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Medi-Cal EPSDT Program

California's Medicaid program, Medi-Cal, is a source of health coverage for over 13 million Californians, including about 5.6 million people under age 21. People under age 21 may be enrolled in Medicaid because: 

  • They are children in families with incomes less than 266% of the federal poverty level;
  • They are eligible for Supplemental Security Income (SSI);  
  • They are adults earning less than 138% of the federal poverty level;
  • They are people with disabilities who are eligible through Medi-Cal's "Aged, Blind or Disabled" program or through Medi-Cal's workers with disabilities program.

Some people under age 21 may also be enrolled in Medicaid through other programs, such as the program for low-income pregnant individuals.  

Medi-Cal beneficiaries under age 21 are entitled to special protections under federal Medicaid law. The law requires that Medi-Cal cover all medically necessary Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. These services can include:

  • Diagnostic assessments
  • Communication assessments
  • Occupational, physical, and speech-language therapies
  • Assistive communication devices and training in use of these devices
  • Other intensive communication interventions

Medi-Cal must cover these services for people under 21 whenever they are medically necessary, even if they aren't included in the official list of services covered by Medi-Cal (also known as the State Plan). Medi-Cal beneficiaries under age 21 are entitled to these services whether they're enrolled in "traditional" Medi-Cal or one of Medi-Cal's managed care programs. 

For more information on EPSDT services that may be required for people with developmental disabilities, see recent guidance from the Centers for Medicare and Medicaid Services (CMS) on the EPSDT rights of people on the autism spectrum. You may also want to refer to California Department of Health Care Services' All-Plan Letters describing EPSDT requirements in general and required behavioral health treatment (BHT) services for people on the autism spectrum (note that many communication-related services for people on the autism spectrum will not count as Behavioral Health Treatment but may still be covered by EPSDT in general).   

How to Access Services Using EPSDT

To request services through EPSDT, go through the regular procedure for requesting coverage for health care services through your Medi-Cal program. This may vary depending on whether the beneficiary is enrolled in traditional Medi-Cal or one of Medi-Cal's managed care programs. 

If the plan responds that the service is not covered, you can file an "internal appeal." The process for filing the appeal should be described in the notice that the claim was denied. Make sure to:

  • Include a letter from a doctor prescribing the screening or service, and explaining why the screening or service is medically necessary
  • Note in the appeal that the service is covered by EPSDT.

If the request is still denied, beneficiaries can ask for a Medi-Cal Fair Hearing. For more information on how to file a hearing request, read the California DHCS web site. Hearing requests can be made over the phone at 1-800-952-5253 (Voice) or 1-800-952-8349 (TDD). People can also request a hearing online.

If a managed care plan cuts off services that the beneficiary was already getting, the beneficiary has special rights. The plan must send the beneficiary a termination notice in advance. When the beneficiary gets this notice, they can file for a Medi-Cal Fair Hearing (see above) to appeal the decision to cut off the services. While the hearing is pending, the beneficiary can ask for "aid paid pending" - which means that the beneficiary can continue receiving the service until the appeal is decided.

Special Note on Assistive Communication (AAC) Devices

Medi-Cal covers many AAC devices as durable medical equipment. Disability Rights California has published a resource for beneficiaries on the process of requesting authorization for these devices. As Disability Rights California notes in its resource, requests often require extensive documentation. These documents are described in the Medi-Cal Durable Medical Equipment and Medical Supplies manual. Because the documentation requirements are extremely complicated, these requests are typically filled out by providers, such as the AAC vendor or speech-language therapist. 

Medi-Cal will only cover the lowest-cost item that will serve the beneficiary's needs. If you need a very specific device, it is important to provide as much documentation of this need as possible and explain why lower-cost items will not adequately meet the beneficiary's needs. 

Multi-use devices

Some AAC devices, such as iPads, Android tablets, software, and Bluetooth keyboards may not necessarily be covered. This is because Medi-Cal is only required to pay for speech-generating devices that are not generally useful to people without disabilities or other medical conditions. Since people without disabilities can use a tablet or Bluetooth keyboard, these may not automatically be covered. 

You can still request coverage for these devices, however, especially if the beneficiary is enrolled in a Medi-Cal managed care program. To request coverage, submit a request for an AAC device that describes all the functions that the device must perform. You can then note that a device like a tablet can perform all of these functions at significantly less cost than the cheapest disability-specific device. 

Timely Access to Care

Medi-Cal managed care companies may require beneficiaries to get services only through a list of in-network providers. This can cause problems if the in-network providers are overloaded and have long wait times for appointments.

California's Timely Access Law protects people enrolled in Medi-Cal. Under the law,

  • Non-"urgent” specialist visits must generally be provided within 15 business days (about three work-weeks) of a request for an appointment;
  • The managed care provider must make "pre-approval" decisions in time to schedule the appointment within 15 business days of the pre-approval request;
  • Phone calls to the plan's customer service phone number during normal business hours should be answered by a staff member within 10 minutes;
  • Urgent phone calls to the plan's customer service number should be answered, or someone must call you back, within 30 minutes. Urgent calls must be answered 24 hours a day, 7 days a week.  

There may be exceptions when a doctor puts a note in the medical record that waiting longer than 15 business days would not harm the beneficiary's health. That means that it is important to make clear that, with communication services and assessments, every day counts. Many people with communication challenges have already waited a very long time before getting an assessment or receiving services. Because it can take a long time to develop communication skills even after the assessment, delays in getting an assessment can result in serious consequences for people’s health care and quality of life. Moreover, even one day without access to effective communication supports can be frustrating or dangerous.

For more information on the Timely Access law, see the California DHCS web site. 

Sample Letters

Medi-Cal Appeal/Hearing Request Letter (new service)

Medi-Cal Appeal/Hearing Request Letter (cut-off service)

More Resources

Disability Rights California: Extra Services for Children and Youth Under The Medi-Cal EPSDT Program

Disability Rights California: Obtaining Assistive Technology through Medi-Cal

Autistic Self Advocacy Network Guide to Medicaid Coverage for Autism Services