Read this if you administer a Medicaid agency, a CHIP program, or a Medicaid-participating managed care organization.
On September 26, 2024, the Centers for Medicare & Medicaid Services (CMS) released its State Health Official (SHO) # 24-005 letter, which addresses best practices for adhering to federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. EPSDT requirements are a cornerstone of the Medicaid program and ensure robust health coverage for children.
The goal of EPSDT is to ensure that eligible children get the healthcare they need, when they need it, in the most appropriate setting. EPSDT entitles eligible children under the age of 21 to Medicaid coverage of healthcare, diagnostic services, and treatment 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’s Medicaid plan.
CMS interprets the “correct or ameliorate” requirement to mean that a service need not cure a condition to be covered under EPSDT as a medically necessary service. States will not be able to comply with EPSDT requirements unless their Medicaid policies and procedures, including medical necessity criteria, prior authorization requirements, and Medicaid fair hearings, reflect consideration of this EPSDT obligation, which creates a higher standard of coverage for eligible children than for adults.
In its State Health Official (SHO) # 24-005 letter, CMS discusses policies, strategies, and best practices to maximize healthcare access and utilization for EPSDT-eligible children. CMS summarizes federal requirements, followed by strategies and best practices to support the following three areas:
1. Promoting EPSDT awareness and accessibility
CMS highlights a series of best practices in SHO #24-005, which include:
- Use plain language in provider and family handbooks to describe the breadth of available services
- Supplement beneficiary handbooks with web-based information, social media platforms, and electronic communication
- Offer a beneficiary services contact line
- Require managed care plans (MCPs) to provide proactive outreach and assistance to members
- Establish Children’s Resource Centers to help families navigate programs that span multiple state agencies
- Use a fixed risk-based payment under transportation broker models and require the broker to develop a beneficiary app to schedule trips
- Use community-based care management entities (CME) to coordinate care for children who need moderate or intensive care coordination
- Regularly review decisions for prior authorization requests, managed care appeals, and/or state fair hearing requests provided to EPSDT-eligible children, by managed care plan or service type, for clinical appropriateness
- Create and require EPSDT-specific web-based provider training
- Prioritize EPSDT-specific expertise
- Extend EPSDT technical assistance to managed care plans (MCPs)
- Use and enforce managed care contract language to require MCPs to use best practices
- Convene MCPs around shared quality goals
- Implement a non-clinical Performance Improvement Project (PIP) to ensure occurrence of well-child visits made by children enrolled in MCPs
- Include children with disabilities or other complex medical needs in managed care quality strategies
- Improve quality and utilization for children through optional focus studies in annual External Quality Review (EQR) for each contracted MCP
2. Expanding and using the child-focused EPSDT workforce
CMS has outlined the goal of broadening qualifications for providers and using additional tools such as telehealth, consultation, and coordination, as well as new payment methodologies to help drive adequate numbers of providers for these services. Best practices noted by CMS include:
- Develop non-licensed practitioner types (such as peer support). CMS has noted that practitioner types that do not require licensure to deliver care have been added by some states where allowable.
- Broaden the role of existing providers. To help reduce referrals to pediatric specialists and make the age range of potential patients broader, some states have offered optional provider training and rate increases.
- Incorporate oral health into children’s primary care visits. At least one state has developed a model to link primary care visits with oral health.
- Support and incentivize general practitioners, particularly in order to help them serve younger children via training, support, and enhanced payments to increase their ability to serve younger children.
- Allow providers to deliver services via telehealth, particularly as it alleviates provider shortages through enrollment of additional providers, and/or enables enrollment of additional provider types in short supply.
- Enroll out-of-state providers. One state has adopted a “Border Status” policy to permit providers in a bordering state to potentially enroll in the state’s Medicaid program. Under this policy, these providers can deliver telehealth services.
- Connect primary care providers and child behavioral health providers. Using a Pediatric Mental Health Care Access Program (PMHCA) can help mitigate the need for referrals to pediatric subspecialists.
- Adopt the Collaborative Care Model (CoCM). This evidence-based approach allows for easier interprofessional consultation to help integrate and improve both behavioral and physical health.
- Attract providers to the Medicaid program using differential rates. To attract providers in regions where care may be sparse, states can set different FFS provider rates based on geography.
3. Improving Care for Children with Specialized Needs
CMS outlines the following best practices for enhancing care for children with behavioral health needs, children in foster care, and children with disabilities or complex health conditions:
i. Improving Care for Children with Behavioral Health Needs
- Provide comprehensive EPSDT services, including screenings, assessments, crisis care, and home-based services per Bright Futures guidelines.
- Remove diagnosis requirements, allow same-day behavioral/primary care billing, and implement unified entry systems for integrated care.
- Focus on integrated care settings and avoid unnecessary residential placements.
- Expand provider networks, leverage federal matching, and ensure Medicaid/CHIP parity, including addiction and tobacco cessation services.
- Incentivize behavioral health screenings during well-child visits with quality payments and add-ons.
- Deliver 24/7 crisis intervention and coordinated, trauma-informed care through Certified Community Behavioral Health Centers (CCBHCs).
ii. Improving Care for Children in or Formerly in Foster Care
- Automatically enroll eligible children (Title IV-E foster care, kinship guardianship/adoption assistance, and former foster youth under 26) in Medicaid, ensuring coverage across state lines.
- Conduct initial health assessments within days of placement in foster care, followed by well-child visits.
- Partner with child welfare agencies to create care plans and implement foster care-specific MCPs with tailored benefits and rates.
- Provide “wraparound” services (such as caregiver support), higher primary care reimbursements, and trauma-informed care managers.
- Support foster parents through outreach, education, and navigation assistance.
- Assist youth transitioning out of foster care or into permanent placements.
- Require MCPs to assign a liaison and trauma-informed care manager to children in foster care.
- Use statewide MCPs to align Medicaid and child welfare, ensure network adequacy, and monitor foster care-specific performance metrics.
iii. Improving Care for Children with Disabilities or Other Complex Health Needs
- Provide EPSDT services, including care from pediatric specialists, therapies, and case management.
- Ensure access to pediatric specialists and out-of-network providers when needed and establish interstate agreements for streamlined coverage.
- Facilitate care through transportation assistance, timely provider enrollment, and streamlined out-of-state processes.
- Implement specialized MCPs with enhanced care coordination and include children with disabilities in managed care quality strategies.
- Establish single-point care coordination to integrate services and support families.
- Develop person-centered service plans (PCSPs) under Home and Community-based Services (HCBS) programs to deliver supports like respite care, home modifications, and parental training.
- Provide family navigation support through hotlines, advisory teams, and care coordinators.
EPSDT resources
- EPSDT – A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (June 2014), Centers for Medicare & Medicaid Services,
- The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children and youth in managed care (January 5, 2017), CMCS Informational Bulletin, Center for Medicaid and CHIP Services,
- Recommendations for Preventive Pediatric Health Care, 2024 Periodicity Schedule, Bright Futures/American Academy of Pediatrics
- SHO # 24-005 RE: Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements (September 26, 2024), Centers for Medicare & Medicaid Services)
If you have questions about EPSDT for Medicaid or need guidance in complying with these requirements, please contact us.
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