​Provider Information

Overview

​ By law, the Department of Health Care Services (DHCS) is responsible to provide full-scope early and periodic screening, diagnostic, and treatment services to Medi-Cal beneficiaries under the age of 21. These services are covered without cost.

​California refers to the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit as Medi-Cal for Kids & Teens.​

Informing Beneficiaries

Medi-Cal providers (medical, dental, and mental health plans, and enrolled) should inform Medi-Cal beneficiaries (under age 21), or their parents, about the following: 

1. Why preventive services and screenings are important
2. What services are offered under Medi-Cal for Kids & Teens
3. Where and how to get services
4. Services are free
5. Free transportation and help scheduling are available
   

Providers should present these five items in clear language:

• In person
• By phone (using dialogue and scripts)
• By written materials 
• Evidence of coverage documents
• Beneficiary handbooks
• Related materials​
  

For help communicating with beneficiaries, see the Resources page.

Medical Necessity

Medi-Cal for Kids & Teens (the EPSDT benefit) allows enrolled members (under age 21) to receive any medically necessary treatment or procedure, regardless of whether or not Medi-Cal covers it.

Definition

For ages under 21, the definition of medically necessary is to correct or ameliorate: 

• health defects
• physical and mental illnesses 
• and conditions discovered by the screening services​
  

Determination

The determination of whether a service is medically necessary:

• must take into account the particular needs of the child
  
• will be made on a case-by-case basis
  

Through the Treatment Authorization Request (TAR) process, additional services will be approved if determined to be medically necessary for an individual child.​

Maintenance services

Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems.

A service need not cure a condition in order to be covered. 

Services are covered when they 

• prevent a condition from worsening
• prevent the development of additional health problems.
  

Services that maintain or improve the child’s current health condition are covered because they “ameliorate” a condition. 

Resources

Training

• Medi-Cal for Kids & Teens Provider Training​
  

Manuals

• EPSDT Manual
  Benefit, coverage, and medical necessity policy information
• Preventive Services Manual​
  Medi-Cal covered preventive services policy information​
  

All-Plan Letters

• 23-005
  Clarifies the responsibilities to provide EPSDT services
• 19-014
  Guidance and requirements for medically necessary Behavioral Health Treatment (BHT) services
  

Contact

More Information 

For more information about the Medi-Cal for Kids & Teens benefit:
Email: medi-calkidsteens@dhcs.ca.gov​​