EPSDT for Members Birth Through Age 20
What is EPSDT?
EPSDT stands for Early and Periodic Screening, Diagnosis and Treatment. This program makes sure members get the comprehensive, preventive health care they need. It catches problems early, treats illness, and helps members with disabilities get the support they need.
Who can get EPSDT services?
- Members from birth to age 21 can get EPSDT services.
Are these services free?
- Yes, EPSDT services are always free to members.
How do I get these services?
- Ask your primary care provider (PCP).
- Call UHA Customer Care at 541-229-4842, TTY: 711.
What’s covered
EPSDT covers a wide range of checkups and treatment. Here is everything included, grouped by type of care.
Growth and development checkups
Immunizations (vaccines)
Dental care
Vision care
Hearing care
Blood and lab tests
Health education and guidance
- You will receive age-appropriate guidance on nutrition, safety, and healthy development.
Referrals and care coordination
- If needed, UHA will refer you to a provider for medically necessary physical, dental, or behavioral health treatment.
- If you need care coordination, UHA will make sure you get it.
Referrals and care coordination
- UHA covers medically necessary and appropriate care even when it is not on OHA’s prioritized list of health services.
- A service is medically necessary if it is needed to prevent, diagnose, or treat a condition, or to support your growth, development, independence, and participation in school.
- A service is medically appropriate if it is safe, effective, and improves your participation in care and activities.
- UHA may choose to cover the least expensive option that works for you.
What happens if a checkup finds a problem?
- A checkup might uncover a medical, mental health, substance use, or dental condition.
- If a condition is found, your provider may refer you to another provider for more tests or treatment, and will explain why you need this referral.
- If you or your parent or guardian agrees, UHA will help you find a provider or make the appointment.
- If you need care coordination, UHA will make sure you get it.
More planning resources
- The full AAP periodicity schedule shows exactly which checkups happen at which ages.
- The American Academy of Pediatrics’ Bright Futures guidelines cover recommended care in more depth.
- The Well Visit Planner is a free tool that helps you prepare for upcoming visits.
YSHCN for Young Adults Ages 19 Through 26
Who qualifies for YSHCN?
- Young adults ages 19 through their 26th birthday can qualify for YSHCN.
- To qualify, you must have a condition that started before you turned 19, including:
- Physical, intellectual, or developmental disabilities
- Long-standing medical conditions like asthma, diabetes, or spina bifida
- Behavioral health conditions like depression or substance use
How do I sign up?
To sign up, call Oregon Health Authority (OHA) Customer Service at 800-699-9075.
What’s covered
Regularly scheduled exams
YSHCN covers regularly scheduled exams in the following areas:
- Physical health
- Behavioral health
- Developmental health
- Oral and dental health
Coverage beyond the standard list
- UHA covers medically necessary and appropriate care even when it is not on OHA’s prioritized list of health services.
- A service is medically necessary if it is needed to prevent, diagnose, or treat a condition, or to support your growth, development, independence, and participation in school.
- A service is medically appropriate if it is safe, effective, and improves your participation in care and activities.
- UHA may choose to cover the least expensive option that works for you.
Information for Both EPSDT and YSHCN Members
Not enrolled with UHA for dental care?
- You can still get dental services through OHP Open Card.
- Call 800-562-4620, TTY: 711.
How does UHA decide if a service is covered?
- UHA considers two things when deciding if a service is covered: the member’s age and medical necessity.
Do some services need prior authorization?
- Yes, some services need approval before you can get them. These reviews help make sure members get medically necessary services.
- This includes services that are not on the Oregon Health Plan Prioritized List, along with some other services. Ask your provider or call UHA Customer Care if you have questions.
- Your provider handles this process for you and sends the request to UHA.
- UHA’s reviewer looks at nationally recognized clinical guidelines, EPSDT standards, and Oregon Health Authority requirements. Some reviews are handled by UHA’s Medical Director.
Need a referral for treatment not covered under EPSDT?
- UHA will give you the phone number for referral assistance. This can help you find social services, education programs, and nutrition assistance programs such as SNAP.
What if a service is denied and I don’t agree?
- You can appeal a denied service.
- Go to the UHA appeals page to learn more.
Don’t have a ride to your appointment?
- UHA’s non-emergent medical transportation (NEMT) service can get you to and from your appointment, and we can help you schedule it.
- Call 877-324-8109, TTY: 711, or go to umpquahealth.com/members/benefits-programs/get-a-ride to get a ride.
Still have questions?
- Talk to your PCP.
- Call UHA Customer Care at 541-229-4842, TTY: 711.
