The EPSDT benefit entitles enrolled members under the age of 21 to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in the SSA, Section 1905(a), regardless of whether or not the service is covered under the Medi-Cal State Plan or is listed in the Manual of Criteria, if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions, meaning that the service is medically necessary under EPSDT. Effective January 1, 2019, Welfare and Institutions Code section 14059.5 distinguishes the definition of medical necessity for individuals 21 and older compared with the definition for those under 21. For individuals younger than 21 years of age, services are determined to be medically necessary when needed to correct or ameliorate defects and physical and mental illnesses or conditions. A service need not cure a condition in order to be covered under EPSDT. Services that maintain or improve the child’s current health condition are also covered in EPSDT because they “ameliorate” a condition. Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems. Services are covered when they prevent a condition from worsening or prevent development of additional health problems. The common definition of "ameliorate" is to "make more tolerable."
Medi-Cal members under age 21 may require dental services that are not part of the current Medi-Cal Dental Program scope of benefits. Conversely, the dental service may be part of the Medi-Cal Dental Program scope of benefits for adult members but not for members under the age of 21, or the dental provider may want to provide the service at a frequency or periodicity greater than currently allowed by the Medi-Cal Dental Program. In these cases, the child member may still be eligible for these services based upon submitted documentation that demonstrates the medical necessity to correct or ameliorate the child’s condition.