Improving Health Outcomes for Eligible Children and Youth Enrolled in Medicaid and the Children’s Health Insurance Program
ACF-IOAS-DCL-24-04
Revised (initially published October 25, 2024)
To: State, territorial, tribal, and local policymakers and administrators of systems, agencies, and programs responsible for children, youth, and family health and well-being
Dear Colleagues,
Quality and accessible health care is critical to support the children, families, and communities we serve. We know that state Medicaid and the Children’s Health Insurance Program (CHIP) agencies are essential partners in this important work. I am excited to share that the Centers for Medicare & Medicaid (CMS) recently released new guidance regarding coverage requirements for eligible children and youth enrolled in Medicaid and CHIP.
The new guidance, in the form of a State Health Official letter entitled, Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements,[1] is intended to support states as they work to strengthen their implementation of EPSDT requirements to help ensure improved health outcomes for children and youth enrolled in Medicaid and CHIP.
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 the Administration for Children and Families (ACF) funded programs are enrolled 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 that comprehensive and preventative health care services (medical, dental, mental health, and specialty services) for children under age 21 who are enrolled in Medicaid or CHIP be provided.
EPSDT and ACF grantees
There are many services that states can elect to include as part of the EPSDT benefit to address risk factors for adverse experiences such as child welfare involvement and youth homelessness. These risk factors often directly intersect with the work of ACF grantees. A few examples included in the new guidance are highlighted below:
| Risk factor for adverse experiences | Potential service to support addressing this need | Detail on how some states are covering this service within Medicaid and/or CHIP |
|---|---|---|
| Developmental, medical, or behavioral health needs in a child and/or undetected parental peripartum depression | Developmental and behavioral health screening in well-child visits, including postpartum depression screenings in infant well-child visits up to 6 months | Most states have adopted the Bright Futures periodicity schedule developed by the American Academy of Pediatrics or a modified version thereof.[2] Periodicity schedules recommend a schedule for screening services, including developmental, mental health, and substance use disorder screenings, and states must ensure children have access to those screenings according to the state-determined schedule. |
| Families challenged to navigate the 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-based Care Management Entities to support families in their own homes and communities by identifying formal and informal resources in their geographic area so they can be incorporated into care coordination plans and by working with families to support successful use of these services. |
| Caregivers experiencing high levels of parenting stress due to parenting a child with medical or behavioral health needs | Caregiver clinical and/or peer support | States have integrated primary care settings, Certified Community Behavioral Health Centers, or other settings where the range of services includes coverage for services that support children and their parents, family members, and caregivers. Some parent-facing services can be paid for through the child’s Medicaid benefit if the service is provided for the direct benefit of the child.
|
| 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 transportation for medically necessary services. In addition, the state may pay for transportation for the parent, family member, or caregiver without the child present in order to ensure their active participation in the child’s treatment. |
While doing so is not required under EPSDT, states also may develop approaches to cover services in addition to those covered under section 1905(a), with the goal of maintaining children with disabilities or other complex health needs in integrated home and community-based settings or helping them return to their community.[3] The CMS guidance contains specifics about how states might use other authorities to cover services beyond what is required under EPSDT.
Suggested Actions
ACF grantees can be valuable thought partners to their Medicaid counterparts in thinking through the advantages of specific Medicaid services across systems. If your organization has the capacity to do so, we strongly encourage you to work closely with your state Medicaid and CHIP agencies to help strengthen access to care for children and youth.
For ACF grantees eager to engage in these conversations, I suggest you take the following actions:
- Identify the best point of contact within your state Medicaid agency to answer questions you might have about what services 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 happening at the state level regarding any of the services mentioned in the table above by reaching out to your state Medicaid agency. Find out if there are plans to amend the state plan or apply to the CMS for a waiver.[4]
- Find out how your state Medicaid agency is engaging providers in your state around these topics.
- Find out how your state Medicaid agency is engaging the lived experience community 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). States must take action by July 2025. Ask your state Medicaid agency how you can become involved.
We hope that you find this guidance 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.
/s/
Meg Sullivan
Principal Deputy Assistant Secretary
[1] SHO # 24-005: Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements (medicaid.gov) (PDF)
[2]Preventive Care/Periodicity Schedule . View more on commonly used screening tools and instruments .
[3]EPSDT entitles enrolled infants, children and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.
[4]A Medicaid and CHIP state plan is an agreement between a state and the Federal government describing how that state administers its Medicaid and CHIP programs. When a state is planning to make a change to its program policies or operational approach, states send state plan amendments to CMS for review and approval.