A federal law requires Medicaid to provide all medically necessary health care services to Medicaid-eligible children. This is called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). The services are required even if the services are not normally covered by children’s Medicaid.
Who Is Eligible for Health Check and EPSDT?
Medicaid-eligible children through the age of 20 are eligible for Health Check and EPSDT services.
To find out if your child is eligible for Medicaid benefits, contact your local Department of Social Services (DSS). You will find them in the phone book under government agencies. You may go to the DSS to apply or ask them to send you an application in the mail. Applications are also available at the local health department. You may complete the application yourself and return it in person or mail it to the DSS.
Why are Health Check and EPSDT Important?
Health Check and EPSDT are important because they:
- provide early and regular medical and dental screenings for all Medicaid eligible-children
- identify treatments that are medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination.
What Treatment Services are Covered?
Services must be ordered by the child’s physician or another licensed clinician. Prior approval from the Division of Medical Assistance may be required to verify medical necessity for some services.
The services must meet all of the conditions stated below:
- The service must be medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination
- The service must be listed in section 1905(a) of the Social Security Act.
- The service cannot be experimental/investigational, unsafe or considered ineffective.
Requests for Non-Covered Services
If your child’s physician or another licensed clinician determines that your child needs a treatment service that is not normally covered by Medicaid, they must request the service by writing to:
Assistant Director for Clinical Policy and Programs
Division of Medical Assistance
2501 Mail Services Center
Raleigh, NC 27699-2501
For More Information
You can ask about Health Check, EPSDT services, and how to obtain medically necessary services not covered by N.C. Medicaid by contacting:
- your child’s doctor
- a Health Check Coordinator (177 KB PDF)
- the contact number listed in your Health Check letters
- the local mental health program or
- any health care provider who accepts Medicaid.