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West Virginia’s Early and Periodic Screening, Diagnosis and Treatment


 

Publication Provided By West Virginia Advocates

Download the EPSDT Booklet in PDF.

HealthCheck is the name of West Virginia’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

What is the EPSDT Program?

The EPSDT program is Medicaid’s comprehensive and preventive child health program. EPSDT serves any child receiving WV Medicaid from birth up to twenty-one (21) years of age.

The EPDST program provides:

  • regular health exams;
  • immunizations; and
  • vision, dental and hearing check-ups.

How Can I Get EPSDT Services For My Child?

In order for your child to receive services under EPSDT, an appointment for an initial examination must be made with a medical provider that accepts WV Medicaid. This can include physicians, nurse practitioners and physician’s assistants. If your child needs a service, the medical necessity for that service MUST be documented as a part of the EPSDT screening exam on the EPSDT form. Screening services required by the Medicaid Act with oversight provided by the Centers for Medicare and Medicaid Services (CMS) include:

  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate immunizations
  • Laboratory tests
  • Lead Toxicity Screening
  • Health Education
  • Vision Services
  • Dental Services
  • Hearing Services
  • Other Necessary Health Care

You should schedule an EPSDT screening exam for your child at your earliest convenience so that his/her medical needs can be met. You might want to take this booklet with you when you meet with your child’s physician. The physician can get more information about services available under EPSDT by contacting the HealthCheck program at 1-800-642-9704 or by visiting the HealthCheck website at http://www.wvdhhr.org/mcfh/ICAH/healthcheck/.

Should your child’s physician order services and they are denied, you will receive a written denial from the West Virginia Department of Health & Human Resources (WVDHHR). The written denial should explain what was denied and the reason. It should also contain an explanation of your right to appeal the denial and instructions how to do that. Please call West Virginia Advocates to see if we may be able to provide assistance.

What Services Can EPSDT Provide?

Services available through EPSDT for children with and without disabilities include many home and community based services:

  • assistive technology;
  • mental health services;
  • home health services;
  • medical equipment and supplies;
  • personal care;
  • skilled nursing;
  • private duty nursing;
  • physical and related therapies; and
  • rehabilitative services.

NOTE: If your child has been found eligible for the WV Title XIX ID/DD (formerly known as the MR/DD) Home and Community Based Waiver Program but was placed on a wait list, and is currently eligible for WV Medicaid, the EPSDT program should be able to meet many of your child’s needs until a slot opens on the Waiver Program.

A child already eligible for Medicaid who is NOT found eligible for the Title XIX ID/DD Waiver program can receive many of the same services through the EPSDT program that they would receive from the Title XIX ID/DD Waiver Program.

What Are Rehabilitative Services?

One of the most important services available under EPSDT are the rehabilitative services. Rehabilitative services were added to Medicaid in 1967 and are defined as: “any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.”

Depending on the need, rehabilitative services can include a range of services such as:

  • basic living skills to restore independent function in the community including food preparation, maintenance of living environment, and/or mobility skills;
  • social skills to develop skills needed to enable and maintain community living, including communication and socialization skills and techniques; and
  • counseling and therapy to eliminate psychological barriers that impede development of community living skills.

Do EPSDT Services Have Limits?

EPSDT should cover the services to the extent the child needs them when the services are necessary to improve or correct the child’s condition.

NOTE: Services deemed necessary under EPSDT can exceed a limit set by the state even if the state places a quantitative limit on the service (such as twenty (20) visits per year for physical therapy). Services not covered by Medicaid for adults could be covered for anyone who is eligible for EPSDT.

Funding

Published by the West Virginia Advocates. Content is solely the responsibility of WVA and does not reflect the official views of the funding agencies. Funding for this publication is provided by the Rehabilitation Services Administration, Office of Special Education and Rehabilitative Services, U.S. Department of Education; Health Resources and Services Administration, U.S. Department of Health and Human Services; Administration on Developmental Disabilities, Administration for Children and Families, U.S. Department of Health and Human Services; Substance Abuse Mental Health Services Administration, Center for Mental Health Services. Version 2.1, August 2011