State Definitions of Medical Necessity Under the Medicaid EPSDT Benefit

State Medicaid programs are required to provide Medicaid enrollees under age 21 with comprehensive and preventive health care services through the Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Federal law requires states to cover “medically necessary services” under the EPSDT benefit “whether or not such services are covered under the State plan.”  The federal statute does not define “medical necessity” but instead describes a broad standard for coverage. States can, therefore, establish their own parameters for medical necessity decisions so long as those parameters are not more restrictive than the federal statute. In March 2021, with support from the Catalyst Center, The National Academy for State Health Policy (NASHP) conducted a 50-state scan of medical necessity definitions used by state Medicaid programs for their EPSDT benefit, updating a previous scan conducted in 2013. This resource presents definitions of medical necessity from all 50 states and the District of Columbia.

Improving Care Coordination for Children with Medical Complexity: Exploring Medicaid Health Home State Options

States are increasingly interested in care coordination as a strategy for improving systems of care for children with medical complexity (CMC) and their families. The Section 2703 Medicaid Health Home State Option and the new Advancing Care for Exceptional (ACE) Kids Act Health Home State Option present opportunities to enhance and expand care coordination for CMC in Medicaid. This new brief compares the two approaches and presents key considerations for states as they explore implementing health home options. Additionally, the brief presents New York as a case study in implementing the Section 2703 Medicaid Health Home State Option to provide care coordination for CMC. 

The Role of State Medicaid and Title V Program Definitions of Children and Youth with Special Health Care Needs in the Provision of Services and Supports

This issue brief, written in partnership with the National Academy for State Health Policy (NASHP), describes how states define CYSHCN within Medicaid and Title V CYSHCN programs and explores the implications of these definitions. Federal and state program approaches to defining children and youth with special health care needs (CYSHCN) can impact how they determine eligibility for health care services and supports (e.g., care coordination), evaluate the impact of services, and measure outcomes.  The brief presents an analysis of data gathered through administrative and interview data from seven states (AZ, FL, NY, OH, OR, UT, and VA), and presents state considerations for establishing and implementing definitions of CYSHCN.

Catalyst Center COVID-19 Resource Series

The public health emergency resulting from the COVID-19 pandemic has real implications for state Title V programs as well as families raising children and youth with special health care needs (CYSHCN).

These fact sheets address a variety of relevant topics, such as Medicaid and CHIP programs and the CARES Act. 

COVID-19: The Coronavirus Aid, Relief, and Economic Security (CARES) Act and Employment

Part of the Catalyst Center COVID-19 Resource Series. 

The public health emergency resulting from the COVID-19 pandemic has real implications for state Title V programs as well as families raising children and youth with special health care needs (CYSHCN).

State programs like Medicaid/CHIP and Title V, which are integral to the system of services and supports for children and youth with special health care needs, must be ready to adapt and respond to the current challenges faced by children, families, providers, and other stakeholders.

These fact sheets help explain employment provisions for families in the CARES Act. Families raising CYSHCN are more at risk than ever for experiencing financial hardship due to job loss, loss of health insurance, and other factors. Understanding these policy changes can aid in reducing the risk of family financial hardship.

Download the full series, or individual fact sheets below. 

COVID-19: The Coronavirus Aid, Relief, and Economic Security (CARES) Act and Health Coverage

Part of the Catalyst Center COVID-19 Resource Series. 

The public health emergency resulting from the COVID-19 pandemic has real implications for state Title V programs as well as families raising children and youth with special health care needs (CYSHCN).

State programs like Medicaid/CHIP and Title V, which are integral to the system of services and supports for children and youth with special health care needs, must be ready to adapt and respond to the current challenges faced by children, families, providers, and other stakeholders.

These fact sheets help explain health coverage provisions for CYSHCN and families in the CARES Act. Understanding these policy changes can support activities related to care coordination, benefits and coverage counseling, and aid in reducing the risk of family financial hardship. This information can also inform the changing landscape of health coverage for CYSHCN.

Download the full series, or individual fact sheets below. 

COVID-19: Flexibility for States: Medicaid and CHIP Programs

Part of the Catalyst Center COVID-19 Resource Series. 

The public health emergency resulting from the COVID-19 pandemic has real implications for state Title V programs as well as families raising children and youth with special health care needs (CYSHCN).

State programs like Medicaid/CHIP and Title V, which are integral to the system of services and supports for children and youth with special health care needs, must be ready to adapt and respond to the current challenges faced by children, families, providers, and other stakeholders.

These fact sheets help explain Medicaid and CHIP program flexibilities to Title V program staff and allies. Understanding these policy changes can support activities related to care coordination, benefits and coverage counseling, and aid in reducing the risk of family financial hardship.

Download the full series, or individual fact sheets below. 

Family Voices Leadership Conference Panel: Partnership Opportunities Panel

On May 10th at the 2019 Family Voices Leadership conference, the Catalyst Center presented on a Partnership Opportunities Panel. The slides detail our work as the National Center on Health Insurance Coverage and Financing of Care for Children and Youth with Special Health Care Needs, how we partner with families and youth leaders, and upcoming opportunities for collaboration.

AMCHP Conference Workshop: Seeing Is Believing

On March 10th at the 2019 Association of Maternal & Child Health Programs (AMCHP) conference, the Catalyst Center presented an infographic series on the fundamentals of financing the system of care for CYSHCN.

The presentation reviews the rationale for the infographic series, key content in each infographic, and explores how infographics can be used to communicate effectively with various stakeholders.

Critical Elements for Financing the System of Care for CYSHCN: An Infographic Series

The Catalyst Center has created an infographic series exploring key focus areas in the world of health care financing and coverage for children and youth with special health care needs (CYSHCN). Each infographic offers a concise look at a complex issue from the perspective of CYSHCN, their families, payers and policymakers, and providers.

These one-pagers are a visually appealing and easy way to share information about the system of care for CYSHCN with stakeholders. Resources for further topic exploration are listed at the bottom of the infographic. Infographic topics include: Medicaid, pathways to Medicaid coverage, EPSDT, inequities in coverage and financing, family financial hardship, the importance of partnerships, family engagement, value-based purchasing, and care coordination.

Thanks to the following family leaders and Title V colleagues for reviewing this project and providing valuable feedback: Cara Coleman, Donene Feist, Janis Guerney, Rylin Rodgers, Nora Wells, Sandra Broughton, Elizabeth Collins, Elaine Gabovitch, Alison Martin, Shirley Payne, and Meredith Pyle.