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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.