The Centers for Medicare & Medicaid Services (CMS) Releases Updated Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Coverage Guide

On May 13, CMS released updated guidance for EPSDT coverage to help states deliver the full range of services for children covered by Medicaid or the Children’s Health Insurance Program (CHIP). The Guide outlines:

Requirements for informing families and children

1. Screening requirements, including interperiodic screening
2. The full range of diagnostic and treatment services under EPSDT, including requirements governing dental, vision, and hearing services
3. Services available under other federal authorities
4. Strategies to ensure appropriate coverage, including ensuring medical necessity
5. Notice and Fair Hearing Requirements
6. States’ responsibilities to ensure access to EPSDT services and providers
7. Assistance to states as they work with managed care providers (MCPs) to provide the best child benefit possible
8. Quality reporting mechanisms to measure EPSDT performance for states

The following is important for EPSDT-eligible individuals and their families to understand.

Requirements for Informing Families and Children

States must inform all eligible individuals of the available EPSDT services in a timely manner, and annually thereafter. This includes families whose EPSDT-eligible children are enrolled in Medicaid but have not used EPSDT services. States use a combination of written and oral methods to ensure that EPSDT-eligible children and their families are aware of and know how to access the comprehensive coverage and benefits available to them. Information must be available in plain language and in a manner that is accessible to those who cannot read or understand English. Additionally, the ADA requires reasonable accommodations for individuals who have difficulty receiving or accessing information because of a disability.

States must inform EPSDT-eligible children and their families:

1. About the benefits of preventive care;
2. Of the services available through EPSDT and how to obtain them;
3. That services are available without charge, except for premiums that may be charged for medically needy children; and
4. That transportation and appointment scheduling assistance are available upon request.

States must offer transportation and scheduling assistance “prior to the due date of a child’s periodic examination,” and once a request for support services has been made, states should assume that the request applies to any follow-up services as well.

Periodic and Interperiodic Screenings

EPSDT covers regular screening services (well-child visits) for infants, children, and adolescents that include medical, vision, hearing, and dental assessments. Well-child visits should be comprehensive and include age-appropriate laboratory, developmental, and other screenings; referrals to diagnostic and specialty services; and referrals to establish ongoing dental, vision, and hearing care.

The five components of a well-child visit are:

1. Comprehensive health and developmental history that assesses both physical and mental health
2. Comprehensive, unclothed physical examination
3. Appropriate immunizations, in line with the schedule set by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices
4. Laboratory tests, which include blood-lead screening appropriate for age and risk factors
5. Health education and anticipatory guidance for both the child and the family.

Treatment Services Available under EPSDT

EPSDT covers all services necessary “to correct or ameliorate defects and physical and mental illnesses and conditions” that the child may be experiencing, regardless of whether or not the state elected to cover the service under its state plan.  Even if the service, supply, or equipment is not listed as covered for adults under the state’s Medicaid, it must be provided for an EPSDT-eligible child if it is “medically necessary.” These services include, but are not limited to

• Case management services, including targeted case management
• Incontinence supplies
• Organ transplants and any related services
• A specially adapted car seat that is need for a medical problem or condition
• Medical foods

Additionally, services that “ameliorate” – maintain or support health problems rather than cure them – must be covered under EPSDT. These services include anything that can prevent conditions from worsening, reduce pain, and avoid the development of more costly illnesses and conditions. Some less common maintenance services include medical supplies, equipment, and appliances (such as pressure-relieving cushions or bed rails). If the service is not available under EPSDT, they may be covered under Home and Community-Based Services (HCBS) in order to prevent or delay institutionalizations.

Other services covered under EPSDT include

• Oral health
• Vision and hearing
• Mental health and substance use disorder (SUD)
• Personal care services

Services Available to Children under Other Federal Authorities

EPSDT-eligible children may have access to other Medicaid services that are no subject to EPSDT requirements. However, when providing children with services, EPSDT services should always be used before using services under other federal authorities. Other federal authorities can include the 1915(c) Home- and Community-Based Services waiver or 1945/1945A Health Homes. Unlike EPSDT services, these services may have limits to enrollment or dollars.

Services under other federal authorities include

• Home- and community-based services (HCBS): Services include respite services, supported employment, or other services approved by CMS to help prevent institutionalization. These can be offered through Section 1915(c) waivers or through State Plans.
• Health Homes: Offer coordinated care for Medicaid beneficiaries with chronic conditions.
• Enabling Services: When requested state Medicaid agencies must provide assistance with
  • Scheduling appointments
  • Transportation to appointments
  • Interpretation and translation

Permissible Limitations on Coverage of EPSDT Services

States may set parameters for

• Medical necessity – Must be made on a case-by-case basis, considering the child’s particular needs. If software is used to “streamline” decisions, it must be consistent with EPSDT requirements. While the child’s provider is responsible for determining or recommending the service, the state plays a role in determining whether is its medically necessary.
• Require prior authorization for certain services – Prior authorization may not delay deliver of needed treatment services. It may not be required for any EPSDT screening services.
• Determine the relative cost-effectiveness of alternatives – States may cover services in the most cost-effective mode if the less expensive services is equally effective and available. When weighing options, the child’s quality of life must also be considered.
• Cover experimental treatments at their discretion – EPSDT does not require coverage of “experimental” or “investigational” treatments, services, or items. State’s may cover experimental treatments if it is determined that the treatment or item could be effective in addressing the child’s condition.

Notice and Fair Hearing Requirements

Children have a right to a fair hearing whenever the state denies a request for benefits or services and when a state attempts to terminate, suspend, or reduce covered benefits or services.

Notice about fair hearing rights need to be sent at least 10 days before the effective date of the action – termination, suspension, or reduction of services. Advance written notice must be

• Written in plain language;
• Accessible to individuals with limited English proficiency and individuals with disabilities; and
• If provided in an electronic format, compliant with rules related to electronic notices and information.

The notice must contain

• What the decision or action is (i.e. termination or suspension), including the effective date
• Reasons for the decision or action
• Specific regulations or changes in federal or state law supporting the decision or action
• An explanation of the individual’s rights to a fair hearing, how to request a fair hearing, who can assist at the hearing, circumstances when benefits will be provided pending the outcome of the fair hearing, and the timeline for final action on the fair hearing.

Beneficiaries are allowed a fair hearing with the state Medicaid agency. Hearings must be conducted at a reasonable time, date, and place by an impartial official or other individual who was not directly involved in the initial decision or action. Beneficiaries have the right to represent themselves or use legal counsel, a relative, a friend, or other spokesperson.

Before the hearing, the individual or their representatives have the right to look at case files and all documents that will be used during the hearing. During the hearing, the beneficiary has the right to: bring witnesses, establish facts, present their case fully, question or refute the state’s case, and ask questions of the state’s witnesses (i.e., cross-examine). The hearing process must be accessible to persons with limited English proficiency and individuals with disabilities.

Beneficiaries have the right to continued coverage of the benefits or services pending the results of the fair hearing. If the beneficiary loses the fair hearing, they may be required to repay the state for cost of those services.

Access to Services

States must arrange for providing necessary to treatment to children, directly or through referrals to appropriate providers or organizations. These individual and group providers must be include a variety of providers who are qualified and willing to provide services to children. States and managed care providers (MCPs) should have online directories of providers that includes information on specialty and languages spoken.

Services should also be available in a variety of settings including

• Schools
• Telehealth
• Out-of-state, as necessary
• Most integrated settings appropriate

Managed Care

Managed care plans (MCPs) providing EPSDT services may not use a definition of “medically necessary” services for children that is more restrictive than the state’s definition. The state’s definition cannot be more restrictive than the “correct or ameliorate” federal standard.

MCPs must inform beneficiaries what EPSDT services the MCP is covering and how enrollees can access EPSDT services that are not included. EPSDT covered individuals still have the right to access all EPSDT covered services and the state must ensure that children receive those services.

Quality Reporting and Monitoring of EPSDT

States are required every year to report the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set) to CMS. Child Core Set measures include access to primary and preventive care, behavioral health care, maternal and perinatal health, care of acute and chronic conditions, dental and oral health, and children’s experience of care. These measures are used to improve access to health care services for Medicaid and CHIP beneficiaries.