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Model Medicaid Managed Care Contract Provisions: EPSDT Vision and Hearing Services

posted on Wed, Jul 8 2015 10:45 am by Network Southeastern Region

An estimated 25 percent of all school children in the United States have some type of vision problem significant enough to affect daily life and school performance. Similarly, despite the proliferation of hospital-based newborn hearing screening programs, a significant number of children with possible hearing loss are not receiving prompt diagnosis and treatment.

Children enrolled in Medicaid are entitled to a comprehensive array of preventive and ameliorative care through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.  As states have increasingly turned to managed care entities to fulfill their Medicaid administrative obligations, these companies are charged with affirmative duties to ensure that children receive EPSDT benefits.

This resource suggests model contract provisions for coverage of vision and hearing services in Medicaid managed care and contains selected or formulated model provisions governing (1) the EPSDT periodicity schedule, (2) inter-periodic screens, (3) content of screens and requirements for referral, (4) provider qualifications, (5) network adequacy for vision and hearing providers, (6) monitoring and reporting, and (7) coordination with outside entities. While many of these activities are also subject to federal and state regulation, having such provisions in the contract between a state and an MCE helps to ensure such obligations are clearly understood by all parties.

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