In Part I in 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 until 19 (21 in some states) years of age. Since 1989, the EPSDT has required that each state of the Union provide every child with “all medically necessary services” that were available under the Federal government’s Medicaid program, even if that state didn’t offer that service to adults. This coverage is expansive enough that it dwarfs most private insurance.

What is ‘Medically Necessary’?

One major difference is that most states adopt a definition of “medically necessary” that only includes those services that “improve or eliminate a condition,” at least for adults. But the EPSDT’s definition of includes services that “correct or ameliorate defects and physical and mental illnesses and conditions.” That might not sound like a big difference, but it’s huge.

That’s because ‘correct or ameliorate’ includes services that stabilize someone who is medically unstable (i.e. vital signs aren’t 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 severely injured yourself, the EPSDT kicks in and whatever services it takes to stabilize you are paid for. If you’re 21 years old by seven hours when you land in the hospital, that (usually quite massive) bill gets sent to your parent’s insurance, and suddenly significant co-pays and deductions apply.

Similarly, ‘correct or ameliorate’ includes services that maintain function in someone who would normally not function without a specific ongoing intervention. (Maintenance is not ‘improving or eliminating’). By far and away the most common example is ADHD medication, which is covered by the EPSDT until 21 years of age, and then, depending on your precise prescription, the cost can jump as high as $300/month with no assistance available regardless of your income level.

A State of Exposure

States have quite broad discretion when it comes to designing the benefit packages they offer adults enrolled in Medicaid. They are obligated 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,

• Physician services,

• Health Center, Rural Health Clinic, and Nursing Home use,

• Nurse Midwife, Certified Pediatric and Family Care Nurse, and Freestanding Birth Center services,

• Lab and X-ray use, and

• Transportation services (for medical reasons only).

This means they are not obligated to provide Medicaid programs covering:

• Prescription drugs,

• Clinic services (i.e. any non-hospital medical facility),

• Therapy services, including physical, occupational, behavioral, and so on,

• Dental, vision, speech, hearing, and language services,

• Respiratory care,

• Podiatry,

• Prosthetics, and

• Private duty nursing services.

As you can see, if you’re an adult on Medicaid, you might be very well-cared-for if you live in the right state… or you may be almost completely without coverage for the services you use most, even if your state accepted the Medicaid expansion. Remember in the first post in the series, we mentioned that the majority of children using the EPSDT were using it for developmental, mental, or emotional disabilities? Notice that all of those fall under “optional” services within this rubric? We’ll talk about what this means in more detail in the next post.

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