EPSDT coverage for pediatric OT, PT and speech therapy

For OT, PT and speech practices treating Medicaid patients under 21, including young adults in adult clinics: EPSDT requires states to cover medically necessary, Medicaid-coverable therapy that corrects or ameliorates a condition, even past adult limits.⁠^1,2 Each request is still judged case by case, so verify benefits, document need and use the appeal routes.⁠³

What is EPSDT, and which therapy patients does it cover?

EPSDT, Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit, covers screening, diagnosis and treatment for eligible Medicaid patients under 21. The Social Security Act makes it a benefit "for individuals who are eligible under the plan and are under the age of 21", and federal regulations define its treatment part as "health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered".⁠^1,11

It matters to therapy practices because of how Medicaid’s benefit list is built. Medicaid.gov lists EPSDT among the benefits states must provide, and physical therapy, occupational therapy, and speech, hearing and language disorder services among the optional benefits a state may add.⁠¹² CMS reads the statute to mean that an optional service a state does not cover for adults "must still be made available to EPSDT-eligible children when it is medically necessary".⁠² A state that offers adults little or no outpatient therapy still owes medically necessary OT, PT and speech-language services to its EPSDT-eligible patients.

Eligibility follows the Medicaid program, not only the age. CMS’s September 26, 2024 letter says EPSDT-eligible children generally include beneficiaries under 21 in Medicaid through a categorically needy group, through a medically needy group where the state has elected to include EPSDT, in a Medicaid-expansion CHIP program, or in a separate CHIP program that has elected to cover EPSDT; groups eligible only for limited services are not included.⁠²

Does EPSDT apply to a 19-year-old seen in an adult clinic?

Yes, if the patient is eligible: the statute’s line is "under the age of 21", not 18.⁠¹ An adult PT clinic treating a 20-year-old on Medicaid after a sports injury, or an adult speech practice seeing a 19-year-old after a brain injury, is treating an EPSDT-eligible patient, and the request is judged under the same correct-or-ameliorate standard as a young child’s.⁠^1,2 Intake scripts that send every adult Medicaid patient down the adult benefit path should check the date of birth first.

What must Medicaid cover for OT, PT and speech under EPSDT?

Medicaid must cover every Medicaid-coverable service that is medically necessary to correct or ameliorate the patient’s condition, whether or not the state plan covers it. The statute covers "such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan", and subsection (a) lists "physical therapy and related services".⁠¹ CMS’s May 2026 guide for states names "physical, speech/language, and occupational therapies" among the services this reaches, and the federal definitions of the three therapies each include "any necessary supplies and equipment".⁠^4,5

The condition does not have to come from a well-child visit: CMS’s letter says the state must cover medically necessary services for a condition "regardless of whether the condition was present and identified during a well-child visit".⁠² The reach has an edge too. Services outside the section 1905(a) categories are not subject to EPSDT; CMS names home accessibility modifications and respite care.⁠⁴

Managed care does not lower the standard. A plan’s contract must require services in no less amount, duration and scope than fee-for-service Medicaid and, for enrollees under 21, as the EPSDT regulations set out, and the state keeps "ultimate responsibility" for EPSDT compliance however large the plan’s role.⁠^2,7

What does "correct or ameliorate" mean for a therapy request?

It means the service has to help the condition, not cure it. CMS’s guide describes ameliorating as making a condition more tolerable and states that "services that maintain or support health problems rather than cure or improve them can be ameliorative".⁠⁴ CMS’s 2024 letter says a service "need not cure a condition" to be covered, that services ameliorate when they "prevent a condition from worsening or prevent development of additional health problems", and that physical and occupational therapy are covered "when they have an ameliorative, maintenance purpose".⁠² The letter’s example names PT and OT; the statutory standard reaches every section 1905(a) service, and Medicaid.gov places speech, hearing and language disorder services in section 1905(a)(11) beside PT and OT.⁠^1,12

So goals that keep a skill, slow a decline or prevent a secondary problem fit the standard when the record shows the service is needed for that purpose, and a reassessment should show what therapy is maintaining or preventing, not only what changed.⁠²

Can a state cap therapy visits for a child on Medicaid?

Not with a hard cap. CMS’s guide uses therapy as its own example: a state may limit physical therapy visits per year for people 21 and older, but "such a hard limit could not be applied to EPSDT-eligible children".⁠⁴ A state or plan may use a soft limit, one that can be exceeded with prior authorization or a medical necessity review; if review of the child’s case shows more visits are medically necessary, "those services would have to be covered".⁠^2,4 The guide also rules out flat, fixed or arbitrary limits, "hourly maximums" among them.⁠⁴

A categorical denial runs into a second rule. Fee-for-service Medicaid may limit services on medical necessity or utilization control grounds but may not deny or reduce a required service "solely because of the diagnosis, type of illness, or condition", and managed care contracts carry the same bar.⁠^6,7 CMS also tells providers not to "assume that hard limits on adult services apply to children".⁠²

Does a child on Medicaid need a prescription for therapy?

For PT and OT, the federal definition calls for a prescription; for speech-language services, it calls for a referral. Medicaid’s regulation defines physical and occupational therapy as services "prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law", and speech, hearing and language services as services "for which a patient is referred" by the same kind of practitioner.⁠⁵ Who may prescribe or refer depends on that practitioner’s scope under state law; what the order must contain and how long it lasts are questions for the state agency or plan, asked before the evaluation.⁠⁵

The same regulation says who provides the service: a qualified physical or occupational therapist meets the personnel qualifications at 42 CFR 484.115, and a speech pathologist holds ASHA’s certificate of clinical competence, has the equivalent education and experience, or "has completed the academic program and is acquiring supervised work experience to qualify for the certificate".⁠⁵ Enrollment with the state and each plan comes on top: the guide to becoming a Medicaid therapy provider covers the state enrollment and plan contracts, and the credentialing guide covers the wider credentialing process.

An order in clinical language is not a bar. When a child’s physician or other provider prescribes a service in terms that do not mirror Medicaid’s, CMS’s guide says "the state must determine if the service or supply could be covered under Section 1905(a)".⁠⁴ The pediatrician referrals guide covers the relationships that produce those orders.

How do you verify EPSDT therapy benefits before the evaluation?

Confirm four facts in writing before the first visit: the patient’s Medicaid program and age, whether therapy runs through fee-for-service or a managed care plan, whether the clinic and clinician are enrolled for that route, and whether the service needs prior authorization. Each one changes who decides the request and where an appeal goes.

Ask who pays for therapy for this patient, not only which card the patient carries. States may deliver services through managed care plans, fee-for-service "or a combination of delivery systems", and CMS’s guide says that when a plan contract excludes benefits above specified limits, the state "must ensure provision of medically necessary services above those limits through another mechanism (e.g., on a FFS basis)".⁠^2,4 A plan’s limit may not be the last word.

Prior authorization lists are now public. Beginning in 2026, state Medicaid agencies post the previous year’s prior authorization data, starting with "a list of all items and services that require prior authorization", and managed care plans post the same list at the plan level.⁠^6,7 Network status matters as well: under fee-for-service a child may use any qualified provider willing to furnish the service, while plans may restrict choice to their networks.⁠⁴

What if the plan has no in-network therapist who can see the child?

Ask the plan for an out-of-network authorization and keep the search record. CMS’s guide says a shortage of treating providers "does not relieve a state of its obligation", that plans may need to cover providers outside the network "when that network is unable to provide necessary services covered under the contract", and that a state may need a single-service agreement with a provider type not participating in Medicaid.⁠⁴ The family’s side is in the guide to finding therapy when no in-network therapist is available.

What must therapy documentation show for EPSDT medical necessity?

It must show, for this patient, the condition, how the requested service corrects or ameliorates it, and why the amount requested is needed, because the state decides case by case on the evidence. CMS’s guide puts the recommendation with the clinician ("the treating health care provider is responsible for determining or recommending that a particular covered service is needed to correct or ameliorate the child’s condition") and the coverage decision with the state, "based on the evidence and application of the EPSDT requirements".⁠⁴ CMS’s letter adds that decisions are made "on a case-by-case basis, taking into account the particular needs of the child", and that the state or plan "should consider the child’s long-term needs, not just what is required to address the immediate situation".⁠²

Build the record around those words:

• The route to therapy: the screening, diagnostic finding or physician visit that identified the need, and the dated prescription (PT, OT) or referral (speech-language).⁠^3,5
• The condition and the child’s particular needs: the diagnoses, the evaluation findings and what the patient cannot yet do, in the standardized and functional measures your discipline uses.⁠²
• The correct-or-ameliorate link: what the service is meant to improve, maintain or keep from worsening; maintenance counts.⁠^2,4
• Long-term needs: what the patient needs across the coming stages of development or school, not only the next few weeks.⁠²
• The plan and the amount: frequency, duration, setting, goals and how progress or maintenance is measured, with the reason for any amount above a soft limit.⁠²
• The plan’s own criteria: a managed care contract’s definition of medically necessary services must address the extent to which the plan covers services for "age-appropriate growth and development" and the ability to "attain, maintain, or regain functional capacity", so tie goals to those phrases where they fit.⁠⁷

Ask for the criteria before writing a request above a limit. A managed care notice must tell the family they can get, free, copies of the documents relevant to the decision, which "includes medical necessity criteria".⁠¹³ Answer each criterion in the request.

What should an EPSDT letter of medical necessity include?

It should name the patient, the order, the condition, the service, the amount and the EPSDT standard, in one or two pages signed by the treating therapist, sent with the evaluation and plan of care.

How does prior authorization work for EPSDT therapy services?

States and plans may require it, but under CMS’s reading it has to look at each patient individually and must not hold up needed treatment: prior authorization "must be conducted on a case-by-case basis, evaluating each child’s needs individually, and it must not delay the delivery of needed treatment services".⁠² Federal rules now set the decision clocks:

Plans owe the requesting clinician two things: they must consult the requesting provider when appropriate, and a decision to deny or approve less than requested must be made by someone "who has appropriate expertise in addressing the enrollee’s medical, behavioral health, or long-term services and supports needs".⁠⁷ When a reviewer offers a call, take it with the record open. A state can weigh cheaper alternatives, but CMS’s guide says the less expensive option must be "equally effective and available", the child’s quality of life must be considered, and treatment may not be denied "based on cost alone".⁠⁴

When should a therapist ask for an expedited decision?

Ask when waiting the standard time could seriously jeopardize the patient’s life, health or ability to attain, maintain or regain maximum function; in managed care, a provider’s indication that this is so puts the request on the expedited track.⁠⁷ For a child still building skills, "attain" is the word in that standard to address. State the reason in one or two sentences with the evidence; fee-for-service expedited decisions are due within 72 hours.⁠⁶

What can a practice do when EPSDT therapy is denied or cut?

First name the problem, because each kind of "no" has its own route. A claim denied only because it is not a clean claim is a billing fix, not an adverse benefit determination; a denied or partly approved authorization, or a reduction or termination of services already authorized, is an adverse benefit determination that can be appealed.⁠⁸ For a fee-for-service decision, the route is the state fair hearing, which the state must offer for "a prior authorization decision" among other actions.⁠¹⁴

For a managed care plan, the steps run in this order:

1. Read the notice. It must give the reasons, the family’s right to free copies of the documents relevant to the decision, including the medical necessity criteria, and the right to have benefits continue during the appeal.⁠¹³
2. File the plan appeal. The family has 60 calendar days from the notice date and may appeal orally or in writing; a provider may appeal for the family with the family’s written consent where state law permits.⁠⁸
3. Send the evidence. Appeals of medical necessity denials go to reviewers with appropriate clinical expertise who take into account everything submitted, whether or not the first reviewer saw it.⁠¹³
4. Track the clock. A standard appeal is resolved within a state timeframe of no more than 30 calendar days, an expedited one within 72 hours, extendable by up to 14 days; a plan that misses its notice and timing rules is deemed to have exhausted its appeal, and the family may go to a fair hearing.⁠⁹
5. Request the state fair hearing. After the plan upholds its decision, the family has no less than 90 and no more than 120 calendar days from the plan’s notice; any external medical review the state offers is optional and cannot be required first.⁠⁹

In fee-for-service Medicaid, the family has a reasonable time, not more than 90 days from the date the notice is mailed, to request a hearing, and the agency ordinarily takes final action within 90 days of the request, with an expedited process when the wait could jeopardize the patient’s life, health or ability to attain, maintain or regain maximum function.⁠¹⁴

Put the EPSDT standard in the first paragraph of every appeal: the patient is under 21, and the request is for a section 1905(a) service needed to correct or ameliorate the condition. CMS’s letter says fair hearing decisions must correctly apply federal and state law, "including the EPSDT ’correct or ameliorate’ standard".⁠² If the plan or a hearing officer reverses a denial of services the patient did not receive during the appeal, the plan must authorize or provide them no later than 72 hours from the notice of reversal, and a plan may not take punitive action against a provider who supports the family’s appeal.⁠^9,15

Can therapy continue while a Medicaid appeal is pending?

Sometimes: when the appeal is about cutting or ending services already authorized, and the family asks in time. In managed care, benefits continue if the appeal is filed on time, the services were ordered by an authorized provider, the original authorization period has not expired, and the family asks within 10 calendar days of the notice being sent or by the intended effective date, whichever is later; a provider cannot make that request for them.⁠^8,15 In fee-for-service, the state must send notice at least 10 days before the action, and a hearing request before the date of action keeps services in place until the decision unless the only issue is one of federal or state law or policy.⁠¹⁴ Either way, the state or plan may recover the cost of continued services if the family loses.⁠^14,15 Tell the family which date matters the day the notice arrives, and let them decide.

Who files the appeal: the family or the therapy practice?

The family holds the right; the practice supplies the evidence and, where allowed, files for them. A provider may appeal, file a grievance or request a state fair hearing for a managed care enrollee "if State law permits and with the written consent of the enrollee".⁠⁸ In a fee-for-service hearing, the family may represent themselves or use a lawyer, relative, friend or other spokesperson.⁠^4,14 Keep the signed consent in the appeal file; the family’s side is in what to do when insurance denies therapy.

What changes for therapy coverage when a patient turns 21?

EPSDT ends, and the patient’s therapy is judged under adult rules from then on. CMS’s letter says a youth who keeps Medicaid moves to the adult benefit package, where services "might be subject to amount, duration, or scope limitations that did not apply under EPSDT"; because states need not cover optional benefits for adults, "some services may no longer be available", and some youth lose Medicaid and need other coverage.⁠² PT, OT and speech-language services are among those optional benefits.⁠¹²

Plan for the birthday inside the plan of care:

• Check the adult benefit for each discipline the patient receives, and whether the same plan continues, well before the 21st birthday.
• Set goals and frequency for the months before 21 knowing what the adult benefit allows, and record the transition in the chart.
• Tell the patient and family in writing what changes, on what day, and whom to call.
• If the clinic does not serve adults, start the handoff early; the pediatric-to-adult transition guide covers the steps, and the guide to discharging patients covers the closing summary.

Can a practice bill the family for therapy Medicaid covers?

Not for a covered service. Federal rules limit Medicaid participation to providers who accept "as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan", and the EPSDT rules tell families that services are without cost to eligible individuals under 18, and at the state’s option up to 21, apart from certain charges for medically needy beneficiaries.⁠^10,16 CMS’s guide spells out two consequences: no billing the family for the difference between the clinic’s charge and the Medicaid payment, and no billing for missed appointments.⁠⁴ A clinic with a no-show fee needs a written exception for Medicaid patients; the appointment reminders guide covers reducing missed visits without one. Rates are a separate question: the statute gives states broad authority to set fee-for-service rates, and managed care plans set what they pay providers in their networks; the guide to negotiating reimbursement rates covers which of those can be negotiated.⁠⁴

What if a child has both private insurance and Medicaid?

Bill the other coverage first unless the state says otherwise. Under the federal third-party liability rule, when the state has established that another payer is probably liable at the time a claim is filed, it "must reject the claim and return it to the provider", then pays to the extent its fee schedule amount exceeds the other payer’s payment.⁠¹⁷ The rule makes an exception for "preventive pediatric services, including early and periodic screening, diagnosis and treatment services", so ask the state how it treats therapy claims for a child with other coverage, and keep the primary plan’s explanation of benefits with each Medicaid claim.⁠¹⁷

How should you explain EPSDT to a family without overpromising?

Explain the standard and the process, not an outcome. States determine medical necessity case by case, so the honest message is that federal law covers medically necessary therapy for eligible patients under 21, the state or plan decides each request, the clinic sends the evidence, and the family can appeal a no.⁠^3,8,14 CMS calls providers "often the primary source of information for beneficiaries", which puts that explanation with the clinic.⁠² States must also tell families that transportation and scheduling help is available, and provide it on request.⁠¹⁶ Families who need an interpreter or other access help can use the guide to finding therapy with Medicaid, access or language needs.

What should a clinic’s listing say about Medicaid plans?

It should name the plans the clinic is in network with, not just "Medicaid". Families search DrSensory free for OT, PT and speech therapy clinics for children and adults; every clinic keeps a basic listing at no cost, and a paid listing adds a description in the clinic’s own words and a Clinic details box that shows the insurance boxes the clinic ticks. Tick the Medicaid box, name the plans the clinic contracts with and the ages it sees in the description, and update both when a contract changes; the profile guide covers each field. DrSensory does not verify clinical quality or decide coverage.⁠^18,19

Which EPSDT situation calls for which document?

Match the response to the reason the plan or state gave.

How should a practice track each EPSDT request it sends?

Keep one record per request, from the order to the final decision, so anyone in the clinic can see the next deadline.

Record status with the same labels every time: requested, more information asked, approved, approved in part, denied, appeal filed, hearing requested, reversed, upheld. Silence is not approval, so a request with no answer stays "requested" until a notice arrives.

What does an EPSDT therapy request look like from start to finish?

The two cases below show the method on invented facts; neither is a likely result or a benchmark.

Sources

1. U.S. Government Publishing Office, govinfo. 42 U.S.C. 1396d, Definitions (section 1905 of the Social Security Act) (United States Code, 2023 edition; subsections (a)(4)(B), (a)(11) and (r)(5)). Checked October 24, 2026.
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   “early and periodic screening, diagnostic, and treatment services (as defined in subsection (r)) for individuals who are eligible under the plan and are under the age of 21”; “physical therapy and related services”; “Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan”.
2. Centers for Medicare & Medicaid Services. SHO # 24-005, Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements (State Health Official letter, September 26, 2024). Checked October 24, 2026.
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   “Children eligible for EPSDT generally include beneficiaries under the age of 21 enrolled: in Medicaid through a categorically needy group; in Medicaid through a medically needy group in a state that has elected to include EPSDT in the medically needy benefit package; in a Medicaid-expansion CHIP program; or in a separate CHIP program that has elected to cover EPSDT”; “other groups of individuals under age 21 who are eligible only for limited services as part of their Medicaid eligibility”; “regardless of whether the condition was present and identified during a well-child visit”; “Children covered through a Medicaid expansion CHIP are entitled to EPSDT”; “States have the option of delivering some or all section 1905(a) services through MCPs”; “or a combination of delivery systems”; “they prevent a condition from worsening or prevent development of additional health problems”; “CMS interprets the ‘correct or ameliorate’ requirement to mean that a service need not cure a condition in order to be covered under EPSDT as a medically necessary service”; “Thus, services such as physical and occupational therapy, for example, are covered when they have an ameliorative, maintenance purpose”; “CMS interprets this to mean that, if an optional 1905(a) service is not covered for adults, the 1905(a) service must still be made available to EPSDT-eligible children when it is medically necessary”; “Regardless of how significant an MCPs’ role may be in administering EPSDT, the state retains ultimate responsibility for assuring compliance with EPSDT requirements”; “Medical necessity criteria cannot have the effect of imposing a limit on the amount, duration, or scope of services that can never be exceeded for EPSDT-eligible children”; “states are not permitted to apply these kinds of limits to any service covered under EPSDT in either a FFS or managed care delivery system”; “a state may establish limits on the amount, duration, or scope of services that may be exceeded with prior authorization and/or a medical necessity review (i.e., a ‘soft limit’)”; “prior authorization must be conducted on a case-by-case basis, evaluating each child’s needs individually, and it must not delay the delivery of needed treatment services”; “State Medicaid agencies must exercise appropriate oversight of their Medicaid fair hearing system to ensure fair hearing decisions correctly apply all relevant federal and state law, regulations, and policies, including the EPSDT ‘correct or ameliorate’ standard”; “To contest an adverse benefit determination from a managed care plan, beneficiaries must file an appeal or grievance with the plan before requesting a state fair hearing”; “Providers are often the primary source of information for beneficiaries; therefore, it is essential they do not assume that hard limits on adult services apply to children”; “Because Medicaid providers request authorization of medical services for EPSDT-eligible beneficiaries, they should clearly understand how to request additional medical services”; “States’ and MCPs’ determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child”; “The state or MCP should consider the child’s long-term needs, not just what is required to address the immediate situation”; “Any youth no longer entitled to EPSDT who maintains Medicaid eligibility would transition to the Medicaid benefit package(s) available to adults in their respective state; the services included in their adult benefits might be subject to amount, duration, or scope limitations that did not apply under EPSDT”; “Because states are not required to cover optional section 1905(a) benefits for adults, some services may no longer be available”; “Depending on the state, some youth may no longer be eligible for Medicaid and would need to transition into other coverage”; “as of the date of this letter, 16 states with a separate CHIP have elected to cover a package of services that adhere to Medicaid EPSDT requirements”.
3. Medicaid.gov, Centers for Medicare & Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment (benefit page, undated). Checked October 24, 2026.
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   “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis”; “Arrange (directly or through referral) for corrective treatment as determined by child health screenings”.
4. Centers for Medicare & Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Guide for States: Coverage in the Medicaid Benefit for Children (guide for states, May 2026). Checked October 24, 2026.
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   “This includes physician, nurse practitioner, and hospital services; physical, speech/language, and occupational therapies”; “In addition to services that can ‘correct’ a condition, services that can ‘ameliorate’ a condition (i.e., make a condition more tolerable) must be covered under EPSDT”; “Services that maintain or support health problems rather than cure or improve them can be ameliorative”; “If an EPSDT-eligible child’s physician or other provider uses medical terminology to prescribe a medical service or supply that does not mirror Medicaid terminology, the state must determine if the service or supply could be covered under Section 1905(a)”; “a state may need to enter into a single-service agreement with a provider if a certain provider type is not participating in Medicaid but is needed for an EPSDT-eligible child’s medically necessary care”; “Services that are not listed in Section 1905(a) are not subject to EPSDT requirements”; “home accessibility modifications and respite care do not fall into a section 1905(a) benefit category and are therefore excluded under EPSDT”; “Flat, fixed, hard, or arbitrary limits (e.g., budget or monetary caps, standard deviations from the norm, or hourly maximums) are not consistent with the EPSDT requirements”; “although a state may include in its state plan a limit on the number of physical therapy visits per year for individuals age 21 and older, such a hard limit could not be applied to EPSDT-eligible children”; “A state could impose a ‘soft’ limit on the number of physical therapy visits, but if it were to be determined through review of an individual child’s case that additional physical therapy services were medically necessary to correct or ameliorate the child’s condition, those services would have to be covered”; “Although the treating health care provider is responsible for determining or recommending that a particular covered service is needed to correct or ameliorate the child’s condition”; “If there is a disagreement between the treating provider and the state’s expert as to whether a service is medically necessary for a particular child, the state is responsible for making a coverage decision for the individual child based on the evidence and application of the EPSDT requirements”; “A state may not deny medically necessary treatment to a child based on cost alone but may consider the relative cost-effectiveness of alternatives as part of the prior authorization process”; “states may cover services in the most cost-effective mode as long as the less expensive service is equally effective and available”; “The child’s quality of life must also be considered”; “EPSDT does not require coverage of treatments, services, or items that are experimental or investigational”; “Such services and items may, however, be covered at the state’s discretion if it is determined that the treatment or item could be effective in addressing the child’s condition”; “Medicare guidance on whether a service is experimental or investigational is not determinative of the issue and may not be relevant to the pediatric population”; “This continued coverage may be referred to as ‘continued benefits,’ ‘benefits pending,’ or ‘aid paid pending.’”; “The state must require enrollees to exhaust the MCP’s appeal process before requesting a state fair hearing”; “Beneficiaries have the right to represent themselves or use legal counsel, a relative, a friend, or other spokesperson”; “a lack of screening and/or treating providers does not relieve a state of its obligation to ensure that services are provided in a timely manner”; “for MCPs to cover services rendered by providers outside the plan’s provider network when that network is unable to provide necessary services covered under the contract”; “Under FFS, a child is entitled to receive Medicaid services from any provider qualified to provide the service and willing to furnish it”; “Although MCPs may restrict choice of providers in creating their networks”; “Although the statute provides states with broad authority to set FFS provider payment rates”; “For managed care, MCPs determine the payment rates that they pay providers that render covered services to their enrollees”; “This means that a provider may not bill a Medicaid beneficiary for the difference between the provider’s charge and the Medicaid payment (called ‘balance billing’). The payment in full requirement also prohibits Medicaid providers from billing beneficiaries for missed appointments”; “if a managed care contract excludes benefits above specified limits, the state must ensure provision of medically necessary services above those limits through another mechanism (e.g., on a FFS basis)”; “Managed care plans may not use a definition of medically necessary services for children that is more restrictive than the state’s definition”; “States have flexibility to cover and pay for Medicaid-covered services delivered via telehealth”; “School health clinics and community clinicians can function as Medicaid providers who are providing services in a school setting”; “That decision may be appealed by the child (or the child’s family) under the state’s Medicaid fair hearing procedures”; “case management; personal care; private-duty nursing; medical equipment and supplies; and physical, occupational, and speech-language therapy”; “Services may be provided by practitioners employed by the school district, by health clinics located in schools, or by community providers who are contracted to provide services in a school setting”.
5. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (current text). Checked October 24, 2026.
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   “Physical therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified physical therapist”; “Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified occupational therapist”; “Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist, for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law”; “It includes any necessary supplies and equipment”; “Has a certificate of clinical competence from the American Speech and Hearing Association”; “Has completed the academic program and is acquiring supervised work experience to qualify for the certificate”.
6. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 440.230, Sufficiency of amount, duration, and scope (current text). Checked October 24, 2026.
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   “Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose”; “Beginning January 1, 2026, make prior authorization decisions within the following timeframes”; “may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of the diagnosis, type of illness, or condition”; “The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures”; “For a standard determination, as expeditiously as a beneficiary’s health condition requires, but in no case later than 7 calendar days after receiving the request, unless a shorter minimum timeframe is established under State law”; “The timeframe for standard authorization decisions can be extended by up to 14 calendar days if the beneficiary or provider requests an extension, or if the State agency determines that additional information from the provider is needed to make a decision”; “For an expedited determination, as expeditiously as a beneficiary’s health condition requires, but in no case later than 72 hours after receiving the request”; “provide fair hearing rights, including advance notice, in accordance with part 431, subpart E, of this chapter”; “The State must make the following data from the previous calendar year publicly accessible by posting them on its website”; “A list of all items and services that require prior authorization”.
7. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 438.210, Coverage and authorization of services (Medicaid managed care) (current text). Checked October 24, 2026.
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   “no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid, as set forth in § 440.230 of this chapter, and for enrollees under the age of 21, as set forth in subpart B of part 441 of this chapter”; “May not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary”; “Is no more restrictive than that used in the State Medicaid program”; “On the basis of criteria applied under the State plan, such as medical necessity”; “The ability for an enrollee to achieve age-appropriate growth and development”; “The ability for an enrollee to attain, maintain, or regain functional capacity”; “Consult with the requesting provider for medical services when appropriate”; “be made by an individual who has appropriate expertise in addressing the enrollee’s medical, behavioral health, or long-term services and supports needs”; “For rating periods that start on or after January 1, 2026, within state established time frames that may not exceed 7 calendar days after receiving the request for service”; “Standard authorization decisions may have an extension to the timeframes in paragraph (d)(1)(i) of this section up to 14 additional calendar days”; “following the standard timeframe could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function”; “no later than 72 hours after receipt of the request for service”; “The enrollee or the provider requests the extension; or”; “at the plan level by March 31”; “For cases in which a provider indicates, or the MCO, PIHP, or PAHP determines”; “justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee’s interest”; “to notify the requesting provider, and give the enrollee written notice of any decision by the MCO, PIHP, or PAHP to deny a service authorization request”; “A list of all items and services that require prior authorization”.
8. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 438, subpart F, Grievance and Appeal System: sections 438.400 and 438.402 (current text). Checked October 24, 2026.
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   “The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit”; “The reduction, suspension, or termination of a previously authorized service”; “A denial, in whole or in part, of a payment for a service solely because the claim does not meet the definition of a ‘clean claim’ at § 447.45(b) of this chapter is not an adverse benefit determination”; “Each MCO, PIHP, and PAHP may have only one level of appeal for enrollees”; “If State law permits and with the written consent of the enrollee, a provider or an authorized representative may request an appeal or file a grievance, or request a State fair hearing, on behalf of an enrollee”; “with the exception that providers cannot request continuation of benefits as specified in § 438.420(b)(5)”; “an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan”; “The enrollee may request an appeal either orally or in writing”.
9. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 438, subpart F: sections 438.408 and 438.410, resolution and expedited appeals (current text). Checked October 24, 2026.
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   “the State must establish a timeframe that is no longer than 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal”; “the State must establish a timeframe that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal”; “may extend the timeframes from paragraph (b) of this section by up to 14 calendar days”; “the enrollee is deemed to have exhausted the MCO’s, PIHP’s, or PAHP’s appeals process. The enrollee may initiate a State fair hearing”; “An enrollee may request a State fair hearing only after receiving notice that the MCO, PIHP, or PAHP is upholding the adverse benefit determination”; “The review must be at the enrollee’s option and must not be required before or used as a deterrent to proceeding to the State fair hearing”; “The enrollee must have no less than 90 calendar days and no more than 120 calendar days from the date of the MCO’s, PIHP’s, or PAHP’s notice of resolution to request a State fair hearing”; “taking the time for a standard resolution could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function”; “The MCO, PIHP, or PAHP must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal”.
10. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 447.15, Acceptance of State payment as payment in full (current text). Checked October 24, 2026.
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    “A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual”.
11. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 440.40, EPSDT definition (current text, paragraph (b)). “Screening and diagnostic services to determine physical or mental defects in beneficiaries under age 21”; “Health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered”. Checked October 24, 2026.
12. Medicaid.gov, Centers for Medicare & Medicaid Services. Mandatory & Optional Medicaid Benefits (benefit list, undated; EPSDT appears under “Mandatory Benefits”, the three therapies under “Optional Benefits”). Checked October 24, 2026.
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    “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process”; “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services (1905(a)(4)(B), 1905(r), 42 CFR 440.40, 42 CFR 441 Subpart B)”; “Physical therapy (1905(a)(11), 42 CFR 440.110(a))”; “Occupational therapy (1905(a)(11), 42 CFR 440.110(b))”; “Speech, hearing and language disorder services (1905(a)(11), 42 CFR 440.110(c))”.
13. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 438, subpart F: sections 438.404 and 438.406, notice and handling of appeals (current text). Checked October 24, 2026.
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    “the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination. Such information includes medical necessity criteria”; “The enrollee’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued”; “Who, if deciding any of the following, are individuals who have the appropriate clinical expertise, as determined by the State, in treating the enrollee’s condition or disease”; “An appeal of a denial that is based on lack of medical necessity”; “Who take into account all comments, documents, records, and other information submitted by the enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination”; “Provide that oral inquiries seeking to appeal an adverse benefit determination are treated as appeals”.
14. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 431, subpart E, Fair Hearings for Applicants and Beneficiaries (current text). Checked October 24, 2026.
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    “That he may represent himself or use legal counsel, a relative, a friend, or other spokesman”; “The State or local agency must send a notice at least 10 days before the date of action”; “A prior authorization decision”; “The agency must allow the applicant or beneficiary a reasonable time, not to exceed 90 days from the date that notice of action is mailed, to request a hearings”; “could jeopardize the individual’s life, health or ability to attain, maintain, or regain maximum function”; “and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing”; “It is determined at the hearing that the sole issue is one of Federal or State law or policy”; “the agency may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary, to the extent they were furnished solely by reason of this section”; “Ordinarily, within 90 days from”; “For all other fair hearings, the date the agency receives a request for a fair hearing”.
15. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 438, subpart F: sections 438.420 and 438.424, continuation of benefits and reversed decisions (current text). Checked October 24, 2026.
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    “Within 10 calendar days of the MCO, PIHP, or PAHP sending the notice of adverse benefit determination”; “The intended effective date of the MCO’s, PIHP’s, or PAHP’s proposed adverse benefit determination”; “The appeal involves the termination, suspension, or reduction of previously authorized services”; “The services were ordered by an authorized provider”; “The period covered by the original authorization has not expired; and”; “recover the cost of services furnished to the enrollee while the appeal and state fair hearing was pending, to the extent that they were furnished solely because of the requirements of this section”; “If the MCO, PIHP, or PAHP, or the State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending”; “must authorize or provide the disputed services promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination”; “the MCO, PIHP, or PAHP, or the State must pay for those services, in accordance with State policy and regulations”.
16. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 441, subpart B, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21 (current text, sections 441.50 to 441.62). Checked October 24, 2026.
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    “providing treatment to correct or ameliorate defects and chronic conditions found”; “That the services provided under the EPSDT program are without cost to eligible individuals under 18 years of age, and if the agency chooses, to those 18 or older, up to age 21, except for any enrollment fee, premium, or similar charge that may be imposed on medically needy beneficiaries”; “That necessary transportation and scheduling assistance described in § 441.62 of this subpart is available to the EPSDT eligible individual upon request”; “must employ processes to ensure timely initiation of treatment, if required, generally within an outer limit of 6 months after the request for screening services”; “The agency must make available a variety of individual and group providers qualified and willing to provide EPSDT services”; “The agency must offer to the family or beneficiary, and provide if the beneficiary requests”; “Necessary assistance with scheduling appointments for services”.
17. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 433.139, Payment of claims (third party liability) (current text). Checked October 24, 2026.
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    “If the agency has established the probable existence of third party liability at the time the claim is filed, the agency must reject the claim and return it to the provider for a determination of the amount of liability”; “When the amount of liability is determined, the agency must then pay the claim to the extent that payment allowed under the agency’s payment schedule exceeds the amount of the third party’s payment”; “The claim is for preventive pediatric services, including early and periodic screening, diagnosis and treatment services provided for under part 441, subpart B, of this chapter”.
18. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 24, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “across all 50 states and Washington, DC”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”; “There is no contract, and nothing is charged while you claim.”; “Therapy and developmental resources for children and adults, plus a directory of providers across the United States.”.
19. DrSensory. Therapy Clinic Directory Pricing (the pricing page and its frequently asked questions). Checked October 24, 2026.
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    “Outpatient physical therapy, occupational therapy, and speech-language pathology clinics. The directory lists clinics rather than individual therapists, so one listing covers your whole practice. Inpatient rehabilitation facilities and chiropractic practices are not listed.”; “$29.99 a month or $349.99 a year for your first location, and $9.99 a month or $99.99 a year for each additional location”; “Claiming your listing is free.”; “A description in your own words”; “We do not verify clinical quality”; “A listing means a practice appears in the directory. It is not a recommendation”; “Families never pay to search it or to contact a clinic”; “When a family writes from your profile, the address you gave for family inquiries is told that a message is waiting; you read it signed in, because what a parent writes about their child is health information, and you reply from your own address.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Each state runs its own Medicaid program and plans, so confirm every benefit, authorization and appeal step with the state agency or plan; its examples are hypothetical, not DrSensory data or benchmarks.