If your child is under the age of 21 and receiving Medicaid, then your child is covered by the civil rights to medically necessary care defined under EPSDT.
In order to obtain EPSDT services for your child you need the following items:
1. an assessment showing the service or item is appropriate
AND/OR
2. a prescription for the service or item from one of your child’s treating practitioners
AND
3. a letter from your child’s physician stating the item or service is medically necessary and why.
While the earlier brochure from DHHS talks about state’s rights to impose limits on EPSDT services, recent court decisions seem to have negated that assertion. According to these legal decisions and other documents, state Medicaid officials and/or their sub-contractors cannot deny, reduce or limit a service or item that a child’s doctor says is medically necessary. The service or item does not need to be one that is offered to everyone by the state’s Medicaid program; it just needs to fall into a Medicaid category and be furnished by a Medicaid provider.
You submit these documents to your child’s Medicaid provider and wait for their decision. If they deny the request, or reduce the service or limit the time during which the service may be offered, then you may have a right to file a complaint with federal authorities for violation of your child’s medical civil rights.
