CMS Publishes EPSDT Strategies and Best Practices for States

On September 26, 2024, the Centers for Medicare & Medicaid Services (CMS) published a State Health Official letter regarding best practices for states to comply with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. EPSDT requirements create a “higher standard of coverage for eligible children than for adults” and ensure that eligible children and youth “get the health care they need, when they need it, in the most appropriate setting.”   

The Social Security Act (SSA) requires state Medicaid programs and Children’s Health Insurance Program (CHIP) to cover medically necessary health care, diagnostic services, and treatment to address or mitigate physical and behavioral health illnesses and conditions for eligible children under 21. According to the May 2024 CMS Enrollment Snapshot, approximately 38 million children were enrolled in Medicaid or CHIP, almost half the total population of youth under 21 in the United States. States’ Medicaid policies and procedures must acknowledge and incorporate the heightened standards for youth under EPSDT. States are also required to educate beneficiaries about EPSDT, report annually to CMS about EPSDT services provided, and ensure there are sufficient qualified providers to offer EPSDT services.   

This article provides an overview of the new guidance CMS provided in the SHO, which states can use to ensure adherence to EPSDT requirements and promote better health outcomes for children and youth enrolled in Medicaid and CHIP. 

State Strategies and Best Practices 

CMS conducted a comprehensive review of state approaches to implementing EPSDT, including reviewing EPSDT educational materials for beneficiaries, provider manuals, managed care contracts, and state coverage of EPSDT services. The agency also conducted listening sessions \with various stakeholder groups, including state Medicaid agencies, parents and caregivers, and advocates.  

Based on its review of state approaches and lessons learned during the listening sessions, CMS organized the SHO into three broad topics: (1) Promoting EPSDT awareness and accessibility; (2) Expanding and using the child-focused EPSDT workforce; and (3) Improving care for EPSDT-eligible children with specialized needs. In the guidance, each section outlines policies, strategies, and best practices for states. Summaries of each section and the best practices highlighted by states are provided below. 

1. Promoting Awareness and Accessibility 

States are responsible for ensuring families understand and children have access to the EPSDT services available to them under Medicaid and CHIP, including coordinating scheduling, facilitating transportation to appointments, and case management. Frequently, families do not understand the full scope of services available to them, how to access these services, or how to ask for help. States can use the best practices included below to ensure they satisfy this component of EPSDT requirements.  

2. Expanding and Using the Children-Focused (EPSDT) Workforce 

Many states face challenges enrolling pediatric providers – challenges that will likely persist for years to come. Understanding the impact on access to EPDST services, the SHO includes best practices that have helped states mitigate some of these challenges. In its guidance, CMS encourages states to reduce administrative burdens by simplifying provider enrollment processes and removing prior authorization requirements for frequently-approved service categories. CMS also underscores the importance of competitive provider reimbursement rates to maintain robust provider networks. 

3. Improving Care for Children with Special Needs 

For children with complex healthcare needs, early detection of conditions and appropriate treatment is particularly crucial for ensuring best health outcomes. CMS shared best practices states have used to assess and meet the needs of children with behavioral health needs, children in foster care or formerly in foster care, and children with disabilities and other complex health needs. In its guidance, CMS underscores the importance of care coordination and case management for individuals nearing the age of transition out of EPSDT eligibility.  

Although the strategies and best practices outlined above are not an exhaustive list, they do illustrate successful tactics taken by states to comply with EPSDT requirements. States approach EPSDT implementation from a variety of angles; although there is no one-size-fits-all strategy, building upon what has worked in other states may help bridge gaps and mitigate challenges around EPSDT awareness and accessibility, workforce, and services for children with complex healthcare needs.