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EPSDT Provider Toolkit

Overview of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services Benefit: Texas Health Steps

EPSDT regulation, known in Texas as Texas Health Steps mandates that all Medicaid-eligible beneficiaries who are birth through 20 years of age receive medically necessary services to treat, correct and ameliorate illnesses and conditions identifies if the service is covered in the state’s Medicaid plan or is an optional Medicaid service. Medicaid Children’s Services Comprehensive Care Program (CCP) is an expansion of the EPSDT service which requires all states to provide all medically necessary treatment for correction of physical or mental problems to Texas Health Steps -eligible members when Federal Financial Participation (FFP) is available, even if the services are not covered under the state’s Medicaid plan.

See below for an overview of the acronym for EPSDT:

  • Early - Assessing and identifying problems early
  • Periodic - Checking children's health at periodic, age-appropriate intervals
  • Screening - Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
  • Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and
  • Treatment: Control, correct, or ameliorate health problems found

The member is periodically eligible for medical checkup services based on the Texas Health Steps medical checkup periodicity schedule. All the checkups listed on the periodicity schedule have been developed based on recommendations of the AAP and recognized authorities in pediatric preventive health. In Texas, Texas Health Steps has modified the AAP periodicity schedule based on the scheduling of a laboratory or other test in federal EPSDT or state regulations.

Texas Health Steps medical checkups must include regularly scheduled examinations and screenings of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth.

Comprehensive Health Screenings: Birth through 20 years of Age

Superior HealthPlan has adopted the Texas Health Steps periodicity schedule which uses guidance set forth by the American Academy of Pediatrics (AAP) and in consultation with recognized authorities in pediatric preventive health. The Texas Health Steps periodicity schedule specifies screening procedures required at each stage of the member’s life to ensure that health screenings occur at age-appropriate points in the member’s life. In Texas, the Texas Health Steps periodicity schedule may differ from the AAP periodicity schedule based on the scheduling of laboratory or other tests in federal EPSDT or state regulations.

For more information, please view the Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents (PDF).

Key Components of Well-Child Visits

Early Periodic Screening services include:

  • Physical exams and health histories
  • Developmental, behavioral, vision, hearing, and dental health screenings
  • Vaccinations as per CDC recommendations

Providers must document screening results and coordinate follow-up care if risks are identified.

All primary care providers to include the following components in each medical screening:

  • Routine physical examinations as recommended per AAP and Texas Health Steps guidelines.
  • Screening for developmental milestones at each visit through the 6th year; and
  • Screening for autism spectrum disorders per AAP guidelines from 18 months through 30 months.
  • Comprehensive unclothed physical examination.
  • All appropriate immunizations, in accordance with the Recommended Childhood and Adolescent Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], AAP, and the American Academy of Family Physicians [AAFP]).
  • Laboratory testing (including blood lead screening appropriate for age and risk factors).
  • Health education and anticipatory guidance for both child and caregiver.
  • Referral for any suspected or diagnosed health conditions.

This chart is a summary of the most common recommended preventive health screenings and assessments for children and adolescents. These screening services must be provided at well-baby and well-child visits. A list of all screenings can be found of the periodicity schedule. Superior manages EPSDT according to the Texas Health Steps guidelines.

Recommended Screening

Timing

Immunizations

All age-appropriate immunizations based on the Recommended Childhood and Adolescent Immunization Schedule. For additional information about immunizations, providers can refer to the Texas Health Steps Immunization Module.

Anemia

Amenia screening must be measured at 12 months for all children. 

Developmental

Developmental surveillance for developmental milestones occurs from birth through six years of age. Developmental Screening begins at nine months through six years of age. Providers can refer to the periodicity schedule for the appropriate screening or surveillance based on the age of the infant, child, or adolescent.

Blood Lead Screening

Required at 12- and 24-months. Children between 15 months and 6 years of age must be tested if they have not been previously tested.

Dental Screening

First dental visit by 6 months and every 6 months after first visit through 20 years of age. When the client turns 21 years of age during a month, the client is eligible for Texas Health Steps dental non-CCP services through the end of that month.

Autism

Autism screening is required at 18 months of age and again at 24 months of age. If not completed at 24 months of age, or if there is a particular concern it should be completed at 30 months of age.

Vision Screening

Vision screening must be performed at each checkup. A visual acuity test must be performed at ages 3 – 6 years; 8, 10, 12, 15, and 18 years. Subjective screening through provider observation or informant report is done at the other checkups.

Hearing Screening

Hearing screening services for newborns are provided at the birthing facility before discharge. Hearing screenings must be performed at each checkup for members who are birth through 20 years of age.  Audiometric screening must be performed at ages 4 – 6 years; 8, 10, and 15 years. Subjective screening through provider observation or informant report is required at the other checkups.

Behavioral Health

Mental health screening for behavioral, social, and emotional development is required at each Texas Health Steps checkup.  Comparable to the American Academy of Pediatrics (AAP) Recommendations for Preventive Health Care guidelines, Texas Health Steps allows members who are 12 through 18 years of age to receive a mental health screening using one of Texas Health Steps recognized mental health screening tools.

HIV/STI Screening

Screening for HIV is required once for members who are 16 through 18 years of age, regardless of risk. Screening for HIV is also based on risk assessment for members who are 11 through 20 years of age. STI testing should be performed on adolescents that are at high risk for infection. It is critical to maintain confidentiality of the member and their specimens.

 

The TVFC program provides vaccines at no cost to eligible providers. Enrollment in TVFC is necessary for access to vaccines at no cost to the provider. The vaccines are recommended according to the Recommended Childhood and Adolescent Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], AAP, and the American Academy of Family Physicians [AAFP]). Providers are encouraged to enroll in TVFC at the Texas Department of State Health Services (DSHS) and must do so to obtain free vaccines for members from birth through 18 years of age. 

Benefits of TVFC:

  • Offers federally purchased vaccines for eligible children.
  • Reduces out-of-pocket vaccine costs for parents and providers.
  • Eliminates cost as a barrier to vaccination.

For more information about the TVFC program, visit DSHS Vaccines.

The EPSDT Program is mandated by Title XIX, Section 1905(r), of the Social Security Act. It is the responsibility of the state to determine medical necessity on a case specific basis. No arbitrary limitations on services are allowed (e.g., one pair of eyeglasses or 10 therapy sessions per year) if determined to be medically necessary.

In Texas, EPSDT is known as Texas Health Steps. The Texas Department of State Health Services (DSHS), by authorization of Texas Health and Human Services Commission (HHSC), operates and administers the outreach and informing, medical and dental checkup, dental treatment utilization components of this program. State authority is found in Title 25 Texas Administrative Code (TAC), Part 1, Chapter 33, Subchapter A, Rule §33.1.

Federal EPSDT Criteria

The following is the Federal EPSDT Criteria:

  1. The EPSDT service must be included in the 1905(s) Social Security Act
  2. Requested service must be medically necessary
  3. Medical in nature
  4. Safe
  5. Effective
  6. Must be recognized as an accepted method of medical practice or treatment
  7. Must not be experimental or investigational

The approval of services is assessed by an appropriately licensed Texas Medicaid medical professional on an individual basis.

Dental health screenings aid in preventing cavities by implementing early preventive measures and/or treatments.

An oral screening must be performed at every EPSDT well-child visit; however, this does not exclude the recommended dental visits that should occur:

  • Starting with the first 6 months of the eruption of the first primary tooth, but no later than one year of age.
  • And every 6 months thereafter.

Based on the American Academy of Pediatric Dentistry’s (AAPD) definition, Texas Medicaid defines a dental home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a client’s dental home begins no later than 6 months of age and includes referrals to dental specialists when appropriate. Members who are from 6 through 35 months of age may be seen for dental checkups by a certified First Dental Home provider.

Dental and Preventive Care Guidelines

Texas Medicaid adheres to the American Academy of Pediatric Dentistry (AAPD) and American Dental Association (ADA) guidelines for dental services within Texas Health Steps. Providers must follow the Texas Health Steps medical checkup periodicity schedule for preventive pediatric healthcare. For more information, please view the Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents (PDF).

Developmental and behavioral health screenings are required for all children and adolescents. Developmental screenings are done as a part of well or sick child visits to determine if a child is meeting typical developmental milestones.

The Texas Health Steps Medical Checkup Periodicity Schedule for Infants,
Children, and Adolescents (PDF) includes 8 types of assessments/screenings; they are:

  • Developmental Screenings
  • Developmental Surveillance
  • Nutritional Screening
  • Autism Spectrum Disorder Screening
  • Mental Health: Psychosocial/Behavioral Health Screening
  • Mental Health: Postpartum Depression Screening
  • Mental Health: Adolescents Screening
  • TB Screening

Each assessment/screening should be performed at the recommended age during the member’s well-child visit. 

Screenings should be:

  • Up-to-date and scientifically validated.
  • Preformed at every visit in accordance with the periodicity schedule.
  • Conducted per AAP guidelines for autism spectrum disorder.

Behavioral Health providers should coordinate with primary care providers and specialists conducting EPSDT screenings.

Early intervention (children between the ages of birth to kindergarten) is essential for children at risk of disabilities, enhancing overall development.

Early Intervention Providers

  • Early Childhood Special Educators
  • Physical, Occupational, and Speech and Language Therapists

Early Intervention Services

  • Audiology Services
  • Speech-language therapy
  • Nutrition services
  • Child service coordination
  • Multidisciplinary evaluation

Care coordination should be comprehensive and facilitate communication among healthcare providers.

Texas Medicaid provides a range of educational resources through the Texas Medicaid and Healthcare Partnership (TMHP) Learning Management System (LMS). Providers can access quick, targeted training modules and regular workshops to stay updated on program requirements.

For more detailed information on guidelines and schedules, please refer to the TMHP LMS Account Login.