Oct, 18, 2024

CMS Guidance on Health Coverage Requirements for Children and Youth Enrolled in Medicaid

Manatt Health

Introduction

On September 26, 2024, the Centers for Medicare & Medicaid Services (CMS) released comprehensive guidance (required by the 2022 Bipartisan Safer Communities Act), accompanied by a summary slide deck, reinforcing and clarifying federal Medicaid requirements regarding Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Under EPSDT, children and youth under the age of 21 (hereinafter referred to 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.[1]

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 United States. In addition, of the 40 states that operate a Children’s Health Insurance Program (CHIP) separate from Medicaid, 16 states have extended EPSDT requirements to CHIP as well. Ensuring fidelity to EPSDT requirements is also essential to improving health equity and reducing health disparities among children. As compared to children in higher income households, Medicaid- and CHIP-enrolled children are disproportionately children of color and experience higher rates of multiple chronic conditions and unmet health-related social needs.

This expert perspective provides an overview of CMS’ new EPSDT guidance, which represents CMS’ most comprehensive discussion of EPSDT requirements in over a decade.

EPSDT Guidance Overview

CMS’ 57-page State Health Official (SHO) letter builds upon the 2014 EPSDT Coverage Guide for States by consolidating, synthesizing, and clarifying CMS’ 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 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 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 in much greater depth than CMS’ 2014 guidance. While states can delegate EPSDT responsibilities to plans, the guidance makes 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 healthcare 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 guardians, other family members or caregivers) play in a child’s care, such as attending medical appointments, participating in care management decision meetings, or joining family therapy sessions. Under EPSDT, states must cover administrative supports to enable this involvement by parents, guardians and caregivers and can also cover additional parent-facing services (such as peer support for parents and guardians) as a direct benefit to the child.

 

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.” To that end, the guidance offers dozens of specific strategies that states have used to effectuate EPSDT requirements, organized into three broad topic areas:

  1. Promoting EPSDT awareness and accessibility for children and their caregivers, including by promoting awareness of EPSDT requirements among pediatric providers, state officials, and managed care plan staff.
  2. Improving care for children with specialized needs, with specific attention to children with behavioral healthcare needs, living with disabilities or other complex health needs, and/or involved in the child welfare system.
  3. Expanding EPSDT provider capacity through more flexible provider qualifications, greater use of telehealth and interprofessional consultation, as well as changes to payment methodologies to help states build sufficient provider networks.

Looking Ahead

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.” Specifically, CMS plans to build on this guidance by holding technical assistance webinars, releasing future guidance for states—including a Children’s EPSDT Behavioral Health Toolkit, drafting a report to Congress, and strengthening EPSDT oversight and compliance. Although not mentioned in CMS’ guidance, the EPSDT standards are also sometimes enforced via private lawsuits filed by patients and providers. While it is incumbent upon states to ensure compliance with federal EPSDT requirements, this obligation also presents an opportunity to improve access to affordable, high-quality healthcare services for children enrolled in Medicaid and CHIP, thereby promoting health equity.

 

[1] These EPSDT requirements are defined in sections 1902(a)(43) and 1905(r) of the Social Security Act.