Section 01

Executive Summary

Children’s hospitals are on the front lines of addressing the child and youth behavioral health crisis. They provide critical care for young people with behavioral health needs, identify issues with the behavioral health system, and work with public and private partners to advance change. Still, more than four years after the Children’s Hospital Association (CHA) and leading pediatric organizations declared a national emergency for child and adolescent mental health, far too many young people and families continue to struggle to access comprehensive, high-quality behavioral health care.¹

An estimated one in four young people have a mental, emotional, developmental, or behavioral issue — yet families are unable to access care due to inadequate coverage, long wait times, or the absence of specialized services in their community.²

CHA and member hospitals, in partnership with Manatt Health, developed this toolkit with concrete, actionable strategies to support children’s hospitals in advocating for a more effective behavioral health system for Medicaid-enrolled children, youth and families.

A young child rests on a caregiver’s lap while the caregiver strokes their hair.

The toolkit’s strategies are rooted in the Medicaid Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit — a federal benefit that requires states to cover all services needed to correct or ameliorate a child’s physical, mental or developmental condition.

The EPSDT benefit is foundational to addressing the behavioral health needs of young people. When implemented as designed, EPSDT offers coordinated, accessible, and high-quality behavioral health care for Medicaid-covered children and families.

However, despite the strong legal foundation established by EPSDT, challenges remain. State Medicaid programs often do not provide the full spectrum of behavioral health services a child or family may need.³ In other places, a full continuum of services is covered but is not accessible in practice by the children and families who need them, due to insufficient provider networks, long wait times, low provider reimbursement rates, or other systemic barriers. There also is wide variation in the quality of available services and supports, often due to a dearth of trained providers or high staff turnover rates in the programs that serve young people. As a result, a growing number of states have faced EPSDT-related litigation – underscoring both the urgency of the problem and the potential power of EPSDT to be part of driving change.⁴

What The Toolkit Provides

The toolkit equips children’s hospitals and their partners with three core resources:

A comprehensive review of the EPSDT benefit and its implications for behavioral health coverage for Medicaid-enrolled children and youth;
A description of a robust continuum of behavioral health services for children, youth and their families aligned with EPSDT requirements; and
Ten advocacy strategies hospitals can use to drive improvements in Medicaid for children with behavioral health conditions, taking into account the current fiscal and policy environment.

The toolkit focuses on Medicaid-related strategies, reflecting that close to half of the nation’s children are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the EPSDT benefit establishes a robust standard of what should be provided to children.⁵ Outside of Medicaid and EPSDT, there are numerous strategies that could be helpful, such as continued work on implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MPHAEA),⁶ but they are not the focus of this resource. The toolkit builds upon past CMS guidance on EPSDT requirements and a recent toolkit on best practices for state Medicaid and CHIP agencies to strengthen the child and youth behavioral health system.⁷ The information and strategies presented are also grounded in federal law and regulations and past EPSDT-related litigation, and were developed in partnership with members of CHA’s Behavioral Health Learning Collaborative (BHLC).

The child and youth behavioral health crisis demands urgent, sustained action. EPSDT provides a legal foundation to improve coverage, access and quality of care available for Medicaid-enrolled children, youth and families. This toolkit provides a framework for children’s hospitals to better understand the EPSDT benefit, assess their state’s continuum of covered behavioral health services, and advocate for change. The 10 strategies in the toolkit give children’s hospitals a practical roadmap for driving change at the state level, rooted in federal law and informed by the expertise of CHA member hospitals and national guidance and best practices.

This toolkit is intended to be an initial step to support children’s hospitals in continuing to build partnerships and advocate for high-priority changes to the Medicaid child and youth behavioral health system. CHA will continue to work with member hospitals on an ongoing basis to ensure the strategies in the toolkit are actionable and hospitals are supported to promote change.

A behavioral health professional listens to a caregiver and child during a consultation.

Why EPSDT?

The toolkit focuses on Medicaid strategies, both because of the program’s role in financing behavioral health services for children and youth, and because of its unique EPSDT benefit for those under 21.

Medicaid’s role in children’s health. Medicaid and the Children’s Health Insurance Program (CHIP) are the largest health insurers for children and youth in the country.⁸ Medicaid and CHIP, on average, provide health insurance coverage for half of all children’s hospitals’ patients and for some children’s hospitals, closer to three-quarters.⁹
EPSDT is a powerful tool to prompt change. The EPSDT benefit is foundational to the role of Medicaid in addressing the behavioral health crisis. EPSDT requires states to provide a robust array of Medicaid-coverable services, namely those contained in Section 1905(a) of the Social Security Act, that would correct or ameliorate a young person’s physical, mental, or developmental condition. When implemented as designed, EPSDT offers coordinated, accessible, and high-quality behavioral health care for Medicaid-covered children and families.

Toolkit Overview

To support hospitals and their partners in advocating for a stronger Medicaid behavioral health system for children and youth, the toolkit provides:

A comprehensive review of the EPSDT benefit and its role in ensuring access to comprehensive behavioral health care for children and youth enrolled in Medicaid;
A description of a robust continuum of behavioral health services for children, youth and their families that is aligned with the EPSDT benefit and informed by national guidelines, past EPSDT litigation, and the clinical expertise of CHA’s members; and
Ten strategies that children’s hospitals can pursue to advocate for changes in their state Medicaid programs to better meet the promise of EPSDT for children and youth with behavioral health needs, considering the current fiscal and policy environment.

The toolkit builds upon past CMS guidance on EPSDT requirements – issued by the Biden Administration – and a recent toolkit – issued by the Trump Administration – on best practices for state Medicaid and CHIP agencies to strengthen the child and youth behavioral health system.¹⁰ The fact that both Administrations have supported addressing the children’s behavioral health crisis through Medicaid and EPSDT is a powerful sign that these issues remain largely above the political fray. Even amid ongoing federal changes and budget constraints, there is strong interest in responding to the behavioral health needs of young people and families.

The toolkit focuses on issues identified by advocates, hospitals and the legal system as most critical to address EPSDT gaps, as well as offers action steps that children’s hospitals can use to advocate for change. The strategies are grounded in national best practices and informed by the expertise of CHA and member hospitals participating in the CHA Behavioral Health Learning Collaborative (BHLC). By design, the strategies align with EPSDT requirements whenever possible, which means that they are not simply “nice-to-have” ideas but rather steps that states can and should be taking to ensure compliance with federal law.

Next section Section 02 EPSDT