EPSDT Rule Changes

October 25, 2017


Last Friday, October 20, 2017, Ohio’s Department of Medicaid finalized rule changes for the Healthcheck (EPSDT) program, to take effect November 1, 2017.  “EPSDT” is shorthand for “Early, Periodic Screening, Diagnosis and Treatment.”  It is a set of services for children enrolled in Medicaid. Federal law requires states to pay for EPSDT’s physical and mental health screenings and to pay for the treatment needs that may be identified through those screenings, even if the services would not be required to be paid for an adult.  EPSDT has been an exceptional tool to help children be ready to learn when they start school, and to continue to be healthy throughout their child and teen years.


The rule change happened as a result of a standard five year review of Ohio Administrative Rules. The revised rules were supposed to simplify the old rules, but not change any of the obligations of the state as far as paying for services and helping the families of children on Medicaid to access the service.


Voices for Ohio’s Children commented on the rules, as did other organizations throughout Ohio.  Voices asked the Department of Medicaid (1) to spell out the definition of “medically necessary,” rather than to link to another web site; (2) keep the list of eligible providers who can be reimbursed for providing EPSDT services, especially to make sure that Advanced Practice Nurses can bill; (3) retain more specificity about what constitutes a screen, especially hearing and vision, and make sure that nutrition screening is included; and (4) retain the current requirement to coordinate with public and private resources to ensure comprehensive screening, evaluation, diagnosis, and treatment.


Some of Voices’ suggestions were incorporated, and reasons were given in some cases where a suggestion was rejected.  Most importantly Medicaid changed “should” to “must” in relation to the obligation to refer a child needing further evaluation to diagnosis and necessary treatment (Section 5160-1-14 (D)(3)). Nutrition screening is back in, but Medicaid prefers not to have a specific list of providers who can bill in order to “to avoid narrowing the definition of who is actually eligible." (e-mail from ODM to Voices  4/27/17).


The "Bright futures guidelines" of the American Academy of Pediatrics are written into the new EPSDT rule to guide the intervals between screenings. However, the EPSDT rule no longer specifies what must be included in a screening. The real question going forward will be whether, without the detail, hearing, vision and other screenings will be sufficiently comprehensive to detect physical or emotional issues of children not yet able to describe their own limitations or problems.


The Department of Medicaid has invited advocates to comment on its Healthchek  web page, in order to make it more informative to the providers who are doing the screenings and to the parents who want to learn about Healthchek.  Take a look and let us know if you can think of ways to make the page more informative. 

Please reload

Featured Posts

Future Directions for Ohio Medicaid

April 11, 2019

Please reload

Recent Posts