We are continuing our look at EPSDT, this time turning to EPSDT and managed care. Nearly 9 out of 10 children in Medicaid and CHIP receive services through some type of managed care arrangement, so understanding how EPSDT works in a managed care context is critical.

If you followed our work on managed care over the summer, you know that the Medicaid managed care statute and regulations play an important part in making good on the promise of the EPSDT benefit for children. The Medicaid statute requires states to provide children with medical, mental health, dental, vision, and hearing screenings at pre-set intervals, regardless of whether there is a particular health problem, and whenever a health problem is suspected. Further, the statute requires states to provide any Medicaid service that can be covered under the federal Medicaid program when necessary to correct or ameliorate a condition or illness.

So how does this work in managed care? What happens when the managed care plan limits the number of speech therapy services, but a child needs more? Does the plan have to provide the extra services? The state? Sadly, this confusion leads to finger-pointing and delayed treatment for children.

Thankfully, recent technical corrections to the Medicaid managed care regulations and CMS guidance clarify how EPSDT should work in a managed care context.

The regulations require MCO, PIHP, and PAHP contracts to define medical necessity in a way that is consistent with EPSDT. However, there was a typographical error in the cross references, which CMS corrected last week. even with the cross reference fixed, it was still unclear how CMS expected states and plans to comply with EPSDT in managed care. The guidance released on January 5 outlines three steps to ensure that the managed care contracts are clear about what the EPSDT benefit includes and whether the state or the plan is responsible for delivering it.

1. Scope of Services. The managed care contracts should be clear about the scope of services provided by the plan, and any remaining gaps in coverage must be covered by the state. If the plan is only expected to provide some EPSDT services (like well-child visits) and not others (like behavioral health) that must be clearly stated. If the plan is expected to provide all services but allowed to impose treatment limits, that must be specified. The combination of benefits provided by the plan and the state must guarantee children have access to the full EPSDT benefit.
2. The contract must specify whether the plan or the state is responsible for informing beneficiaries about the EPSDT benefit. If the plan’s contract includes coverage of services within EPSDT, the enrollee handbook must include information about the benefit and services provided by the plan as well as any additional services provided by the state.
3. The contract must also ensure that states have access to plan data necessary to meet the statutory reporting requirements. States are required to report EPSDT data by age and basis of eligibility on child health screening services, referrals for corrective treatment, and dental services every year.

This guidance is a helpful resource for child health advocates interested in making sure children in managed care receive the full EPSDT benefit. Are your state managed care contracts following the three steps outlined above?

A special thanks to the Robert Wood Johnson Foundation for its support of our work ensuring that Medicaid managed care works well for children and families.