DCL 25-11
January 17, 2025
Dear Colleague:
The Centers for Medicare & Medicaid Services (CMS) recently released State Health Official (SHO) letter# 24-005 (PDF), Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements. The CMS guidance in this letter is designed to help States comply with coverage requirements for eligible children and youth under the age of 21 who are enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This Dear Colleague Letter from ORR builds upon that foundation to help ORR State and Replacement Designee beneficiaries strengthen their implementation of EPSDT requirements, improving health outcomes for such children and youth.
Reach and importance of Medicaid and CHIP
Nearly 80 million individuals are enrolled in Medicaid and CHIP, including nearly half of all children and youth in the United States. Many of the individuals served through ORR-funded programs are enrolled in or eligible for Medicaid or CHIP.
Medicaid and CHIP are jointly financed by the federal government and States, and they are administered by States within broad federal guidelines. Though each State may take a tailored approach, EPSDT requires States to provide comprehensive and preventive health care services (medical, dental, mental health, and specialty services) for most1 individuals under age 21 who are enrolled in Medicaid or CHIP.
EPSDT Policies, Strategies, and Best Practices to Maximize Health Care Access and Improve Health Outcomes
To improve health outcomes and meet EPSDT requirements, States can use a range of policies, strategies, and best practices. Some examples of EPSDT services are provided in Table 1.
Table 1: Example of EPSDT interventions to improve health outcomes
| Examples of the need for interventions to improve health outcomes for ORR-eligible children | Relevant EPSDT requirement | How some States are operationalizing within Medicaid and/or CHIP |
|---|---|---|
| Families unaware of the breadth of services available to children eligible for EPSDT | Written and oral communication materials to inform beneficiaries and their families about services available under EPSDT, including materials in formats for individuals who cannot read or understand English. | Most States provide information in easy-to-understand language and through multiple accessible methods (e.g., mail, web-based information, and electronic communication). States are encouraged to review their practices as they relate to the national standards for culturally and linguistically appropriate services (CLAS). Further, States must inform families of the availability of language assistance services and offer this assistance to individuals who have limited English proficiency. |
Need for early access to preventive health services due to minimal availability of services prior to resettlement
| Developmental, physical, and behavioral health screenings conducted during routine medical visits and screenings. | States are required to develop or adopt a schedule of recommended screenings to determine the existence of physical or mental illnesses or conditions for EPSDT-eligible children. Most States have adopted the Bright Futures periodicity schedule developed by the American Academy of Pediatrics or a modified version thereof2. Periodicity schedules recommend a schedule for screening services, including developmental, physical, mental health, and substance use disorder screenings. States must ensure that children have access to those screenings according to the State-determined schedule. |
| Families navigating a complex health care system to get the right services for their child | Care coordination or care management, depending on a child’s needs
| Some states cover community health workers (CHW) to provide a range of services that address beneficiaries’ health and social needs. CHWs have strong ties to the communities they serve and can be members of communities who are typically underrepresented in care settings or who are specifically qualified to provide culturally competent care. They may conduct activities such as health promotion and education, patient outreach and follow-up, assistance in navigating the health care system, translation and interpretation of medical information, and care coordination. |
| Caregivers experiencing high levels of economic stress that make it difficult to meet basic health needs, including participating in children’s medical appointments | Non-Emergency Medical Transportation (NEMT)
| States are required to ensure that beneficiaries have access to necessary transportation to receive covered care and must also cover the cost of transportation for any person who needs to accompany an eligible child to their medical service(s). In addition, if a child is receiving residential or facility-based care (e.g., inpatient, neonatal intensive care unit (NICU), etc.), and the presence of the parent, family member, or other caregiver is necessary so that they can actively participate in the treatment/intervention for the direct benefit of the child, then the State may pay for transportation for the parent, family member, or caregiver without the child present in order to ensure the child’s medically necessary services are provided. |
Suggested Actions for State Refugee Coordinators and State Refugee Health Coordinators
EPSDT requirements can be particularly relevant to populations served by the Refugee Resettlement Program. As such, State Refugee Coordinators (SRCs) and State Refugee Health Coordinators (SRHCs) can be valuable thought partners to their Medicaid and CHIP counterparts in identifying the advantages of specific Medicaid and CHIP services across programs. ORR strongly encourages SRCs and SRHCs to work closely with State Medicaid and CHIP agencies to help strengthen access to care for ORR-eligible individuals, as possible.
ORR suggests SRCs and SRHCs take the following actions:
- Identify the best point of contact within your State Medicaid and CHIP agency to answer questions you might have about what EPSDT policies are already in place. States vary in how they choose to operate CHIP programs, and your Medicaid agency will know whether it makes sense to have a separate point of contact regarding CHIP.
- Find out if there are active conversations about any of the services mentioned in the table above by reaching out to your State Medicaid and CHIP agency.
- Find out how your State Medicaid and CHIP agency is engaging providers in your state on these topics.
- Find out how your State Medicaid and CHIP agency is engaging with Medicaid enrollees and their families to ensure opportunities for feedback on service delivery in your area. In May 2024, CMS set new standards for State agencies to better engage Medicaid enrollees and their families in the Medicaid decision-making process through implementation of Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs)3. States must take initial action by July 2025. Ask your State Medicaid agency how you can become involved.
ORR hopes that SRCs and SRHCs find this information helpful in supporting children, youth, and their families in receiving the health coverage services they need and may be entitled to under federal Medicaid law. Thank you for your dedication and partnership. If you have any questions, please contact your State Medicaid agency. Together, we can ensure that all children and youth have the health care, services, and supports necessary to thrive.
Sincerely,
Ken Tota
Bureau Chief, Refugee Program Bureau
Office of Refugee Resettlement
Footnotes
1 Children eligible for EPSDT generally include beneficiaries under the age of 21 enrolled: in Medicaid through a categorically needy group; in Medicaid through a medically needy group in a state that has elected to include EPSDT in the medically needy benefit package; in a Medicaid-expansion CHIP program; or in a separate CHIP program that has elected to cover EPSDT. This includes beneficiaries with an institutional level of care who are eligible for Medicaid by virtue of their enrollment in a home and community-based services (HCBS) waiver under section 1915(c) of the Social Security Act. EPSDT is not available to beneficiaries without satisfactory immigration status who are eligible only for treatment of an emergency medical condition and other groups of individuals under age 21 who are eligible only for limited services as part of their Medicaid eligibility, such as, for example, family planning services. [State Health Official Letter #24-005 (PDF), Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment Requirements, p1].
2 American Academy of Pediatrics, Preventive Care/Periodicity Schedule . More detail on commonly used screening tools and instruments can be found here .
3 For more information, see CMS’ Ensuring Access to Medicaid Services — A guide for States to the Fee-For-Service Provisions of the Final Rule July 2024 (PDF). Relevant section begins p. 35.