As discussed in our blog series on the CMS’s new EPSDT guidance, the 57 page state health official letter lays out a number of policies and strategies to help states meet their EPSDT requirements under Medicaid – including care for children with behavioral health needs.

As you may recall, in 2022, CMS released an informational bulletin on leveraging Medicaid, CHIP, and other federal programs in the delivery of behavioral health services for children and youth. Importantly the informational bulletin reiterated that the obligation to provide all medically necessary care under Medicaid’s EPSDT requirement extends to prevention, screening, assessment and treatment for mental health and substance use disorders. It also included strategies and state examples for the provision of high-quality behavioral health services for children and youth.

Last month’s EPSDT guidance builds off of the 2022 informational bulletin with additional EPSDT policy specifics and best practices, including a section on improving care for children with behavioral health needs (which CMS notes includes mental health conditions and substance use disorders). There are a number of behavioral health policies, strategies and best practice throughout the section, but a few policy highlights include the following:

“A service array of behavioral health care that is consistent with EPSDT requirements includes, but is not limited to: 1) screening and assessment; 2) services to build skills for mental health and/or to address early signs or symptoms of concern with or without a diagnosis; 3) community-based services at varying levels of intensity necessary to correct or ameliorate a wide range of behavioral health acute and/or chronic conditions, including routine community-based services as well as community-based services to meet more intensive needs; 4) services to address urgent and crisis needs; and 5) inpatient care only when medically necessary.” (pp. 40-41)

“States should avoid requiring an EPSDT-eligible child to have a specific behavioral health diagnosis for the provision of services, as screenings may identify symptoms that require attention but do not meet diagnostic criteria. This may be particularly salient when addressing the developmental and behavioral health needs of children under age 5.” (pp. 41)

“As children should be cared for in the most integrated setting appropriate for their needs, inpatient and residential levels of care must not be the default treatment setting, either explicitly or because of a lack of capacity of services offered in integrated settings, including for children and youth with severe needs, and should be reserved for children with acute needs on a short-term basis.” (pp. 42)

“Critical components of a high functioning behavioral health system for children include 1) a single point of entry, 2) supporting the management of children with mild to moderate needs in primary care settings, 3) covering a range of specialty care provided in the community to meet the specific needs of children when and where they arise, and 4) relying on inpatient behavioral health treatment only when medically necessary.” (pp. 44)

Be sure to take a look at the guidance to learn even more. And don’t stop with just the children with behavioral health needs section. There are lots of other relevant policies and best practices related to children with mental health and substance use disorder needs included throughout the guidance. Here are some examples from other sections:

On EPSDT generally:

“Available services for EPSDT-eligible children must not be limited to those that are convenient for the state to cover simply because they are aligned with services typically available for adults. For example, states must cover a range of behavioral health services that meet the assessed needs of an EPSDT-eligible child and not rely solely on inpatient and counseling services as sufficient to meet the requirements of EPSDT. States must adhere to EPSDT requirements, which create a higher standard of coverage for eligible children than adults, when administering their Medicaid programs.” (pp. 7)

On transportation:

“…if a child is receiving residential or facility-based care (e.g., inpatient, neonatal intensive care unit (NICU), psychiatric residential treatment facility (PRTF), etc.) and the presence of the parent, family member, or other caregiver is necessary so that they can actively participate in the treatment/intervention for the direct benefit of the child, then the state may pay for transportation for the parent, family member, or caregiver without the child present in order to ensure the child’s medically necessary services are provided (e.g., to provide breast milk or breastfeed, participate in family therapy, medical decision making, and consent for surgery, etc.).” (pp. 13)

On care coordination:

“Like other services covered under EPSDT, case management covered under EPSDT must address a child’s specific needs. One child may need care coordination between two providers (e.g., between a primary care provider and an orthopedic specialist for a child with a broken bone), whereas another child with co-occurring medical, developmental, and/or behavioral health conditions may need more complex case management to support the child’s access to services and supports provided by a wide range of providers, state agencies, and the education system.” (pp. 16)

On workforce:

“Workforce shortages in rural or medically underserved areas can be mitigated by state Medicaid agencies allowing providers to deliver services, including behavioral health services, using telehealth. To address behavioral health workforce challenges in particular, states may use strategies like optimizing Pediatric Mental Health Care Access (PMHCA) programs and using telehealth as a model of integration. Mental health care access programs are a high-value means of supporting pediatric primary care providers to manage mild to moderate mental health and SUD treatment without the need to refer patients to specialty care.” (pp. 35)

“Subject to section 1903(a) of the Act, many states are able to claim FFP for some of the costs incurred to administer a PMHCA program, subject to Medicaid administrative claiming rules. Additionally, states can partner with their PMHCA lead agency (which may be the Health and Human Services agency, the Behavioral Health Agency, or Title V agency within the state Health and Human Services Department) to ensure funding sustainability through claiming for Medicaid covered services delivered to EPSDT-eligible Medicaid beneficiaries.” (pp. 36)

With Medicaid (alongside CHIP) serving as the single largest payer of behavioral health services and covering about half of all children, ensuring Medicaid’s EPSDT promise is realized remains essential in meeting the behavioral health needs of youth and ensuring America’s children grow and thrive. This new CMS guidance, including policies related to behavioral health care, can serve as a tool to help advance this effort. We look forward to writing more as CMS continues its EPSDT work – including an anticipated EPSDT Behavioral Health Services Toolkit. More to come!

[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. ]