Written by a parent, not a doctor. Nothing here is medical advice.

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Ask 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 Cardinal Care managed care, an internal appeal is generally due within 60 calendar days after the plan sends its adverse decision. The plan ordinarily decides within 30 calendar days after receiving the appeal, or within 72 hours for a qualifying urgent appeal; a permitted extension is at most 14 calendar days and requires the stated reason and notice. After the final plan appeal decision, Virginia's regulation gives 120 days from that decision's date to request a DMAS hearing. A plan that misses required notice or timing rules can be treated as having exhausted its appeal process. The shorter deadlines for keeping existing services are different and are explained below.
  • To keep an existing service during a managed-care appeal, request both the appeal and continued benefits by the later of the proposed action date or 10 calendar days after the plan sends the adverse notice. The dispute must concern a previously authorized service being reduced, suspended or stopped, ordered by an authorized provider, with the original authorization period still unexpired when continuation is requested. If the plan upholds its decision, request both a DMAS hearing and continued benefits within 10 calendar days after the plan sends its final appeal decision. The plan may seek repayment for services provided only because the appeal was pending if the final decision goes against the child, under the applicable recovery rules; continuation is not automatic coverage of a new service.
  • Under Virginia’s hearing rules, final administrative action generally occurs within 90 days measured from the original plan appeal, excluding the time taken to request the state hearing and subject to the stated exceptions.
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
  1. Ask the Medicaid care manager, in writing, to review the specific service under EPSDT.
  2. Have the clinician send records describing the service, frequency, expected benefit and the risk of going without.
  3. If denied, get the reason in writing and appeal within the deadline; ask for urgent review when needed.

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 Virginia card: Nursing hours at home, and pay for a parent doing the care.

Official sources
Ask your social worker

“Once our child is on Medicaid, if a service is refused, can the team ask for an EPSDT review, and who at the plan would we contact?”

Why I’m asking: We want to know the route before a refusal happens.

More background and detailed requirements

How this works

The rule is called EPSDT. It can matter for nursing, equipment, therapy or other care needed to improve or manage your child's condition.

Your clinician explains what is needed, how often and what could happen without it. Medicaid then reviews medical necessity and whether the service falls within the federal Medicaid benefit categories. A doctor's recommendation alone is not an approval.

  1. Ask the Medicaid care manager to review the specific service under EPSDT and have the clinician send supporting records.

Before you start

  • This is a coverage protection within Medicaid, not a separate cash benefit or a promise of any service requested.
  • A denial should explain the reason and appeal rights. For urgent care, ask the team to request an expedited review.

This is a coverage protection within Medicaid, not a separate cash benefit or a promise of any service requested.

A denial should explain the reason and appeal rights. For urgent care, ask the team to request an expedited review.

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.

  1. Ask the Medicaid plan for a care manager.
  2. Put the request in writing under EPSDT.
  3. 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

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