Well Child Visits

Medicaid Health Benefit for Members Under 21 Years Old

Members under 21 years old have access to a broad menu of federal health care benefits referred to as “Early and Periodic Screening, Diagnosis and Treatment Services.” The “EPSDT guarantee” covers wellness visits and treatment services.

Early and Periodic Screening and Diagnosis
The “screening” visits are wellness care. They are no cost for members under age 21. These visits include a complete exam, vaccines, and vision, and hearing tests. Your provider will also monitor your child’s physical and emotional growth and well-being at every visit and “identify” any conditions that may exist. At these visits, you will get referrals to any treatment services your child needs to get well and to stay healthy.

The “T” in EPSDT: Treatment for Members Under 21 Years Old
Sometimes children need medical treatment for a health problem. Home State Health and Show Me Healthy Kids may not offer every service covered by the federal Medicaid program. When a child needs treatment, we will pay for any service that the federal government Medicaid plan covers if the service is considered medically necessary. The proposed treatment must be evaluated on its ability to treat, fix, or improve your child’s health problem or condition. This decision is made specifically for your child. Home State Health and Show Me Healthy Kids cannot deny your child’s service just because of a policy limit. Also, we cannot deny a service just because that service is not included in our coverage policies. We must complete a special EPSDT review in these cases.

When Home State Health or Show Me Healthy Kids approves services for children, important rules apply:

There are no copays / costs for Medicaid covered services to members under 21 years old.
There are no limits on how often a service or treatment is given.
There is no limit on how many services the member can get on the same day.
Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.

You will find the entire menu of Medicaid-covered services in the Social Security Act.

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