This overview is excerpted from Manatt on Health, Manatt’s subscription service that provides in-depth insights and analysis focused on the legal, policy and market developments. For more information on how to subscribe and to activate a complimentary one week trial to Manatt on Health, please reach out to Barret Jefferds.
On September 26, the Centers for Medicare and Medicaid Services (CMS) released comprehensive guidance to states that reinforces and clarifies federal Medicaid requirements regarding Early and Periodic Screening, Diagnostics, and Treatment (EPSDT). Under EPSDT, children and youth under the age of 21 (referred to here as “children”) are entitled to coverage of all medically necessary preventive, diagnostic, and treatment services that are coverable under Medicaid, including services that are optional for adults.
CMS describes EPSDT as a “cornerstone of the Medicaid program” for the 30 million children enrolled in Medicaid—two out of every five children in the America. In addition, of the 40 states that operate a Children’s Health Insurance Program (CHIP) separate from Medicaid, 16 states have extended ESPDT requirements to CHIP as well.
The new 57-page guidance document, which was required by the 2022 Bipartisan Safer Communities Act (P.L. 117-159) and was accompanied by a summary slide deck, builds upon CMS’s 2014 EPSDT Coverage Guide for States by consolidating, synthesizing, and clarifying CMS’s current regulations and guidance regarding coverage and access for children. In addition to setting out longstanding federal requirements, CMS emphasizes key areas of Medicaid policy and operations that are integral to ensuring proper implementation of the EPSDT guarantees for children, including the following:
- Because states must cover all medically necessary services that are coverable in Medicaid even if not in the state plan (and therefore not available to adults), states must be prepared to provide the full continuum of services a child may need. As an example in the behavioral health context, CMS points to the range of behavioral health services that a child may need beyond emergency, inpatient, and outpatient counseling services. Even if not in place for adults, states must establish a continuum of care to ensure a comprehensive array of services are available to children. Moreover, to prevent avoidable institutionalization, states must ensure that services are available in home and community settings when clinically appropriate, consistent with federal rights for people with disabilities.
- Congress established a child-specific approach for defining and assessing medical necessity, which is what determines when a service must be authorized for any particular child. The statutory definition is stronger than the definition applicable to adults, not least because it requires an individualized assessment of services that would “correct or ameliorate” a child’s health condition. States must ensure this standard—and associated requirements to ensure children actually receive the care they need—is applied for all EPSDT children and in all administrative processes, from initial outreach and education through prior authorization and administrative appeals for any service denials.
- Recognizing that managed care is now the primary delivery system for Medicaid in most states, the guidance reviews policies and strategies relating to managed care plans (MCPs) in much greater depth than CMS’s 2014 guidance. While states can delegate EPSDT responsibilities to plans, the guidance makes it clear that delegation does not relieve the state of its ultimate responsibility to monitor and ensure compliance with federal requirements.
- EPSDT’s guarantees are particularly important to children with special health care needs, including with respect to care coordination and case management services that assist children and families to connect with appropriate providers, logistical support, and social services. CMS reminds states that these care coordination and case management services must be available to all children at a level commensurate with the child’s needs.
- CMS emphasizes the role that parents (or other family members or caretakers) play in a child’s care, such as attending medical appointments, participating in care management decision meeting, or joining family therapy sessions. Under EPSDT, states must cover administrative supports to enable this involvement by parents and caretakes and can also cover additional parent-facing services (such as peer support for parents) as a direct benefit to the child.
In addition to reviewing these federal requirements, the guidance offers dozens of specific strategies that states have used to effectuate these requirements, organized into three broad topic areas:
- Promoting EPSDT awareness and accessibility for children and their caregivers, including by promoting awareness of EPSDT requirements among pediatric providers, state officials, and MCP staff.
- Improving care for children with specialized needs, with specific attention to children with behavioral health care needs, living with disabilities or other complex health needs, and/or involved in foster care.
- Expanding EPSDT provider capacity through more flexible provider qualifications, greater use of telehealth and interprofessional consultation, as well changes to payment methodologies to help states build sufficient provider networks.
While recognizing that “states implement EPSDT in varying ways due to different Medicaid program designs,” CMS encourages all states to “identify and implement the strategies and best practices that will have the most impact on the EPSDT-eligible children in their state.” The guidance notes that “CMS will be working with all states to ensure adherence” to EPSDT requirements, including “regular technical assistance webinars and planned future guidance.” Although not mentioned in CMS’s guidance, the EPSDT standards are also sometimes enforced via private lawsuits filed by patients and providers.
For more information on how to subscribe and to activate a complimentary one week trial to Manatt on Health, please reach out to Barret Jefferds.