In 2021, Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure testified before a U.S. Senate panel, advocating for state Medicaid programs to meet their obligations in providing essential services to children. CMS is intensifying efforts to ensure compliance, particularly concerning services for children with developmental disabilities.

Federal guidance was recently released to clarify the requirements under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). These requirements guarantee that children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) have access to a range of preventative, diagnostic, and treatment services. This includes services such as well-child visits, dental care, mental health services, and access to medical specialists.

A 57-page letter from CMS to state health officials outlines strategies for meeting EPSDT standards. Brooks-LaSure emphasized the importance of these services, noting, “The implementation of EPSDT requirements, in partnership with states, is crucial for the millions of children covered by Medicaid and CHIP. We will continue working to ensure every child receives the care they need, when they need it.”

The guidance highlights the need for states and managed care plans to ensure an adequate number of providers, including pediatric specialists and children’s hospitals. It also requires procedures for accessing out-of-network or out-of-state providers when necessary, ensuring children with complex health needs receive timely care. States must expedite the enrollment of out-of-state providers when in-state care options are insufficient.

Congress, through the Bipartisan Safer Communities Act of 2022, directed CMS to issue guidance on EPSDT compliance. Disability advocates, such as Kim Musheno of the Autism Society of America, have raised concerns about the inconsistent application of EPSDT benefits across states and managed care plans. Musheno noted that many families and healthcare providers are often unaware of the services they are entitled to under EPSDT, such as access to care in the least restrictive settings and the right to out-of-state services when necessary.

For years, Autism Speaks has advocated for the inclusion of treatments like applied behavior analysis (ABA) under EPSDT, following a 2014 CMS directive. However, the organization reports that many families still face challenges in securing access to necessary therapies like ABA, Floortime, and TEACCH.

David Sitcovsky, vice president of advocacy at Autism Speaks, acknowledged the challenges but expressed optimism about the new guidance. “While no single federal action will resolve all issues for autistic children and their families, this guidance will strengthen EPSDT compliance and improve access to quality care and services for many children with autism across the country,” he said.

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