Today, the Centers for Medicare & Medicaid Services (CMS) released much-anticipated guidance on Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. For those who don’t live in Medicaid jargon land, EPSDT is the pediatric benefit in Medicaid and establishes a higher standard for children than adults covered by Medicaid. Most, but not all, children covered by CHIP are also entitled to EPSDT services – although some states with separate CHIP programs have not elected to provide EPSDT1. WIth approximately half the children in the United States covered by Medicaid and CHIP (over 38 million), ensuring that EPSDT’s promise is realized is essential for ensuring that America’s children grow and thrive.
Most children in Medicaid are covered by managed care organizations; the guidance underscores that EPSDT requirements apply regardless of the delivery system and reinforces the fact that the state is ultimately accountable to the child.
As noted by CMS, the guidance, along with additional technical assistance and guidance, is intended to provide states with the information they need to meet EPSDT requirements. CMS commits to working to ensure compliance with the requirements in all states.
Background
Under Medicaid’s EPSDT benefit, states are required to provide comprehensive services and furnish all coverable, appropriate and medically necessary services needed to correct and ameliorate health conditions, including behavioral health conditions, if the service could be covered under the state plan. In addition, states are also required to inform eligible individuals under the age of 21 of the availability of EPSDT services. As the guidance reiterates, states must cover all “medically necessary” services for a child – not just those identified in a well-child visit (P. 6).
Yet, despite the requirements of EPSDT, children across the country continue to face long standing unmet health needs. For example, in 2018 only about half of all non-institutionalized youth enrolled in Medicaid or CHIP who experienced a major depressive episode received mental health treatment and as of 2021 about half of children enrolled in Medicaid or CHIP did not receive any dental care. Unfortunately, monitoring the provision of EPSDT services to determine whether the requirements of the Medicaid statute are being met has been challenging due to data accuracy and collection issues, low state compliance rates, and lack of reporting enforcement.
As we’ve blogged about before, the Bipartisan Safer Communities Act included a number of provisions targeted at improving state implementation of EPSDT services and state and CMS oversight. This included a requirement to issue guidance to states on the Medicaid coverage requirement for EPSDT services, including best practices – this is what precipitated the 57 page guidance released today.
The Guidance
As highlighted by CMS, the new guidance is intended to provide an overview of EPSDT requirements and information on how states can meet the goal of EPSDT: “the right care, to the right child, at the right time, in the right setting.” It also reiterates that “states cannot ensure compliance with EPSDT requirements unless they have processes in place to oversee, verify, and enforce these requirements, regardless of whether services are delivered through FFS or managed care.”
We will be writing more in the coming days and weeks about the particulars but at a high level, the guidance is divided into three broad topics:
- Promoting EPSDT Awareness and Accessibility
- Expanding and Using the Child-Focused (EPSDT) Workforce
- Improving care for EPSDT-eligible children with special needs
Topics within these sections include using care coordination and case management for improving health care accessibility and continuity for children, broadening provider qualifications to expand the EPSDT workforce, and improving care for children with behavioral health needs, foster youth, and children with disabilities and complex health needs.
As summarized in the guidance, the EPSDT mandate represents a critical part of the Medicaid program to ensure eligible children have access to essential medical, dental, behavioral health and developmental services from an early age. However, ensuring appropriate oversight and enforcement is critical to making this promise a reality. Stay tuned as we unpack more of the guidance here on Say Ahhh! Health Policy Blog.
[This is part of a blog series on federal guidance that aims to improve enforcement of the Early and Periodic Diagnostic Screening and Treatment (EPSDT) requirement for children enrolled in Medicaid. ]
- 10 states (AZ, GA, ID, KS, LA, ME, OK, RI, SD, WI) cover EPSDT in their separate CHIP programs and six states cover EPSDT for some separate CHIP groups (CA, MA, MN, MO, NJ, WA) according to CMS. ↩︎
