Supporting Healthy Futures: Capitalizing on Medicaid’s EPSDT Medical Necessity Standard

Authors

Teressa Colhoun, Washington and Lee University School of LawFollow

Abstract

Youth mental health is in crisis. Children report increased rates of suicidal ideology, depression, and anxiety. Diagnosis rates soar. Pediatric mental health care remains difficult to access. When services are accessible, they are costly—often sending families into medical debt.

This Note discusses Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (“EPSDT”) benefit. Specifically, it studies the EPSDT benefit’s creation, structure, and administration. This Note focuses on the context in which the EPSDT benefit operates, particularly how health care financing models impact benefit administration. It suggests that the EPSDT benefit has the capacity to address crucial gaps in pediatric mental health care. However, this Note summarizes key issues in the benefit’s current administration. Specifically, it articulates how EPSDT’s medical necessity standard is manipulated by states to deny coverage to children, despite their providers’ opinion that such treatment is necessary. It further discusses inconsistencies that exist when courts are asked to apply the EPSDT benefit’s medical necessity standard in coverage determination challenges.

This Note ultimately advocates for consistency and predictability in medical necessity standards, so that children receive coverage for crucial health care services. It urges three possible solutions to address the EPSDT benefit’s current shortcomings: First, it suggests federalizing a definition for medical necessity. Next, it advocates for the establishment of a consistent burden shifting framework to apply in courts where coverage determinations are being challenged on the basis of medical necessity. Finally, it proposes the implementation of a specialized patient advocacy model. Ultimately, these solutions share a common goal: to capitalize on the potential of the EPSDT benefit’s broad promise to cover medically necessary services so that children can access much needed care, particularly given the ongoing youth mental health crisis.

Recommended Citation

Teressa Colhoun, Supporting Healthy Futures: Capitalizing on Medicaid’s EPSDT Medical Necessity Standard, 81 Wash. & Lee L. Rev. 845 (2024).
Available at: https://scholarlycommons.law.wlu.edu/wlulr/vol81/iss2/8