Biden-Harris Administration Releases Historic Guidance on Health Coverage Requirements for Children and Youth Enrolled in Medicaid and the Children’s Health Insurance Program

In another demonstration of the Biden-Harris Administration’s unwavering commitment to children’s health, today the Centers for Medicare & Medicaid Services (CMS) released comprehensive guidance to support states in ensuring the 38 million children with Medicaid and the Children’s Health Insurance Program (CHIP) coverage – nearly half of the children in this country – receive the full range of health care services they need.Â

Under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements, eligible children and youth are entitled to a comprehensive array of prevention, diagnostic, and treatment services — including well-child visits, mental health services, dental, vision, and hearing services. These requirements are designed to ensure that children receive medically necessary health care services early, so that health problems are averted, or diagnosed and treated as early as possible. Because of the EPSDT requirements, Medicaid provides some of the most comprehensive health coverage in the country for children and youth.Â

The guidance issued today reinforces the EPSDT requirements and highlights strategies and best practices for states in implementing those requirements. This guidance, which was required by section 11004 of Title I of Division A of Bipartisan Safer Communities Act (BSCA) (P.L. 117–159), is the most comprehensive EPSDT guidance that CMS has released in a decade and is a critical step to ensuring the health of children. Â

“We need to make sure our children have what they need to stay well. Medicaid makes that possible,” said HHS Secretary Xavier Becerra. “This guidance to our states today will help millions of kids get the services that are crucial to their health and development, no matter where they live.”

“Our children are the future. They 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,” said CMS Administrator Chiquita Brooks-LaSure. “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.”

Today’s guidance is a critical step in CMS’ efforts to strengthen the Medicaid and CHIP programs across the country. The guidance clearly explains the statutory and regulatory EPSDT requirements, and suggests best practices across key areas, including increasing access to services through transportation and care coordination, expanding the children-focused workforce, improving care for children with specialized needs (including children in the child welfare system and children with disabilities), and expanding awareness among families of their children’s rights under the EPSDT requirements.

The EPSDT guidance also includes information to help address the needs of children with behavioral health conditions. Youth in the United States are experiencing a mental health crisis, research shows. The EPSDT guidance includes a series of strategies and best practices that states can use to meet children’s and youth’s behavioral health needs. For example, it suggests that states create a children’s behavioral health benefit package and support the management of children and youth with mild to moderate behavioral health needs in primary care settings. States must provide coverage for an array of medically necessary mental health and SUD services along the care continuum – including in children’s own homes, schools and communities -- in order to meet their EPSDT obligation. This work builds on the HHS Roadmap to Behavioral Health Integration, which outlines the Department's commitment to providing the full spectrum of integrated, equitable, evidence-based, culturally appropriate, and person-centered behavioral health care to the populations it serves, and builds on the President’s Unity Agenda to advance mental health.

The EPSDT requirements play a crucial role in the long road to achieving health equity by helping to provide access to essential care for children enrolled in Medicaid and CHIP. The guidance released today is one important step in the Biden-Harris Administration’s commitment to child health and access to affordable, quality health coverage for all, and is part of CMS’ broader strategy to ensure that children have the comprehensive and high-quality care they need.
Beyond the importance of the EPSDT requirements, Medicaid more broadly is vital for ensuring the health of America’s youth. A new HHS report, Medicaid: The Health and Economic Benefits of Expanding Eligibility, by researchers in the Office of the Assistant Secretary for Planning and Evaluation (ASPE) examines the impact of Medicaid throughout its six decades and highlights the importance of Medicaid coverage for low-income children. Studies show that access to Medicaid coverage is associated with a significant improvement in health and mortality that continues beyond childhood. In addition to improved health outcomes, children with Medicaid have improved educational and economic outcomes.Â

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