EPSDT Coverage for Children’s Residential Care Facility Level of Care​

Jun 21, 2022

In certain exceptional and high-risk situations for youth under the age of 21, the Office of MaineCare Services (OMS) will approve a MaineCare member’s clinical eligibility for services in a Children’s Residential Care Facility (CRCF) under the Early Periodic Screening Diagnostic and Treatment (EPSDT) benefit, MaineCare Benefits Manual (MBM) Chapter II, Section 94, without requiring an attempt to use a lower level of care. 

This exception process is targeted to situations where youth are unable to step down from long-term hospitalization due to a lack of community-based services, where youth are hospitalized long enough that they could never meet the criteria of having tried home and community-based services in the prior six months, or where other exceptional circumstances prevent the member from being safe in a home or community setting. 

MaineCare members under age 21 are eligible under EPSDT for medically necessary treatment services, including behavioral health services, whose type, frequency, or duration exceeds what is specified in the MBM. MBM Section 94.05-2 describes the prior authorization (PA) process through which a provider may demonstrate the member’s medical need for EPSDT services, which includes addressing why standard MBM services are inappropriate or insufficient to meet the member’s needs. For behavioral health services, Kepro, on behalf of the Department, conducts assessments using a standardized instrument (CALOCUS-CASII) with the goal of determining the appropriate level of care which would be the most effective and least restrictive environment.  

Kepro will use defined criteria that take into consideration the overall intent of MBM Section 97.02(A)(5) to promote the least restrictive level of care, as well as the EPSDT process under MBM Section 94.05-2 to approve CRCF services under EPSDT.