Note: For a quick introduction to EPSDT, see the attached powerpoint titled "NYLAG Presentation on EPSDT." Please feel free to share those slides, as well as the material below, widely.

In this article:

Part 1 - Basics about EPSDT Requirements

Part 2 - Select Services that Must be Covered when Medically Necessary for Children

1. Homecare
2. Speech Therapy / Physical Therapy / Occupational Therapy
3. Activity Chairs
4. Out-of-Network Care
5. Case Management

Part 3 - Where to Find Help

Part 4 - Additional Resources about EPSDT – and Legal Citations

Part 1 – Basics about EPSDT Requirements

The federal Medicaid Act requires heightened protections and robust coverage for children enrolled into Medicaid who are under 21 years old. This federal protection is established in Section 1905 of the Social Security Act and called “Early and Periodic Screening, Diagnostic and Treatment,” often abbreviated as “EPSDT.”  See citations here.

In the words of the United States Centers for Medicare and Medicaid Services (“CMS”), in its 2014 publication, EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (referred to below as “2014 EPSDT Guide for States”) on page 1, “[t]he goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting.”

EPSDT mandates that each state Medicaid agency meet EPSDT-specific coverage and administrative requirements, including the requirements to:

• Cover early and periodic preventive, diagnostic, and screening services. See the CMS Dear State Health Official Letter No. SHO # 24005 (“RE: Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements”), Sept. 26, 2024, at page 6: “Section 1905(r) of the Act entitles eligible children to a comprehensive array of prevention, diagnostic, and treatment services. Well-child visits, referred to in statute as screening services, are the foundation of EPSDT coverage and are a crucial entry point for identifying concerns and conditions that require follow-up care. These visits are intended to be comprehensive and include age-appropriate screenings, referrals to diagnostic and specialty services, and referrals to establish ongoing dental, vision, and hearing care. States are required to develop or adopt a schedule of recommended screenings; most states have adopted the Bright Futures periodicity schedule developed by the American Academy of Pediatrics (AAP) or a modified version thereof.[1] All states are required to provide coverage of appropriate immunizations to EPSDT-eligible children according to the pediatric vaccine schedule established by the Centers for Disease Control and Prevention (CDC).[2] Each state is also required to develop or adopt a dental periodicity schedule in consultation with recognized dental organizations involved in child health.” (This CMS Dear State Health Official guidance is referred to below as "2024 CMS SHO #24-005.")
• Cover for EPSDT-eligible children all “health care, diagnostic services, treatment, and other measures described in section 1905(a) that are medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions, whether or not such services are covered under the state plan;”[3]
  • States must cover “mandatory” section 1905(a) services as well as “optional” section 1905(a) services for EPSDT-eligible children.  The chart below, which is slide 16 from the Oct. 2023 CMCS All-State Call: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), shows all of the section 1905(a) Medicaid services divided into two categories – mandatory and optional.  States must cover the “mandatory” section 1905(a) benefits for all adults and children, with limits states may define. States do not have to cover “optional” section 1905(a) benefits for adults – but they must cover those benefits for children under EPSDT.  If you’re interested in learning more generally about mandatory benefits and optional benefits, including those found in section 1905(a) as well as those found in other sections of the Social Security Act, you can do so on the Medicaid.gov page titled Mandatory & Optional Medicaid Benefits.

• • Medicaid must cover 1905(a) services when necessary to maintain (prevent regression) or improve a condition, not only when services will cure a condition. This is the “correct or ameliorate” standard, which CMS explains in its 2014 EPSDT Guide for States at page 10: “A service need not cure a condition in order to be covered under EPSDT. Services that maintain or improve the child’s current health condition are also covered in EPSDT because they ‘ameliorate’ a condition. Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems. Services are covered when they prevent a condition from worsening or prevent development of additional health problems. The common definition of ‘ameliorate’ is to ‘make more tolerable.’ Thus, services such as physical and occupational therapy are covered when they have an ameliorative, maintenance purpose. This is particularly important for children with disabilities, because such services can prevent conditions from worsening, reduce pain, and avert the development of more costly illnesses and conditions. Other, less common examples include items of durable medical equipment, such as decubitus cushions, bed rails and augmentative communication devices. Such services are a crucial component of a good, comprehensive child-focused health benefit.”
• States may not impost hard limits or caps on medically necessary 1905(a) services for EPSDT-eligible children, and any utilization controls used must be consistent with EPSDT. See the 2024 CMS SHO # 24-005, at page 21: “while services available to adults may include limits on the amount, duration, and scope of services that can never be exceeded (i.e., a ‘hard limit’), states are not permitted to apply these kinds of limits to any service covered under EPSDT in either a FFS or managed care delivery system. . . . [S]tates may impose—and may permit MCPs to impose—utilization controls to safeguard against unnecessary use of care and services in a manner that is consistent with the EPSDT requirements.[4] For example, a state may establish limits on the amount, duration, or scope of services that may be exceeded with prior authorization and/or a medical necessity review (i.e., a ‘soft limit’). Importantly, under CMS’s interpretation of section 1905(r)(5), prior authorization must be conducted on a case-by-case basis, evaluating each child’s needs individually, and it must not delay the delivery of needed treatment services. Additionally, under CMS’s interpretation of section 1905(r), states may not impose prior authorization requirements for EPSDT screening services. In sum, CMS expects states to align prior authorization or other utilization controls broadly for services covered under EPSDT with what Congress has described as the ‘preventive thrust’ of the EPSDT benefit.[5]”
• The determination of “medical necessity” of section 1905(a) services must be made on an individualized, case-by-case basis for each EPSDT-eligible child. See the 2024 CMS SHO # 24-005, at page 26: “States’ and MCPs’ determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child.[6] The state or MCP should consider the child’s long-term needs, not just what is required to address the immediate situation. Given the obligation under EPSDT requirements to ensure a child receives coverage of medically necessary section 1905(a) services to correct or ameliorate identified medical needs, medical necessity reviews cannot have the effect of imposing a hard limit for EPSDT-eligible children, nor can they result in inappropriate limits on access to a service.”
• The cost effectiveness of alternatives may only be considered within certain limits, including the Olmstead decision requiring services be provided in the most integrated setting appropriate to the child’s needs. See CMS’s 2014 EPSDT Guide for States, at page 25:  “A state may not deny medically necessary treatment to a child based on cost alone, but may consider the relative cost effectiveness of alternatives as part of the prior authorization process. Also, a state need not make services available in every possible setting as long as the services are reasonably available through the settings where the service is actually offered. States may cover services in the most cost effective mode as long as the less expensive service is equally effective and actually available.[7] The child’s quality of life must also be considered.[8] In addition, the ADA and the Olmstead decision require states to provide services in the most integrated setting appropriate to a child’s needs, as long as doing so does not fundamentally alter the state’s program. See above, Section IV.D. Thus, if an institutional setting is less costly than providing services in a home or community, the ADA’s integration mandate may nevertheless require that the services be provided in the community.[9]”
• Inform EPSDT-eligible children and their families of the services available to EPSDT-eligible children “generally, within 60 days of the individual’s initial Medicaid eligibility determination and in the case of families which have not utilized EPSDT services, annually thereafter;”[10]
  • For more about informing families about EPSDT, see Table 1 of the 2024 CMS SHO # 24-005, pages 9-11.
• Assist families with scheduling appointments for, and transportation to, services when needed;[11]
  • For more about assisting with scheduling appointments, see Table 2 of the 2024 CMS SHO # 24-005, pages 11-13.
  • For more about assisting with transportation to appointments, see Table 3 of the 2024 CMS SHO # 24-005, pages 13-15.  For more on non-emergency medical transportation in New York State, see the article Medicaid Transportation in NYS on New York Health Access.
• Cover case management when medically necessary;
  • For more about case management, see Table 4 of the 2024 CMS SHO # 24-005, pages 16-20.  
• Ensure the consideration of EPSDT in state Medicaid policies and procedures – including medical necessity criteria, prior authorization requirements/utilization controls, and Medicaid fair hearings;
  • For more about ensuring that state Medicaid policies and procedures consider EPSDT, see Table 5 of the 2024 CMS SHO # 24-005, pages 20-24.
  • In New York’s Medicaid Managed Care contract, the definition of “medically necessary” is consistent with EPSDT. Section 1 (“Definitions”) of the Medicaid Managed Care model contract from March 1, 2024 states: “‘Medically Necessary’ means health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap. For children and youth, medically necessary means health care and services that are necessary to promote normal growth and development and prevent, diagnose, treat, ameliorate or palliate the effects of a physical, mental, behavioral, genetic, or congenital condition, injury or disability.”
• Clearly outline, in the Medicaid Managed Care contract, the role of Medicaid Managed Care Plans to deliver EPSDT benefits;[12]
  • For more about Medicaid Managed Care and EPSDT, see Table 6 of the 2024 CMS SHO # 24-005,  pages 24-32.
  • In New York’s Medicaid Managed Care contract, the EPSDT benefit is called the “Child/Teen Health Program” or “C/THP.” For more about New York’s Child/Teen Health Program, see Section 10.4 of the Medicaid Managed Care model contract from March 1, 2024. You can also read the eMedNY Provider Manual on the Child/Teen Health Program and EPSDT, a guidance document that applies to “straight” Medicaid as well as Medicaid Managed Care Plans.
  • In New York, the majority of children under 21 are enrolled in a specific type of Medicaid Managed Care plan called a Mainstream Plan or health plan. You can read more about Mainstream Plans on our NYHA article titled Medicaid Managed Care. You can also read the Legal Aid Society page, What You Need to Know About Using Medicaid to Get Health Care.
• Ensure there are an adequate number of Medicaid providers with pediatric expertise who are qualified and willing to deliver services under EPSDT,[13] and ensure that Medicaid Managed Care plans have an adequate number of in-network providers including pediatric specialists and children’s hospitals, to timely deliver section 1905(a) medically necessary covered services that meet the needs of all children – including those with disabilities or other complex health needs; and
  • For more about improving care for children with disabilities or other complex health needs, see Table 13 of the 2024 CMS SHO # 24-005,  pages 50-56. 
  • For more about expanding and using the child-focused (EPSDT) workforce, see Table 7 of the 2024 CMS SHO # 24-005, pages 33-34.
  • For more about the requirement of timeliness:
    • See the 2024 CMS SHO # 24-005, page 27: “Services under EPSDT, like all Medicaid services, must be provided with ‘reasonable promptness.’[14] MCPs must maintain a sufficient network of providers with pediatric expertise who can be accessed in a timely manner.[15]”
    • See CMS’s 2014 EPSDT Guide for States at page 32: “The state must set standards to ensure that EPSDT services are provided consistent with reasonable standards of medical and dental practice. The state must also ensure that services are initiated within a reasonable period of time. What is reasonable depends on the nature of the service and the needs of the individual child.”
• Cover a variety of medically necessary mental health and Substance Use Disorder (SUD) services along the full care continuum, from screening and assessment, to community-based services at varying levels of intensity, to inpatient care (only when medically necessary);
  • For more about covering an array of behavioral health services, see Table 11 of the 2024 CMS SHO # 24-005, pages 40-48.
  • A federal class action lawsuit, C.K. v McDonald, was recently settled, regarding the availability of timely, intensive home and community-based mental and behavioral health services in New York for Medicaid-eligible children. See: https://healthlaw.org/resource/c-k-v-bassett-eastern-district-of-n-y/ . This lawsuit, brought by the National Health Law Program (NHeLP), Disability Rights New York, Children’s Rights, and Proskauer Rose LLP, was initially filed in March 2022. Parties reached a preliminary settlement agreement in August 2025, which can be read here.
• Submit annual reports to CMS.[16]

As mentioned above, EPSDT mandates coverage of all medically necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) of the Social Security Act. However, EPSDT does not mandate coverage of services not covered under section 1905(a). This means that EPSDT does not include services authorized through:

• Social Security Act section 1915(c) – this includes the Home and Community Based Services (HCBS) Waiver services, such as those in the Children’s HCBS Waiver and the OPWDD HCBS Waiver;
• Social Security Act section 1915(g) – this includes Targeted Case Management services;
• Social Security Act section 1915(i) – this includes certain state plan HCBS services in states that opted to offer 1915(i), which New York has not done;
• Social Security Act section 1915(j) – this includes certain self-directed personal assistance services in states that chose this option, which New York has not done (see the section below on “homecare” to see that New York’s CDPAP program is operated under New York’s Personal Care Services which are 1905(a) services);
• Social Security Act section 1915(k) – this includes Community First Choice (CFC); or
• Social Security Act section 1945 – this includes Health Home services.

Note that EPSDT still protects children enrolled in any of the waivers or programs listed above, to the extent those children are seeking section 1905(a) services. For example, Personal Care Services, Consumer Directed Personal Assistance Program (CDPAP) services, and durable medical equipment are not waiver services.  Rather they are “state plan” services under section 1905(a) of the Social Security Act, so must be made available to EPSDT-eligible children when medically necessary.  See more below about particular services. 

The 2024 CMS SHO # 24-005 at pages 53-54 includes this helpful explanation of how section 1905(a) services and other services relate: 

"[U]nder section 1905(r)(5) of the Act, the EPSDT mandate includes coverage of any medically necessary service under section 1905(a) of the Act. States must determine whether any medically necessary services included on an EPSDT-eligible child’s PCSP are coverable as section 1905(a) services under EPSDT obligations before covering them under a 1915(c) HCBS waiver program, or a state plan option under 1915(i) (HCBS), 1915(j) (self-directed personal care services), or 1915(k) (Community First Choice). As a result, any 1915(c) waiver program services and state plan 1915 services that could be covered under a section 1905(a) benefit must be covered first as a section 1905(a) service for EPSDT-eligible children.

. . .

Additionally, CMS interprets section 1905(r)(5) to mean that a state’s decision to cover a section 1905(a) service under a section 1915 authority cannot be used to deny, delay, or limit access to medically necessary section 1905(a) services for which coverage is required under EPSDT.

An EPSDT-eligible child who is also eligible under a section 1915(c) waiver program or 1915 state plan benefit may need section 1905(a) services above and beyond what is medically necessary, to enable them to live in the community and avoid institutionalization. In this case, the child is entitled to all necessary services: those that are identified in their approved PCSP that assist the child to function in the home and community and avoid institutionalization via a section 1915(c) waiver program or section 1915 state plan authority, as well as any medically necessary section 1905(a) services under EPSDT. It is the responsibility of states to ensure that EPSDT-eligible children receive all services to which they are entitled."

Part 2 - Select Services that Must be Covered when Medically Necessary for Children

The rest of this article focuses on select services and supplies that must be covered when medically necessary for EPSDT-eligible children: Homecare, Speech Therapy / Physical Therapy / Occupational Therapy, Activity Chairs, Out-of-Network Care, and Case Management. Resources about other aspects of the federal EPSDT mandate are linked throughout this article and at the bottom of the article.

1. Homecare

Homecare (Private Duty Nursing, Personal Care Services, Consumer Directed Personal Assistance Program or “CDPAP,” and Home Health Aide services) must be provided when medically necessary for a child.

These are section 1905(a) services!

• Private Duty Nursing services are covered under Social Security Act section 1905(a)(8).
• Personal Care Services are covered under Social Security Act section 1905(a)(24).
• CDPAP services are covered under Social Security Act section 1905(a)(24).
  • Quick note on CDPAP: As outlined on page 733 of 2839 pages of the New York State Medicaid State Plan, CDPAP in New York “has operated under the State’s Personal Care Services benefit since 1990. As such, the eligibility, assessment and prior authorization of services processes mirror that of the Personal Care Services Program (PCSP).” Because Personal Care Services are a 1905(a) service, CDPAP services must be covered for EPSDT-eligible children when medically necessary.
• Home Health Aide services are covered under Social Security Act section 1905(a)(7).

Medicaid administrators – whether managed care plans or local departments of social services – are often quick to deny various types of homecare for children, stating that homecare is not meant to replace “normal parental duties.” However, the care that is medically necessary for children and youth with disabilities often exceeds the tasks of normal parental duties, as what is “normal” considers the needs of a typically developed child without disabilities or chronic health conditions.

Further, parents may be unavailable to provide around the clock uncompensated care to their child – they may need to take care of other children and go to work, for example. And the 2024 CMS SHO # 24-005 at page 13 mandates that the actual availability (not hypothetical availability) of family members be taken into account:

[T]he determination of whether a child needs personal care services must be based upon the child’s individual needs and a consideration of family resources that are actually—not hypothetically— available.

Also, what is medically necessary for any EPSDT-eligible child under 21 must be evaluated on an individualized, case-by-case basis, taking into account their short term and long term needs, and taking into account all aspects of a child’s needs including social development. CMS’s 2014 EPSDT Guide for States provides at page 23:

Services that fit within the scope of coverage under EPSDT must be provided to a child only if necessary to correct or ameliorate the individual child’s physical or mental condition, i.e., only if “medically necessary.” The determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child. The state (or the managed care entity as delegated by the state) should consider the child’s long-term needs, not just what is required to address the immediate situation. The state should also consider all aspects of a child’s needs, including nutritional, social development, and mental health and substance use disorders.

Finally, forcing the parents to provide care that Medicaid should pay for not only violates EPSDT, but also is illegal per other areas of Medicaid law applicable to Medicaid members of any age. Federal law states that while natural supports (such as unpaid caregiving by a parent) can be considered, natural supports must be voluntary. In other words, states and Medicaid Plans may not compel natural supports.  See, e.g., 42 C.F.R. §§ 441.301 (c)(2)(v), 441.725(b)(5) (Regulations for 1915(c) HCBS waiver services and 1915(i) HCBS state plan option, respectively) (plans of care are required to reflect natural supports, which are provided voluntarily); 42 C.F.R. § 441.540(b)(5) (regulations for 1915(k) Community First Choice Option services) (“Natural supports cannot supplant needed paid services unless the natural supports are unpaid supports that are provided voluntarily to the individual…”); HHS, Home and Community-Based State Plan Services, 73 Fed. Reg. 18,676, 18,681 (April 4, 2008) (Preamble to proposed 1915(i) HCBS state plan option regulations) (“…we conclude that the statute requires that the plan of care should neither duplicate, nor compel, natural supports…); HHS, 77 Fed. Reg. 26,828, 26,857 (May 7, 2012) (preamble to 1915(k) final rule) (“We expect that the identification of these natural, unpaid supports be taken into consideration with the purpose of understanding the level of support an individual has, and should not be used to reduce the level of services provided to an individual unless these unpaid supports are provided voluntarily to the individual.”)

Tip: The child’s parent should write a personal statement explaining why they are unable or unwilling to continue providing uncompensated care.

Medicaid administrators – whether managed care plans or local departments of social services – sometimes deny care by stating that the parent must stay home with the child.

Various NYSDOH policy documents state that parents may leave the home when their child is receiving Medicaid homecare. See the sources cited below.

If a parent, grandparent, neighbor, or family friend has been providing uncompensated care for the child and is unable or unwilling to continue doing so, they should write a personal statement explaining this. These personal statements should be sent directly to Medicaid, be it the Local Department of Social Services (for children with regular or “Straight” Medicaid) or to the Medicaid Plan (for children enrolled into Medicaid Managed Care).

A few examples of reasons why a parent or other caretaker may be unable or unwilling to continue providing uncompensated care to a child, are below.

• The parent/caretaker needs to return to work (or work increased hours than they currently are), be it work done inside the home, outside the home, or a hybrid mix of the two.
• The parent/caretaker has their own health conditions or disabilities that make it painful, difficult, and/or dangerous for them to take care of the child.
• The parent/caretaker has other children who they need to take care of, such that they are not able to spend as much time caring for this particular child as the child needs.
• The parent/caretaker is unable to sleep at night because of frequent and unscheduled overnight needs that the child has, such as to be turned and positioned in bed every two hours to prevent bedsores.

So long as a parent/caregiver has explicitly notified Medicaid that the parent/caregiver is unable/unwilling to continue providing uncompensated care to their children, Medicaid must ensure paid homecare is provided to the child.

Tip: Cite to the following sources.

• Department policy dated January 16, 1997, titled ‘Policies and Procedures for Assessing and Authorizing Personal Care/Home Attendant Services for Children.’ This policy states: “A parent, legal guardian, or other responsible adult other than the personal care aide/home attendant does not have to be present in the home while PC/HAS are being delivered to the child. The requirement for self-direction of the service when the patient is not capable of self-direction does not require that the directing person be present in the home when services are being delivered . . . . A person legally responsible for a child, such as a parent or guardian, may request assistance with the care of his or her child. Being legally responsible for a child does not mean that that person must physically provide all of the child care services needed. Generally, a child needing personal care services results from a medical condition that impairs the child’s ability to carry out age-appropriate activities of daily living. However, there also may be instances where a child’s medical or social condition(s) require that an aide perform or assist with a task needed which normally would be provided by the parent or other adult. An example of this is a child at one year old who would not be expected to bathe him/herself. While bathing would normally be a parent’s function, medical or social circumstances may require that personal care services be provided to perform or assist with the task.” This policy is frequently cited in Fair Hearing decisions, and can be found in over 800 fair hearing decisions by searching the OTDA Fair Hearing Decision Archive.
• New York State Medicaid Policy 12 OHIP/ADM-1, titled Changes to Personal Care Services Program and Consumer Directed Personal Assistance Regulations Resulting From MRT #4652. This policy from April 9, 2012 explains on page 5: “With regard to informal caregivers, such support cannot be required but should be evaluated and discussed with the patient and the potential caregivers.” Later, on page 6, it explains that “the contribution of family members or friends is voluntary and cannot be coerced or required in any manner whatsoever.”
• The May 2025 NYSDOH Children’s HCBS Waiver policy. This document, titled Children’s Waiver Home and Community-Based Services (HCBS) Service Definitions and Necessity Criteria Policy, explicitly states on page 9 that some services “include[] general supervision of the child in the caregiver’s absence, such as applied behavior analysis, [and] personal care assistance.” Note that this is helpful if/when Medicaid even states that the parent must remain home while the nurse, aide, or personal assistant is taking care of the child.
• Fair Hearings with favorable outcomes to the child appellant requesting an Activity Chair:
  • Fair Hearing # 8929140H, dated 8/26/25 – appellant around 1 year old.
    • “As cited above, minors under the age of 18 are eligible to receive PCS. Parents may request assistance with the care of their child. Being legally responsible for such child does not mean that the parent must physically provide all of the child care services needed. Generally, a child needing PCS results from a medical condition that impairs the child’s ability to carry out age-appropriate activities of daily living. There also may be instances where a child’s medical or social condition(s) require that an aide perform or assist with a task needed which normally would be provided by the parent or other adult. According to policy, the assessment must identify PCS tasks that the child is unable to complete independently and which exceed normal child care activities that a parent or guardian is expected to provide to an age appropriate child. . . . Here, the Appellant has established that, both at the time of the FAD and at the time of the hearing, the personal care tasks with which the Appellant requires assistance result from a medical condition that impairs the child’s ability to carry out physical age-appropriate activities of daily living, and thus, the authorization of PCS to meet those personal care tasks is warranted and the Plan’s determination to deny the request for PCS will not be sustained.”
  • Fair Hearing # 8287776J, dated 2/1/22 – appellant age 14.
    • “The credible evidence establishes that the Appellant has a need for assistance with walking and locomotion and eating, as well as with toilet transfer and use, that is unscheduled and unpredictable. In addition, while the Plan indicated in its April 12, 2021 Final Adverse Determination Denial Notice that the Appellant could walk and get off the toilet ‘as long as someone watches you” and could “eat with a little help,’ arguing that ‘Supervision is considered a normal parental responsibility. Consumer Directed Personal Care Aide Services are not to be used as supervision . . . or to replace normal parental duties,’ it is submitted that a 14-year-old child without the Appellant’s medical condition would not need supervision and/or limited assistance with toilet transfer, toilet use, wiping, and eating. Thus, the credible evidence establishes that the Appellant has established eligibility for a personal assistance services authorization, including for unscheduled needs for toileting, mobility assistance, and eating, as requested.”
  • Fair Hearing # 8084262R, dated 3/12/21 – appellant age 2.
    • “The Plan’s argument that the Appellant’s needs can be met by his mother and father are also unpersuasive and not supported by the evidence. . . . The Appellant’s mother credibly testified that although she is still willing to provide almost all informal support to the Appellant, she requires assistance due to her own disability. She testified that the Appellant requires the 2 hours of CDPAS per day (or 14 hours per week) for assistance with bathing, laundry and clearing the [redacted] site. Administrative Directive 12 OHIP/ADM-1 states that support from informal caregivers cannot be required but should be evaluated and discussed with the patient and the potential caregivers. Appellant’s mother credibility testified to the Appellant’s household composition and the Appellant’s needs. Although she provides the Appellant with all his informal support, she is unable to do so without assistance. The Plan has not established the Appellant’s father resides in the home, or that he is otherwise available to take care of the Appellant. The Plan has also failed to establish the mother is able to take care of the Appellant’s needs without assistance. . . . The Plan’s final argument, that CDPAS services are not permitted for supervision, is also unpersuasive and unsupported by evidence. As discussed, the Appellant’s mother credible testified that the Appellant requires 14 hours of CDPAS for assistance with bathing, laundry, [redacted] feeds and changing his [redacted] bandages. Based on the Appellant’s health condition, the Plan’s presentation does not establish that supervision or oversight is provided while this task is completed, and even if it is, the Plan has not established that the supervision or oversight the Appellant receives while this task is performance not incidental to the performance of bathing, laundry, [redacted] feeds and bandage changes. It has also not established that the 14 hours of CDPAS per week is used for supervision in any other way. . . . The Plan failed to establish that it applied the EPSDT standards in determining medical necessity for the Appellant prior to discontinuing the requested CDPAS services. Although the Plan argues it made its determination based on 18 NYCRR §§ 505.14, MLTC Policy 16.06, it should have also included the EPSDT in its determination to discontinue his CDAPS services. The record establishes that the Appellant meets the medical necessity requirements as outlined in the EPSDT with respect to the request under review in this decision. The record establishes that the Appellant meets the age and illness requirements and CDPAS hours would serve to help correct and ameliorate some symptoms of the Appellant’s diagnoses which interfere with his capacity for certain normal activities. Accordingly, the Plan’s determination to discontinue the Appellant’s CDPAS services is incorrect.”

2. Speech Therapy, Physical Therapy, and Occupational Therapy

For many children with chronic health conditions and complex disabilities, Speech Therapy (ST), Physical Therapy (PT), and Occupational Therapy (OT) are medically necessary to maintain their functioning – and prevent regression. For the purposes of this article, these three therapies will be referred to as: ST/PT/OT.

These are section 1905(a) services!

• ST/PT/OT services are covered under Social Security Act section 1905(a)(11) and under Social Security Act section 1905(a)(7).

In a school setting (and in the special education world), ST/PT/OT are some of the services often referred to as “related services.” According to federal law, “[t]he term ‘related services’ means transportation, and such developmental, corrective, and other supportive services (including speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, . . .) as may be required to assist a child with a disability to benefit from special education, and includes the early identification and assessment of disabling conditions in children.”[17] You can find the New York City Department of Education explanation of “related services” on its Related Services page.

As explained by the New York City Department of Education, “[t] Individualized Education Program (IEP) is a written statement of our plan to provide your child with a Free and Appropriate Public Education (FAPE) in their Least Restrictive Environment (LRE).” (An example of a blank IEP can be found on the New York City Department of Education website here, and the section for recommended “related services” is on page 12.) If a child’s IEP indicates that the child needs certain related services, those services should be made available to the child for free by the New York City Department of Education. However, as the New York State Education Department states in a 2016 FAQ titled School Supportive Health Services Program Preschool Supportive Health Services Program, Questions & Answers (referred to below as “Dept. of Ed. FAQ”) at page 20, “[t]he IEP determines which related services are needed to facilitate the student’s educational progress. It does not constitute medical necessity.”

• Relationship of Medicaid to IEPs: IEP services are funded through a mix of funding sources. IDEA Part B entitlement grants funds (for children ages 3 through 21) are allocated per school year to each Local Education Agency (LEA)/school district, which then gives funding to Approved Special Education Providers (ASEPs) who provide special education and “related services” to students with IEPs. If these services cannot be paid for by IDEA Part B entitlement grant funds for some reason, then state Medicaid funds may be used to pay for these services delivered to Medicaid-eligible students during the school day. This program is known federally as “Medicaid In Education,” or in New York State as “Preschool/School Supportive Health Services Program.” Dept. of Ed. FAQ at page 5.  For this reason, parents are sometimes asked by their child’s school to sign a parental consent form stating that their child’s Medicaid Client Identification Number (CIN) may be used to check Medicaid eligibility and for Medicaid billing of health services provided in school. Dept. of Ed. FAQ at page 20. However, simply because Medicaid is funding some of the services a child receives in school, does not change the fact that Medicaid must also fund all medically necessary ST/PT/OT that a child needs outside of school. See more on this, below. For additional reading on the relationship of Medicaid and IEPs, see the Center on Budget and Policy Priorities (CBPP)’s 2017 report, Medicaid Helps Schools Help Children.

Tip: Gather medical documentation from treating providers outside of the school setting (pediatricians, speech therapists, etc.) stating that your child needs more therapy than what is available through school. Make sure the documentation uses the term “medically necessary” to describe the frequency needed for your child to maintain their function, prevent regression, and/or secure additional skills, functions, or abilities.

Medicaid is always what’s called “the payer of last resort” (with the exception of Title V Maternal and Child Health funding – but that is beyond the scope of this article). This means that if a school system will and can provide ST/PT/OT services for the child, the school system must pay for it before Medicaid will pay.

However, as explained above, an IEP does not determine what is medically necessary for a particular child. And EPSDT mandates that Medicaid cover all medically necessary ST/PT/OT sessions for EPSDT-eligible children under 21.

It is important to note that Medicaid will not pay for duplicative services. This means that if a child is in fact receiving all of the ST/PT/OT sessions that are medically necessary for them from school, Medicaid will not pay for additional sessions outside of school. However, some children are unable to receive all of the ST/PT/OT services that are medically necessary for them through a school setting. For those children, so long as they are enrolled in Medicaid and have documentation regarding what is medically necessary, Medicaid must cover all remaining medically necessary ST/PT/OT for the child outside of the school setting.

• Example: Bobby is an 8-year-old child enrolled into a Medicaid Managed Care Plan, and he also has an IEP to receive special education services through school. According to his IEP, he only needs speech therapy once a week, physical therapy once a week, and occupational therapy once a week, to benefit from special education. But according to his long-term Pediatrician, his Psychologist, and notes from recent hospital discharges from Blythedale and St. Mary’s, Bobby actually needs speech therapy twice a week, physical therapy three times a week, and occupational therapy five times a week, as medically necessary services. This means that Medicaid must pay for the difference! In other words, Bobby’s Medicaid should cover the following for Bobby to receive outside of school: one speech therapy session per week (2 – 1 = 1), two physical therapy sessions per week (3 – 1 = 2), and four occupational therapy sessions per week (5 – 1 = 4). Although his Medicaid Managed Care plan has denied his family’s request for at-home therapy sessions, stating that Bobby should be getting these therapy services at school, Bobby’s family should appeal and point to the unmet needs that Bobby has for medically necessary ST/PT/OT outside of the school setting.

Tip: If you are looking for an evaluator of what is medically necessary for your child and/or a regular provider of those services, contact St. Mary’s Healthcare System for Children, a Special Needs CHHA.

New York State has various Special Needs CHHAs (Certified Home Health Agencies), each approved by the Department of Health to serve an identified specific targeted population or identified special needs population. St. Mary’s Healthcare System for Children is the sole Special Needs CHHA focused on serving medically complex and fragile children, adolescents, young adults, adults, and their families.

St. Mary’s Care in the Home program sends Speech Therapists, Physical Therapists, and Occupational Therapists (among other providers) to work with your child in their home. Further, St. Mary’s accepts all types of Medicaid (including Straight Medicaid and most if not all Medicaid Managed Care Plans) and works with families in NYC, Nassau, and Suffolk (pending availability of staff).

You can find more information on the St. Mary’s Care in the Home website.

You can call St. Mary’s Care in the Home Central Intake, here: 1-800-270-2478.

Tip: Cite to the following sources.

There are many sources of law regarding the required Medicaid coverage of ST/PT/OT for children under 21. Below are a few key sources:

• Federal guidelines:
  • The 2024 CMS SHO # 24-005 states at pages 6-7: “CMS interprets the “correct or ameliorate” requirement to mean that a service need not cure a condition in order to be covered under EPSDT as a medically necessary service. Services that maintain or improve a child’s current health condition are also covered under EPSDT because they “ameliorate” a condition; they prevent a condition from worsening or prevent development of additional health problems. Thus, services such as physical and occupational therapy, for example, are covered when they have an ameliorative, maintenance purpose.”
  • CMS’s 2014 EPSDT Guide for States explains at page 10: “A service need not cure a condition in order to be covered under EPSDT. Services that maintain or improve the child’s current health condition are also covered in EPSDT because they “ameliorate” a condition. Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems. Services are covered when they prevent a condition from worsening or prevent development of additional health problems. The common definition of “ameliorate” is to “make more tolerable.” Thus, services such as physical and occupational therapy are covered when they have an ameliorative, maintenance purpose. This is particularly important for children with disabilities, because such services can prevent conditions from worsening, reduce pain, and avert the development of more costly illnesses and conditions. . . . Such services are a crucial component of a good, comprehensive child-focused health benefit.”
• New York State guidelines:
  • The eMedNY Provider Manual for Rehabilitation Services requires Medicaid to cover long term therapy services when required for an individual to maintain their physical and/or functional status. The guideline defines “Long Term Therapy Services” on page 4 as “Physical, Occupational, and/or Speech therapy services, that due to a beneficiary’s unique physical, cognitive or psychological status, require the knowledge or expertise of a licensed practitioner in order to maintain their physical and/or functional status. Outcomes must be functional, individualized, relevant, and transferrable to the current or anticipated environment. Therapeutic goals must meet at least one of the following characteristics: prevent deterioration and sustain function; provide interventions that enable the beneficiary to live at their highest level of independence in the case of a chronic or progressive disability; and/or provide treatment interventions for a beneficiary who is progressing, but not at a rate comparable to the expectations of restorative care.” You can read the ‘Coverage Criteria’ section on page 7 of the manual, and the ‘Documentation Requirements’ section on pages 9-10 of the manual, for further instruction on how to establish medical necessity for long term therapy services. This policy document applies both to regular or “straight” Medicaid and to Medicaid managed care plans.
  • New York State DOH Medicaid Update - April 2021 Volume 37 - Number 5 from 2021 states that the caps for ST/PT/OT for adults were removed effective January 1, 2021, pursuant to Social Services Law SSL §365-a.  Further, this change removed the requirement to obtain prior approval for ST/PT/OT for children (birth to 21) enrolled in regular or “straight” Medicaid. (However, as a reminder, even when there are state-permitted hard caps on section 1905(a) services for adults, there may be no hard caps on these services for children.)

3. Activity Chairs

EPSDT not only mandates coverage of services, such as homecare or ST/PT/OT – it also mandates coverage of medically necessary supplies, such as Durable Medical Equipment (DME). One such piece of equipment that is medically necessary for some children with disabilities is an Activity Chair.

These are section 1905(a) services!

• Durable Medical Equipment is covered under sections 1905(a)(7) and 1905(a)(11) of the Social Security Act.

As written by the Medicaid and CHIP Payment and Access Commission (MACPAC) in the July 2019 Issue brief titled Durable Medical Equipment Fee-for-Service Payment Policy, “Durable medical equipment (DME) includes a wide range of medical equipment that is appropriate for use in the home, such as hospital beds, wheelchairs, and oxygen, as well as medical supplies that are typically not reused, such as incontinence supplies and diabetic test strips. The Social Security Act (the Act) does not define DME for the purposes of Medicaid; however, medical supplies, equipment, and appliances are a mandatory home health care benefit authorized by Section 1905(a)(7) of the Act. Section 1905(a)(11) of the Act also authorizes coverage and payment for certain supplies and equipment used during physical, occupational, and speech-language therapy.”

There is some overlap between the term “DME” and the term “Assistive Technology device,”  which is defined by the Individuals with Disability Education Act (IDEA) in 20 U.S.C. §1401(1)(a) as “any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of a child with a disability.” Assistive Technology refers to a wide range of items including Activity Chairs, wheelchairs, and augmentative and alternative communication devices. Although this section of the article focuses on Activity Chairs as a piece of DME, Assistive Technology must also be covered under EPSDT if it is medically necessary for an individual child. For a great article with tips on securing Assistive Technology, read the American Academy of Pediatrics Journal article Prescribing Assistive Technology: Focus on Children With Complex Communication Needs: Clinical Report, written by Larry W. Desch, et al. and published in June 2025.

Unfortunately, Activity Chairs are often denied by Medicaid as a “duplicative” service to a wheelchair, or to a different mobility or seating device. However, an Activity Chair is a positioning device – not a mobility or seating device – and thus the two pieces of equipment serve distinct purposes. So long as multiple pieces of DME are medically necessary for an individual child and are not duplicative, they all must be covered by Medicaid.

Tip: Cite to the following sources.

There are many sources of law regarding the required Medicaid coverage of Activity Chairs for children under 21. Below are a few key sources:

• Federal guidelines:  CMS’s 2014 EPSDT Guide for States explains at page 10: “A service need not cure a condition in order to be covered under EPSDT. Services that maintain or improve the child’s current health condition are also covered in EPSDT because they ‘ameliorate’ a condition. Maintenance services are defined as services that sustain or support rather than those that cure or improve health problems. Services are covered when they prevent a condition from worsening or prevent development of additional health problems. The common definition of ‘ameliorate’ is to ‘make more tolerable.’ . . . This is particularly important for children with disabilities, because such services can prevent conditions from worsening, reduce pain, and avert the development of more costly illnesses and conditions. Other, less common examples include items of durable medical equipment, such as decubitus cushions, bed rails and augmentative communication devices. Such services are a crucial component of a good, comprehensive child-focused health benefit.”

• New York State Medicaid policies and hearing precedents prohibit a hard limit of only one piece of Durable Medical Equipment per child: The state Medicaid agency and Medicaid Managed Care Plans sometimes deny coverage for Activity Chairs, stating that Medicaid will only cover one mobility, seating, or positioning device. However, that limitation is not correct. The eMedNY New York State Durable Medical Equipment (DME) policy guidelines state at page 3738 that the State will also pay for a backup manual wheelchair, in addition to a main wheelchair, when necessary.  So there is no hard limit on one mobility device per member. Further, per the 2024 CMS SHO # 24-005 EPSDT mandate, at page 21, any hard limits on what Medicaid covers for adults cannot be used as a hard limit for a child, if that particular child requires the coverage of more than one device.

Multiple fair hearings have interpreted New York State Medicaid policy to mean that Medicaid must cover one mobility device, one seating device, and also one positioning device. For example, the fair hearing decision # 8859254P approves an Activity Chair as a positioning device for a child who already had a wheelchair at home as their mobility device. In this Decision from September 2024, the child appellant won coverage of an Rifton Hi-Lo Activity Chair with accessories. The state Medicaid agency had previously denied the Activity Chair, stating it would be duplicative with the child’s existing wheelchair (called a “Quickie Iris tilt-in-space manual wheelchair”). The Administrative Law Judge writes clearly that “Medicaid pays for one mobility, one seating, and one positioning device.”  One helpful paragraph to cite as precedent is pasted in full below:

• • “Appellant has received a Quickie Iris tilt-in-space manual wheelchair. This wheelchair is used for outdoor mobility, whereas the Rifton Hi-Lo Activity Chair is not, according to the manufacturer’s manual. The activity chair does have four small removable caster wheels, which is meant to allow someone to be able to drag the device across flat surfaces, but it is a seating/positioning device. Medicaid pays for one mobility, one seating, and one positioning device. The Agency’s contention that approval of the activity chair would result in a duplication of services is unfounded. The Agency’s contention that the most cost effective option would be to only authorize the wheelchair because it can be used in all environments. However, this is not a proper alternative since Appellant has unique positioning needs in the home that a wheelchair cannot accommodate. Appellant’s Occupational Therapist stated that the wheelchair is good for transporting Appellant to school because it keeps him immobile and safe when he is being transported on the bus to and from school, but Appellant needs different equipment for different physical needs. Appellant’s Occupational Therapist further stated that other options have been tried but have not been successful, and the Rifton Hi-Lo Activity Chair is the only medically appropriate equipment to meet Appellant’s seating/positioning needs.”

• Other Fair Hearings with similarly favorable outcomes to the appellant requesting an Activity Chair:
  • Fair Hearing # 8927346R, dated 8/27/25 – appellant under 21.
  • Fair Hearing # 8772867L, dated 5/9/24 – appellant age 7.
  • Fair Hearing # 8191789Z, dated 5/28/21 – appellant under 21.
  • Fair Hearing # 7361357K, dated 6/16/17 – age of appellant not listed.

• Other Fair Hearings with similarly favorable outcomes to the appellant requesting other pieces of DME:
  • Fair Hearing # 8646518Z, dated 05/07/2024 – appellant age 3, reversing Plan’s denial of a Haven 360 Safety Canopy Enclosure Bed.
  • Fair Hearing # 8502857H, dated 1/23/23 – appellant under 21, reversing Medicaid denial of a Sleep Safe Tall-Hi Low Electric Bed.

4. Out-of-Network Care

State Medicaid agencies must ensure that EPSDT-eligible children have timely access to providers with relevant pediatric expertise.

This means if there is no suitable in-network provider available within the timeframe and geographic distance to meet your child’s needs, Medicaid is required to pay for out of network (and even out of state) care.

However, the state Medicaid agency (for children enrolled into regular or straight Medicaid) or the Medicaid Managed Care Plan (for children enrolled into Medicaid Managed Care) may initially deny out-of-network care. If this happens, you can follow the tips below to advocate for your child to get the care they are entitled to under federal law.

Tip: Call each in-network provider and document whether they are, or are not, timely available to meet your child’s individual needs.

One way to document the lack of any suitable in-network providers to meet your child’s needs, is to do all of the following:

1. 1. Secure a list of all in-network providers within a reasonable distance to you. You can ask your child’s Medicaid Plan for an updated list of in-network providers in the specialty that your child needs, or you may be able to download it from a provider directory online. (Note that these directories are often outdated, so the phone numbers may not work and/or the providers may no longer be providing the type of service they are listed as providing.)
   2. Call each provider and ask:
      1. Do you take my child’s type of Medicaid insurance?
      2. Do you treat children of my child’s age?
      3. Are you taking new patients?
      4. When is the first available new patient appointment?
      5. Can you provide [insert the type of care your child needs] to children with [insert your child’s disabilities/conditions]?
   3. Record your notes, including the date and time you called, the name of the person you spoke with, and exactly what that person said.
   4. Share these notes with the Medicaid plan during appeals, and ultimately, with an Administrative Law Judge in a Fair Hearing.

Tip: Cite to the following sources.

• Federal regulations: Federal regulations state that if there are no suitable providers available in-network for a child’s Medicaid Plan, the Medicaid Plan “must adequately and timely cover these services out of network for the enrollee, for as long as the [Medicaid Plan] provider network is unable to provide them.”[18]
• Federal guidance: The 2024 CMS SHO # 24-005 includes the following guidance on timeliness of services and the coverage of out-of-network care:
  • “Services under EPSDT, like all Medicaid services, must be provided with ‘reasonable promptness.’[19] MCPs must maintain a sufficient network of providers with pediatric expertise who can be accessed in a timely manner.[20] If an EPSDT-eligible child does not have timely access to a network provider for medically necessary care, the MCP must arrange for and cover medically necessary covered services out-of-network, including out-of-state if necessary, for as long as the MCP's provider network is unable to provide the medically necessary services.[21] This includes cases in which an enrollee cannot access a medically necessary service within a timeframe contractually imposed on the MCP.” The 2024 CMS SHO # 24-005 at page 27.
  • “Children with disabilities or other complex health needs can often require specialized care not available close to home. To ensure that EPSDT-eligible children receive timely access to providers, including pediatric subspecialists, states and MCPs should have clear procedures on how to access out-of-network and/or out-of-state providers. For EPSDT-eligible children enrolled in Medicaid managed care who need access to out-of-network care, states and their MCPs must ensure mechanisms exist to guarantee timely access to medically necessary services.[22] States are required to pay for EPSDT-eligible children’s medically necessary 1905(a) services furnished by out-of-state providers (such as pediatric subspecialists) when the state determines on the basis of medical advice that the services are more readily available in another state.[23] The 2024 CMS SHO # 24-005 at page 52.
• Principles for Medically Fragile Children (MFC): The NYS Department of Health Office of Health Insurance Programs issued guidance in 2017 regarding when managed care plans must approve out-of-network care for medically fragile children (MFC). Relevant provisions of the NYS DOH Principles for Medically Fragile Children (Oct. 2017) are below:
  • Section D: “It is Health Plan’s network management responsibility to identify an available provider of needed covered services, …. Medicaid managed care companies are required to approve the use of out of network (OON) providers if they do not have a participating provider to address the needs of the child.” (p. 93).
  • Section E: “MMCOs must ensure that MFC receive services from appropriate providers that have the expertise to effectively treat the child and must contract with providers with demonstrated expertise in caring for the MFC. Network providers shall refer to appropriate network community and facility providers to meet the needs of the child or seek authorization from the MMCO for out-of-network providers when participating providers cannot meet the child’s needs. The MMCO must authorize services as fast as the enrollee’s condition requires …” (p. 94).
• Fair Hearing # 8656978H: In this Decision After Fair Hearing (DAFH) from September 2023, the child appellant won coverage of an out-of-network speech therapist and an out-of-network occupational therapist because there were no in-network Fidelis speech therapists or occupational therapists who met the child’s individual needs. The Administrative Law Judge cites extensively to federal EPSDT requirements, as well as New York State requirements related to out-of-network coverage.
• Your child’s Medicaid Plan’s Clinical Policy for “Out of Network” services. Some Medicaid plans have a policy that the plan may cite to in its Initial Adverse Determination notice (IAD) and/or Final Adverse Determination notice (FAD) as a reason for the denial. If you can show that you exhausted the requirements outlined in the clinical policy (for example, you can show that there is no participating provider who can see your child in a reasonable timeframe, within a reasonable distance, or with the appropriate training or experience for your child), this may be compelling to the Plan and/or to an Administrative Law Judge.

5. Case Management

Medicaid must cover Case Management when medically necessary for Medicaid-enrolled children under 21.

These are section 1905(a) services!

• Case Management is covered under Section 1905(a)(19) of the Social Security Act.

CMS describes Case Management as an EPSDT covered service in the 2024 CMS SHO # 24-005 at pages 18-19:

Case management services are established in 1905(a) of the [Social Security] Act and defined in regulation as “services furnished to assist individuals, eligible under the State plan who reside in a community setting or are transitioning to a community setting, in gaining access to needed medical, social, education, and other services.” [Section 1905(a)(19) of the Social Security Act and 42 C.F.R. § 440.169(a). See also section 1915(g)(2)(A) of the Social Security Act.] Therefore, case management services must be available to EPSDT-eligible children who meet medical necessity criteria for this service. … Case management includes the following four components [42 C.F.R. § 440.169(d)]:

1. Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social, or other services.

2. Development (and periodic revision) of a specific care plan based on the information collected through the assessment.

3. Referrals and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services.

4. Monitoring and follow up activities.

Case management is especially important for children with disabilities and other complex health conditions. In the 2024 CMS SHO # 24-005 at page 50, CMS writes:

Case management . . . is an essential tool for coordinating across a beneficiary’s care team to ensure that [children with disabilities or other complex health needs], when eligible for EPSDT, receive the medically necessary services they are entitled to under EPSDT requirements.

Targeted Case Management (TCM)

New York State Medicaid rules also entitle certain children to Targeted Case Management (TCM). In New York, children with special health care needs (defined in the Mainstream Medicaid Managed Care Model Contract as “those who have or are suspected of having a serious or chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally”) are explicitly entitled to heightened case management in the Mainstream Medicaid Managed Care Contract.  See the Mainstream Medicaid Managed Care Contract (Mar. 1, 2024) Section 10.20 (“Children with Special Health Care Needs”) citing to Section 10.19 (“Adults with Chronic Illnesses and Physical or Developmental Disabilities”).

Because this case management is targeted to a subgroup of Medicaid beneficiaries, it can be referred to as “Targeted Case Management.”

Health Homes

In New York, some children are enrolled into what’s called a “Health Home Serving Children” (HHSC). In the 2024 CMS SHO # 24-005 at page 19, CMS writes:

Health Homes and Health Homes for Children with Medically Complex Conditions, while not covered as part of the EPSDT requirements, are optional Medicaid state plan benefits that support care coordination for eligible people, including children, with chronic conditions, and for children with medically complex conditions. Health Home services include comprehensive care management; care coordination; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support; and referral to community and social support services.

Additional resources about HHSCs in New York are below:

• DOH webpage on health homes for children.
• Full list of HHSCs by county on the DOH website.

Part 3 - Where to Find Free Legal Help  

• For any Medicaid Managed Care issue: You can email the New York State Department of Health’s Managed Care Complaint Unit, and they will reach out to the Medicaid Plan to try to help resolve the issue.
  • Email: managedcarecomplaint@health.ny.gov
  • Include: The name of the child, their CIN (Client Identification Number), their date of birth, what happened and what you’ve tried to do so far in terms of resolving the issue, and a signed HIPAA (signed by the parent/legal guardian) authorizing the New York State Department of Health to speak with you about the child’s case.
  • Note: If you received an IAD (Initial Adverse Determination) notice, and you have not yet tried to Appeal, the Managed Care Complaint Unit will sometimes tell you to submit a Plan Appeal, and send them the FAD (Final Adverse Determination) before they will get involved.

• For homecare (homebased Private Duty Nursing, Personal Care Services, CDPAP, or Home Health Aide services): There are a variety of free legal sources of help for Medicaid homecare.
  • See a list of organizations on our New York Health Access Article titled Getting Help with Managed Long Term Care and Other Types of Medicaid Managed Care.

• For ST/PT/OT services (provided outside of school): Community Health Advocates (CHA)
  • https://communityhealthadvocates.org/
  • Phone: (888) 614-5400
  • Email: cha@cssny.org
  • You can also read DIY Packets written by CHA, on their website here: https://communityhealthadvocates.org/healthcareqa/fight-a-denial/

• For ST/PT/OT services (provided during the school day): Advocates for Children and NYLAG’s Special Education Unit.
  • Advocates for Children
    • Website with resources, trainings, and fact sheets: https://advocatesforchildren.org/get-help/
    • Helpline: (866) 427-6033 Monday to Thursday from 10am to 4pm
    • Online help form: https://advocatesforchildren.org/contact-us/
  • NYLAG’s Special Education Unit
    • Website: https://nylag.org/special-education/
    • Helpline: Call 212-613-5000, choose the option for a new case intake, then choose Special Education and leave a voice message. Someone will get back to you within a week.

• For Activity Chairs and other pieces of Durable Medical Equipment: Disability Rights of New York (DRNY)’s P&A for Assistive Technology (PAAT) team.
  • Website: https://www.drny.org/page/pa-for-assistive-technology-paat-23.html
  • Website: https://www.drny.org/page/paat-49.html
  • Phone: (518) 432-7861 or (800) 993-8982
  • Email: intake@drny.org

Part 4 - Additional Resources about EPSDT – and Legal Citations

For more about EPSDT, please visit the following resources. Each of the following resources is a trusted document, published either by the federal government, federal advisory committees, or leading national advocacy organizations with EPSDT expertise. The resources are arranged in chronological order, with the most recent resource at the top and the oldest resource at the bottom.

• EPSDT in federal Medicaid law – sections of the Social Security Act:
  • Section 1902(a)(10)(A) – EPSDT required as part of Medicaid benefit package
  • Language following section 1902(a)(10)(G) – comparability exception for EPSDT
  • Section 1902(a)(43) – administrative requirements
  • Section 1905(a)(4)(B) – EPSDT benefit inclusion in 1905(a) service menu
  • Section 1905(a) – list of services included in EPSDT
  • Section 1905(r) – definition of EPSDT services
• Federal guidance about EPSDT
  • CMS, SHO # 24-005, Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements (Sept. 2024)
  • CMS, EPSDT – A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (June 2014)
  • CMS, CMCS All-State Call: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) (Oct. 2023) (This is an educational presentation about EPSDT that CMS gave to states in 2023. CMS describes this presentation, on slide 1, as "general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance that it is based upon.")
• EPSDT in State Law and Policies  
  • 18 NYCRR Part 508 - 508.1(a): “Child/Teen Health Plan (C/THP) … means a program … assisting [persons under 21 years of age who are in receipt of Medicaid] to receive ongoing primary and preventive health care in order to discover any physical and mental problems and to provide treatment to correct or ameliorate such problems or chronic conditions . . . .”
  • NYS Managed Care Model Contract, section 10.4 – Child Teen Health Program/Adolescent Preventive Services, pages 79-80 of 537.
• NYLAG Slidedeck
  • See the attached slides with education about EPSDT. Please feel free to use and share these widely!
• Other Resources
  • GAO Report # GAO-25-107570, Medicaid Managed Care: Actions to Improve the Extent to Which Children Receive Medical Screenings and Treatment (June 2025)
  • National Health Law Program (NHeLP), Why Medicaid is Important: EPSDT and Services for Children and Youth with Disabilities (Jan. 2025)
  • Georgetown University Center for Children and Families (CCF), CMS EPSDT Guidance Blog Series” (Sept. through Nov. 2024)
  • National Health Law Program (NHeLP), EPSDT’s Legal Landscape & Implementation History (Sept. 2023)   
  • National Health Law Program (NHeLP), EPSDT Litigation Trends and Annotated Docket (May 2023)
  • Medicaid and CHIP Payment and Access Commission (MACPAC), EPSDT in Medicaid (Jan. 2021)