Ongoing Advocacy Needed to Ensure Children Covered by Managed Care Plans Receive Medicaid’s Guaranteed Pediatric Benefit

Child health advocates know the importance of five simple but powerful letters in Medicaid: EPSDT or Early and Periodic Screening Diagnostic and Treatment Services. EPSDT – that is, Medicaid’s comprehensive pediatric benefit standard – provides children with preventive and diagnostic services and ALL medically necessary services that can be covered under federal Medicaid law to correct and ameliorate health conditions, even if such services are not included in a specific state’s plan.

The concept of ensuring all medically necessary services can be at odds with managed care, which typically limits certain benefits such as physical, speech or occupational therapy. As more and more children in Medicaid are required to enroll in managed care, it is imperative that child health stakeholders work with state Medicaid agencies and the managed care plans to ensure that the full scope of EPSDT benefits are provided to children as the law intends. This was the focus of two projects that CCF developed under a broader project concentrated on unpacking the modernized Medicaid managed care rules that were finalized in spring 2016.

In Iowa and Illinois, advocates undertook efforts to assess and improve EPSDT in the state’s Medicaid managed care delivery system. The case studies of these projects reflect some common themes:

  • The full scope of EPSDT is not well understood. We find that state officials, managed care organizations, and providers are not always knowledgeable about the depth and breadth of EPSDT.
  • Managed care contracts often lack specificity about EPSDT. If the roles are not clearly defined in managed care contracts, it can lead to ambiguity about who (the state, the plan or the provider) is responsible for what. This is particularly true when it comes to educating families about EPSDT through required outreach and education.
  • Child health advocates can play a valuable role in educating stakeholders about EPSDT. In Iowa and Illinois, advocates filled a critical need by training plan administrators and providers. Advocates also helped educate stakeholders by designing critical outreach and education materials to inform families and providers about EPSDT and its importance to child health and development.

We are continuing this work with a small group of state-based child health policy and advocacy organizations in partnership with the American Academy of Pediatrics and state AAP chapters. What we are learning is that EPSDT cannot be left on autopilot. Continual education and training is needed to ensure that all children enrolled in Medicaid benefit from EPSDT, and that all stakeholders understand their roles and responsibilities. But even when the benefit standard is well understood, there are often barriers to medically-necessary care, which points to an important and ongoing role for child health advocates in educating stakeholders, including families, and monitoring EPSDT compliance.

Tricia Brooks
Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families