CMS Reminds States EPSDT Requirement Includes Behavioral Health, Offers Specific Strategies

Medicaid’s pediatric benefit, Early and Periodic Screening Diagnostic and Treatment (EPSDT), is getting more attention from federal officials. As part of its child health-focused release yesterday, CMS released a new Informational Bulletin reiterating EPSDT’s requirement to cover screenings and medically necessary treatment for children’s behavioral health, mental health and substance use disorders. The timing is critical going into another school year, as CMS’s data show declining access to mental health services for children after the onset of the pandemic.

Say Ahhh! readers know that while EPSDT is the definitive standard for pediatric benefits, the promise has not lived up to its full potential. This bulletin provides strategies and concrete examples encouraging states to:

  1. Improve prevention, early identification, and engagement in treatment, through strategies such as removing a diagnosis requirement to access treatment, paying for behavioral health services in primary care, or using age-appropriate diagnostic criteria, such as the DC:0-5 for young children (more on this in a later blog!).
  2. Increase access to treatment across the continuum of care, beyond screening to care coordination, crisis response and recovery services, telehealth, in-home and wrap-around services based on identified need to “ensure that individual children get the health care they need in the right place when they need it.” (p. 7)
  3. Expand provider capacity by recognizing new provider types, such as schools or community health workers, providing behavioral health training to primary care and emergency providers, removing barriers to provider enrollment and, of course, raising reimbursement rates.
  4. Increase integration of behavioral health and primary care, through new delivery models to center mental health in primary care, joining the pediatric mental health access program, and enhancing reimbursement for integrated care.

This guidance goes hand in hand with the draft core set reporting rule and a second bulletin on school-based services. But these appear to be merely the beginning of CMS’s work on EPSDT. The Safer Communities Act passed earlier this summer calls on HHS to review state EPSDT implementation and provides some additional resources to do so. We are thrilled to see CMS start to set expectations and highlight the ways states can start to prioritize children’s behavioral health before the more in-depth reviews begin.

Elisabeth Wright Burak is a Senior Fellow at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.