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H H S Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health

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Boosting Performance in EPSDT

Core EPSDT Program Activities

 Printer-friendly Core EPSDT Program Activities (19 KB)

  • Establish EPSDT periodicity schedules for comprehensive screening visits
  • Establish EPSDT periodicity schedules for dental screening
  • Establish EPSDT periodicity schedules for vision and hearing screening
  • Set managed care performance standards
  • Clearly define medical necessity
  • Use reasonable and appropriate prior authorization standards, particularly related to preventive services
  • Finance outreach, informing, and transportation assistance

Links to More Information on EPSDT Rules 

  • The Center for Medicare and Medicaid Services (CMS) is the federal agency responsible for administering Medicaid and EPSDT. Links here to data, regulations, and other policy.
  • Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health Screening Services US General Accounting Office. (July 2001).

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Title V - EPSDT Partnerships to Improve EPSDT Administration

Printer-friendly Title V - EPSDT Partnerships to Improve EPSDT Administration (23 KB)

Improving EPSDT performance through managed care contracts and pediatric purchasing specifications Specificity of contract language is particularly important for EPSDT. MCOs need to know exactly what services they are responsible for covering. Enrolled children and their families need to know what services they are entitled to receive from the MCO and what services they are entitled to under the state Medicaid program.

In five years of studying Medicaid managed care contracts, GWU researchers saw ways states could improve the specificity of their contracts.

Thus, GWU developed “purchasing specifications,” which offer model language on various topics for states to consider as they draft their contracts.  

 

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State Strategies for Improving EPSDT Performance 

Printer-friendly State Strategies for Improving EPSDT Performance (20 KB)

Rhode Island is Paying for Performance. RIte Care is the Rhode Island managed care program for families covered by Medicaid, including uninsured families with incomes up to 185 percent of poverty and uninsured pregnant women and children under 19 with family incomes up to 250 percent of poverty. Since 1994, the program has sought to improve access to and quality of care and outcomes while containing costs. Since 1998, contracts with health plans has specified administrative, access, and clinical performance measures, with each measure having a standard (current 19 of these “benchmarks”). Under the Performance Incentive Program, health plans can earn payments over and above their capitation as rewards / incentives for improving performance. For EPSDT, the standard include: a) 85 percent of members under age two are immunized according to schedule, b) members between [ages] 6 and 20 are provided EPSDT age-appropriate screenings, and c) new members under age 18 receive a first visits with a [primary care provider] PCP within 90 days of enrollment. The state also is piloting measure related to emergency room visits for child enrollees with asthma, and first outpatient pediatric visit of infants born into RIte Care. Visit the RIte Care Research and Evaluation Home Page at Washington State Focuses on Four Domains. Each year Washington evaluates preventive health care delivered by managed care organizations through study of the content well-child checkups to infants, children, and adolescents covered by Medicaid. To qualify, a well-child checkup must meet state Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements at each visit by addressing a minimum number of elements within four health “domains”—physical health, developmental health, mental health, and health education. To count as an EPSDT screening visit, the provider must document the core elements in each the four health domains were addressed during the visit. Traditionally, providers have done well documenting one or two domains—chiefly the physical health and developmental health—but have been less successful in documenting mental health and health education. The state has found that using structured exam forms with age specific items increases the likelihood that all four domains will be addressed and documented. Evaluators have found that focusing by age provides for more reliable benchmarking. For more information, go to OMPRO. OMPRO is a nonprofit organization dedicated to improving the quality and effectiveness of health care; it is Washington’s external quality review organization (EQRO). Dr. Anita Bobinet is the EPSDT Project Coordinator, Health Services Quality Assessment Department, OMPRO.

Keeping Track in Arizona. Arizona’s Health Care Cost Containment System (AHCCS) developed age-specific EPSDT tracking forms, designed to help providers deliver comprehensive, age-appropriate, screening exams. With input from managed care organizations (MCO) and pediatric leaders, the form identifies the components of EPSDT called for at each visit. When the form is completed during the visit, one copy is kept in the child’s medical record and the other copy is set to the MCO. The MCO is, in turn, responsible for ensuring that the EPSDT screens are performed on schedule, with adequate content, and the completed tracking form data is available for performance monitoring.

Wisconsin's New Quality Performance Measure System for Medicaid Managed Care Wisconsin has implemented MEDDIC-MS, a new system of performance measures that addresses many of the most difficult issues not adequately addressed by current quality assurance / performance monitoring systems. It is perhaps the first automated, rapid-cycle quality performance measure system to be successfully implemented in a large, state-wide, publicly funded healthcare system. Delivery of EPSDT (known as HealthCheck in Wisconsin) services for children between birth and age two years are a priority in the Medicaid/BadgerCare program because they facilitate the delivery of vital early childhood preventive health services and offer opportunities for screening, diagnosis, and intervention for potentially serious conditions, thereby improving quality of life and preventing future complications. MEDDIC-MS measures are: percent of children who receive seven or more, six, and five comprehensive HealthCheck examinations by the age of two years (MEDDIC-MS).

One study of “Quality Oversight In Medicaid Primary Care Case Management Programs (Schneider et al.) found that the Medicaid PCCM programs had different partterns of performance monitoring and quality management. Some State Medicaid Agencies were aiming to boost performance by paying incentives. In PCCM programs, the clinical areas most commonly targeted for quality improvement were childhood immunizations, diabetes, and asthma, followed by satisfaction with care. Five state PCCM programs (20 percent) reported that they were able to demonstrate improvements in satisfaction with care, and another five reported improvement in childhood immunizations. Of twenty-five PCCM programs, five states (20 percent) reported bonus payments for EPSDT.

The Iowa Quality Assurance Technical Assistance (TA) effort was sponsored through CompCare, a joint initiative of Health Resources and Services Administration (HRSA) and the Center for Medicare and Medicaid Services (CMS). A State-level workgroup comprised of representatives from the Iowa’s Department of Human Services and the Department of Public Health identified a need for better coordination of quality assurance (QA) efforts in child health. The aim was to shift from individual- and program-level quality assurance efforts toward a more comprehensive child health quality improvement system.

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Advocacy Strategies for Improving EPSDT Performance

Printer-friendly Advocacy Strategies for Improving EPSDT Performance (11 KB)

Connecticut: The Children's Health Council in Connecticut has developed and implemented a tracking and performance monitoring program aimed at increasing EPSDT participation. “EPSDT O n-Time Visit Rates” (an estimate of the screening rates for individual children enrolled in Medicaid managed care) are calculated monthly and reported quarterly to the Department of Social Services by age and by health plan.

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Provider-Focused Strategies for Improving EPSDT Performance

Printer-friendly Provider-Focused Strategies for Improving EPSDT Performance (22 KB)

In terms of EPSDT, Title V and Medicaid agencies working together might:

  • Develop and implement EPSDT-specific provider recruitment and retention projects
  • Offer training and administrative support to participating providers (see example below)
  • Monitor the provider supply and design strategies to improve access to care in under-served communities
  • Study the supply of providers available for treatment of diagnosed conditions, particularly for children’s mental health, dental care, and developmental services.
  • Educate providers on EPSDT and how to bill for covered services

Training Providers on Evidence-based Practice

Basic Provider Information about EPSDT

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