The Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), recently issued SHO #24-005 – Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements. This guidance provides comprehensive guidance to support states to ensure that the 38 million children with Medicaid and Children’s Health Insurance Program (CHIP) coverage nationwide receive all the health care services they need. By highlighting best practices and strategies that states can use to implement EPSDT requirements, CMS hopes to improve and expand the number of children receiving the full array of available medical services.

Medicaid’s EPSDT requirements entitle eligible children to a wide range of preventive, diagnostic, and treatment services, such as well-child visits, mental health services, dental, vision, and hearing services. Obtaining these services early in life can result in children receiving early diagnoses that lead to the prevention of some health problems and the early treatment of others.

The CMS guidance consists of three major sections, as follows:

• Promoting EPSDT Awareness and Accessibility – The guidance emphasizes the need to ensure eligible beneficiaries have coverage, understand their benefits, and know how to access them. This section also focuses on providing support such as transportation and care coordination to facilitate providing services to children.
• Expanding and using the child-focused (EPSDT) workforce by broadening provider qualifications – The guidance gives examples of best practices to address provider shortages, such as using telehealth, interprofessional consultation, and new payment methodologies.
• Improving care for EPSDT-eligible children with specialized needs – This section focuses on how EPSDT requirements relate to children with unique needs, such as behavioral health conditions, foster care placement, disabilities, and other complex health needs.

Each of the three sections summarizes the EPSDT requirements. Next, each section outlines strategies and best practices to meet those requirements, recognizing that not all potential solutions work well in every state. As a result, states are not required to adopt the examples in the guidance and may develop other strategies and practices to meet EPSDT requirements as needed.

General Guidance Concerning Children with Special Needs

The section of this guidance that focuses on EPSDT for children with special needs is particularly interesting to our law firm and clients.

The guidance acknowledges the complexity of cases involving children with disabilities, who may receive health services through multiple federal programs. The intersection of the various programs can make it difficult for families to navigate the necessary services on their own. Medicaid agencies are required to have interagency agreements with Title V Maternal and Child Health programs and may have agreements with other state agencies. However, unlike most other programs, Title V is a secondary payor to Medicaid.

States must provide adequate enrolled providers, including pediatric specialists and pediatric hospitals, if possible, to meet their EPSDT obligations and provide medically necessary services for these children. States also must develop and enforce minimum standards for pediatric-specific providers in the network.

As children with disabilities may need specialized care not available close to their homes, states must have specific procedures for families to access out-of-network and out-of-network providers to ensure timely access to necessary medical services. States must pay for necessary medical services from out-of-state providers when medical advice indicates that those services are more readily available in another state. The process of obtaining out-of-state care should be streamlined and made as easy as possible for families with disabled children. States also must assist with transportation and scheduling assistance.

This guidance also notes that state may wish to at least partially fulfill their community integration obligations under Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, and the Supreme Court’s ruling in Olmstead v. L.C. by helping maintain children with disabilities in home-based or community settings. However, states are not obligated to include these measures.

CMS further points out that section 1915 services, including HCBS waivers, are not included under EPSDT. However, states are still required to provide children with EPTSD medically necessary services, regardless of the services they receive under their waivers. Furthermore, suppose a child needs EPTSD services that go beyond medical necessity to live in the community and avoid institutionalization. In that case, states must also provide them with those services and all EPTSD services to which they are entitled.

This section of the CMS guidance also emphasizes the need for states to assist children with special needs when they are nearing the age that they will transition out of EPSDT eligibility. More specifically, the guidance recommends that states assist with “coordinating appointments, transferring medical records, and connecting with new health care providers to ensure continuity of, and access to, necessary health care” (SHO #24-005, p. 39).

Recommended Strategies Affecting Children with Special Needs

First, CMS recommends that states expand managed care plan (MCP) enrollment to include children with disabilities, either in separate MCPs or in existing MCPs along with other children. This strategy is designed to enhance care coordination and focus on pediatric subspecialties.

Next, CMS cites the need for states to provide care coordination. Due to the complexity and sheer number of medical providers that children with disabilities may need, some states offer intensive care coordination. This type of coordination allows families to have a single point of contact and integrate the child’s providers.

Finally, CMS recommends that states coordinate programs for children with disabilities, provide them with a range of non-medical services, and implement a care navigation system for their families. This strategy aims to develop a cohesive system of care for the family and offer services tailored to a family’s needs, such as respite care, home modifications, and parental skills training.

Call Rubin Law Today to See How We Can Help  

Rubin Law is the only Illinois law firm to dedicate itself exclusively to providing compassionate legal services for children and adults with special needs. We offer unique legal and future planning techniques to meet your family’s individual needs.

Call us today at 866-TO-RUBIN or email us at email@rubinlaw.com to learn more about the services we can offer you and your family.