Federal, exists in every state
Ask Utah Medicaid to review care your child needs (EPSDT)
Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.
What it is
Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.
For a child under 21 on Medicaid, medically necessary care that fits a Medicaid benefit category must be covered, even when the plan’s usual list leaves it out. It is a coverage protection, not cash, and a doctor’s order is not automatic approval; the clinician explains the need and the plan reviews it.
Rules
- The service must fit a federal Medicaid benefit category and meet medical-necessity rules.
- For a Utah Medicaid managed-care denial, the member handbook gives 60 calendar days from the denial notice to appeal. Standard appeal decisions are due within 30 calendar days; urgent ones within 72 hours when delay threatens health or function. A delay of up to 14 days needs the member’s request or a supported need for information in the member’s interest, with notice and a right to challenge the delay. After the plan appeal, Utah’s published handbook gives 120 days to request a state hearing; continuation of existing services has a much shorter deadline.
- Keeping existing care during a Medicaid managed-care appeal requires a separate timely request. The appeal must concern reduced, suspended or ended care ordered by an authorized provider, with the original authorization still unexpired. The initial continuation deadline is the later of 10 calendar days after the plan sends notice or the proposed change date. After an unfavorable plan appeal, the hearing and continuation requests generally must arrive within 10 calendar days after the resolution is sent, not the ordinary 120-day hearing window. Permitted repayment can apply if the final decision goes against you. For fee-for-service decisions or transportation-only plans, your social worker can check the different process and notice deadlines.
- A permitted appeal extension can last up to 14 calendar days. When the plan extends for additional information, written notice is due within 2 calendar days and includes grievance rights. Failure to follow appeal timing or notice duties can count as exhaustion of the plan appeal. Your social worker can check the notice and circumstances.
What you get
- A route to coverage of nursing, equipment, therapies or other care the plan’s standard list omits.
- Expedited review when waiting could harm your child.
What it is not
- Not a promise of any service requested, and not a cash program.
If you decide to apply
- If you choose to request a review, ask your Utah Medicaid care manager to consider the specific service under EPSDT.
- Have the clinician send records describing the service, frequency, expected benefit and the risk of going without.
- If care is denied, discuss the written reason, appeal deadline and any urgent-review request with your care team.
Medicaid: EPSDT · Official page ↗
Records
- Keep the request date and the plan’s reference number.
Good to know
Ask for a named care manager at the plan as soon as your child is enrolled; that is who receives these requests. If a service might be cut, do not wait for the reduction to happen before asking about continued services.
Other details
- This applies inside Medicaid only; a work plan has its own appeal route (below).
Related Utah card: Skilled nursing at home.
Official sources
“If care is refused, what are the benefits and risks of requesting an EPSDT review, and could you help us decide and reach the care manager?”
Why I’m asking: We want to know the route before a refusal happens.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask the plan for a care manager, keep a two-week log of the daily tasks, and put every request in writing under Medicaid's rule that a child under 21 gets what is medically needed.
Your social worker
Gets the care manager assigned and sends the request to the right approval desk.
The care team
Writes the order and the letter of medical necessity naming the service, the frequency and the risk without it.
- Who decides
- The Medicaid plan or agency, on medical necessity
- Ask your social worker
- “Can you get us a care manager at the Medicaid plan? Will the team write the letter asking for home nursing, equipment and rides?”
How to apply
First step: Ask the Medicaid plan for a care manager. Put the request in writing and ask for review under EPSDT.
- Ask the Medicaid plan for a care manager.
- Put the request in writing under EPSDT.
- Ask the clinician to write what the service corrects, how often, and the risk without it.
Where it starts: Written request to the plan's care manager. Medicaid appeal if denied
What to gather
- The doctor's order and a letter of medical necessity
- A two-week log of the daily tasks at home
- Any denial letter, with the date
How long: An appeal of a “no” is decided within 30 days, or 72 hours when waiting is unsafe.
What a yes looks like
An approval with hours or units and a start date.
What a no looks like, and the next move
A written denial with appeal rights. Appeal within the notice's period and ask for benefits to continue.
Watch out
- “Not a covered benefit” is not the end of it for a child. Ask the plan to review the request under Medicaid's rule that a child under 21 gets what is medically needed, in writing.
- Medical necessity is still reviewed. The doctor's letter must say what the service corrects or prevents, how often, and what happens without it.
- Nursing and personal care fit. A parent's wages for care usually do not, unless the state runs a paid-caregiver option.
- Hospice does not mean stopping chemo for a Medicaid child. Since 2010 a child under 21 can have hospice and treatment at the same time. A CHIP-only plan can choose not to cover hospice; if it does, the same rule applies.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 8, 2026.
What it is worth
Home nursing, personal care, equipment, therapies and transport paid by Medicaid on the doctor's word.
Covers: Private-duty nursing at home · Personal care · Feeding pumps, oxygen and other equipment · Therapies and behavioral health · Rides to treatment
Legal protection: Correct-or-ameliorate standard for any service in a Medicaid category · The state owes the benefit even when a managed-care plan says no · Hospice does not mean stopping treatment: since March 23, 2010 a Medicaid child under 21 can have hospice and curative care at the same time (a doctor still certifies a prognosis within six months for hospice)
What it costs the family: Part of Medicaid. No separate premium.
The eligibility facts, as published
- Age under
- 21
- Medicaid required
- yes
Decisions this site cannot make: Medical necessity · Medicaid service category (section 1905(a))
Expect friction on: Prior approval · Clinical documentation
The trap: Medicaid's rule that a child under 21 gets what is medically needed changes the standard, not the review: the doctor's letter still has to say what the service corrects, how often, and what happens without it.
What changes by state: Nothing in the rule. The plan's forms and the state's paid-caregiver option do.
Where I read this
- Early and Periodic Screening, Diagnostic, and Treatment — Centers for Medicare & Medicaid Services, read August 27, 2026
- State Medicaid Director letter 23-006: non-emergency medical transportation guide — Centers for Medicare & Medicaid Services, read September 7, 2026
- 42 CFR 438.408: Resolution and notification of managed-care appeals — Cornell LII (eCFR mirror), read September 7, 2026
- CMS State Medicaid Director letter 10-018: concurrent care for children (ACA §2302) — Centers for Medicare & Medicaid Services, read September 8, 2026