October 29, 2015

Defining Medical Necessity for Children and Youth with Special Health Care Needs


Defining Medical NecessityThe National Academy for State Health Policy (NASHP) has published a brief that addresses current issues affecting state Medicaid EPSDT (Early and Periodic Screening, Diagnosis and Treatment) and CHIP officials who implement medical necessity policy, and looks ahead to new and emerging issues that may affect state EPSDT policy in years to come. It captures key themes that emerged during a May 2015 teleconference of state EPSDT coordinators and CHIP directors convened by NASHP with the support of the Health Resources and Services Administration’s Alliance for Innovation on Maternal and Child Health (AIM).

NASHP's Description: Medicaid programs nationwide are mandated to use the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit to improve the health of low-income children with special physical, emotional, and developmental health care needs. This benefit supports children and youth with special health care needs (CYSHCN) by ensuring they receive individualized health care when they need it—provided those services are deemed medically necessary for the individual beneficiary.

Determining the medical necessity of services under EPSDT can prove challenging for states. The EPSDT benefit and the challenges surrounding its implementation are nothing new for states. In a recent survey and conference call, state EPSDT coordinators and CHIP directors shared their experiences navigating the definition of medical necessity for CYSHCN. The brief takes a fresh look at the current issues affecting the state EPSDT and CHIP officials who implement medical necessity policy, and looks ahead to new and emerging issues that may affect state EPSDT policy in years to come.