In Part I of this series, we discussed the state of Medicaid and the EPSDT — the Early and Periodic Screening, Diagnosis, and Treatment Benefit — which covers most American children with disabilities from birth to 19 (21 in some states) year. age. Since 1989, the EPSDT has required every state in the Union to provide every child with “all medically necessary services” that were available under the federal government’s Medicaid program, even if that state did not offer that service to adults. This coverage is broad enough to dwarf most private insurance policies.
What is ‘medically necessary’?
An important difference is that most states have a definition of “medically necessary” that includes only those services that “improve or eliminate a condition,” at least for adults. But the EPSDT’s definition includes services that “correct or ameliorate defects and physical and mental illnesses and conditions.” That may not sound like a big difference, but it is huge.
That’s because “correct or improve” includes services that stabilize someone who is medically unstable (ie, vital signs are not consistently within the defined safe range). So if you’re 20 years and 262 days old and your epilepsy lands you in the hospital because you’ve seriously injured yourself, the EPSDT kicks in and pays for all the services needed to stabilize you. If you’re seven hours old when you end up in the hospital, that (usually pretty hefty) bill gets sent to your parent’s insurance and suddenly significant co-pays and deductions apply.
Similarly, “correct or improve” includes services that preserve the function of someone who would not ordinarily function without specific ongoing intervention. (Maintenance is not ‘improve or eliminate’). By far the most common example is ADHD medication, which is covered by the EPSDT up to age 21, and then, depending on your precise prescription, the cost can be as high as $300/month with no help available, regardless of your income level.
A state of exposure
States have fairly broad discretion when it comes to designing the benefit packages they offer adults enrolled in Medicaid. They are required to provide coverage for a specific list of services, including (but not limited to):
• The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program,
• Inpatient and outpatient hospital care,
• Doctor services,
• Health center, rural health clinic and use in nursing homes,
• Nurse Midwifery, Licensed Pediatric and Family Care Nurse and Freestanding Birth Center Services,
• Lab and X-ray use, and
• Transport services (for medical reasons only).
This means they are not required to offer Medicaid programs that cover:
• Prescribed medicines,
• Clinical services (ie any non-hospital medical facility),
• Therapy services, including physical, occupational, behavioral, etc.,
• Dental, vision, speech, hearing and language services,
• Respiratory care,
• Prosthetics, and
• Private nursing services.
As you can see, if you’re an adult on Medicaid, you could very well be taken care of if you live in the right state… or you have next to no coverage for the services you use the most, even if your state accepted Medicaid expansion. Remember in the first post in the series we mentioned that the majority of children taking the EPSDT were using it for developmental, mental or emotional disabilities? Notice that all of these fall under “optional” services within this section? We’ll discuss what this means in more detail in the next post.