DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
 
DATE:  January 5, 2017 
 
FROM:  Vikki Wachino, Director 
Center for Medicaid & CHIP Services (CMCS) 
SUBJECT:   The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 
benefit for children and youth in managed care 
For more than 40 years, Medicaids EPSDT benefit has ensured that children and youth under 
age 21 receive a comprehensive array of preventive, diagnostic, and treatment services, as 
specified in section 1905(r) of the Social Security Act (the Act).  This pediatric benefit is a 
comprehensive, high quality health benefit and helps meet childrens health and developmental 
needs. EPSDT covers age-appropriate medical, dental, vision and hearing screening services at 
specified times, and when health problems arise or are suspected. In addition to screening, 
EPSDT covers diagnostic and treatment services described in section 1905(a) of the Act to 
correct or ameliorate identified conditions. 
States have flexibility in determining how to ensure the provision of these services.  Specifically, 
beneficiaries under age 21 are entitled to EPSDT services, whether they are enrolled in a 
managed care plan or receive services in a fee-for-service (FFS) delivery system.  In states that 
use managed care to deliver some or all of the services included in the EPSDT benefit, it is 
important to include enough specificity in managed care plan contracts to avoid confusion about 
what the benefit includes and what entity is responsible for delivering it to ensure that eligible 
individuals under age 21 have access to the full EPSDT benefit. 
States and plans can accomplish this in three ways. 
First, states can be clear in their managed care contracts about the scope of services the state 
expects the plan to provide to children.  Contracts between the state and the managed care plan 
must identify, define, and specify the amount, duration, and scope of each service that the 
managed care plan is required to furnish to enrollees (42 C.F.R. 438.210(a)(1)).1  If a managed 
care plan is expected to provide the full range of preventive, screening, diagnostic and treatment 
services which must be available to beneficiaries under age 21, in other words the full EPSDT 
benefit, it must be clearly stated and described in the contract between the state and the managed 
care plan.  Alternatively, states may carve out some EPSDT services, or services beyond 
contracted limits, and retain responsibility for them in fee-for-service coverage, or contract with 
another managed care plan to provide those services. For example, states may include well-child 
screenings and medical services within the managed care contract, but exclude behavioral health, 
dental care, or other services when they are provided through other contracts or through FFS. If a 
                                                 
1 Pursuant to 42 C.F.R. 457.1230(d), the provisions in 438.210, excluding paragraphs (a)(5) and (b)(2)(iii), apply 
to CHIP managed care contracts.   
 
CMCS Informational Bulletin  Page 2  
 
 
managed care plan is not required under its contract to provide all EPSDT services, the contract 
must clearly describe which services are included. 
Any EPSDT benefits not provided by the managed care plan remain the responsibility of the 
state Medicaid agency, so that in combination with benefits delivered through managed care and 
directly by the agency, eligible individuals under age 21 will have access to the full EPSDT 
benefit. If a managed care contract excludes benefits over specified limits, the state retains 
responsibility for providing necessary services above those limits.   
Second, contracts should reflect a states decision with respect to whether a plan or the state 
carries responsibility for informing beneficiaries of EPSDT benefits.  States must inform all 
eligible individuals under age 21 about EPSDT benefits, provide or arrange for the provision of 
screening services in all cases where they are requested, and arrange for corrective treatment (42 
C.F.R. 441.56). If the managed care plans contract includes coverage of services within the 
EPSDT benefit, the plans enrollee handbook must include information about EPSDT, both 
information on services provided by the plan as well as other EPSDT services delivered outside 
the plan and how to access them if applicable.  
Finally, states must also report EPSDT data, by age and by basis of eligibility, on child health 
screening services, referrals for corrective treatment, and dental services to the Secretary each 
fiscal year, pursuant to section 1902(a)(43) of the Act. Fulfilling this obligation requires 
participation from contracted managed care plans, and contracts should ensure that states have 
access to the plan data necessary to meet this requirement. 
In addition, states have options as to how to incorporate the EPSDT benefit into their state plan. 
Many states add language to each service section of the plan specifying that limitations in the 
plan do not apply to EPSDT eligible beneficiaries under age 21. Other states detail services 
available only to children in a separate EPSDT section of the state plan. To assure consistency 
and that the state plan reflects the statutory requirements, we encourage states to consider 
including the following language in their state Medicaid plan:  
All medically necessary 1905(a) services that correct or ameliorate physical and mental 
illnesses and conditions are covered for EPSDT-eligible beneficiaries ages birth to 
twenty-one, in accordance with 1905(r) of the Social Security Act. 
For more information about EPSDT, please see EPSDT - A Guide for States: Coverage in the 
Medicaid Benefit for Children and Adolescents 
For more information about this bulletin, please contact Susan Ruiz at susan.ruiz@cms.hhs.gov 
or call 415-744-3567.