Initiatives to Improve Access

The Medicaid benefit for children and adolescents covers screening, preventive, diagnostic, and treatment services. Ensuring that children have adequate access to primary care providers, as well as that states have referral systems to facilitate access to other providers and specialists when necessary, is a priority for states. This section contains information on referral systems and initiatives in place in several states to improve access to care for children, including for behavioral health and oral health services. These include examples of incentive programs for providers and managed care plans.


Alabama No information at this time.
Alaska Alaska is part of the Tri-State Child Health Improvement Consortium (T-CHIC), in which it is collaborating with Oregon and West Virginia as part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Project. Through this project Alaska is working to develop medical homes for children enrolled in Alaska Medicaid and Denali Kid Care as a way to increase access to EPSDT services.
Arizona As outlined in the AHCCCS Contractor Operations Manual, managed care plans are required to develop and maintain a provider Network Development and Management Plan to assure AHCCCS that services are being provided as specified.
Arkansas created ARKids First health insurance to provide additional coverage options for more than 70,000 Arkansas children. ARKids A is Medicaid and offers children and their families a comprehensive package of benefits, including EPSDT services. ARKids B provides coverage for families with higher incomes.
California No information at this time.
Colorado Colorado offers Family Health Coordinators through its Healthy Communities initiative. The coordinators offer outreach and case management to help children and their families access coordinated health care services. In addition to helping families apply for Medicaid coverage and educating them on how to access benefits (including preventive services) in appropriate settings, the coordinators also work to connect families to a medical home and provider information and referrals to other community programs and resources.
Behavioral Health:  An Enhanced Care Clinics system for behavioral health has enhanced access to behavioral health services for Medicaid-enrolled children. Connecticut Behavioral Health Partnership (CTBHP), a Medicaid behavioral health carve-out plan that serves approximately 260,000 children and youth, launched a quality improvement initiative aimed to improve access and reduce waiting times for behavioral health services for children entering the child welfare system in and around Bridgeport and Waterbury.
The quality improvement objectives were to:
  • Increase by 25 percent the rate of connection to behavioral health services for children removed from their homes for the first time and identified as needing behavioral health services by the state’s multidisciplinary exam process (MDE); and
  • Reduce by 10 percent the average time to behavioral health appointments for these children.
Oral health: The Connecticut Dental Health Partnership has established specific standards for access, including waiting time limitations for emergency cases, urgent cases, and preventative and non-urgent care. The Partnership also requests that dental providers use an answering machine or answering service to field calls from Medicaid beneficiaries during hours in which staff are not available. Dental providers must also be reachable in case of emergency.
Delaware No information at this time.
District of Columbia
District MCO contracts include child/EPSDT network adequacy requirements such as:
  • Include medical subspecialists and pediatric specialists and subspecialists;
  • Demonstrate a hospital network in the District capable of furnishing a full range of tertiary services to enrollees, including at least one hospital that specializes in pediatric care; and
  • Maintain a sufficient number of dental providers, including dentists, pediatric dentists, orthodontists and oral surgeons to meet the need of enrollees.
Florida’s Children’s Medical Services (EPSDT) provider handbook requires that primary care providers have capacity to see and “render a clinical decision” on children 24 hours a day, 7 days a week.
The state allows physician extenders—Advanced Registered Nurse Practitioners and Physician Assistants—to provide services to Medicaid-enrolled children as long as the physician is responsible for managing the overall care of a child and concurs with the extender’s findings. Payment for these services is made to the supervising physician.
Managed care organizations (MCOs) are required to provide primary care providers with a monthly list of Health Check eligible children who are not in compliance with the state’s periodicity schedule; the MCO or provider must then contact the child’s family to schedule an appointment.
MCOs are eligible for performance incentive payments based on the percentage of Health Check well-child visits and screens achieved above a minimum 80% threshold.
Hawaii Pay for Performance
Hawaii Medicaid implemented a pay for performance incentive program to encourage improvements in quality and access. Child-specific benchmark measures include childhood immunizations, and getting care needed-child CAHPS.
No information at this time.
MCO Network Adequacy Requirements
Illinois requires its managed care organizations (MCOs) to provide at least one pediatrician for each 2,000 enrollees under 19 and at least one full time equivalent physician for each 1,200 enrollees.
Incentive Payments
Illinois makes an annual incentive payment of $30 per patient to enrolled Illinois Health Connect primary care providers, Maternal and Child Health (MCH) physicians, Advanced Practice Nurses and Federally Qualified Health Centers (FQHCs) who render all recommended well child visits during each year of a patient’s life from ages 0-5.
Indiana No information at this time.
Primary care providers (also known as patient managers) in the primary care case management (PCCM) program are required to provide 24-hour access for their members and must establish a 24-hour access telephone number for scheduling appointments, accessing information, and for use by members when the provider’s office is closed.
When a child or adolescent is due for an EPSDT Care for Kids screening provided through the PCCM program, the Department of Public Health is required to issue a reminder to the family.
Iowa uses specialized software, verification of provider appointment availability and 24-hour access, and a review of referral documentation to monitor access to the PCCM program.
Kansas No information at this time.
Kentucky No information at this time.
No information at this time.
Primary Care Case Management (PCCM)
The state operates a Primary Care Provider Incentive Payment (PCPIP) program which pays additional compensation to providers who delivery high quality healthcare to Medicaid PCCM patients and who rank above the 20th percentile for certain measures compared to other physicians within their specialty. Participating physician specialties include Family Practice, Pediatrics, General Practice, Obstetrics/Gynecology, and Internal Medicine.
The goals of the PCPIP program are to increase access of Medicaid members to providers, reduce unnecessary/inappropriate ER utilizations, and increase utilization of preventive/quality services.
Improving Health Outcomes for Children (IHOC)
In 2010, Maine was awarded a five-year grant from the Centers for Medicare and Medicaid Services (CMS) to improve the quality of children’s health care. Under the grant, the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative was launched to “increase the rate of Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) services for children receiving MaineCare benefits by providing tools and data monitoring, offering comprehensive educational support, and engaging primary care practices in multiple change interventions to build patient centered medical homes for children.”
The First STEPS Learning Initiative was implemented in multiple phases. Phase I (September 2011-April 2012) focused on improving pediatric immunization rates. Overall, immunization rates in participating practices increased by 5.1% after twelve months.
Phase II (May-December 2012) focused on improving developmental, autism, and lead screening rates for children under age three. Participating practices more than doubled the global developmental screening rates in all targeted age groups.
Phase III (April-November 2013) focused on oral health and healthy weight screening. Evaluation results of this phase are not yet completed.
Maryland’s Medical Assistance Program funds local health departments to provide assistance to families when children under 21 need to access follow-up treatment services resulting from a Healthy Kids preventive care screen. Local health departments are also responsible for assisting high-risk beneficiaries, including children, to access necessary health care services.
No information at this time.
No information at this time.
Minnesota has included multiple financial incentive programs in managed care contracts designed to increase and improve service delivery to children. Managed Care Organizations (MCOs) can receive:

  • $90 for each well child examination beyond the previous year’s rate. The rate is measured by the number of participants screened per 1,000 enrollee months;
  • $50 for each lead screening conducted beyond the previous year’s rate. There is no monetary cap on the incentive payment, but the number of lead screenings is limited to 2 screenings per child (a 5% withhold on each MCO contract is tied to lead screening performance, as well); and
  • $25 for each child mental health or developmental screening conducted beyond the previous year’s rate.
The Department of Health (DOH) is a major provider of Mississippi Cool Kids (EPSDT) well-child services in the state. In partnership with Mississippi Medicaid, DOH has developed nurse-run clinics that provide well-child screens, and refer out to physicians for other services, referrals, and follow up. These nurses work with Head Start programs and visit daycare centers to expand access to Mississippi Cool Kids well-child services.
Mississippi works with schools to support a range of school-based health services designed to identify and assist children who have medical issues that interfere with learning. Nurses employed by the Department of Education may also perform Mississippi Cool Kids screens.
No information at this time.
Montana Medicaid-enrolled children (as well as other children) in Montana have access to Pediatric Specialty Clinics sponsored by Children’s Special Health Services in the Montana Department of Public Health and Human Services.
No information at this time.
Nevada No information at this time.
New Hampshire No information at this time.
Providers in New Jersey are paid a $10 incentive payment for each documented EPSDT screening examination.
The Human Services Department (home to Medicaid) is a partner in a children’s health care quality initiative spearheaded by the University of New Mexico, Envision New Mexico, that includes telehealth programs linking pediatric sub-specialists at the university with primary care providers throughout the state.
Behavioral Health
In October of 2011, New York expanded Medicaid reimbursement for telemedicine services to additional care settings, and incorporated tele-psychiatry into the model. The Office of Mental Health’s (OMH) Division of Child and Family Services has established a New York Consultation and Telepsychiatry (NYCaT) program to address child psychiatric consultation needs in areas of the state with workforce shortages. The program supports mental health treatments for children in mental health programs as well as in primary care practices. To improve access to behavioral health services, New York made a policy change with CMS approval in mid-2011 allowing Medicaid reimbursement for counseling services provided by social workers. Before that change, only Federally Qualified Health Centers had been able to seek reimbursement for those services when provided by social workers.
Managed Care Incentives
New York has incorporated managed care plan performance on well child measures into its auto-assignment algorithm; higher-performing MCOs are assigned a higher proportion of new enrollees who do not make a specific choice when they enroll.
No information at this time.
North Dakota No information at this time.
Managed care contracts in Ohio require health plans to have on staff an “EPSDT/Maternal Child Health Manager” to help Medicaid-enrolled families navigate the health care system and access EPSDT benefits.
These managers also help to coordinate services specific to the maternal and child health needs of enrollees and link members to community-based resources.
No information at this time.
The Oregon Health Policy Board (the entity that serves as the oversight body for the Oregon Health Authority) and the Oregon Early Learning Council created a joint subcommittee focused on integrating child healthcare and early learning policies with the goal of having children healthy and ready to receive education. The subcommittee’s work has included a number of recommendations on integrating the early learning system with the CCOs, as well as providing additional support in the area of developmental screening.
No information at this time.
No information at this time.
South Carolina No information at this time.
South Dakota No information at this time.
Tennessee Managed care contracts require that if a managed care organization’s EPSDT “screening rate is below ninety percent (90%), as determined in the most recent CMS 416 report, the CONTRACTOR shall conduct New Member Calls for all new members under the age of twenty- one (21) to inform them of TENNderCare services including assistance with appointment scheduling and transportation to appointments.”
No information at this time.
No information at this time.
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Virginia No information at this time.
Washington’s administrative code (WAC 182-534-0200) provides for enhanced payments for EPSDT screens provided to children in out-of-home placements.
Primary care providers participating in a Medicaid managed care organization’s provider network must provide 24-hour, seven-days-per-week access.
West Virginia’s Medicaid agency encourages providers to deliver services using telehealth to improve access for beneficiaries. Providers with the appropriate infrastructure can receive reimbursement for services delivered via telehealth and must use a service code modifier when billing.
Wisconsin No information at this time.
Wyoming No information at this time.