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 members 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 Members
Medi-Cal providers (medical, dental, and mental health plans, and enrolled) should inform Medi-Cal members (under age 21), or their parents, about the following:
- Why preventive services and screenings are important
- What services are offered under Medi-Cal for Kids & Teens
- Where and how to get services
- Services are free
- 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
Member handbooks
Related materials
For help communicating with members, 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
Please note, DHCS advises all providers to work with and direct all inquiries regarding the Medi-Cal for Kids & Teens provider training requirements to their respective Managed Care Plans (MCPs) for clarification. See also All Plan Letter 23-005 for additional information related to training requirements.
- Medi-Cal for Kids & Teens Provider Training
- Medi-Cal for Kids & Teens Provider Training Resource Companion
California Child and Adolescent Mental Health Access Portal (Cal-MAP)
Cal-MAP is a free, statewide behavioral health consultation and training program. Through Cal-MAP, providers access with free, essential tools to better address their young patients’ behavioral health needs, including:
- Expert consultations with psychiatrists or psychologists
- Systems of care navigation support and referrals
- Topic and diagnosis-specific information for families and PCPs
- Continuing Medical Education (CME) credit training for PCPs
Brochures
- WellCare Brochure Child (English)
- WellCare Brochure Child (Espanol)
- Know Your Rights (English)
- Know Your Rights (Espanol)
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
Behavioral Health Information Notices
- 21-019
Medical necessity determination and level of care placement as part of California’s Advancing and Innovating Medi-Cal (CalAIM) - 18-048
Data submission requirements for EPSDT services - 17-052
Specialty mental health services performance outcomes system functional assessment tools for children and youth - 16-063
Substance Use Disorder (SUD) services available under EPSDT - All notices
Federal Approvals
- SPA 15-034
Updates language for EPSDT preventive and wellness services
Related Services
- Child Health and Disability Prevention Program (CHDP)
- Children’s Medical Services
- Medi-Cal Dental Program
- California Children’s Services
- Genetically Handicapped Persons Program (GHPP)
- Mental Health and Substance Use Disorder Services (MHSUDS)
Contact
More Information
For more information about the Medi-Cal for Kids & Teens benefit:
Email: medi-calkidsteens@dhcs.ca.gov
To sign up as a Medi-Cal Provider: Please see the Provider Enrollment website.
Medi-Cal Managed Care Plans: Please reach out to your assigned contract manager for any inquiries.
For general Medi-Cal Provider support or questions: Please visit the Contact Us webpage for further information or call the Telephone Service Center at 1-800-541-5555.