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EPSDT: Early and Periodic Screening, Diagnosis and

Treatment ProgramPresenter:

Diana M. StraubeNational Assistive Technology Advocacy

Project, Neighborhood Legal Services

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Medicaid covers DME that:

• can withstand repeated use

• are primarily and customarily used for medical purposes

• are generally not useful in the absence of an illness or injury

• usually not fitted, designed or fashioned for a particular individual’s use.

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Equipment may also be covered under

• physical therapy

• occupational therapy

• speech pathology services

• rehabilitation

• prosthetics

• orthotics, etc.

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Medical NecessityPrevent, diagnose, correct or cure a condition that:

• causes acute suffering

• endangers life

• results in illness or infirmity

• interferes with the capacity for normal activity

• threatens to cause a significant handicap

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EPSDT:

• comprehensive and preventative health care program for recipients under 21

• early and periodic screening and diagnosis to ascertain physical or mental defects

• such health care, treatment or other measures to correct or ameliorate defects and chronic conditions

• broadens definition of medical necessity

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Medicaid must provide:

• Outreach and informing

• Screening

• Diagnosis

• Treatment

• Adequate provider participation

• Reporting

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EPSDT screenings (assessments) must include:• Gross and fine motor development

• Communication skills or language development

• Self-help or self-care skills

• Social-emotional development

• Ability to engage in social interaction

• Cognitive skills, focusing on problem solving or reasoning

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As children age, assessments should include:

• Visual-motor integration

• Visual-spatial organization

• Visual sequencing processing skills

• Auditory sequential memory

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Assessments of adolescents should include:

• Identification of potential learning disabilities

• Peer relations

• Psychological/psychiatric problems

• Vocational skills

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Matter of J.P., NY FH # 3689971R

Sip-and-puff mechanism for wheelchair was necessary to:

• maximize child’s opportunity for cognitive development

• allow him to be more responsible for own self-care and safety

• foster his learning capacity• foster his general ability to explore his

environment “as is necessary for any child his age”

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Matter of John, NY FH # 4337314K

• Medicaid denied prior approval for power wheelchair for young child, claiming child always had a caregiver present who could push him.

• Decision rejected agency’s argument that continued reliance on caregivers to push him would be developmentally inappropriate for child.

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Following services are available if medically necessary:• computers, such as the Apple II Computer with

printers, computer software

• exercise equipment including exercise bikes, swing sets, and tricycles

• communication devices such as the Dynavox

• specialized eating utensils and other daily living aids