New EPSDT guidance supports maintenance therapy coverage
According to the Centers for Medicare and Medicaid Services (CMS), the goal of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services is to ensure “the right care, to the right child, at the right time, in the right setting” (CMS, 2024). To ensure states comply with these requirements, CMS recently released SHO# 24-005: Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements outlining state requirements for complying with EPSDT policies created by the Bipartisan Safer Communities Act (BSCA). This new guidance document includes several key statements important to occupational therapy practitioners (OTPs) struggling with coverage for maintenance therapy in their state.
EPSDT requirements under the BSCA
Included in the Bipartisan Safer Communities Act (Safer Act), which was signed into law in 2022, was a provision to strengthen and improve the EPSDT benefit. Under the Safer Act, the Department of Health and Human Services (HHS) must evaluate each state's implementation of EPSDT services under Medicaid within two years of the bill’s passage and then every 5 years going forward. These reviews aim to identify gaps and deficiencies in state compliance with federal EPSDT requirements, including the provision of occupational therapy (OT) services, and provide technical assistance where needed.
Maintenance Therapy is a covered EPSDT service
EPSDT regulations direct that each state must cover medically necessary services from a qualified provider to correct or ameliorate an identified medical need. According to the EPSDT coverage manual, these medical needs include “defects and physical and mental illnesses or conditions” (CMS, 2014). The lack of consistency in state definitions of “ameliorate” has created barriers to Medicaid reimbursement for skilled OT services focused on maintenance therapy for both physical and mental health conditions in some states. However, in this new EPSDT letter to state officials, CMS clearly defines the “correct or ameliorate” requirement to include maintenance therapy. The guidance specifically highlights that OT services targeted at maintaining a child’s current health condition are covered under EPSDT benefits because they prevent a condition from worsening or developing into additional health problems.
AOTA continues to advocate with state and federal agencies to better define and highlight OT’s role in EPSDT services. This new CMS guidance document outlining mandatory coverage of medically necessary maintenance therapy is a step in the right direction. AOTA hopes that this state-level guidance will help OTPs advocate for reimbursement with their state’s Medicaid program where barriers to maintenance therapy coverage are encountered.
To learn more about EPSDT advocacy and coverage of OT services, contact ASKFAD@AOTA.org.
References:
Centers for Medicare and Medicaid Services. (2024, September 26). Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements. Medicaid.gov . https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf
Centers for Medicare and Medicaid Services. (2014). EPSDT -A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents Early and Periodic Screening, Diagnostic and Treatment (EPSDT)-CHIP-Program-Information/By- Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html EPSDT: A Guide for States. https://www.medicaid.gov/medicaid/benefits/downloads/epsdt-coverage-guide.pdf