Last month, CMS released a state health official (SHO) letter outlining the requirements states and managed care plans must meet under Medicaid’s pediatric benefit, known as Early and Periodic Screening, Diagnostic and Treatment or EPSDT. The EPSDT SHO also describes some strategies and identifies best practices currently in use by states to meet the various requirements. As my colleagues have already written, this guidance marks an important step forward in ensuring that EPSDT lives up to its promises. Because the EPSDT SHO is long and detailed, we will continue to unpack it over the coming weeks. This post focuses on promoting EPSDT awareness.
Federal law specifically requires that states inform families about the availability of EPSDT services (§1902(a)(43)(A)) and yet, we often hear stories evidencing confusion about EPSDT from both families and providers. For example, thinking that EPSDT refers only to screening or that hard limits on the number of services are allowable. Without a clear understanding of EPSDT, families and providers are unable to advocate effectively for children needing more or different services.
The guidance points to existing regulatory provisions implementing the statutory requirement to inform, specifically that states must use a combination of written and oral methods to inform beneficiaries about EPSDT within 60 days of initial Medicaid enrollment and annually thereafter in the case of families who have not utilized EPSDT services (42 CFR §441.56(a)(4)). Such notifications must be accessible to individuals who are blind or deaf or who cannot read or understand English (42 CFR §441.56(a)(3)). Though not specifically identified in the guidance as a best practice, I would argue that an annual notification about EPSDT is worthwhile, even if a family has utilized EPSDT services in the past year.
States may delegate the responsibility to inform families to managed care organizations (MCOs) by including such requirements in their contracts, but throughout the EPSDT SHO, CMS emphasizes that states are ultimately responsible for complying with EPSDT, including complying with the requirements to inform families, regardless of whether the state chooses to contract with MCOs to deliver some or all services for children with Medicaid coverage. MCOs must define covered benefits and describe how to access them in their enrollee handbooks, including how enrollees can access transportation services if needed (42 CFR §§438.10(c)(4) and (g)(2)(ii)). The emphasis on state responsibility serves as an important reminder that EPSDT is the statutorily-required benefit for children and youth in Medicaid, regardless of delivery system.
The guidance offers some proven strategies and best practices to help states implement these requirements, including sharing information directly from the state in plain, easy-to-understand language, describing the breadth of EPSDT services in both provider and family handbooks, and supplementing such information with social media posts and text message reminders. Rhode Island’s Medicaid provider handbook offers a good example of how EPSDT benefits can be described clearly and concisely, including emphasizing that Medicaid benefits are more robust for children than for adults, EPSDT supports case-by-case treatment decisions, and states may not impose “hard limits” on services.
Medicaid is the backbone of our health care system, covering almost 40% of all children and even larger shares of low-income children, children of color, and children with special health care needs. And EPSDT is Medicaid’s pediatric benefit. Working to make sure that families and providers know about and understand EPSDT is critical to ensuring that children get the right care at the right time and grow into healthy, strong adults. CMS intends to work one-on-one with states to improve EPSDT compliance, but in the meantime, review your state’s enrollee and provider handbooks, managed care contracts (as applicable), and other EPSDT informational materials to see if you think they are meeting the standards laid out in the guidance. If not, identify the areas that fall short and work with your state to implement any changes necessary. And if you think your state is doing a good job informing families and providers about EPSDT, spread the word so that children in other states can benefit too.
[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. ]
