Benefits for Children under Age 21 and Young Adults with Special Health Care Needs
EPSDT benefits are for OHP members who:
- Are under age 21 or
- Are under age 26 and have Young Adults with Special Health Care Needs (YSHCN) benefits.
These benefits include comprehensive preventive health care services from birth until they turn age 21 (or age 26, for members with YSHCN benefits).
Beginning Jan. 1, 2023, Oregon Health Authority (OHA) and coordinated care organizations (CCOs) must cover all medically necessary and medically appropriate services for OHP members under age 21, regardless of placement on the Prioritized List of Health Services. Medical necessity and medical appropriateness are determined on a case-by-case basis, taking into account the member's needs.
Who Qualifies for EPSDT in Oregon?
All children and youth in Oregon up to age 21 who are enrolled in OHP. This includes children and youth under age 21 who enrolled in OHP through Healthier Oregon and
OHP Bridge.
Effective Jan. 1, 2025, OHP members with
YSHCN benefits also have EPSDT coverage.
EPSDT coverage ends on a member's 21st birthday, or on the 26th birthday for members with YSHCN benefits.
What Services Are Provided?
EPSDT benefits include:
- Age-appropriate medical exams, screening and diagnostic services and
- Medically necessary Medicaid-covered services (defined in
Section 1905 (a) of the Social Security Act)to treat any physical, dental, developmental and mental health conditions discovered. States must cover all medically necessary and medically appropriate services that are part of the federal EPSDT benefit, even if the service is not available or defined under the state's Medicaid plan.
Screening visits (also known as well child visits or adolescent well visits) at age-appropriate intervals following the American Academy of Pediatrics and Bright Futures guidelines and periodicity schedule. These visits must include:
- Full physical exam
- Full health and developmental history (including assessment of both physical and mental health development)
- Developmental screening
- Preventive laboratory tests (including lead toxicity testing and genetic testing)
- Appropriate immunizations
- Assessment of nutritional status
- Anticipatory guidance and health counseling for parents and children
- Referrals for medically necessary health and mental health treatment
EPSDT also covers screenings for vision, hearing and oral/dental health.
EPSDT also covers unscheduled check-ups or exams that can happen at any time. This can be due to an illness, injury or a change in condition.
EPSDT covers all medically necessary and medically appropriate services that are required for an OHP member under age 21, or an OHP member wtih YSHCN benefits. This includes treatment of conditions identified as part of an EPSDT screening or health exam.
Examples include:
- Physical health services (treatment for illness and injury)
- Behavioral health services (mental health and substance use disorder treatment, including Applied Behavior Analysis)
- Case management
- Speech-language-hearing, occupational and physical therapy
- Eyeglasses, hearing aids and augmentative communication devices
- Dental care
- Medical equipment and supplies
- Health services provided by school staff, for example as part of an Individualized Education Program
- Personal care services
- Rehabilitation services
- Nutritional supplements/medical foods
Determination of whether a service is medically necessary and medically appropriate must be available on a case-by-case basis, taking into account a particular child's needs. EPSDT Medically Necessary and EPSDT Medically Appropriate are defined in
Oregon Administrative Rule 410-151-0001.In cases where prior authorization is required, providers can ask OHA or the child's CCO to review services for medical necessity by submitting a prior authorization request as described on the OHP Prior Authorization page.
OHA makes the final determination of medical necessity and medical appropriateness for hearing requests for denied services and for fee-for-service (open card) prior authorizations.
EPSDT’s goal is to ensure individual children on Medicaid get the health care they need when they need it – the right care to the right child at the right time in the right setting.
Find Resources for Members, Provider and CCOs
Resources for members
Resources for providers
Resources for CCOs