in the EPSDT program.
Program Eligibility
The Early and Periodic Screening, Diagnosis and Treatment benefit serves
children and adolescents from birth through age twenty-one who meet Medicaid
income eligibility requirements, and the Medi-Cal medical necessity criteria for
this age group. Most children who meet Medicaid eligibility requirements are
from families with annual incomes up to approximately 100% of the federal
poverty level, or have been removed from their homes and made dependents of the
court. For the most part, children and adolescents who meet Medi-Cal medical
necessity criteria have a recognized mental disorder; are not developing
appropriately; and interventions have been identified that are likely to help
the child to progress developmentally as appropriate.
Program Services
The Early and Periodic Screening, Diagnosis and Treatment benefit provides
eligible children access to a range of mental health services that include, but
are not limited to:
Mental health assessment: A service activity which may include a
clinical analysis of the history and current status of a beneficiary’s mental,
emotional, or behavioral disorder; relevant cultural issues and history;
diagnosis; and the use of testing procedures.
Collateral contacts: A service activity to a significant support
person in a beneficiary’s life with the intent of improving or maintaining the
mental health status of the beneficiary.
Therapy: A service activity, which is a therapeutic intervention that
focuses primarily on symptom reduction as a means to improve functional
impairments.
Rehabilitation: A service activity which includes assistance in
improving, maintaining, or restoring a beneficiary's or group of beneficiaries'
functional skills, daily living skills, social and leisure skills, grooming and
personal hygiene skills, meal preparation skills, and support resources, and/or
medication education.
Mental health services: Individual or group therapies and
interventions that are designed to provide reduction of mental disability and
improvement or maintenance of functioning consistent with the goals of learning,
development, independent living, and enhanced self-sufficiency.
Medication support services: Those services that include prescribing,
administering, dispensing and monitoring of psychiatric medications or
biologicals, which are necessary to alleviate the symptoms of mental
illness.
Day rehabilitation: A structured program of rehabilitation and therapy
to improve, maintain or restore personal independence and functioning consistent
with requirements for learning and development.
Day treatment intensive: A structured, multi-disciplinary program of
therapy, which may be an alternative to hospitalization, to avoid placement in a
more restrictive setting, or maintain the beneficiary in a community
setting.
Crisis intervention/stabilization: A service, lasting less than 24
hours, to or on behalf of a beneficiary for a condition which requires more
timely response than a regularly scheduled visit.
Targeted case management: A service that assists a beneficiary to
access needed medical, educational, social, prevocational, vocational,
rehabilitative, or other community services.
Therapeutic behavioral services: In 1999 “TBS” became the newest EPSDT
benefit as a result of the second EPSDT lawsuit filed against the Department of
Health Services. This service is one-to-one therapeutic contact between a mental
health provider and a beneficiary for a specified short-term period of time,
which is designed to maintain the child/youth’s residential placement at the
lowest appropriate level by resolving target behaviors and achieving short-term
treatment goals.