Understanding the EPSDT Medicaid Benefit

January 15, 2019

Early and Periodic Screening Diagnosis and Treatment (EPSDT) is a Medicaid benefit for children established in 1967.  It was introduced to ensure that children under age 21 have access to comprehensive high-quality health benefits.  As the title indicates, the benefit was created to ensure that potential health and developmental problems in Medicaid-eligible children can be found early and addressed thoroughly with the goal of preventing issues or reducing their effects. In New Jersey, Medicaid is part of NJ FamilyCare, the state’s publicly funded health insurance program.

The types of treatment that can be covered under EPSDT are broad and can address a range of concerns including physical and mental health, hearing and vision, dental health, immunizations, and more.

According to the federal Centers for Medicare & Medicaid Services (CMS), “the EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.”

How Does the EPSDT Benefit Apply to Identifying and Treating ASD in Children?

In 2014, CMS issued an informational bulletin clarifying Medicaid coverage of services to children with autism and gave states the authority to decide how to implement the guidance.  Importantly, “states are required to arrange for and cover for individuals eligible for the EPSDT benefit any Medicaid coverable service listed in section 1905(a) of the [Social Security] Act that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions.”

In this same year and in preparation for offering this benefit on a statewide basis, the State of New Jersey began providing Applied Behavior Analysis (ABA) services to some Medicaid-eligible children via the New Jersey Comprehensive Waiver, a Section 1115 research and demonstration waiver under the Social Security Act.

These waiver services are administered by the New Jersey Department of Children and Families Children’s System of Care (CSOC) under what is commonly referred to as the “ASD Pilot.”  The scope of the waiver has been limited to approximately 200 children who have been assessed to have an acute level of need, e.g., severe challenging behaviors such as property destruction, aggression and injury to self or others, and elopement. Due to the high clinical threshold required for a child to be eligible for services, the criteria tended to exclude very young children and children who could realize other medically necessary benefits of ABA treatment, e.g. outcomes such as increased adaptive behavior, independence, communication skills, and social skills.

Fortunately, under EPSDT requirements, the criteria for medically necessary treatment would apply to a broader range of autism symptoms that affect a child’s behavioral, communication, and social development, and allow more children to access treatment such as Applied Behavior Analysis.

How will the State of New Jersey Cover Treatment for Autism Beyond the Pilot Under Medicaid/EPSDT? 

The State of New Jersey is currently designing the coverage of autism treatment for all Medicaid-eligible individuals under ESPDT and has provided notice that it is currently seeking public input on how to do so. Coverage for autism treatment services could be available in the next few months.

What is Autism New Jersey doing to help families access this benefit? 

Autism New Jersey helps all families understand the eligibility criteria for a variety of services. We have been and remain committed to helping Medicaid-eligible families access the EPSDT benefit. Our involvement includes:

  • Helping families understand and access the ASD pilot.
  • Since CMS issued its initial guidance in 2014, we’ve been engaged on a statewide level to encourage expansion of the pilot to all Medicaid-eligible children.
  • Most recently, Autism New Jersey participated in the Autism Executive Planning Committee convened by the Department of Human Services and the Department of Children and Families to provide expert recommendations on the design of this benefit.
  • Autism New Jersey also provided public comment at the open forum on January 9 and offered written recommendations regarding how the coverage is designed.