Let’s start with the basics:
EPSDT is a Medicaid program, so if your child does not have access to Medicaid, then this is one less thing you need to worry about.
EPSDT stands for ‘Early and Periodic Screening, Diagnosis and Treatment’ and is a federally required component of Medicaid for children under the age of 21. (It is important to note that the Youth Empowerment Services (YES) system of care is only for children under the age of 18…just don’t want any confusion there.)
In simple terms, there are many Medicaid services available nationwide but not all states have every possible Medicaid service written into their state plan. Therefore, it is possible that some Medicaid services offered in one state are not generally available in another state. In other situations, there are services written into the plan but there are no providers contracted with Medicaid in your area. The EPSDT process allows children with medical necessity to access services that are not normally available in their state plan.
So how does this impact you?
EPSDT covers services far beyond mental health, and includes things like:
- Necessary Healthcare Services
- Diagnostic Services and
- Treatment to ameliorate defects and physical and mental health conditions.
The word ameliorate is an important word in the federal language because it means to make a situate better or improved. The key point here is that ameliorating is different than stabilizing. In the mental health world many services just try and stabilize. That means they are trying to keep it from getting worse. EPSDT services continue until the condition is improved. That is a very important distinction.
Highlights vs. Details
EPSDT services can be requested one of two ways. (Remember, these requests are for services that are not part of what the Idaho State Plan already has included and you will know that because Optum won’t pay for it as an “included service.”)
- If you want a service that will be completed in an outpatient setting, contact Optum for their current EPSDT form.
- If you want a service that will require inpatient treatment (such as a residential behavioral health facility then use the forms on the Idaho Department of Health and Welfare site.
EPSDT forms are not always easy to fill out. The look fairly simple, but parent experience tells us that successful EPSDT requests give more detail than is implied in the form. The Parent Network has created a resource to help fill out the Department of Health and Welfare form specifically, but it can be useful for the Optum form as well.
General EPSDT Tips
- Always keep a copy of everything you submit!
- Provide as much documentation as you can.
Sometimes it feels like we are burying them in paperwork, but the more information they have to understand what else you have tried and why it did (or did not) work, the more likely you are to have a smooth EPSDT process.
- Provide all the information you can to fill out the form.
Sometimes it feels like the doctor or other providers you are working with should fill out this form. (The Department of Health and Welfare form specifically asks you to have the doctor or specialist fill it out.) In our experience, it is helpful to fill in all the contact information and write out the answers to the questions in the “Additional Information” section and give it to your doctor (or other provider as appropriate) to review. We know that parents are experts on our own children, and we have a lot more time and focus to keep track of our children’s details, so it makes sense for us to write down what we know and have the providers add to it as needed.
- Make sure you get the form signed by the correct provider.
- Email is much faster than regular mail.
Not only do you avoid the time in the mail, you avoid the time it takes to route it to the correct person.
- If you send a lot of information, be sure to break up your emails.
Sometimes the file sizes on the reports and medical records needed to support your EPSDT application is larger than can be sent in one email. It is suggested that if you exceed 9-10 MB in attachments that you break up your email into parts. If you need to send multiple emails to transmit all of the documents, it is suggested that you indicate that in the subject line (example: EPSDT Application for Billy Jones Part 1 of 3) and give a full list of documents that should be received in each part of the full email chain. Always ask them to email you back to verify they received the entire packet of information.
For the Optum Form:
- The form they provide online is a non-fillable pdf, so you will need to print it out and write in your answers. It is okay to say “See attached” and add information in a typed document.
For the Department of Health and Welfare Form:
- The form they provide online is a fillable pdf, so you have the choice if you want to print it out and write in your answers, or type them in online. The text boxes under the “Additional Information” Section will allow you to add a large amount of text, but the text gets smaller as you type. It is okay to say “See attached” and add information in a typed document.
- The Parent Network has created a resource for parents attempting to get EPSDT approval for a Residential Behavioral Health Service (also called a psychiatric residential treatment facility (PRTF)). We do our best to keep the information updated to match the current form that the Department has published. If you notice that our resource no longer matches the date on the current form, please let us know.