Last month my colleague Anne Dwyer summarized the now-enacted Bipartisan Safer Communities Act and its provisions with potential to boost access to mental health services for children and families. One we will be watching closely: a review of state Medicaid EPSDT requirements, services, and practices.
Long time Say Ahhh! Readers know that Medicaid’s Early Periodic Screening Diagnostic and Treatment (EPSDT) requirement is the pediatric benefit in Medicaid. Federal statute requires states to provide comprehensive screenings and furnish all coverable, appropriate and medically necessary services needed to correct or ameliorate health conditions, even if such services are not included in the Medicaid state plan. EPSDT is more comprehensive than benefits for adults, and arguably private plans, namely the requirement to ensure children receive the right preventive and treatment services as early as possible to prevent or minimize conditions (see “correct or ameliorate”). This broader standard makes sense given children’s ever-changing developmental needs, including brain development that is most rapid during the earliest months and years of life but extends well beyond.
The new law directs the HHS secretary to review state EPSDT implementation by 2024 at the latest, in both managed care and fee-for-service arrangements, by:
- Reviewing state requirements for EPSDT, including services provided in managed care arrangements
- Identifying gaps and deficiencies in services that impact state compliance with EPSDT
- Providing support to states to address gaps; and
- Issue guidance to states on the Medicaid coverage requirements, which includes best practices for ensuring children have access to comprehensive health care services, including children without a mental health or substance use disorder diagnosis.
A few things to highlight here:
On guidance to states, don’t let the short phrase I’ve bolded fool you– it has the potential for long-lasting impact. It directs CMS to showcase the ways states can use screening results, (e.g. parent depression screenings, social-emotional or health-related social needs screenings such as ACES), to help streamline access to needed services without the traditional gateway of a formal medical diagnosis, as California recently put in place for family therapy. For young children, this is especially key to prevent a diagnosis from occurring. But even for those whose challenges rise to the level of a diagnosis, access to the right services can provide time needed to ensure a formal diagnosis for a young child is necessary, rather than risking use of a diagnosis label to speed up access to needed care without additional red tape.
Another not-so-small inclusion: a reference to reviewing requirements for managed care arrangements. With roughly half the nation’s children in Medicaid, and most of those children in managed care, this is a critical inclusion. Andy Schneider blogged this week about a new CIB and reporting templates for state Medicaid agencies, which referenced the potential for CMS to require states to report plan-specific performance data that it could make public. Seems to me that it would be in CMS’s best interest to collect and report this data to review EPSDT performance by MCOs.
Finally, this new provision aligns well with the need for more transparent and consistent data on how children fare in getting required screenings and access to care. The 2024 requirement for states to report every measure in the Child Core Set, an important state-level baseline from which to build. It would be great to see CMS make quick work of this to ensure states get the most out of their core set reporting. A national database of MCO-specific EPSDT performance data, combined with MCO-specific Child Core Set data, would be a game-changer for MCO accountability to children in 40 states and DC.
Together, CMS’s new data reporting tools, state core set reporting and this new EPSDT implementation review have great potential to improve accountability and transparency in Medicaid for children. It can also help states place sorely needed attention on what is needed to truly achieve EPSDT’s full potential. We will be eager to see how CMS takes on this new charge.