The child health portion of Medicaid – Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program – aims to improve the health of low-income children in every state. Required in every state, EPSDT finances appropriate and necessary pediatric services.
Since one in three U.S. children under age six are eligible for Medicaid, EPSDT offers a way to ensure that young children receive appropriate physical, mental, and developmental health services.
The elements of the program include:
|Early||Identify problems early, starting at birth|
|Periodic||Check children's health at periodic, age-appropriate intervals|
|Screening||Provide physical, mental, developmental, hearing, vision, and other screening tests to detect potential problems|
|Diagnosis||Perform diagnostic tests to follow up when a risk is identified|
|Treatment||Treat any problems that are found|
Anyone under age 21 enrolled in Medicaid receives required benefits and services – at regular intervals and whenever a problem appears – to identify physical and mental health conditions. Needed services include assistance in scheduling appointments and with transportation to keep appointments.
Screening includes a comprehensive health and developmental history, an unclothed physical exam, appropriate immunizations, laboratory tests, and health education.
Other key activities include:
- Establishing regular EPSDT schedules for dental, vision and hearing screenings, including appropriate screening, diagnostic, and treatment
- Setting managed care performance standards
- Clearly defining medical necessity
- Using reasonable and appropriate prior authorization standards, particularly related to preventive services
- Financing outreach, promotion, and transportation assistance
EPSDT is designed to help ensure access to needed services, including assistance in scheduling appointments and transportation assistance to keep appointments.
Mental Health and EPSDT
Federal law requires complete well-child examinations with screening services through EPSDT, including screening for potential developmental, mental, behavioral, and/or substance use disorders. EPSDT also finances diagnostic and treatment services, if medically necessary, for these conditions.
Child Mental Health Resources
EPSDT not only finances health care for children but also ensures that children receive appropriate, quality services to improve their health.
As described in federal program rules: “The EPSDT program consists of two, mutually supportive, operational components:
- assuring the availability and accessibility or required health care resources; and
- helping Medicaid recipients and their parents or guardians effectively use them.”
Within broad federal guidelines, states have the flexibility to design an EPSDT program that fits with their Medicaid, public health, and medical care systems. Informing and support services are specifically described in the federal EPSDT rules.
States are required to:
- Inform all Medicaid-eligible children under age 21 and their families about EPSDT on a timely basis (i.e., within 60 days of enrollment).
- Use effective methods of communication and clear, non-technical language in informing families with a recommended combination of face-to-face, oral, and written information.
- Inform Medicaid-eligible pregnant women about EPSDT, as well as adoptive and foster care parents of eligible children.
- Offer and provide, if requested and necessary, assistance with transportation to medical care.
- Specify in the state plan the state’s responsibility for transportation assistance and describe the methods to use.
- Offer and provide, if requested and necessary, assistance with scheduling appointments for EPSDT care and services.
Title V agencies – both the federal Maternal and Child Health Bureau and the state programs that receive block grant funding – have a strong commitment to promoting family-centered, community-based, culturally competent systems of care. By promoting this approach for EPSDT, Title V agencies can help Medicaid agencies better fulfill their responsibilities to provide outreach and information to families.
- Parent- to-Parent of Vermont produced an excellent guide for parents (particularly those whose children have special health needs) called Six Ways to Access Medicaid/EPSDT.
- Oklahoma Health Care Authority (OHCA) has a state website that includes an AAP and immunization schedule, ride assistance telephone line, FAQ, and treatment examples.
Title V program leaders often create or fund care coordination. While there is no specific care coordination category under Medicaid, some Title V care coordination may qualify for reimbursement as case management.
Medicaid describes case management as an activity under which responsibilities for locating, coordinating and monitoring necessary and appropriate services for a recipient rests with a specific individual or organization.
- Administrative – Activities that help the program operate efficiently ensuring children receive needed health care. The federal government contributes at a rate of 50% for administrative case management.
- Case management in the EPSDT process is a type of administrative case management. It generally refers to the outreach, informing, and other administrative roles under EPSDT.
- Targeted case management – a type of medical assistance – in which states have the option to design and provide targeted case management for specific patients, specific geographic areas, or specific sets of services.
- For example, several states offer targeted case management for pregnant women and other states deliver targeted case management through home visits to young children.
- Targeted case management is added as a benefit to the state Medicaid plan, and the federal contribution is at the medical assistance rate (i.e., like other medical care services).
The George Washington University purchasing specifications on Medicaid Managed Care for Children in Substitute Care also provide relevant information.
Federal rules encourage partnerships between state Medicaid agencies and Title V grantees to ensure better access to screening, diagnostic, and treatment services.
Between 1967 and 1989, Congress enacted a number of amendments to Title V, adding requirements to work closely with and assist Medicaid in a number of activities. Currently, the Title V law requires that state MCH programs:
- Assist with coordination of EPSDT.
- Establish coordination agreements for with their state Medicaid programs.
- Provide a toll-free number for families seeking Title V or Medicaid providers.
- Provide outreach and facilitate enrollment of Medicaid-eligible children and pregnant women.
- Share data collection responsibilities, particularly related to infant mortality and Medicaid.
- Provide services for children with special health care needs not covered by Medicaid.
Federal EPSDT rules call for coordination with Title V, but in different ways than the Title V law requires coordination with Medicaid. Federal EPSDT requirements include:
- Establishment of written state MCH-Medicaid agreements which provide for maximum use of Title V-supported services and aims to improve child health status.
- Reimbursement of Title V providers for services rendered, even if such services are provided free of charge to low-income uninsured families. Payment mechanisms include reimbursement for costs, capitation payments, or prospective interagency transfers with retrospective adjustments.
States use relationships between Title V and Medicaid, including the EPSDT program, to improve child health. Over the years, states have:
- Provided EPSDT screening through Title V funded child health clinics operated by local health departments.
- Created toll-free hotlines to assist families with information about and enrollment in Medicaid and EPSDT.
- Funded local health departments to provide outreach, coordination, and referral services. Used home visiting programs as a strategy for EPSDT outreach and informing.
- Recruited, trained, and supported public and private EPSDT providers, including through “medical home” initiatives.
- Funded centers of excellence and regional centers for specialty pediatric care, including child development, genetic services, orthopedic care, sickle cell disease treatment, and HIV/AIDS.
- Promoted use of EPSDT financing for school-based health centers in medically under-served communities, as well as other school health initiatives.
- Assisted in development of EPSDT screening tools and periodicity schedules.
- Developed standards of care and policies to support quality improvement in EPSDT, including development of managed care contract provisions.
- Promoted dental screening and preventive oral health services (e.g., fluoride rinsing, dental sealants) in pediatric care settings.
- Evaluated and/or monitored EPSDT program performance.
State Title V agencies can play an important role in monitoring EPSDT. The examples below describe some current and past data and monitoring activities undertaken by Title V agencies.
- Assist Medicaid agency in tracking screening ratio, as they aimed to reach 80%.
- Collect data on service use and outcomes of children with special health care needs enrolled in Medicaid.
Provider Related Activities
- Collaborat with the Academy of Pediatrics, Academy of Family Physicians, Primary Care Association, and other professional organizations to train about and promote participation in EPSDT.
- Develop EPSDT data collection tools for maternity and pediatric providers.
- Monitor EPSDT screening rates among local health departments that provide well-child care.
Activities Related to Managed Care
- Assist in conducting managed care record review or focus studies.
- Monitor the adequacy of screens.
The Center for Medicare and Medicaid Services (CMS) is responsible for administering Medicaid and EPSDT. Partnerships between CMS, HRSA (through Title V), health agencies, families, providers, and managed care organizations are important to ensuring access to needed services for children.
State Title V agencies can play an important role in guiding EPSDT. In fact, the EPSDT rules encourage state Medicaid agencies to delegate tasks to Title V agencies to assure access and receipt of the full range of screening, diagnostic, and treatment services.* Such delegation may be local, regional, or statewide. The examples below describe some specific activities undertaken by Title V agencies.
Family Support Activities
- Develop and implement outreach initiatives
- Assist with eligibility and enrollment - MEDICAID Managed Care for Pediatric Services
- Coordinate service delivery for children with special health care needs enrolled in Medicaid
- Recruit and train providers
- Develop clinical guidance for providers based on Bright Futures and EPSDT rules
- Oversee EPSDT screening in local health departments, including data collection to monitor screening rates
- Help ensure continuing care through care coordination projects
Activities Related to Managed Care
- Assist in developing managed care contract provisions
- Monitor the adequacy of managed care plan provider networks
Other Administrative Activities
- Develop standards of care and regular schedules
- Convene expert panels and medical advisory boards
- Review medical necessity decisions using skilled medical personnel with expertise in maternity and pediatric care
Note - EPSDT rules state that: Federal financial participation (FFP) is available to cover the costs to public agencies of providing direct support to the Medicaid agency in administering the EPSDT program. Generally, the administrative matching rate is 50%.
Local health care systems can vary based on provider supply, public health structures, health coverage patterns, and state laws. Increasing the effectiveness of relationships between pediatric providers and other child serving entities is one key step toward improving care and services for families.
State Title V MCH programs can and should help local public health agencies learn about managed care and the Memorandum of Understanding (MOU) process. As it relates to EPSDT, MOUs might define interaction related to case management, data reporting, immunization billing, and children with special health care needs.
Studies by the GWU-Center for Health Research Policy show that:
- MOUs play a useful role in establishing working relationships between public health agencies and managed care organizations (MCOs).
- Often, MOUs do not address core public health functions beyond the provision of personal health services.
- While MOUs often describe billing arrangements for covered services delivered by a local health department, such arrangements are often not in use.
MOUs have a limited impact on resolving certain issues and do not typically improve:
- State and local public health agencies’ access to data needed for community-wide disease observation (e.g. immunization registries).
- MCO participation in larger community efforts to control public health threats (e.g., communicable disease outbreaks, lead exposure).
- MCO understanding of quality improvement standards advocated by public health agencies as a means of community-wide public health protection.
Specific contract language is particularly important for EPSDT. MCOs need to know exactly what services they are responsible for covering. Enrolled children and their families need to know what services they are entitled to receive from the MCO and what services they are entitled to under the state Medicaid program.
Children with Special Health Care Needs (CSHCN) Programs
Many children identified by Title V Agencies as CSHCN are Medicaid recipients. Program connections can improve care, reduce expenditures, and better support families.
Child Welfare Programs, including Foster Care
Children entering the foster care system are entitled to Medicaid and an initial or ongoing EPSDT screening. States have a variety of approaches to fulfilling this obligation.
IDEA Part C Early Intervention Program
Under the federal Individuals with Disabilities Education Act (IDEA) Part C program, states provide early intervention services for infants and toddlers (up to age three) that currently have, or have a high risk for experiencing developmental delays. Some children qualify for both Medicaid and IDEA financing. Federal law permits Medicaid financing for certain services provided to a child and family under Part C.
Head Start Programs
A majority of children served in Head Start programs are Medicaid-eligible. The federal Head Start program calls for coordination to improve access to care for these children.
Millions are enrolled with managed care organizations (MCOs) operating under contracts with Medicaid. The George Washington University’s (GWU) Managed Care Purchasing Specifications offer sample language that can be used by states, MCOs, and family advocates to enhance Medicaid managed care contract language and improve child health services.
Keeping Track in Arizona: Arizona’s Health Care Cost Containment System (AHCCS) developed age-specific EPSDT tracking forms, designed to help providers deliver comprehensive, age-appropriate, screening exams.
With input from managed care organizations (MCO) and pediatric leaders, the form identifies the components of EPSDT called for at each visit. When the form is completed during the visit, one copy is kept in the child’s medical record and the other copy is set to the MCO. The MCO is, in turn, responsible for ensuring that the EPSDT screenings occur on schedule, with adequate content, and the completed tracking form data is available for performance monitoring.
Title V and Medicaid agencies working together might:
- Develop and implement EPSDT-specific provider recruitment and retention projects
- Offer training and administrative support to participating providers
- Monitor the provider supply and design strategies to improve access to care in under-served communities
- Study the supply of providers available for treatment of diagnosed conditions, particularly for children’s mental health, dental care, and developmental services
- Educate providers on EPSDT and how to bill for covered services
Basic Provider Information
- The University of Utah Healthy U CHECK program offers provider education and administrative support to pediatricians and others.
State Medicaid agencies must report annually on EPSDT services. The annual report provides basic information on the number of children (by age and basis of Medicaid eligibility) who receive medical or dental screens and the number referred for diagnostic or treatment services.
For the overall program, states have opportunities to:
- Determine the number of scheduled screenings according to the periodicity schedule and rate of EPSDT screens
- Assess the percentage of children with health problems identified through screening or diagnostic tests paid for by Medicaid
- Conduct record reviews/audits
- Track pediatric providers’ billing for screens
- Monitor provider participation and use patterns
In Medicaid managed care, states have opportunities to:
- Require managed care organizations (MCOs) to submit encounter data for EPSDT screening.
- Link databases, such as immunization registries, lead screening databases, and Head Start EPSDT data sets.
- Use data to monitor performance of MCOs as part of a quality improvement/feedback loop.
- Distribute MCO performance data as an incentive to report complete and accurate data.
Private Organizations Offering Data on EPSDT
- The Kaiser Family Foundation offers summary data on EPSDT screens.
- The American Academy of Pediatrics compiles and publishes a variety of data regarding Medicaid, EPSDT, and child health. The AAP routinely produces reports on EPSDT screening rates, eligibility and enrollment, as well as payment rates.
Under the Deficit Reduction Act of 2005 (DRA, enacted February 2006), states were given the option to modify the delivery approach of services to children enrolled in Medicaid. Two DRA changes to Medicaid law may have direct impact on EPSDT.
- The DRA gives states the option to restructure their approach to benefits under Medicaid without a federal waiver, using the state plan amendment process. Under this option, states may enroll certain groups (mainly those in optional eligibility groups) in benchmark or benchmark equivalent benefit packages and wrap-around benefits consisting of EPSDT benefits for any child under age 19 covered under a state plan.
- The DRA also includes a more specific definition of case management and places limits on use of targeted case management and administrative case management and. Since state Medicaid agencies use both EPSDT case management and targeted case management for infants, children, and adolescents, such programs may be affected by the DRA provisions.
For over 35 years, EPSDT has evolved. As Medicaid changed (e.g. use of managed care), states clarified EPSDT rules. Congressional and court actions have also had an effect on the program. It adapted to changing pediatric guidelines. The program’s purpose is “to discover, as early as possible,” and provide “continuing follow up and treatment so that handicaps do not go neglected.”