EPSDT Resources to Improve Medicaid for Children and Adolescents
Medical Necessity
Green State has adopted definition specific to children (8 states)
Orange State has adopted its own parameters or definition and
uses the same definition for adults and children (30 states)
Behavioral Health
Green State pays an additional fee for recognized standardized behavior or developmental screening (26 states)
Light Blue State recommends standard behavioral or developmental screening tool but does not pay (6 states)

Care Coordination
Light Blue State uses medical home and/or other strategy (4 states)
Green State uses medical homes that include children (21 states)
Dark Blue State uses strategy other than medical home (7 states)

About This Map
Beyond the screening and preventive health services covered under EPSDT, the Medicaid benefit for children and adolescents, diagnostic and treatment services are also covered to correct or ameliorate a child’s physical or mental condition(s). In general, states must ensure the provision of, and pay for, any services, including treatment, in accordance with mandatory and optional benefits identified in section 1905(a) of the Social Security Act, determined to be “medically necessary” for the child or adolescent. The determination of whether a service is medically necessary must be made on a case-by-case basis, taking into account the particular needs of the child.

NASHP has been studying state activity to improve the delivery of services to Medicaid-enrolled children. The Medicaid benefit for children and adolescents (also known as the Early and Periodic Screening, Diagnostic, and Treatment benefit or EPSDT) has been Medicaid¹s comprehensive and preventive child health program for individuals under the age of 21 since 1967. In FY2012, more than 37 million children across the country were eligible to receive services under this benefit. The benefit includes a range of preventive and screening services, as well as vision, dental, and hearing services for children. Additional services that are medically necessary to correct or ameliorate conditions discovered in children through the screening services are also covered under the benefit, regardless of whether the service is covered under a state’s Medicaid State Plan.*

This NASHP resource page provides state policymakers, Medicaid officials, and other interested parties with state-specific information about strategies for delivering the Medicaid benefit for children and adolescents in states around the country. Use this resource page or section to access information from state Medicaid agencies on a variety of topics including:

1. General and specific definitions of medical necessity used by states
2. Initiatives to improve access to preventive and treatment services for children
3. Reporting and data collection strategies around children’s services
4. Approaches to behavioral health screening and service delivery
5. Resources developed to support providers and families
6. Initiatives to improve care coordination for children
7. Oral health service delivery for children

*Disclaimer
The information on this resource compendium was drawn from a number of sources including state websites, interviews with state officials, and CMS reports. NASHP has made efforts to confirm all information. This resource was funded by the Centers for Medicare & Medicaid Services (CMS) under a subcontract from NORC at the University of Chicago. This information has not been reviewed or approved by CMS.

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