In the first part of this series, we discussed the state of Medicaid and EPSDT — an advantage of early and periodic screening, diagnosis, and treatment that covers most American disabled children from birth to age 19 (21 years in some states). Since 1989, EPSDT has required each state of the Union to provide each child with “all medical services” that were available through the federal government’s Medicaid program, even if that state did not offer this service to adults. This coverage is expansive enough to overshadow most private insurance.
What is Medical Support?
One of the main differences is that most states accept the definition “from a medical point of view”, which includes only those services that “improve or eliminate the condition”, at least for adults. But the definition of EPSDT includes services that "correct or improve defects, physical and mental diseases and conditions." This may seem like a big difference, but it is huge.
This is because it is correct or improved. includes services that stabilize a person who is physically unstable (i.e., vital signs do not always fall within a certain safe range). So, if you are 20 years old and 262 days old, and your epilepsy lands at the hospital because you have hurt yourself badly, EPSDT kicks, and everything that is required to stabilize you is paid. If you need seven years when you land at the hospital, this (usually quite massive) bill goes to your parent's insurance, and suddenly there are significant co-payments and discounts.
Similarly, correct or improved includes services that support the function of those who usually do not function without any specific intervention. (Maintenance is not improved or is not eliminated). The most common example is the drug ADHD, which is covered by EPSDT until the age of 21, and then, depending on your prescription, the cost can reach $ 300 per month without any help, regardless of your income level.
Exposure status
States have quite a wide leeway when it comes to developing benefit packages that they offer to adults with Medicaid. They are required to provide coverage for a specific list of services, including (but not limited to):
• Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT)
• inpatient and outpatient hospital care,
• Medical services,
• Health center, rural health clinic and household,
• Nurse nurses, certified nurse for the care of children and family sisters, as well as free birth services,
• Use of laboratory and x-rays and
• Transport services (only for medical reasons).
This means that they are not required to provide Medicaid programs that include:
• Prescription drugs,
• Clinic services (for example, any hospital facility)
• Therapeutic services, including physical, professional, behavioral, etc.
• Dentistry, vision, speech, hearing and language services,
• Respiratory care,
• Podiatry,
• Prosthetics and
• Care services for individuals.
As you can see, if you are an adult in Medicaid, you can be very good if you live in the right state ... or you can almost completely not use the services that you use the most, even if your state accepted the Medicaid extension. Remember in the first post in the series, we stated that most children using EPSDT used it for development, mental or emotional disorders? Please note that they all fall under the “optional” services in this category? We will talk about what this means in more detail in the next post.
