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.

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.

Infographic: EPSDT And Children And Youth With Special Health Care Needs

The Catalyst Center has created a one-page infographic illustrating the importance of EPSDT for children and youth with special health care needs (CYSHCN). This is one page in a series of infographics exploring key focus areas in the world of health care financing and coverage for CYSHCN.

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 exploration of EPSDT are listed at the bottom of the infographic.

Infographic: Pathways to Medicaid Coverage For Children And Youth With Special Health Care Needs

The Catalyst Center has created a one-page infographic illustrating important elements of pathways to Medicaid coverage for children and youth with special health care needs (CYSHCN). This is one page in a series of infographics exploring key focus areas in the world of health care financing and coverage for CYSHCN.

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 exploration of pathways to Medicaid coverage are listed at the bottom of the infographic.

The Louisiana Family Opportunity Act Medicaid Buy-in Program

This article, published in the December 2015 issue of the Maternal and Child Health Journal, describes the process and results of a survey of parents and caregivers whose children with disabilities were enrolled in Louisiana Family Opportunity Act (FOA) Medicaid Buy-in program. Results suggest that the Louisiana FOA program fills a niche in coverage needs among families of children with disabilities in Louisiana; however, small sample size and significant differences between the sample enrolled in the FOA and the comparison groups limits how generalizable the results are.

Access to Care among Children with Disabilities in the MassHealth CommonHealth Buy-In Program

This article, published in the Journal of Child Health Care, describes the process and results of a survey of parents and caregivers whose children with disabilities were enrolled in CommonHealth, the state’s Medicaid Buy-in program. Results suggest that the MassHealth CommonHealth program improves access to care for children with disabilities overall; however, the article identifies barriers to address in five domains to improve accessibility.

Title V and Medicaid/CHIP Interactive Worksheets

The Catalyst Center created two interactive worksheets for Title V program staff, family leaders, and other stakeholders. These worksheets provide an overview of Title V, and Medicaid and the Children’s Health Insurance Program (CHIP). Each worksheet includes resources you can use to find and insert state-specific information to help demonstrate the importance of Title V, Medicaid and CHIP for children with special health care needs (CSHCN). The worksheets were created as companion materials to the Catalyst Center’s Public Insurance Programs and Children with Special Health Care Needs: A Tutorial on the Basics of Medicaid and the Children’s Health Insurance Program (CHIP).