Massachusetts – EPSDT

In Massachusetts:
  • As of July 1, 2011, there were 1,566,222 individuals enrolled in the state’s Medicaid program, known as MassHealth. 832,064 of these individuals were enrolled in one of the state’s managed care programs, including:
    • Managed Care Organization (MCO) Program, a capitated model for members under age 65 that delivers physical, behavioral and oral health services;
    • Primary Care Clinician (PCC) Plan Program, a primary care case management plan for Medicaid beneficiaries under age 65 delivering physical and oral health services. Beneficiaries receiving care through this program have access to behavioral health services through a prepaid inpatient health plan (PCC Plan BH Program);
      • Under a new Primary Care Payment Reform Initiative (PCPRI), bundled payments are being provided to the PCC plan.
  • Medicaid-eligible children ages 0-8 with an autism spectrum disorder may be eligible for services through The Massachusetts Children’s Autism Spectrum Disorder Waiver. Services include community integration, habilitation/education, respite, and behavioral supports and consultation. The waiver serves up to 157 children at any time.
  • Children in foster care with special health care needs may be eligible to receive services through the Special Kids/Special Care Pilot Program, which offers coordinated and individualized managed care services through a plan that contracts with MassHealth.
As of 2013, 632,680 individuals were eligible for the Massachusetts Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 100% and a participant ratio of 71%. 311,935 children received dental services of any kind, with 290,475 receiving preventive dental services.
Last updated September 2014
Medical Necessity
As defined in the MassHealth Provider Manual, a service is medically necessary if:
  1. “it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in the illness or infirmity; and
  2. there is no other medical services or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to the MassHealth agency.”
Initiatives to Improve Access
Chapter 224 of the Acts of 2012 requires MassHealth to pursue alternate payment methodologies for Medicaid enrollees; one way the state is doing so is through the Primary Care Payment Reform Initiative (PCPRI). This initiative seeks to improve access to care, patient experience, and quality of care, and to increase efficiency through the medical home model and integrated behavioral health homes. For more information on medical homes in Massachusetts, visit NASHP’s medical home map page.
Reporting & Data Collection
All MassHealth managed care contracts include requirements for quality measurement, quality improvement, and reporting. The state collects HEDIS data from managed care plans and also requires plans to conduct patient experience surveys including CAHPS 5.0H, CAHPS-CG, and the Health Outcomes Survey (HOS).
MassHealth requires managed care plans to report on various CMS child core measures, including childhood immunization status, screening using standardized tools, well care visits in the first 15 months of life, dental treatment, and follow-up after hospitalization for mental illness, among others.
Behavioral Health
Since 2007, Medicaid primary care providers in Massachusetts have been required to offer to use standardized behavioral health screening tools when administering the behavioral health screening component of the well-child care visit as required by the state’s EPSDT Medical Periodicity Schedule to all enrolled children under age 21.
The state’s Children’s Behavioral Health Initiative offers resources on screening for behavioral health conditions in children.
Support to Providers and Families
Support to Providers
MassHealth operates a web page on the EPSDT program that includes information on EPSDT program regulationsmedical and dental protocol and periodicity schedulescreening service codes, and billing guidelinesfor providers.
PCC Plan Integrated Care Management Program (CMP)
Providers participating in the PCC Plan Integrated Care Management Program (CMP) receive increased support from nurses and social workers for managing the care of high needs beneficiaries. Through its contract with the behavioral health plan, the PCC Plan operates also operates a Nurse Advice Line available to members 24 hours per day/7 days per week.
Support to Families
The MCO program requires plans to ensure the availability of multi-lingual providers and skilled medical interpreters as well as written materials in prevalent languages. 
Care Coordination
All MassHealth managed care entities (MCEs) are required to have procedures for monitoring care coordination. Plans must also ensure that each enrollee has an ongoing source of primary care and a person or entity responsible for coordinating the enrollee’s health care services. A patient’s care management coordinator develops an Individual Care Plan (ICP), if needed, to address an enrollee’s care needs and to assist in ongoing management and assessment of needs as indicated in the care plan.
Medicaid beneficiaries with complex medical conditions and/or behavioral health care needs in the PCC Plan are provided with increase support and coordination of care.
Oral Health
The Massachusetts EPSDT program bases its dental protocol and periodicity schedule on the Preventive Pediatric Oral Health Care recommendations from the American Academy of Pediatric Dentistry Reference Manual 2007-2008.