Where Does EPSDT Stand in Post-ACA Medicaid Expansion 1115 Waivers?

In the last few months, CMS has approved Medicaid expansion 1115 waiver demonstrations in Arkansas, Iowa and Michigan. Pennsylvania has a draft 1115 waiver proposal to expand Medicaid out as well. One important question that has emerged is: How will states continue to provide EPSDT and other benefits to 19 and 20 year olds who are part of the expansion population?  This question comes up because 19 and 20 year olds are in a bit of a funny spot under Medicaid law. They are considered children for purposes of Medicaid benefit requirements (and hence they must receive EPSDT), but are treated as adults for purposes of eligibility in the Medicaid expansion.

The bottom line is that in this recent round of waivers, CMS has not allowed any state to waive EPSDT, but Arkansas and Iowa will provide EPSDT as a benefit that wraps around qualified health plan (QHP) coverage. Allowing states to wrap EPSDT around private coverage is far from ideal. It raises concerns about whether 19 and 20 year olds will know EPSDT is available and be able to access the services, and there is scant evidence that Medicaid beneficiaries in other premium assistance programs are receiving wraparound benefits like EPSDT.  But, the right to EPSDT lives on.

Why does access to EPSDT matter?  Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is the cornerstone of social policy to optimize child development for millions of poor children in the U.S. It was put in place more than 30 years ago to address documented, widespread, and preventable mental and physical conditions among poor children. ESPDT, required under Medicaid law for children and young adults up to age 21, includes periodic screening, vision, dental and hearing services; reflects the professional pediatric standard of care; and emphasizes early and preventive health care. States are required to provide medically necessary health care services to correct and ameliorate physical and mental conditions even if the service is not included under the state’s Medicaid plan.

Below is a closer look at how EPSDT shakes out in each state’s post-ACA 1115 waiver approach, scroll down to see my summary chart.

Arkansas  — Arkansas’ approved “private option” waiver uses Medicaid funds to enroll adults, ages 19 to 64 (0-133% FPL) in QHPs. Arkansas proposed providing EPSDT for 19 and 20 year olds through its fee-for-service Medicaid program as wrap-around since it is not covered by qualified health plans in the private option. This would include pediatric vision and dental services, as well as other EPSDT services, to the extent such services are not covered under the QHP.  Advocates commented that 19 and 20 year olds should not be included in the private option at all, because CMS guidance issued on March 29, 2013, stated that only populations with benefit packages that are easily aligned with the Essential Health Benefits that QHPs will provide should be included in premium assistance arrangements like the Arkansas “private option.” Children entitled to Early and Periodic Screening, Diagnosis, Treatment (EPSDT) services are not in a category easily aligned…. But that is water under the bridge. CMS approved Arkansas’ proposal, so EPSDT will be provided as a fee for service wrap around QHPs. In addition to receiving an insurance card for a QHP, CMS required private option enrollees to receive a Medicaid Client Identification Number (CIN) through which providers can bill Medicaid for wrap-around benefits.  CMS also required the notice with the CIN to include information about which services they can receive through Medicaid and how to access them and also be provided on AR website and through call centers and QHP issuers. Stakeholders and evaluators will have to monitor whether enrollees actually receive notice and are able to access EPSDT services.

Iowa – Iowa’s approved waiver creates a Medicaid wellness program for adults 0-100% FPL and uses Medicaid funds to enroll adults, ages 19 to 64 from 101 to 133% of FPL into QHPs. Iowa proposed to waive EPSDT for 19 and 20 year olds in both the wellness (0-100% FPL) and marketplace choice (101-133% FPL) plans. CMS did not grant this waiver.  Instead, EPSDT will be provided in the wellness plan and REPSDT will be provided as a wraparound service in the marketplace choice program.  Enrollees in marketplace choice will receive a Medicaid card (in addition to a card for the QHP) for any services covered by the Health and Wellness plan and not by the QHP (like EPSDT).

Michigan – Michigan’s approved waiver creates a new type of health savings account and copays for the all adults enrolled, ages 19 to 64. Michigan actually did not propose to waive EPSDT, in fact, the state proposed adding services for adults in Medicaid, including hearing aids, and preventive and habilitative health care services to comply with essential health benefits rules. The state is also planning to use the enhanced Medicaid financing to help pay for early identification, care coordination and treatment in its existing mental health and substance abuse program.

Pennsylvania – Under Pennsylvania’s draft waiver proposal, traditional Medicaid would continue to provide coverage through age 21.  The private option, work requirements, and other proposed changes would kick in at age 21.  The waiver proposal does not affect children and young adults eligible for EPSDT.

State Proposed to waive EPSDT Proposed to wrap EPSDT Did not propose to waive EPSDT CMS approved EPSDT to wrap around QHPs