CMS Releases Series of EPSDT Briefs, Addresses Medical Necessity Issues

Last week CMS published three new guides focused on Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. Over the past many years states as well as providers, patients and their families have raised questions about various aspects of EPSDT. The guides are intended to assist states in complying with CMS’ interpretation of the EPSDT statute and regulations.

The “EPSDT: A Guide for States” is a comprehensive document addressing a range of topics, including the following:

  • EPSDT’s screening requirements, including when interperiodic screening should be provided;
  • Scope of services covered under EPSDT;
  • EPSDT’s requirements governing dental, vision, and hearing services;
  • Permissible limitations on service coverage under EPSDT;
  • States’ responsibilities to assure access to EPSDT services and providers;
  • Assistance to states as they work with managed care plans to provide the best child health benefit possible; and
  • Notice and appeal procedures required when services are denied, reduced or terminated.

The guidance also discusses the provision of services in schools. Specifically, there is no benefit category in the Medicaid statute titled “school health services” or “early intervention services.” Instead, states must describe school health services in terms of the specific section 1905(a) services that will be provided. In addition, there must be a provider agreement in place between the state Medicaid agency and the provider billing for the service; and the school must agree to comply with Medicaid-specific requirements regarding service documentation and claims submission.

Read full update in NAMD Newsletter…