Improving Health Outcomes for Eligible Children and Youth Enrolled in Medicaid and the Children’s Health Insurance Program

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.

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.

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:

Care coordination or care management, depending on a child’s needs

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.

Non-Emergency Medical Transportation (NEMT)

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.

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:

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] SH

Tags: child, guidance, medicaid, policy, scope
Organization: U.S. Department of Health & Human Services