Understanding Behavioral Health Approaches in CMS’s 2024 EPSDT Guidelines
By Aishwarya Sreenivasan MPH, Project Coordinator-NECBHN
“Families often have little knowledge of the advantages of EPSDT, and clinicians, including pediatricians, are unaware of its full reach. This leads to treatment hurdles, delayed services, and care denials, especially for children with chronic diseases.”
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a critical Medicaid benefit designed to ensure that children and adolescents from low-income families receive the comprehensive and preventive healthcare they need to grow and thrive. Despite its potential, EPSDT remains underutilized across many states. In this blog, we explore the history of EPSDT, expected changes in 2025, key policy updates from the 2024 CMS EPSDT guidelines, and how stakeholders can advocate its enhancement.
The History of EPSDT
EPSDT was established in 1967 as an amendment to the Social Security Act to fill a significant gap in Medicaid coverage. At the time, Medicaid focused primarily on emergency and acute care, often overlooking preventive services for children. EPSDT was created to change that, guaranteeing regular screenings, early diagnosis, and treatment for physical, developmental, dental, vision, hearing, and behavioral health conditions.
Over the years, EPSDT has evolved into a cornerstone of pediatric Medicaid coverage, with an increasing emphasis on behavioral health, a shift solidified in the 2024 CMS EPSDT guidelines.
Case Study: John's Journey with EPSDT
Let’s understand how EPSDT operates through a hypothetical example:
John, a 10-year-old enrolled in Medicaid, begins struggling academically due to symptoms of ADHD. His pediatrician, following EPSDT guidelines, initiates a comprehensive behavioral health assessment. John’s care plan, enabled by EPSDT, includes:
Medication Management: After consultation with a child psychiatrist, John begins medication, fully covered under EPSDT, removing cost barriers for his family.
Behavioral Therapy: John receives regular therapy with a licensed professional specializing in ADHD, aligned with EPSDT's focus on early intervention and skill-building strategies.
School-Based Services: Through EPSDT’s coordination with educational support, John accesses an Individualized Education Program (IEP) and school counseling services.
This scenario reflects policy guidance from CMS encouraging states to support services to address behavioral symptoms even without a formal diagnosis, particularly for children under five (CMS, pp. 41).
Outcomes:
John gains focus and improves academically.
His family receives vital support to help manage his condition.
The intervention reduces long-term costs by addressing behavioral issues early.
Behavioral Health Strategies in the 2024 EPSDT CMS Guidelines
The CMS EPSDT 2024 guidelines offer a roadmap for states to build stronger behavioral health systems. Key highlights include:
Comprehensive Behavioral Health Service Array: States must offer services ranging from screening and early interventions to intensive community-based and, when medically necessary, inpatient care (pp. 40–41).
EPSDT services should be accessible even without a formal diagnosis, especially when addressing early developmental or behavioral concerns (pp. 41).
Children must be served in community-based, integrated settings whenever possible—not defaulted to residential care due to lack of alternatives (pp. 42).
Core System Components: A high-functioning system includes:
A single point of entry
Behavioral health support within primary care settings
Specialty community-based services
Inpatient treatment only when necessary (pp. 44)
These guidelines help states comply with federal EPSDT standards while tailoring services to local needs.
EPSDT in New England: State Highlights
While CMS provides the federal structure, each state customizes EPSDT implementation. Here's how it plays out across New England:
Rhode Island: Rhode Island’s Medicaid provider handbook serves as a strong model for clearly and concisely outlining EPSDT benefits. It highlights that Medicaid offers more comprehensive coverage for children than adults, allows for individualized treatment decisions based on each child’s needs, and makes clear that states cannot enforce strict service limits under EPSDT.
Connecticut: Under EPSDT, Connecticut’s Medicaid program offers a comprehensive range of preventive, diagnostic, and treatment services for children. Specifically, children and adolescents diagnosed with autism spectrum disorder are entitled to a full spectrum of medically necessary care, including Applied Behavior Analysis (ABA) services, as part of their EPSDT benefits.
Massachusetts: MassHealth includes home-based therapy, dental services, and comprehensive behavioral health support through its Children’s Behavioral Health Initiative.
Vermont: The Dr. Dynasaur program ensures early intervention services and emphasizes preventive care and a list of Preventive Pediatric Health Care recommendations, including Maternal Depression Screening.
Maine: MaineCare rebranded the EPSDT program as VitalCare for Kids. Here are the list of screening tools that health providers use under EPSDT Preventative Health Screening Tools (PDF) in conjunction with the AAP Bright Futures Guidelines for well-child visits, along with Autism Toolkit – Caring for Children with Autism Spectrum Disorders.
Challenges:
Despite growing enrollment in Medicaid and CHIP and a broader shift to managed care, EPSDT requirements have remained largely unchanged and underenforced. States and the federal government have not developed consistent systems to monitor EPSDT implementation, often leaving enforcement to legal advocates. Many states lack staff with in-depth knowledge of EPSDT, and responsibility is frequently passed to managed-care plans, which also have limited training and apply unproven utilization-management tools.
Families often have little knowledge of the advantages of EPSDT, and clinicians, including pediatricians, are unaware of its full reach. This leads to treatment hurdles, delayed services, and care denials, especially for children with chronic diseases.
Looking Ahead:
The 2024 CMS guidance reaffirms states’ legal responsibilities under EPSDT, regardless of whether care is managed by MCOs. It offers best practices, outlines monitoring and review processes, and highlights strategies to expand behavioral health services, including through telehealth and care delivered without a formal diagnosis. Increasing awareness and oversight are essential to ensure children and adolescents receive the care they are entitled to.
Advocating for Stronger EPSDT Policies and Strategies
The strength of EPSDT depends on federal, state and local advocacy. Here’s how stakeholders can enhance the program:
Educate Families and Providers: Many families are unaware of their EPSDT rights. Outreach campaigns can increase utilization.
Engage policymakers: Work with legislators to expand behavioral health coverage, simplify access, and fund preventive services.
Use Data Strategically: Highlight service gaps, especially in behavioral health, using Medicaid utilization data.
Collaborate Locally: Partner with schools, non-profits, and healthcare systems to provide EPSDT services where families already are.
Conclusion
To improve the health and well-being of children and families, Medicaid and CHIP are essential as they provide access to preventive care and create the framework for a sustainable workforce in the future. It is critical that the children’s behavioral health system not only supports these programs but also advocates for the full implementation of the EPSDT benefit as Medicaid reform talks continue. To guarantee that all children, particularly those with the most pressing requirements, receive the all-encompassing care to which they are entitled, it is imperative to fulfill the potential of EPSDT services.
