The Title V Maternal and Child Health Services (MCH) Block Grant program and the Medicaid program are required under federal law to coordinate activities, using coordination agreements and partnerships between state Medicaid agencies and Title V MCH program grantees to improve access to services for children and pregnant women. (Section 505 [42 U.S.C. 705] (a)(5)(F)) This website describes the law and opportunities states are using to coordinate Title V and Medicaid. In particular, coordination with the Medicaid Early Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is required.
The EPSDT benefit provides comprehensive health coverage for all children under age 21 enrolled in Medicaid. Created in 1967 and required in every state, EPSDT finances various appropriate and necessary pediatric services. This benefit requirement includes children enrolled in a state’s Children’s Health Insurance Program (CHIP) through Medicaid Expansion CHIP, but not those in separate, private CHIP health plans.
Since Medicaid covers one-third of children age 1–6, and more than 40% of school-age children and adolescentsone, EPSDT offers a way to ensure that children birth to age 21 receive appropriate physical, dental, developmental, and mental health services—from prevention to treatment.
The Centers for Medicare and Medicaid Services produced EPSDT – A guide for states: Coverage in the Medicaid Benefit for Children and Adolescents (PDF) to describe states' roles and responsibilities.
Core EPSDT Program ActivitiesThe elements of the program include:
| Early | Assess and identify problems early, starting at birth |
| Periodic | Check children’s health at periodic, age-appropriate intervals in comprehensive well-child visits, including health education |
| Screening | Provide physical, dental, mental, developmental, hearing, vision, and other screening or laboratory tests to detect potential problems |
| Diagnosis | Perform diagnostic tests and assessments to follow up when a risk is identified during screening and examinations |
| Treatment | Control, correct, or ameliorate any problems that are found |
Anyone under age 21 enrolled in Medicaid receives coverage for EPSDT benefits and services—at regular intervals and whenever a possible problem appears—to identify physical, dental, developmental, and mental health conditions. In addition to health services, benefits include scheduling appointments, arranging for treatment, and financing transportation to keep appointments. (42 U.S.C. Sections 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B), 1396d(r)). As described in federal rules, states are required to: “[a]ssure that health problems found are diagnosed and treated early, before they become more complex and their treatment more costly, … that informing methods are effective, … [and] that services covered under Medicaid are available.” (CMS, State Medicaid Manual Sections 5010, 5121, 5310)
Known as EPSDT screening visits, the program defines and finances preventive well-child visits that include a comprehensive health and developmental history, an unclothed physical exam, immunizations, laboratory tests, and health education and guidance for parents and children. Such EPSDT “check-up” visits are covered at age-appropriate periodic intervals recommended by professionals on a schedule set by states and at other times, as needed.
HRSA has supported the Bright Futures Initiative since 1990, working to increase the quality of primary and preventive care through maintenance and dissemination of age-specific, evidence-driven clinical guidelines. The Bright Futures Guidelines are listed in CMS’ State Medicaid Manual (Section 5123.2), as an example of recognized and accepted clinical practice guidelines for EPSDT screening. In 2018, the American Academy of Pediatrics (AAP), supported by a grant from HRSA, developed state-specific reports providing detailed information about each state Medicaid program’s EPSDT benefit and how this compares to the AAP/Bright Futures 4th edition guidelines and recommendations.
Vision, hearing, and dental services are typically provided separately from medical primary care under a distinct schedule based on professional standards but must include Medicaid coverage for screening, diagnosis, and treatment services. For example, eyeglasses and hearing aids are covered. Required dental services include:
The professionally recommended schedules for vision, hearing, and dental check-ups are different than the recommended schedule for well-child health care visits set out in Bright Futures.
EPSDT requires states to “arrang[e] for … corrective treatment,” either directly or through referral to appropriate providers or licensed practitioners, for any illness or condition detected by screening. (CMS, State Medicaid Manual Section 5124) As described by CMS, this obligation to connect children with any Medicaid service, including optional services not covered for adults that are medically necessary treatment, is unique.
Under EPSDT, Medicaid covers medically necessary services to treat identified physical, dental, developmental, and mental health conditions. This includes all medically necessary services within the categories of mandatory and optional services (as defined under listed in Medicaid law section 1905(a)), regardless of whether a state chooses to cover such services for adults and the elderly. Examples of services covered for children include the following:
Determinations of medical necessity are made by the state or, under delegated authority, by the health plan for a child under EPSDT and must be made on a case-by-case basis, taking into account the individual child's particular needs and guided by information from the child’s health providers. Hard, fixed, or arbitrary limits (e.g., based on dollar amounts, standard deviations from the norm, lists of diseases) are not permitted. States may and do set limits for an individual. For example, the state cannot limit physical therapy visits to 12 per year for all children as an arbitrary cap on such services but might determine that an individual child needed only 12 monthly visits in a year. The goal is to ensure that children in Medicaid receive treatment services (PDF) ; that are “medically necessary to correct or ameliorate any identified conditions – the right care to the right child at the right time in the right setting.” Services may be necessary to prevent further advancement of a condition (maintenance or control), ameliorative, or corrective, as when services help a child reach the age-appropriate developmental level.
Federal law requires coordination and partnerships between state Medicaid agencies and Title V MCH program grantees to ensure better access to screening, diagnostic, and treatment services. Interagency agreements, a requirement in Medicaid and Title V statute and regulation, are the primary mechanism for structuring coordination and partnerships. While both the federal Medicaid/EPSDT and Title V law call for coordination between the programs, the language is different, as noted below.
Federal Medicaid/EPSDT law requires
In addition, between 1967 and 1989, Congress enacted several amendments to Title V, adding requirements to work closely with and assist Medicaid in a number of activities. Current Title V law requires that state MCH programs do the following.
While the Center for Medicare and Medicaid Services (CMS) is responsible for administering the federal guidelines for Medicaid and EPSDT, state partnerships are critical among state Medicaid agencies, Title V MCH programs, families, providers, and managed care organizations to ensure access to needed services for children. States use coordination and partnerships between Title V and Medicaid to improve child health access and outcomes. The more flexible funding from Title V can complement Medicaid and support activities not funded under health coverage. As discussed above, federal law requires that Medicaid State Plans specify cooperative arrangements, payment, and other service-related agreements with Title V grantees. (42 CFR 431.615(e))
EPSDT rules state that Federal financial participation (FFP) is available to cover the costs to public agencies such as Title V MCH grantees for providing direct services to Medicaid child beneficiaries. EPSDT rules suggest opportunities and, over the years, states have adopted a variety of best practices.
State Title V MCH programs play a role in developing strong and effective EPSDT programs to reach children with prevention and treatment services. The EPSDT rules encourage state Medicaid agencies to delegate tasks to the state Title V agency and its grantees to assure access and receipt of the full range of screening, diagnostic, and treatment services. Such delegation may be local, regional, or statewide. In some cases, a Title V program may be designated as a “Medicaid Provider”. Below are strategies undertaken by Title V Agencies to improve EPSDT programs.
Title V program leaders often create or fund care coordination. While there is no specific care coordination benefit category under Medicaid, care coordination may qualify for reimbursement as case management. Often the terms care coordination and case management are used interchangeably in the case of children. Medicaid describes case management as an activity under which responsibilities for locating, coordinating, and monitoring necessary and appropriate services for a recipient rests with a specific individual or organization. Title V should work with the state Medicaid staff on specifying case management services, as their support is key.
Administrative case management includes activities that help the program operate efficiently and ensure that children receive needed health care. The federal government contributes at a rate of 50% for administrative case management under EPSDT, which in many states is less than FFP for medical services. Case management in the EPSDT process is a type of administrative case management. It generally refers to the outreach, informing, and other administrative roles that support the delivery of services required under EPSDT.
States have the option to design and provide targeted case management for specific patients, specific geographic areas, or specific sets of services. Targeted case management is added as a benefit through a State Plan Amendment (SPA), and the federal contribution is at the medical assistance rate (i.e., like other medical care services). For example, more than 30 states use targeted case management to provide care coordination for pregnant women and infants. More than 10 states use targeted case management or other Medicaid benefit categories to finance home visiting services, to supplement the resources available under the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. States are also using targeted case management to provide enhanced support for children with special health care needs and developmental disabilities.
A large majority of children covered under Medicaid are enrolled in managed care arrangements. Federal law requires that state contracts with managed care organization must identify, define, and specify the amount, duration, and scope of each service that the managed care plan is required to furnish to enrollees.
EPSDT benefits not provided by the managed care plan remain the responsibility of the state Medicaid agency, so that in combination benefits delivered in managed care and those covered on a fee-for-service will ensure access to the full EPSDT benefit. If a managed care contract excludes benefits, the state retains responsibility for providing necessary services. Contracts between states and managed care organizations should also reflect whether the contractor or the state is responsible for informing beneficiaries of EPSDT benefits and offering scheduling, transportation, and other assistance. The specific contract language is essential for EPSDT. MCOs need to know exactly what services they are responsible for covering. Enrolled children and their families need to know what services they are entitled to receive from the MCO and what services they are entitled to under the state Medicaid program.
Local health care systems can vary based on provider supply, public health structures, health coverage patterns, and state laws. Increasing the effectiveness of relationships between pediatric providers and other child-serving entities is one key step toward improving care and services for families. State Title V MCH programs can and should help local public health agencies learn about managed care and the Memorandum of Understanding (MOU) process. As it relates to EPSDT, MOUs between health agencies and managed care organizations might define interaction related to care coordination, data reporting, immunization billing, and services for children with special health care needs.
Title V's Role in Data and Quality Monitoring in EPSDTState Medicaid agencies report annually on EPSDT services using CMS Form 416 (PDF) . The annual report provides basic information on the number of children (by age and basis of Medicaid eligibility) who receive medical or dental screens and the number referred for diagnostic or treatment services. The data is limited because it provides data on the numbers of children screened, not how many children are receiving diagnostic or treatment services under EPSDT. CMS has publicly available EPSDT data as reported by states using CMS 416 forms.
The CMS Center for Medicaid & CHIP Services (CMCS) has worked with stakeholders to identify core sets of health care quality measures that can be used to assess the quality of health care provided to children enrolled in Medicaid and CHIP. CMS has publicly available data regarding the use of children’s preventive services, including well-child visits for children and adolescents, as part of reporting on the Medicaid/CHIP child core measures (PDF) .
Since the core sets were established in 2010, states have made significant progress in voluntary reporting on measures in the child core set, and some states have demonstrated high performance. Moreover, regular updates are being made to the measure set as knowledge and data capacity evolve.
State Title V agencies can play an important role in monitoring EPSDT. The examples below describe some current and past data and monitoring activities undertaken by Title V agencies.
EPSDT goes beyond addressing efforts to respond to physical health needs, acute illnesses, and specific diseases. One of the program’s strengths is in addressing child health in a comprehensive manner. Four examples—developmental services, mental health services, dental care, and vision and hearing services—underscore the importance of EPSDT for promoting overall health and well-being and reducing disabilities.
Developmental screening is a national goal and a Title V priority. Screening to promote early identification of developmental risks and conditions is critical to the well-being of children and their families. The American Academy of Pediatrics recommends that developmental screening with an objective tool begin at the nine-month well-child visit. One Title V National Performance Measure (NPM) is the percent of children, ages 10 through 71 months, receiving a developmental screening using a parent-completed screening tool.
Developmental screening is also part of EPSDT. Federal law requires comprehensive well-child visits through EPSDT, including periodic developmental screening based on nationally recognized professional recommendations for periodicity. During early childhood, screening for physical and mental/behavioral health and other risks is essential to identify risks and possible delays in development. Developmental screening at specific times in early childhood, developmental surveillance at each well-child visit, and follow-up diagnosis and treatment are recommended for all children to ensure early intervention to correct or ameliorate conditions. Developmental screening is required for children enrolled in Medicaid, and covered for children enrolled in Medicaid expansion CHIP. A CMS Fact Sheet (PDF) describes CMS resources to support states in ensuring Medicaid-enrolled children receive these screenings. A joint effort initiative between the Department of Health and Human Services and the Department of Education, Birth to 5: Watch Me Thrive! provides additional resources to support states, providers, and communities to increase developmental and behavioral screening of young children.
Federal EPSDT rules call for screening of young children across six primary domains of development, including: gross motor, fine motor, communication skills or language development, self-help and self-care skills, social-emotional development, and cognitive skills. While no specific list of screening instruments is prescribed, federal rules call for the use of a culturally sensitive and validated tool, and some states recommend a short list of specific, validated tools. State Title V MCH grantees play an essential role in advancing evidence-based practice, identifying recommended tools, and promoting widespread use of developmental screening.
The Medicaid/CHIP Child Core Measurement Set includes a measure of: “Developmental Screening in the First Three Years of Life.” This measure is designed to monitor how Medicaid and CHIP programs are performing terms of developmental screening of very young children and can be used in quality improvement programs intended to help providers and manage care organizations improve their performance. To help states collect and report data on this measure, CMS hosted a webinar (PDF) in June 2013: Developmental Screening in the First Three Years of Life: Understanding How to Collect and Use the Child Core Set Measure.
Federal law requires complete well-child examinations with screening services through EPSDT, including screening for potential developmental, mental, behavioral, and/or substance use disorders. EPSDT also finances diagnostic and treatment services, if medically necessary, for social-emotional, behavioral, and mental health conditions. EPSDT covers mental health and substance use disorder services, regardless of whether these services are covered for adult services. Treatment for mental health conditions is available under several Medicaid service categories, including hospital and residential treatment facilities, outpatient clinic services, physician services, and services provided by a licensed professional such as a psychologist and clinical social workers. Medicaid finances intensive care coordination and so-called “wrap-around” services for children with mental health conditions. CMS has an informational bulletin (PDF) (released on March 27, 2013) on:&Prevention and Early Identification of Mental Health and Substance Use Conditions in Children.
Dental services required in the EPSDT benefit include: dental care needed for relief of pain, infection, restoration of teeth, and prevention and maintenance of dental health (provided at as early an age as necessary); and emergency and therapeutic services for dental disease that, if left untreated, may become acute dental problems or cause irreversible damage to the teeth or supporting structures. In addition, medically necessary oral health and dental services, including those identified during an oral screening or a dental exam, are covered for children. Under EPSDT, states must cover orthodontic services necessary to prevent disease, promote oral health, and restore oral structures to health and function. A special report by CMS, Keep Kids Smiling provides more detailed guidance for states.
Although an oral screening may be part of a physical examination, federal law requires a direct referral from an EPSDT medical screening visit provider to a dental professional. Professional recommendations call for dental visits to begin by age one.
The recommended schedule for dental visits is different than the medical periodic visit schedule. With the American Academy of Pediatric Dentistry and MCHB-HRSA, CMS issued a Guide to Children’s Dental Care in Medicaid (PDF) . American Academy of Pediatric Dentistry schedule for “Periodicity of Examination, Preventive Dental Services, and Oral Treatment for Children,” recommends that a dentist see children following the eruption of the first tooth, but no later than 12 months of age. Many states have adopted this professional standard for EPSDT.
The federal resource website Insure Kids Now offers families a tool to find a dental provider who accepts Medicaid. The Dentist Locator is a resource that can be used by parents, pediatric providers, and public health agencies to find a dentist in their community who is available to see children covered by Medicaid/EPSDT. State Medicaid has a responsibility to maintain up-to-date provider lists for the Dentist Locator and Title V MCH programs.
Vision and hearing services are an essential component of the EPSDT benefit. Hearing impairments can lead to other problems, including interference with normal language development in young children. They can also delay a child’s social, emotional, and academic development. Vision problems can be evidence of serious degenerative conditions, and can also lead to learning and social development delays. EPSDT calls for screening, diagnosis, and treatment of vision and hearing services, generally including speech and language services.
States’ Responsibilities to Inform and Assist FamiliesEPSDT finances health care for children and ensures that children receive appropriate, quality services to improve their health. As described in federal program rules:
“The EPSDT program consists of two, mutually supportive, operational components: assuring the availability and accessibility or required health care resources, and helping Medicaid recipients and their parents or guardians effectively use them.”
Within broad federal guidelines, states have the flexibility to design an EPSDT program that fits with their Medicaid, public health, and medical care systems. Informing and support services to families are specifically described in the federal EPSDT rules.
Title V agencies—both the HRSA’s Maternal and Child Health Bureau and the state MCH programs that receive block grant funding—have a strong commitment to promoting family-centered, community-based, culturally competent systems of care. State MCH programs, in particular, can play an important role in helping Medicaid agencies fulfill these EPSDT requirements. By promoting and helping to implement EPSDT, Title V agencies can help Medicaid agencies better fulfill their responsibilities, particularly to provide effective outreach, information, and assistance to families.
For over 40 years, EPSDT has evolved. As Medicaid changed, states have updated and improved their benefits and financing approaches (e.g. use of managed care, coverage of more low-income children, following Bright Futures recommended schedule). Congressional and court actions have also affected the program. It has adapted to changing pediatric guidelines. The program’s purpose continues to be “to discover, as early as possible,” and provide “continuing to follow up and treatment so that handicaps do not go neglected.” To that end, Medicaid’s EPSDT coverage works interactively with an array of other public programs, including but not limited to Title V MCH programs. The following examples illustrate the importance of these interactions.
Children entering the foster care system are entitled to Medicaid coverage, with initial and ongoing EPSDT well-child visits and other benefits. States have a variety of approaches to fulfilling this obligation. For example, many states have specific rules and guidelines for promoting the EPSDT among children in foster care, and approaches for informing and supporting foster parents.
Under the federal Individuals with Disabilities Education Act (IDEA) Part C program, states provide early intervention services for infants and toddlers (up to age three) that currently have a high risk of experiencing developmental delays. Some children qualify for both Medicaid and IDEA financing. Federal law permits Medicaid financing for certain services provided to a child and family under Part C, particularly health-related services such as occupational, physical, and speech-language hearing therapies. The IDEA states that “Nothing in this part may be construed to permit a State to reduce medical or other assistance available in the State” or to alter eligibility under Title V MCH programs or Medicaid regarding medical assistance for services furnished to an infant or toddler with a disability when those services are included in the child’s plan under IDEA Part C. (34 CFR Section 303.510(C))
Health has been a component of Head Start, and the program’s history is linked to the history of EPSDT. Head Start 2016 Standards (PDF - 773 KB) maintain health as a critical component of the Head Start model, retaining previous screening and ongoing care requirements and strengthening and expanding the role that programs play in ensuring health services for their children and families. Head Start standards are specific and strong in relation to health and EPSDT. For example, within 90 days of a child’s admission, Head Start programs must assess whether each child is up-to-date in relationship to Medicaid’s EPSDT well-child health and dental periodicity schedules and help parents stay up-to-date with such visits. (45 CFR Chapter XIII Section 1302.42) Current standards also emphasize mental health, oral health, and parent education on health issues. A majority of children served in Head Start programs are Medicaid-eligible. The federal Head Start program calls for coordination to improve access to care for these children. Many Head Start local programs rely on Medicaid participating providers to provide screening, diagnosis, and treatment services for participating children. Many local Head Start agencies report that the families they serve face challenges in finding child health providers—physicians, dentists, developmental, and/or mental health providers—who accept Medicaid. While it covers health-related services for children in Head Start, Medicaid does not pay for Head Start services.
The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program support pregnant women and families, particularly those considered at-risk, to gain the necessary resources and skills to raise physically, socially, and emotionally healthy and ready children to learn. The goals are to:
At a minimum, MIECHV funded home visiting programs have a role in referral families to Medicaid, encouraging the use of preventive health services (e.g., prenatal care, well-child visits, immunizations, developmental screening), and supporting healthy behaviors. In some programs, stronger linkages with pediatric primary care providers are being developed. In most states, a large majority (80-90%) of families participating in MIECHV are Medicaid beneficiaries, indicating opportunities for MIECHV sites to help families secure EPSDT funded services. A few states are augmenting MIECHV resources with evidence-based home visiting services financed by Medicaid.
WIC provides supplemental food and nutrition education at no cost to low-income pregnant, postpartum, and breastfeeding women, infants, and children up to their fifth birthday. WIC nutrition, both food, and education serve as an adjunct to good health care. Coordination with the WIC program is required under EPSDT rules, and referrals to EPSDT are required for all WIC’s target population categories. Medicaid does not pay for WIC services.