EPSDT Services

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for Medi-Cal members under age 21 are based upon members' identified health care needs. Diagnostic and treatment services are provided to treat, correct or ameliorate any physical or behavioral conditions by the appropriate provider or organization. The EPSDT program allows for periodic medically necessary screening and appropriate preventive, mental health, developmental, vision, hearing, dental and specialty services. For Medi-Cal members under age 21, dental screening or assessment must be performed at every periodic assessment. EPSDT services include case management and targeted case management services designed to assist children in gaining access to necessary medical, social, education and other services, such as pediatric day health center services, cochlear implant and transportation services.

The Health Net Medi-Cal Health Services staff or delegated participating physician group (PPG) coordinates with primary care physicians (PCPs) to identify children under age 21 who would benefit from these services and assists with appointment scheduling. Health Net determines medical necessity of most EPSDT services according to criteria established by the Department of Health Care Services (DHCS). When EPSDT services are provided for the California Children's Services (CCS) program, or are specialty mental health services (which are carved-out from Health Net's coverage responsibilities), Health Net does not determine medical necessity.

The Health Net Medi-Cal Health Services staff or delegated PPG ensures that members under age 21 who qualify for EPSDT services are referred to an EPSDT services provider or to an entity that provides EPSDT services. If these referred providers render EPSDT care management services, the care manager and Health Net medical director or delegated PPG medical director determine medical necessity. If EPSDT care management services are not available from these referred providers, the health plan or delegated PPG arranges and pays for EPSDT services.

According to Department of Health Care Services (DHCS) All Plan Letter(APL) 19-010: Medi-Cal managed care health plans (MCPs) and delegated PPGs are to provide all medically necessary Medi-Cal covered services while EPSDT program eligibility is pending. The EPSDT benefit is more robust than the Medi-Cal benefit package required for adults and states may not impose limits on EPSDT services and must cover services listed in Section 1905(a) of the Social Security Act (SSA) regardless of whether or not they have been approved under a state plan amendment. Health Net or delegated PPG shall determine the medical necessity of EPSDT services using the criteria established in 42 USC Section 1396d(r) and W & I Code Section 14132(v).