Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program

Oregon Health Plan (OHP) Benefits for Children and Youth under Age 21

EPSDT benefits are for OHP members under age 21. These benefits include comprehensive preventive health care services from birth until they turn age 21, such as:

Age-appropriate medical exams, screening and diagnostic services and
Medically necessary Medicaid-covered services (defined in Section 1905 (a) of the Social Security Act) to treat any physical, dental, developmental and mental health conditions discovered.

Coordinated care organizations (CCOs) cover these benefits for CCO members. The Oregon Health Authority (OHA) covers EPSDT benefits for members not enrolled in a CCO (these members have fee-for-service OHP, also known as open card coverage).

Most EPSDT services have been provided in Oregon for many years. This includes through adolescent and well child visits and other routine medical, dental and behavioral health care.

Like all other OHP benefits, both OHA and CCOs must ensure that EPDST benefits are provided in a timely manner and at no cost.

Child with doctor and parent at well-child visit

About EPSDT

Who Qualifies for EPSDT in Oregon?

All children and youth in Oregon up to age 21 who are enrolled in OHP. This includes children and youth under age 21 who enrolled in OHP through OHP Covers Me! (Cover All Kids), Healthier Oregon and OHP Bridge.

EPSDT coverage ends on a member's 21^st birthday.

Father holding child

What Services Are Provided?

Screening visits (also known as well child visits or adolescent well visits) at age-appropriate intervals following the American Academy of Pediatrics and Bright Futures guidelines and periodicity schedule. These visits must include:

Full physical exam
Full health and developmental history (including assessment of both physical and mental health development)
Developmental screening
Preventive laboratory tests (including lead toxicity testing and genetic testing)
Appropriate immunizations
Assessment of nutritional status
Anticipatory guidance and health counseling for parents and children
Referrals for medically necessary health and mental health treatment

EPSDT also covers screenings for vision, hearing and oral/dental health.

EPSDT also covers unscheduled check-ups or exams that can happen at any time. This can be due to an illness, injury or a change in condition.

EPSDT covers all medically necessary and medically appropriate services that are required for an OHP member under age 21, including for treatment of conditions identified as part of an EPSDT screening or health exam.

Examples include:

Physical health services (treatment for illness and injury)
Behavioral health services (mental health and substance use disorder treatment, including Applied Behavior Analysis)
Case management
Speech-language-hearing, occupational and physical therapy
Eyeglasses, hearing aids and augmentative communication devices
Dental care
Medical equipment and supplies
Health services provided by school staff, for example as part of an Individualized Education Program
Personal care services
Rehabilitation services
Nutritional supplements/medical foods

Determination of whether a service is medically necessary and medically appropriate must be available on a case-by-case basis, taking into account a particular child's needs. Medically Necessary and Medically Appropriate are defined in Oregon Administrative Rule 410-120-0000.

In cases where prior authorization is required, providers can ask OHA or the child's CCO to review services for medical necessity by submitting a prior authorization request as described on the OHP Prior Authorization page.

OHA makes the final determination of medical necessity and medical appropriateness for hearing requests for denied services and for fee-for-service (Open Card) prior authorizations.

EPSDT’s goal is to ensure individual children on Medicaid get the health care they need when they need it – the right care to the right child at the right time in the right setting.

EPSDT Coverage in Oregon Expanded January 1, 2023

Oregon did not renew the longstanding waiver around EPSDT for children. The decision came as a result of clear feedback from the community, advocates, children's service organizations, and other interested parties. Beginning January 1, 2023, OHA and CCOs must cover all medically necessary and medically appropriate services for OHP members under age 21, regardless of placement on the Prioritized List of Health Services. Medical necessity and medical appropriateness are determined on a case-by-case basis, taking into account the member's needs.

States must cover all medically necessary and medically appropriate services that are part of the federal EPSDT benefit, even if the service is not available or defined under the state's Medicaid plan.

Teens sitting on a park bench, looking at their phones A child stands before two smiling health care providers at a desk