Improving health outcomes for eligible AI/AN children, youth, and families enrolled in Medicaid and the Children’s Health Insurance Program
To: Tribal Child Welfare Agencies, Child Care programs, Head Start, and Tribal Home Visiting
Dear Colleagues,
Quality and accessible health care is critical to supporting the children, families, and communities that the Administration for Children and Families (ACF) serves. We know that state Medicaid and the Children’s Health Insurance Program (CHIP) agencies are critical sources of care for American Indians and Alaska Natives (AI/AN). I am excited to share that the Centers for Medicare & Medicaid Services (CMS) recently made several announcements impacting care for AI/AN populations, including updates related to flexibility to cover traditional health care practices through Medicaid as well as new guidance regarding coverage requirements for eligible children and youth enrolled in Medicaid and CHIP.
Importance of Medicaid and CHIP in AI/AN Communities
More than one million AI/ANs are enrolled in Medicaid and CHIP. Far more are eligible for coverage, including many of the individuals served through ACF-funded programs. Medicaid and CHIP are jointly financed by the federal government and states, and they are administered by states within broad federal guidelines. States are prevented from imposing Medicaid premiums or any other Medicaid cost sharing on AI/AN Medicaid beneficiaries.
States that have an Indian Health Service, tribal, or urban Indian organization (ITU) facility located in their state must establish a process for the State Medicaid Agency to obtain advice and input on State Plan Amendments (SPA) or waivers with Tribal implications.[1] [2] States describe the process for seeking advice from ITUs through a Tribal consultation SPA.[3]
Coverage of Traditional Health Care Practices
In October, CMS announced that they approved section 1115 (a) demonstration amendments that allow, for the first time ever, Medicaid and CHIP coverage of traditional health care practices provided by ITUs. These amendments apply to tribal communities in Arizona, California, New Mexico, and Oregon, and also serve as a framework for other states interested in submitting similar proposals.[4]
EPSDT and ACF grant recipients
In September, CMS released new guidance in the form of a State Health Official letter entitled Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements.[5] This guidance is intended to support states as they work to strengthen their implementation of EPSDT requirements to help ensure improved health outcomes for children and youth enrolled in Medicaid and CHIP. Though each state may take a tailored approach, EPSDT requires comprehensive and preventive health care services (medical, dental, mental health, and specialty services) for eligible children under age 21 who are enrolled in Medicaid or CHIP be provided.
There are many services that states can elect to include as part of the EPSDT benefit to address risk factors for adverse experiences such as child welfare involvement and youth homelessness. These services can be helpful as part of a broader strategy to reduce the overrepresentation of AI/AN children and youth in the child welfare system, as well as the disproportionate rates at which AI/AN children, youth, and families experience other adverse social and health outcomes. A few examples included in the new guidance are highlighted below:
| Table 1: Example EPSDT services to support families at risk for adverse experiences such as child welfare involvement and youth homelessness | ||
| Risk factor for adverse experiences | Potential service to support addressing this need | Detail on how some states are covering this service within Medicaid and/or CHIP |
| Developmental, medical, or behavioral health needs in a child and/or undetected parental peripartum depression | Developmental and behavioral health screening in well-child visits, including postpartum depression screenings in infant well-child visits up to 6 months | Most states have adopted the Bright Futures periodicity schedule developed by the American Academy of Pediatrics or a modified version thereof.[6] Periodicity schedules recommend a schedule for screening services, including developmental, mental health, and substance use disorder screenings, and states must ensure children have access to those screenings according to the state-determined schedule. |
| Families challenged to navigate the health care system to get the right services for their child |
Care coordination or care management, depending on a child’s needs
|
Some states cover community-based Care Management Entities to support families in their own homes and communities by identifying formal and informal resources in their geographic area so they can be incorporated into care coordination plans and by working with families to support successful use of these services. |
| Caregivers experiencing high levels of parenting stress due to parenting a child with medical or behavioral health needs | Caregiver clinical and/or peer support | States have integrated primary care settings, Certified Community Behavioral Health Centers, or other settings where the range of services includes coverage for services that support children and their parents, family members, and caregivers. Some parent-facing services can be paid for through the child’s Medicaid benefit if the service is provided for the direct benefit of the child. |
| Caregivers experiencing high levels of economic stress that make it difficult to meet basic health needs, including participating in children’s medical appointments. |
Non-Emergency Medical Transportation (NEMT)
|
States are required to ensure that beneficiaries have access to transportation for medically necessary services. In addition, the state may pay for transportation for the parent, family member, or caregiver without the child present in order to ensure their active participation in the child’s treatment. |
Improving Care for Children in or Formerly in Foster Care
The updated EPSDT guidance from CMS also includes a dedicated subsection specific to improving care for children in or formerly in foster care. This guidance can serve as a powerful tool in better serving AI/AN children and youth in the child welfare system and addressing disparate outcomes throughout the child welfare process, including in entry into out-of-home care and exits from care. It encourages state Medicaid agencies to work with the state child welfare agency to identify and address the priority needs for children in or formerly in foster care in their state and to ensure that they have access to the Medicaid covered services to which they are entitled.
A brief summary of the CMS guidance on specific EPSDT policies, strategies, and best practices for children in foster care is highlighted below:
| Table 2: Specific EPSDT policies, strategies, and best practices for children in foster care | |
| Policy | Within a few days of placement in foster care, or as statutorily obligated, states should ensure that children receive an initial assessment of acute physical and behavioral health needs, followed by a comprehensive visit similar to a well-child visit. |
| To address challenges in the transition to adult coverage and care, state Medicaid agencies are required to maintain coverage for former foster youth until age 26, including for those foster youth who were enrolled in another state when they turn age 18. | |
| Strategy | Develop and maintain a collaborative relationship with the child welfare agency to ensure that children in foster care receive all medically necessary services to which they are entitled under EPSDT requirements. |
| Support youth in foster care by using dedicated Managed Care Plans (MCPs), covering “wraparound” services, paying enhanced provider rates for primary care visits, and/or using an EQR study to examine health care utilization among these youth. | |
| Best practice |
Require MCPs to assign a liaison and trauma-informed care manager to children in foster care.
|
| Implement an MCP dedicated to children in foster care. | |
While doing so is not required under EPSDT, states also may develop approaches to cover services in addition to those covered under section 1905(a), with the goal of maintaining children with disabilities or other complex health needs in integrated home and community-based settings or helping them return to their community.[7] The CMS guidance contains specifics about how states might use other authorities to cover services beyond what is required under EPSDT.
Recommendations
In recognizing the importance of your voice and perspective, we invite you to strengthen partnerships with state Medicaid and CHIP agencies by taking the following actions:
- Identify the best point of contact within the state Medicaid agency to answer questions you might have about what services are already in place. States vary in how they choose to operate CHIP programs, and your Medicaid agency will know whether it makes sense to have a separate point of contact regarding CHIP.
- Find out how your state Medicaid agency is engaging providers serving the AI/AN community in your state around these topics.
- Ask how your state Medicaid agency is engaging individuals with lived experience in your area. In May 2024, CMS set new standards for state agencies to better engage Medicaid enrollees and their families in the Medicaid decision-making process through implementation of Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs). States must take action by July 2025. Ask the state Medicaid agency how you can become involved.
- Find and participate in active conversations happening at the state level regarding any of the services, policies, strategies, and best practices mentioned in the two tables above. Find out if there are plans to amend the state plan or apply to CMS for a waiver.[8]
Thank you for your dedication and leadership in supporting AI/AN children, youth, and families in receiving the health coverage services they need and may be entitled to under federal Medicaid law. If you have any questions, please contact your state Medicaid agency. Together, we will ensure that all children, youth, and families have the health care, services, and supports necessary to thrive.
/s/
Meg Sullivan
Principal Deputy Assistant Secretary
[1]A Medicaid and CHIP state plan
is an agreement between a state and the federal government describing how that state administers its Medicaid and CHIP programs. When a state is planning to make a change to its program policies or operational approach, states send state plan amendments to CMS for review and approval.
[7]EPSDT entitles enrolled infants, children and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.
[8]A Medicaid and CHIP state plan
is an agreement between a state and the federal government describing how that state administers its Medicaid and CHIP programs. When a state is planning to make a change to its program policies or operational approach, states send state plan amendments to CMS for review and approval.
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