Could EPSDT Overturn Your Denied Claims?

Claim denials for children 21 years of age or younger should be disputed through EPSDT.

As you know, many states have expanded Medicaid. I am not saying whether that is good or bad. Just that some states have expanded, and some states have not. North Carolina is one that has not expanded Medicaid. The state’s Department for Medicaid received a waiver from the Centers for Medicare & Medicaid Services (CMS) to extend Medicaid and the Children’s Health Insurance Program (CHIP) coverage for 12 months after pregnancy.

As a result, up to an additional 28,000 people in North Carolina will now be eligible for Medicaid or CHIP for a full year after pregnancy. CMS gave its blessing for waivers to 24 states. An estimated 361,000 Americans annually are now eligible for 12 months of postpartum coverage. If all states adopted this option, as many as 720,000 people across the United States would be guaranteed Medicaid and CHIP coverage for 12 months after pregnancy.

CHIP piggybacks Medicaid for children. Not adults. But so does Early and Periodic Screening, Diagnostic and Treatment (EPSDT). The EPSDT benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. As a hospital or any provider, if you serve children and get your claims denied, EPSDT should overturn your denials. Check your compliance department. If claims are getting denied for children 21 years of age or younger, then you should be disputing these denials based on EPSDT.

CHIP differs from Medicaid EPSDT. There can be premiums or cost sharing with CHIP. CHIP is also a pre-set amount, whereas Medicaid EPSDT creates exceptions for those in need under 21.

CHIP was designed to cover children who fall outside of Medicaid eligibility, but who otherwise were not able to be insured through a family plan. This program vastly increased the number of children eligible for health insurance. However, CHIP is not governed by the same legislation as Medicaid and offers drastically different levels of coverage.

Certain states have different names for their Medicaid and CHIP programs. For example, in California, both programs are called Medi-Cal. In Georgia, Medicaid is called Georgia Medical Assistance, and their CHIP program is called PeachCare for Kids.

Medicaid and CHIP provide 51 percent of health care to our nation’s youth – more than 40 million children.

In the last few months, CMS has published numerous bulletins regarding the importance of EPSDT, especially germane to mental health. Be sure to check them out.

Programming note: Listen to healthcare attorney Knicole Emanuel’s RAC Report every Monday on Monitor Mondays at 10 Eastern.


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