Last week, the Center for Medicaid and CHIP Services within the Centers for Medicare & Medicaid Services (CMS) released what it calls “historic” guidance to states on best practices for adherence to early and periodic screening, diagnostic, and treatment (EPSDT) requirements. To help me provide an overview of these requirements and describe the significance of this guidance (and why CMS believes it to be so important), I’m bringing in my colleagues Maddie News and Kayla Holgash.
CMS estimates that as of May 2024, around 38 million children are enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). Many of these children are eligible for EPSDT, because the eligibility criteria include children under the age of 21 who are enrolled:
- In Medicaid through a “categorically” needy group (including families with incomes below certain thresholds);
- In Medicaid through a medically needy group in a state that has elected to include EPSDT in the medically needy benefit package (some states offer Medicaid to other individuals beyond those traditionally covered);
- In a Medicaid-expansion CHIP program; or
- In a separate CHIP program that has elected to cover EPSDT.
Overall, every state Medicaid program is required under federal law to meet EPSDT requirements, and states operating separate CHIP programs can choose to cover EPSDT, which most do.
EPSDT requirements, as defined under the Social Security Act, ensure that eligible children receive “healthcare, diagnostic services, treatment, and other measures . . . that are medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions, whether or not such services are covered under the state plan.” Simply put, EPSDT is meant to fill the coverage gaps for children’s services that the traditional Medicaid and CHIP programs may not cover. EPSDT services are more comprehensive than the services covered for adults, with the goal of supporting children’s health and wellbeing as they develop.
Due to concerns about children not receiving or facing barriers to accessing services under the EPSDT benefit, the Bipartisan Safer Communities Act (BSCA) of 2022 charged CMS with issuing guidance on the EPSDT requirements, including best practices for ensuring children and youth have access to comprehensive healthcare services. The BSCA also charged CMS with identifying gaps and deficiencies regarding state compliance with EPSDT requirements, providing technical assistance to states to address such gaps and deficiencies, and issuing a report to Congress on its findings and actions taken.
The guidance CMS released does just that. After evaluating different state EPSDT educational materials and resources and reaching out to states and stakeholders, CMS identified three topics in the guidance for states to consider to improve adherence to EPSDT requirements:
- Promoting EPSDT awareness and accessibility;
- Expanding and using the children-focused (EPSDT) workforce; and
- Improving care for children with specialized needs.
Each topic includes illustrative strategies and best practices that states can integrate into their programs to meet EPSDT statutory and regulatory requirements and enhance access and utilization. As most children in Medicaid and CHIP are covered through managed care, CMS highlights throughout the guidance how managed care plans (MCPs) can be leveraged to reach children, improve EPSDT care coordination, and facilitate access to services.
Through the first topic, CMS identifies ways to inform children and their parents about their benefits and how to receive services. CMS also clarifies that states must provide EPSDT services if an MCP contract excludes some EPSDT services. If an MCP contract includes all medically necessary services, the MCP must cover all EPSDT services. CMS reminds states that EPSDT requires them to provide necessary assistance with scheduling appointments and obtaining transportation to services. CMS also outlines specific care management and care coordination requirements and best practices in order to address each child’s individual needs. Finally, under this first topic, CMS outlines approaches to ensure that children gain access to all their entitled services, including recommending that states review MCPs’ prior authorization and appeals processes and decisions to ensure they are not unnecessarily impeding access to care.
The second topic deals with an issue that extends beyond Medicaid: workforce challenges. CMS lays out policies, strategies, and best practices that states can adopt to expand the workforce and facilitate access to EPSDT. Strategies include broadening provider qualifications, such as by incorporating dental care into primary care visits, encouraging interprofessional consultation, and expanding the use of telehealth. CMS also details how states can incentivize physicians and other providers to treat children. In CMS’s view, states have considerable flexibility to develop Medicaid payment methodologies, including enhanced payment rates, to reward physicians who provide high quality services to EPSDT-eligible children.
The third topic details strategies to help treat children with specialized needs, including how to improve care for children with behavioral health conditions. While providing adequate mental health services to children is particularly challenging, CMS lays out a general approach to tackling the issue:
- Providing a single point of entry to the healthcare system;
- Supporting the management of children with mild to moderate needs in primary care settings;
- Covering a range of specialty care provided in the community to meet the specific needs of children when and where they arise; and
- Relying on inpatient behavioral health treatment only when medically necessary.
Lastly, CMS provides strategies to address the specific needs of foster children and children with disabilities or other complex healthcare needs. CMS specifically discusses the intersection of the EPSDT benefit and home- and community-based services, reminding states of their obligation to ensure that children with disabilities receive all the medically necessary care to which they are entitled.
So, now that we’ve described the guidance, we can ask ourselves why CMS considers this to be such a big deal. CMS labels the guidance as the most comprehensive EPSDT guidance that the agency has released in a decade. In addition to spotlighting the need to protect kids’ access to healthcare, the guidance touches on two other Biden Administration priorities: addressing the mental health crisis and promoting health equity. With respect to mental health, in its press release, CMS states that the guidance “builds on the HHS Roadmap to Behavioral Health Integration, which outlines the Department’s commitment to providing the full spectrum of integrated, equitable, evidence-based, culturally appropriate, and person-centered behavioral health care to the populations it serves, and builds on the President’s Unity Agenda to advance mental health.”
With regard to promoting health equity, CMS indirectly notes that expanding access to Medicaid helps reduce healthcare and economic disparities. The guidance was released concurrently with a report from the Assistant Secretary of Planning and Evaluation at the US Department of Health and Human Services that shows that being covered by Medicaid not only provides significant health benefits for low-income children but also improves educational outcomes, which leads to greater health and financial success over children’s lifetime.
Finally, let’s discuss CMS’s next steps. During a webinar last week, CMS announced its intention to host technical assistance webinars for states and monitor their adherence to EPSDT requirements. States currently report data on EPSDT services through specific forms known as “CMS-416 forms,” and reporting on the standardized Child Core Set quality measures is also mandatory as of 2024. While the Child Core Set is not specific to EPSDT and collects broader data than the CMS-416 forms, it provides valuable insights on how children are receiving care. CMS is working with states to help with this reporting requirement and is gearing up to publicly post the Child Core Set data to facilitate cross-state comparisons. We’ll keep an eye out for the Core Set data, which CMS is anticipated to post by fall 2025.
Until next week, this is Jeffrey (and Maddie and Kayla) saying, enjoy reading regs with your eggs.
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