Pennsylvania – EPSDT

In Pennsylvania:
  • As of July 1, 2011, there were 2,134,956 individuals enrolled in the state’s Medicaid program, known as Medical Assistance; 1,152,069 of these individuals received physical and dental services through one of 12 Medicaid-only managed care organizations through the state’s managed care program, HealthChoices.
  • 302,300 Medical Assistance recipients not served by HealthChoices received physical health services through the primary care case management (PCCM) program ACCESS Plus.
  • Mental health and substance use disorder services are provided through 34 prepaid inpatient health plans.
  • 454,519 Medicaid beneficiaries also received services through a transportation-only prepaid ambulatory health plan (PAHP).
  • Medicaid-eligible children may receive services through the following waiver programs:
    • Consolidated Waiver for Individuals with Intellectual Disability, which provides a variety of services to promote community living for individuals over the age of three who would be recommended for an intermediate care facility level of care;
    • Infant, Toddlers, and Families Waiver, which provides Early Intervention and habilitation services to children from birth to age three who would otherwise require an intermediate care facility for persons with mental retardation or other related conditions level of care.
As of 2013, 1,263,429 individuals were eligible for Pennsylvania’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known as the Children’s Checkup program. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 69% and a participant ratio of 58%. 499,806 children received dental services of any kind, with 449,583 receiving preventive dental services.
Last updated September 2014
Medical Necessity
Pennsylvania Medical Assistance Regulations define a “medically necessary” service, item, procedure, or level of care as “one that
  1. Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability;
  2. Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability;
  3. Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.”
Initiatives to Improve Access
Modified School Health Services
Forty-two school districts in Pennsylvania have modified school health services programs, which allow certified nurse practitioners to be paid directly for EPSDT screens.
Reporting & Data Collection
Behavioral Health
Behavioral health services provided by the Pennsylvania Medicaid program are administered at the county level by Mental Health and Developmental Services (MH/DS) program offices on a fee-for-service basis or by a HealthChoices behavioral health MCO.
Behavioral health plans provide inpatient and outpatient psychiatric care, drug and alcohol treatment, family-based mental health treatment for children, and mental health case management. One behavioral health plan operates in each county in Pennsylvania; contact information for each behavioral health plan is available on the HealthChoices enrollment website.
Guidelines for Best Practice in Child and Adolescent Mental Health Services
The Pennsylvania Medicaid agency published a report, “Guidelines for Best Practice in Child and Adolescent Mental Health Services,” which includes checklists for EPSDT mental health submissions, expected practices, and suggested approaches for obtaining service approvals in managed care.
Support to Providers and Families
Support to Providers
Pennsylvania Medicaid operates a Medical Assistance page for providers, which includes information on managed care programs, regulations and handbooks, bulletins, and fee schedules.
HealthChoices plans are required to offer EPSDT training to any provider who serves members under age 21.
Support to Families
HealthChoices operates an enrollment website for beneficiaries that offers information on how to enroll, how to find a provider, and benefits and services.
Care Coordination
MCOs participating in HealthChoices are required to “ensure seamless and continuous coordination of care across a continuum of services for the individual member with a focus on improving health care outcomes.”
HealthChoices plans are required to establish Special Needs Units (SNU) and employ a Special Needs Coordinators to deal with issues relating to members with special health care needs, ensure access for these members to PCPs, dentists, and specialists, and coordinate care across settings. Plans must also employ a maternal health/EPSDT coordinator to coordinate maternity, prenatal, and EPSDT services.
Medical Assistance recipients in the ACCESS Plus program are assigned a primary care provider (PCP) who serves as the recipient’s medical home. PCPs coordinate care, direct recipients to specialty services, and provide intensive case management for delivery of disease-specific care and monitoring.
Medical Homes
As part of the Chronic Care Initiative (CCI), Pennsylvania launched medical homes in seven regions across the state.  In phase I (2008-2011), participating practices were encouraged to focus on diabetes and pediatric asthma.
For more information on medical homes in Pennsylvania, see NASHP’s medical homes map page.
Oral Health
Pennsylvania Medicaid operates a dental information page for recipients and their families, which includes information on eligibility, when to visit the dentist, and which provider a beneficiary is able to see based on the Medical Assistance program he or she is enrolled in.