Essential Updates on Health Coverage Requirements for Children and Youth in Medicaid and CHIP: A Guide for MCOs

Transforming Health Coverage for Children and Youth

The Biden-Harris Administration’s recent guidance aims to revamp health coverage for children and youth enrolled in Medicaid and the Children's Health Insurance Program (CHIP). It Emphasizes the importance of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, and focuses on equity, accessibility, and integrated services. For MCOs, understanding and implementing these requirements is essential for effective care delivery, improving health outcomes and providing equitable care to over thirty-eight million young Americans.

Context for Enhanced Health Coverage

At the forefront of this initiative is the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which ensures that states provide a comprehensive range of preventive, diagnostic, and treatment services for children. This requirement is crucial for delivering medically necessary health care early, helping to avert or promptly address health issues. Despite the EPSDT’s significance in offering some of the most comprehensive health coverage in the country for children and youth, many still face barriers to accessing essential care.

Important Changes MCOs Should Be Aware Of

1.     Comprehensive Services: MCOs are required to ensure that all mandated services including dental care and mental health, are readily accessible to enrolled children and youth.

2.     Access and Equity: Organizations must develop strategies to eliminate barriers faced by underserved populations, enhancing outreach and enrollment efforts.

3.     Integrated Care Models: The guidance promotes the integration of physical and behavioral health services, facilitating coordinated and holistic care for young patients.

4.     Data Monitoring: MCOs must improve their data collection and report systems to effectively track compliance with EPSDT requirements and monitor health outcomes.

Final Remarks

The guidance takes effect immediately, and MCOs are encouraged to integrate these requirements into their operations promptly to ensure equitable care.

In alignment with Agilian’s mission to support health equity for beneficiaries, we are dedicated to supporting MCOs through this transition to make enhanced health coverage for children and youth a reality.