The U.S. Centers for Medicare & Medicaid Services (CMS) recently released new guidelines intended to better support state-based pediatric reimbursement systems and help improve equitable health access among youth populations.
The new guidance includes best practices for state Medicaid programs and the Children’s Health Insurance Program (CHIP) to implement and comply with early and periodic screening, diagnostic and treatment (EPSDT) coverage requirements.
One of the most significant challenges confronting children living with serious illness and their families is the heterogeneity of policies and programs across the country, said Allison Silvers, chief health care transformation officer at the Center to Advance Palliative Care (CAPC).
CMS’ new guidelines have the potential to clarify payment policies and expand awareness of and access to pediatric palliative care, Silvers said. A potential impact of the expanded EPSDT guidelines is greater recognition around pediatric palliative care as “essential treatments” for seriously ill children given the nature of these services in preventing unnecessary suffering and alleviating crises among families, she explained.
“While children who are covered by Medicaid and CHIP are entitled to EPSDT services, inconsistencies in implementation have stymied easy and universal access to care,” Silvers told Palliative Care News in an email. “These needed clarifications to existing guidance will go a long way toward ensuring that vulnerable children can access the full range of services to which they are entitled. We hope this clarified guidance affords palliative care champions an opportunity to remind state policymakers and others that palliative care is essential for children with service.”
The goal of the EPSDT guidance is to ensure that every eligible child receives timely access to care, CMS stated in a letter to the U.S. Department of Health & Human Services (HHS).
The new guidance outlines the statutory and regulatory EPSDT requirements and suggests strategies across key areas such as increasing access to early screening and testing services through transportation and care coordination.
The EPSDT guidelines also include best practices to expand awareness of these services among families and suggestions related to expanding the pediatric-focused workforce and improve care for children with specialized needs such as individuals with disabilities and serious illnesses.
“[Children] deserve the very best care possible and CMS is committed to ensuring that our nation’s children and youth get the right care, at the right time, in the right setting,” CMS Administrator Chiquita Brooks-LaSure said in a statement shared with Palliative Care News. “The implementation of the EPSDT requirements, in partnership with states, is vital to the tens of millions of children in the nation who are covered by Medicaid and CHIP. We’ll keep working until every child can get the care they need, when they need it.”
CMS’ guidance contained state payment strategies for providers working within the fee-for-service Medicare realm, where some palliative care programs receive reimbursement. The strategies include ways for providers in managed care plans (MCPs) to improve disparities among underserved pediatric populations.
EPSDT requirements play a crucial role in the long road to achieving health equity, according to CMS. States contract with managed care plans to cover some or all of a Medicaid beneficiaries’ care costs. MCP providers are paid a risk-based capitation rate, typically for a per-member, per-month payment. The new guidance outlines requirements to ensure that these rates are actuarially sound, meaning that coverage should be provided for all “reasonable, appropriate and attainable costs for services and populations,” CMS stipulated.
“States have considerable flexibility under Medicaid authorities to develop Medicaid payment methodologies, including payment incentives for services delivered to EPSDT-eligible children. States are required under a fee-for-service delivery system to ‘assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area,’” the agency stated.