The COVID-19 pandemic has reduced access to children’s preventive care across the country, with some providers reporting a 70 to 80 percent decrease in well-child visits, and far fewer children receiving vital in-person services, such as immunizations. Some primary care practices also have limited their services or shut down to comply with mandatory social distancing policies. To ensure children and families are able to stay safe and receive appropriate care, states are providing new guidance for telehealth visits.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT), the required Medicaid benefit for comprehensive and preventive health care services for children and youth up to age 21, includes well-child visits and immunizations. Well-child visits are necessary to prevent disease, administer scheduled immunizations, track healthy growth and development, identify health concerns early when they are easier and less costly to treat, and address parental and caregiver concerns.

In addition to a drop in well-child visits because of the pandemic, the US Centers for Disease Control and Prevention (CDC) released data showing that provider requests for childhood immunizations began dropping within a week of the national emergency declaration, signaling an immediate decline in routine immunizations for children. Several states, including California, Indiana, Kentucky, New Hampshire, North Carolina, South Carolina, Tennessee, and Washington State, have issued specific bulletins with information on EPSDT/well-child visits, including clarification of what services can be delivered via telehealth and billing guidance, so that these services can be provided during the pandemic to maintain healthy child development.

The Centers for Medicare & Medicaid Services (CMS) has also provided states with overarching telehealth guidance to promote access to care. Through executive orders and legislative authority, many states are ensuring telehealth services are easily accessible and that patients are not deterred from seeking necessary care during the pandemic that they would otherwise be unable to receive in person. States are also working to ensure that telehealth policies do not exacerbate existing disparities in care. Some examples of general state telehealth policy changes include:

• Arkansas and Missouri recently relaxed the requirement that telehealth visits must only be conducted with previously established patients.
• Arizona mandated that cost sharing for telehealth visits should be lower than in-person visits.
• Oregon stipulated that cost sharing for telehealth services should not be greater than that for in-person visits.

While expanded telehealth policies increase access to primary care virtually during the pandemic, limiting in-person visits can reduce children’s ability to receive timely immunizations. Childhood immunizations are a cost-effective way to prevent disease, and vaccines are one of the most important public health tools to ensure health in a community, however, overall immunization rates are decreasing during the pandemic. The American Academy for Pediatrics (AAP) guidance encourages providers to prioritize in-person newborn care and well-child visits and immunizations for infants and children up to 24 months, and new CDC data shows a less prominent decline in immunizations for children under 24 months compared to children over 24 months. To address these immunization lags and promote access to other important preventive care, states have released guidance based on the needs of their own populations and their own provider capacity. For example:

• Indiana and Kentucky’s policies for EPSDT visits note that providers need to complete the components of the visit that could not be done via telehealth (e.g., immunizations) in a follow-up visit within six months of the end of the public health emergency.
• South Carolina and Tennessee’s guidance notes that when pediatric well care is provided via telehealth, the providers must inform the Medicaid enrollee (or parent/guardian) of any immunizations that would normally be administered and schedule a time to administer the vaccines as soon as possible after the telehealth visit. The providers bill for administering the immunization whenever it is delivered outside of the telehealth visit, such as on a different day, at a separate location, or through a drive-up immunization model.
• Several states, including Maine, are encouraging practices to schedule well-child visits and administer immunizations in the morning and sick visits in the afternoon to keep the healthy and sick segregated. Other guidance to maintain well-child visits includes separating patients spatially, by placing patients with sick visits in different areas of the clinic or a different location from patients who are present for well visits.
• Washington, DC and North Carolina’s guidance recommends providers utilize telehealth visits wherever possible, and that the subsequent, in-person follow-up visit should be as soon as is safe, based on the provider’s discretion. Washington, DC’s guidance also notes that if possible, pediatric immunizations, vital signs for infants up to 12 months, blood lead level screenings for children under 26 months, and infant anemia screening should not be delayed.

States also choose the billing codes and modifiers to track telehealth well-child visits and the subsequent follow-up visits for immunizations and other in-person services. For example:

• Alabama directs providers to use code 02 in the place of service field to indicate telemedicine and use the modifier CR, for a “catastrophic event.”
• Washington State providers must use EPSDT codes plus the CR modifier. For in-person follow-up appointments to complete the EPSDT visit, providers should use code 99429 with the CR modifier.
• Kentucky providers should use 02 in the place of service field, and no modifiers are needed. For vaccine administration, providers bill code 90460 at the time of vaccine administration.
• Alaska providers should use 02 in the place of service field, and modifiers 95, GT, or GQ to indicate a telehealth visit.

Well-child visits are an important vehicle for providers to assess healthy child development. There are many potential long-term implications of the pandemic on these visits, including primary care practices permanently shutting down due to lack of funding. Limited workforce capacity may lead to potential pent-up demand for pediatric preventive services resulting in:

• A reduction in immunizations that can lead to an increase in vaccine-preventable diseases;
• Less access to blood lead level screenings, which also has implications for children’s health outcomes; and
• Reduced identification of adverse childhood experiences and trauma, with less capability to connect children and families to needed treatment and follow-up services.

State Medicaid and public health agencies are working closely to follow guidance from the Department of Health and Human Services (HHS), CMS, and CDC, with guidance from the AAP and American Academy of Family Physicians (AAFP) to ensure well-child visits are as uninterrupted as possible, so children can receive preventive services like immunizations, and subsequent vaccine-preventable outbreaks do not occur.

The National Academy for State Health Policy is continuing to monitor state and federal guidance to support states in ensuring children stay healthy during this pandemic and beyond.

This blog is supported by the David and Lucille Packard Foundation and the Centers for Disease Control and Prevention (CDC). To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.