Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federally mandated benefit that every state Medicaid program must provide to children, birth to age 21, who are enrolled in Medicaid. This benefit ensures children have access to all medically necessary services, even if the service is not part of the state plan. Medicaid must also educate parents about this benefit and help them access care by providing services such as transportation, assistance with scheduling appointments, and connections to other supports, particularly services offered by state Women, Infants, and Children (WIC) programs, and Title V. Many Medicaid and Title V programs work in partnership to ensure children have access to EPSDT.
All of the Louisiana Medicaid Managed Care health plans must have full time EPSDT coordinators so Medicaid can engage them relative to the EPSDT mission and CYSHCN. This is a contractual requirement that helps promote preventive health care and ensures the child health population enrolled in Managed Care receives medically necessary services under EPSDT.
In an effort to provide outreach and education about the EPSDT benefit, a Massachusetts Medicaid Managed Care Organization (MCO) sends a yearly birthday card to members to remind them about the screenings and preventive services they should receive during the year. The card also encourages members to reach out to their Primary Care Physician to schedule a check-up and receive screenings and/or preventive services.
The Virginia Medicaid program has a Memorandum of Agreement (MOA) with their state health department, which manages the Title V program. These two state agencies have a long history of working together to address different aspects of care for children with special health care needs (CSHCN). As an example, in an effort to increase the rate of developmental screenings, Medicaid has collaborated with the Title V program to promote Bright Futures (child health guidelines developed by the American Academy of Pediatrics) along with the EPSDT benefit. They are working to update their business-associated agreement with the state health department, which includes a variety of services in addition to the CSHCN program.
The West Virginia Title V Agency administers HealthCheck, the state’s EPSDT program. The state uses HealthCheck to facilitate health screenings, diagnosis, treatment, and other necessary care required by the federal EPSDT law. It operates to support the national standard for well-child care, the American Academy of Pediatrics’ Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, on behalf of West Virginia individuals up to age 21 enrolled in Medicaid. As part of the outreach component of the EPSDT benefit, Title V has nine community-based specialists that work to make primary care providers aware of the EPSDT benefit and the process for accessing the diagnostic and treatment benefit for their patients. The HealthCheck program conducted medical record reviews of more than 200 providers throughout the state to establish a baseline for the performance of developmental screenings over the first three years of life. The results showed that developmental screenings were not occurring per the national standard for preventive pediatric health care. In response to these findings, HealthCheck provided education and technical assistance about developmental screenings and then repeated the medical record review. By implementing this quality improvement model, Title V has seen a huge improvement in this aspect of the standard of care. The HealthCheck program is extremely helpful and it positively affects the standard of care for children with special health care needs (CSHCN). The West Virginia Title V/CSHCN program also collaborates with Medicaid to help maximize the EPSDT benefit for CSHCN who have Medicaid as secondary insurance coverage. If a service is found to be necessary through the EPSDT screening and is not covered by the child’s private insurance, Title V staff help the child access the service through the EPSDT benefit.
- 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) Section 12