New Opportunities and Continuing Challenges: A Report from the NASHP EPSDT Forum

Early access to high-quality child health care and development programs builds a foundation that ensures each child the optimum chance to grow strong physically, emotionally, and socially.

Medicaid, the primary insurer for more than a quarter of all children in the United States, is the critical link to building this foundation for poor and low-income children. In 1967, in response to documented, widespread, preventable mental and physical illnesses among poor children, Congress added Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for beneficiaries under the age of 21. EPSDT is Medicaid's comprehensive and preventive child health program that ensures that each child's health and developmental needs are assessed through initial and periodic examinations and evaluations, and that health and developmental problems found are identified and treated early. Each state administers its own program within rules established by the federal government.

Previous work by NASHP and others has shown that states face many challenges in ensuring that children receive comprehensive, high-quality EPSDT services. Several events over the past few years have presented new challenges as well as opportunities, including both flexibility and restrictions offered by the Deficit Reduction Act of 2005 and increasing efforts to employ health information technology to improve care.

In January 2008, with the support of the Robert Wood Johnson Foundation, NASHP convened a small group of state Medicaid and maternal and child health (MCH) staff, Centers for Medicare and Medicaid Services (CMS) and provider representatives, and other experts on Medicaid and EPSDT to begin to help states address both ongoing challenges and recent changes. This group examined effective state strategies for maximizing Medicaid-enrolled children’s access to timely, appropriate, and comprehensive health services through the EPSDT benefit. Participants identified challenges to effective delivery of the benefit as well as opportunities for its improvement. 

This report summarizes the discussion at the meeting and is designed to help states learn of innovations, challenges, and opportunities, especially those related to the DRA, in efforts to ensure the best access to care for Medicaid-covered children. It examines four general areas of EPSDT services delivery:

• Ensuring effective coverage, including both the structure of the benefit package and the definition of medical necessity;
• Securing the participation of primary care providers in delivering EPSDT services and subsequent support of those providers;
• Care coordination and case management; and
• Data collection, reporting, and quality.