Department of Health and Human Servces 
OFFICE OF

INSPECTOR GENERAL

EARLY and PERIODIC SCREENING,

DIAGNOSIS, AND TREATMENT (EPSDT) -

PERFORMANCE MEASUREMENT

AUGUST 199 OEI-01-90130
 EXECUTIVE  SUMMAR Y

PUROSE 
To assess the accuracy of State reporting of Early and Periodic Screening, Diagnosis 
and Treatment (EPSDT) seIVces to Medicaid-eligible children. 
BACKGROUN 
The EPSDT program was established in 1961. The EPSDT is a comprehensive child 
health program that provides for initial and periodic examiations and medically 
The program objective is to find and treat the problems 
necessary follow-up care. 
discovered by the screening seIVces early, before they become more complex and 
costly to treat.

The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) expanded EPSDT 
coverage. Provisions effective April 1, 1990 mandated establishment of annual 
participation goals and reporting. In July 1990, the Health Care Financing 
Admnistration (HCFA) issued instructions to the State agencies that established an 
80 percent participation goal by the end of Fiscal Year (FY) 1995. The HCFA also 
established annual reportg requiements for the EPSDT program which replaced 
quarterly reporting by the States. The fist report was due April 1, 1991 for the six 
month period April 1, 1990 through September 30
, 1990. 
When HCF A undertook implementation of OBRA 1989, the existing data system was 
inadequate to provide comprehensive data on screening. They began a major 
initiative to improve the measurement system. Recognizing the need to test the 
reporting formats, instructions, and data entry structures, HCF A decided to use the 
data from the first report that covered the last six months of FY 
1990 to evaluate 
these changes. At the end of the first reporting period, HCFA formed a Work Group 
to analyze the reporting process. Based on this evaluation, this Work Group, whose 
efforts paralleled our own, is now considerig ways to improve the performance 
measurig system. 
METHODOWGY 
We obtained HCFA's instructions to States for reporting screening activities and 
nie 
participation rates. We randomly selected  States for review, three each from the 
lower, middle, and higher participation levels. We obtained copies of these States 
, 1990 to September 30, 1990. We evaluated the 
reports for the period April 1
methods prescribed for calculating screenig and participation ratios and assessed how 
well the sample States complied with instructions.  FIINGS 
mee States
Th  screening and partpant rati used to  ' perormnce in the EPSDT 
program are esentill inccuate. 
Some States' EPSDT reportg is inonstent wih cuent HCF A intrtins. 
RECOMMATIONS 
HCFA shoul moif the metho by whih it meases screeng and partpatin 
Th  tht th 
rates so  co"ectly refct States' progres in meetig statury goals. 
ase 
HCFA shoul ennce moniorig proedes to  the accuacy of States 
Th 
reportg. 
As noted previously, a HCFA Work Group is evaluating the EPSDT reporting system.
We hope that the fidings and recommendations in this report will prove useful to the 
Work Group. 
AGENCY COMMNT 
The HCF A concurs with recommendations in the report, suggesting mior editorial 
changes. We have reviewed the report and made applicable modications. The full 
text of HCF A's comments are included in APPENDIX E of this report.  INTRODUCTION

PUROSE 
To assess the accuracy of State reporting of Early and Periodic Screening, Diagnosis 
and Treatment (EPSDT) servces to Medicaid-eligible children. 
BACKGROUN 
RECENT PROGRA AMENDMENT 
Medicaid' s EPSDT program, established in the 1967 amendments to the Social 
Security Act, is a comprehensive child health program that provides for initial and 
follow-up care. The program objective 
periodic examinations and medically necessary 
is to fid and treat the problems discovered by the screening seIVces early, before 
they become more complex and costly to treat. 
The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) expanded EPSDT 
age 21. Effective Apri 1 
health coverage for most Medicaid-eligible children under 
children through age five in famiies with 
1990, Medicaid programs must cover 
income at or below 133 percent of the Federal Poverty Level (FPL) as established by 
the Department of Health and Human Servces (HHS). States that extended 
Medicaid coverage to all pregnant women and inants with incomes up to 185 percent 
of the FPL, prior to passage of OBRA 1989, must maintain that coverage. Also under 
OBRA 1990, States must phase in coverage of children under age 19 born after 
FPL. 
September 30, 1983, whose family income does not exceed 100 percent of the 
The OBRA 1989 amendments made changes to the Social Security Act. The following 
is now the structure of the EPSDT program. 
SERVIQ3: Secton 1905(r) 
which are provided at intervals which meet reasonable 
Screenig servces 
standards of medical and dental practice, as determined by the State after 
consultation with recognized medical and dental organizations involved in child 
necessary to 
health care and, at such other intervals indicated as medically 
existence of certain physical or mental illnesses or conditions. 
determine the 
These seIVces shall at a minimum include the followig: 
- a comprehensive health and developmental history (including 
assessment of both physical and mental health development); 
examiation; 
- a comprehensive unclothed physical 
- appropriate imunizations accordig to age and health history;  - laboratory tests (including lead blood level assessment appropriate for 
age and risk factors); and 
- health education (including anticipatory gudance). 
hearg 
Vision and  servces which are provided at intervals that meet 
reasonable standards of medical practice, as determined by the State after 
consultation with recognized medical organizations involved in child health care 
and at such other intervals as medically necessary to determine 
the existence of 
a suspected ilness or condition. Vision servces include, at a minimum: 
- diagnosis and treatment for defects in vision, including eyeglasses. 
Hearig seIVces include, at a minimum: 
- diagnosis and treatment for defects in hearig, including hearig aids. 
Dental servces which are provided at intervals that meet reasonable standards 
of dental practice, as determined by the State after consultation with recognized 
dental organizations involved in child health care, and at such other intervals as 
medicaly necessary to determine the existence of a suspected ilness or 
, at a minium: 
condition. Dental servces include
- relief of pain and infections, restoration of teeth, and maintenance of 
dental health. 
The States must allow participation by providers who wish to furnsh only one 
(or more) but not all diagnostic and treatment servces. 
The Secretary shall not later than July 1, 1990, and every 12 months thereafter 
develop and set annual participation goals for each State for participation of 
individuals who are covered under the State plan under this title in EPSDT 
servces. 
The States must reimburse for diagnostic servces, treatment, and other 
measures described in section 1905(a) of the Act whether or not they are in the 
States' Medicaid plan. 
REPORTIG: Secton 190(a)(43) 
The State plan for medical assistance must provide for reporting to the 
Secretary (in a uniform form and manner established by the Secretary, by age 
group and by basis of eligibilty for medical assistance, and by no later than  April 1 after the end of each fiscal year, beginning with Fiscal Year (FY) 1990) 
the following information relating to EPSDT seIVces provided under the plan
during each fiscal year: 
(1)	 the number of children provided chid health screening servces; 
(2)	 the number of children referred for corrective treatment (the 
need for which is disclosed by such child health screening 
servces ); 
(3)	 the number of children receivig dental servces; and 
(4)	 the State s results in attaining the participation goals set for the 
State under section 1905(r) of the Act. 
EPSDT REPORTIG FORM 
The Health Care Financing Adminstration (HCF A) reporting 
instructions issued in 
July 1990 require each State to submit an annual report on EPSDT servces provided 
to children durig the previous Federal fiscal year. The Anual EPSDT Participation
Report, form HCFA-416, (Appendix A), which replaced the quarterly Form HCFA
420, provides EPSDT participation information by age group and by basis of eligibilty 
(i.e., categorically-needy (CN) or medically-needy (MN)). Included in the report are: 
1) number eligible for EPSDT, 2) total number of eligibles enrolled in continuing care 
arrangements, 3) number of eligibles receivig screening seIVces, 4) total number of 
eligibles provided child health screening supeIVsion, 5) participant ratio, 6) total 
number of screening examinations, 7) screening ratio, 8) number of eligibles referred 
for corrective treatment, 9) number of eligibles receivig vision seIVces, 10) number of 
eligibles receivig preventive dental seIVces, and 11) number of eligibles receiving 
hearing seIVces. 
Enrollees in continuing care arrangements are identified separately in the report. 
Continuig care providers agree to provide continuous and comprehensive child health 
seIVces for EPSDT enrollees. 
The participant ratio (Line 5 of the form HCFA-416) is one measure of States 
progress in reachig their participation goals. The annual participant ratio is the 
unduplicated count of chidren provided health screening supervsion divided by the 
number of EPSDT -eligible children. The number of children provided health 
screening supervsion is the sum of those receiving screening servces and those 
enrolled in continuous care arrangements. 
The screening ratio (Line 7) is a second measure of participation. Following the 
instruction contained on the form, this ratio is determined by dividing the number of 
screening seIVces by the number of children eligible for EPSDT. 
When HCFA undertook implementation of OBRA 1989, the existing data system was 
inadequate to provide comprehensive data on screening. They began a major 
initiative to improve the measurement system. The HCF A recognized the need to test  the reporting formats, instructions, and data entry structures. They decided to 
use the 
preliminary data from the first report that covered the last six months of FY 1990 to 
evaluate these changes. At the end of the first reporting period, HCF A formed a 
Work Group to analyze the reporting process. Based on this evaluation, this Work 
Group, whose efforts paralleled our own, is now considering ways to improve the 
performance measurig system. 
ANNUAL PARTICIPATION GOAL 
With instructions also issued in July 1990, the HHS set a yearly participation goal for 
each State, by the end of FY 1995, to screen at least 80 percent of EPSDT -eligible 
children and to provide at least 80 percent of screenings recommended for those 
children (Appendix B). The individual States' FY 1989 proxy participation ratios 
became their baselines for interi goals for FY 1991 to FY 1995. 
METHODOWGY 
We obtained HCF A's instructions to States for reporting screening activities and 
participation rates. We used HCFA's compilation of FY 1989 EPSDT participation 
rates by State to select the sample of nie States (Appendix B). We randomly 
selected nine States for review, three each from the lower (0 - 33 percent), 
middle (34 - 66 percent), and higher (67 - 100 percent) participation levels. 
We obtained copies of these States' reports for the period April 1 , 1990 to September 
, 1990. We evaluated the methods prescribed for calculating screening and 
participation ratios and assessed how well the sample States complied with 
instructions. 
Inter 
Standards for Insections 
Our review was conducted in accordance with the 

issued by the President's Council on Integrity and Effciency.  FINDINGS

TI 
SCRENG AN PARTICIAN  MEUR 
RATIOS USED TO  STATE'
TI  ESENY
PERORMCE IN  EPSDT PROGRA AR 
INACCTE. 
The numbers and rates of chidren paricipating in the EPSDT program
, as reported
on the form HCFA-416, are open to question, as are the ratios of screens those
chidren receive. The form itself, the instructions, and the States' application of them
lead to figues which are at best unreliable and at worst lead to inated screening and
participant ratios. 

screeng rati 
Th  miates th States' screening perormnce. 
The "Guidelies for Health SupeIVsion" of the American Academy of Pediatrics
(AA) establishes an expected annual number of 
are divided into four age groscurepensig:  seIVces. The guidelines
Under age one: five screens 
withi the year 
Ages one through five: seven screens with 
five years 
Ages six though foureen: five screens withi nie years, and 
Ages fieen through twenty: three screens within six years. 
States are not requied to use the AA 
periodicity schedule. Rather, a State may
develop its own periodicity schedule in consultation with recogned medical and 
dental organitions involved in chid health care. We wi use the AA standard 
however, to ilustrate the problems that arise if the screenig ratio does not take into 
account the expected number of screens per year for each age group. 
The method used to calculate the screenig ratio on the form HCFA-416 neglects to
take expected screens into account as HCF A intended by their manual instrction.
The HCF A State Medicaid Manual, Part 5, Section 5360, descn"bes two methods to
calculate the screening ratio of chidren receivig EPSDT servces. One method is the 
ratio of screenig seIVces to individuals eligible for EPSDT durg 
the period (Part 5
Sectiori 5360C.1. See also Section 5320.2D7 and Part 2, Section 2700.4). The second
method is the ratio of screening servces to the number of EPSDT-eligible chidren
reported for each age group multiplied by the number of screening servces expected
for each age group member 
(Par 5, Section 5360C.5). Both methods of calculation 
use the same data but have different results. 
The form HCFA-416 uses the fist calculation method to determne the screening ratio 
as descn"bed in Part 2, Section 2700.4 of the State Medicaid Manual. This method 
misstates the actual screening ratio since the unduplicated count does not indicate how 
many scheduled screens a chid should receive, nor does it indicate for what length of 
tie chidren are Medicaid eligible and thus able to receive EPSDT screening seIVces  under the established screening schedule. Since the ratio is calculated using the 
number of screens as the numerator, and the number of eligible children as the 
denominator, ratios can easily exceed 100 percent. Using this method necessitates 
additional adjustments to approximate the actual screenig ratios. It also creates 
confusion among policyakers as to States' actual performance in meeting EPSDT
goals (Appendi C). 
Ths problem can best be demonstrated by focusing on State reporting of 
screenings
for children under one year of age, where the number of AA recommended 
screenigs in one year (five) is highest. In our sample, four States reported screening
ratios greater than 100 percent for chidren under one year of age. 
As an example
one State reported a screening ratio of 164 percent for children under one year of
age. If the screenig ratio is adjusted to include the total number of screens 
recommended for this age group (five), assumig that each 
EPSDT-eligible should
receive all five screens, the resultant ratio is reduced to 33 percent for this State. 
The followig chart compares the screening ratio for children under age one reported 
by the sample States versus the adjusted screenig ratio as calculated by our offce.
The adjusted screenig ratio results from factoring the expected number of screens for 
children under age one (i.  , five) into the denominator of the ratio. 
REPORTED VS.  USTED SCREEN 
I NGS

Ch i I d  en Unde  Age One

Per-cent age
200"' _.mm..........m.m..m.m...mmm...mm......m.mm.......mm..... .m.mm....mmm".........m"'.m.m"'..mm.....no

'16"1" 
150%  -"".n_n__._un............-.---......---.......-.----....---nO"'h_____........--...........---------........---u......------......_----.....

100% 
50"' 
0", 
States ' Screen i ng Rat 
i 0 
RQport.tid  AdJ us't9d 
Reportd figues from th HCFA-416s as provi by th States  Overall, the States in our sample reported a screenig ratio of 94 percent for children
under age one. However, if the calculation included the total goal as the number of 
scheduled screens due for children under age one, the overall screening ratio would be 
19 percent.

Even this adjustment falls short in correctly stating the screening ratio as the number 
of eligible children who received all the screens they were scheduled to receive. 
This 
adjustment, like both formulas for the screenig ratio listed in the Medicaid manual 
fails to properly account for children who are eligible for only part of the year. 
such cases, error is introduced in the opposite direction, understating the true 
screening ratio as defied above. Using our example of children under age one, a
child born late in the reporting year may be scheduled to receive only one or two 
screens, rather than five, yet the screenig ratio does not include this factor in its 
calculation. The end result is that the current method of reporting makes it difficult 
not impossible to ascertain the number of children who are receivig: 
all scheduled screenings

some of their scheduled screenings, or

none of the scheduled screenings.

Similar problems occur in the calculation of screenig ratios in chidren of all ages.
The amount of distortion in the measurement varies by age group because of 
differences in the number of screens scheduled for each. 
inlu  contg 
Th  partpant ratis  chilen in  care a"angemts who ma not
receig all approprite screens. 
The form HCFA-416 defines the participant ratio as the chidren receiving "health 
screenig supeIVsion" divided by all eligible children. The number of children 
receivig screenig supeIVsion is defined as the number of eligibles enrolled in 
continuig care arrangements (Line 2 of the form HCF A-416) and the number of 
eligibles receivig screening servces (Line 3 of the form HCFA-416). 
The HCF A defies continuing care arrangements as those with EPSDT providers that 
furnish continuous care and monitoring. There are a number of arrangements 
including those that allow a choice of doctors. These may include pediatricians, other 
practicing physicians, Health Maintenance Organizations, and community health 
centers. The HCF A allows States to count all enrollees in continuing care 
arrangements as havig been screened as long as the State has a monitoring process in 
place. Section 5240 states that the State Medicaid agency "is deemed to have met 
EPSDT requirements for participants enrolled with a continuing care provider. 
Three States in our sample had continuing care arrangements. One of the States 
counted in their report only the screenings specifcally documented as having been 
provided to participants in continuing care arrangements. That State s report shows 
less than one-third of the enrollees received a screening for the six-month period of  Apri 1, 1990 through September 30, 1990. The other two States counted the 
continuig care enrollees as participants in EPSDT screening, although they could not 
verify that all children enrolled with continuing care providers received a screening 
examination during the period. 
WI CUNT 
SOME STATE' EPSDT REPORTIG IS INCONSISTE 
HCFA INSlRUCTONS.

The form HCFA-416 instruction provides for unform collection of EPSDT 
participation and screening data. However, the wide range of reporting differences by 
the sampled States suggests widespread reportg problems, in addition to those 
discussed above. The number of errors found in State reporting can be attnlmted 
both to the fact that States were using the form for the fist time and that HCF A 
needed to refie their manual instructions on reporting. 
Most of the form HCFA-416s we reviewed had errors. Several sample States 
submitted reports containing incorrect data and miscalculations of the data. Also, one 
State merely estimated the number of hearing and vision seIVces for inclusion in the 
report. Two States submitted a revised form HCFA-416 after they discovered 
problems with the intial report submitted to HCF A One State determined that the 
number of vision and hearing servces was incorrectly counted on the initial report. 
The other State revised the number of individuals eligible for EPSDT and the 
participant ratio initially reported. 
In some instances, we also found that States did not follow RCF A Manuafinstructions 
for the form HCFA-416. For example, one State reported on the form HCFA-416 
only those who actually enrolled in the EPSDT program as EPSDT -eligible. Another 
State did not use the format of the form HCFA-416. As a result, the participation 
ratio and the screening ratio were not reported. Another State used a date different 
from the instruction to determne the eligibilty age of the children reported on the 
form HCFA-416. Also, four States included emergency and treatment servces along 
with the preventive dental care. 
States vary on the manner and method of counting screens. For example, in the 
reported participation ratio for the last six months of FY 1990 (Appendix D), one 
State did not count well-child visits while other States counted these servces as 
EPSDT screenings. Some States count claims while others count procedure codes 
toward EPSDT vision and hearing seIVces. Some States use only an EPSDT claim 
form to count screenings. 
One State respondent told us that the guidelines on the report form were "confusing 
when compared to the instructions contained in Part 2, Section 2700.4. Ths confusion 
led the State to report a percentage not in line with the gudelines on the form, or 
instruction in the HCF A Manual. These inconsistencies resulted in inaccurate counts 
of the screens provided and the number of children receiving EPSDT seIVces.  (%)  (%)  (%)  (%)  (%)

APPENDIX 

SCRENG 
EPSDT  RATIO (%) 
CHREN 
FOR EUGmLE 
Apri 1, 199 - Sept. 30, 199 
ALL 
ELIGIBLE  UNDER  1 - 5  6 - 14  15 - 20 
SAMPLE  CHILDREN  YEAR  YEARS  YEARS  YEARS 
STATES 
164 
108 
126 
108 
Source: Form HCFA-416 
C - 1
 (%)  (%)  (%)  (%)  (%)

APPENDIX D

EPSDT PARTICIPAN RATIO (%)

CHRE

FOR EUGmlE 
Apri 1, 199 - Sept. 30, 199 
ALL 
ELIGIBLE  UNDER  1 - 5  6 - 14  15 - 20 
SAMLE  CHILDREN  YEAR  YEARS  YEARS  YEARS 
STATES 
Source: Form HCFA-416 
D - 1
 APPENDIX E

HETH CAR FIANCING ADMISTRTION'S COMMNT

E - 1
 &. 
DEPARTMENT OF HEALTH  HUMAN SERVICES  Health Care
Financing Administration 
5 &1 
Memorandum 
".""1a 
Date 
Wi1

Acting Admstrator

From 
OIG Draf Repon: "EPSDT Performance Measurement" (OEI-07-90130) 
Subject 
Inpector General

Offce of the Secretary 
We reviewed the subject draf repon in which OIG assesses the accuracy of
State reponing of Ealy and Periodic Screenig, Diagnosis and Treatment (EPSDT) 
servces for Medicad-eligible chidren. OIG focused its review on EPSDT program 
expansions, anual paricipation goals, and reponing fuctions mandated by the
Omnibus Budget Reconcilation Act of 
1989. 
OIG found that the screenig and paricipant ratios used to measure States

performance in the EPSDT program were inaccurate. Alo
, OIG found that some

States' EPSDT reponing was inconsistent with current Health Cae Financig

Admistration (HCF A) instructions. To address these problems, OIG recommends

that HCFA: (1) modif the methods by which it measures 
screenig and parcipation

rates to reflect States' progress in meeting statutory goals correctly; and,

(2) enhance monitorig procedures to ensure the accuracy of States' reportg. OIG 
acknowledges that a HCF A Work Group is aleady performg an independent
evaluation of the EPSDT reponing system
, where these recommendations wi be 
implemented. 
We are pleased that OIG used HCFA's comments made on an earlier workig
draft of the above-captioned report in the version now released for our 
review. Our 
, lited 
curent comments to brief techncal points, are attached for your
consideration. We concur with this report and its recommendations subject to the
incorporation of these techncal comments in the 
fial report. 
Than you for the opportunity to review and 
comment" on this 
draft report.
Please advise whether you agree with our suggested techncal 
report
revisions to the 
at your earliest convenience. 
Attachment 
E - 2
 , "
Comments of the Health Care Financing Administration ( 
on the DIG Draft Report: "EPSDT Performance Measurement 
07-90-00PO) 
Recommendation 
That HCFA should modify the methods by which it measures screenig and participation 
rates so that they correctly reflect States' progress in meeting statutory goal. 
HCFA Response 
HCF A concurs with this recommendation. However
last 
, we suggest the text of the 
paragraph followig this recommendation (page 9) be amended to read as follows: 
Chidren enrolled in continuing care arrangements are counted as havig
received the appropriate number of screens accordig to the screenig
schedules. We suggest that HCF A require States to document that all 
eligibles reported as havig received Early and Periodic Screenig, 
Diagnosis and Treatment (EPSDT) screenings, including continuing care 
enrollees, actually receive such servces. 
Recommendation 2

That HCF A enhance monitoring procedures to ensure the accuracy of States' reporting. 
HCFA Response 
HCFA concurs with this recommendation. OIG acknowledges that a HCFA Work 
Group is already evaluating the EPSDT reporting system. Ths evaluation seeks to 
ensure that documentation of EPSDT participation and 
screenig servces is accurate 
uniform, and useful to decision makers in their assessments of the servces provided to 
eligible chidren. 
Technical Comments 
Page i  Background" section, first paragraph. We suggest this paragraph be amended to 
read: 
The EPSDT program was established in 1967. EPSDT is a comprehensive
child health program that provides for initial and periodic examiations and 
medical1y necessary fol1ow-up care. The program objective is to fid and 
treat the problems discovered by the screening servces early, before they 
become more complex and costly to treat. 
E - 3  ,,,   """
Page 2

Page 1  Recent Program Amendments" section, fist paragraph. We suggest thi 
paragraph be amended to read: 
Medicaid' s EPSDT program, established in the 1967 amendments to the 
Social Security Act, is a comprehensive chid health program that provdes 
for intial and periodic examations and medicay necessar follow-up 
cae. The program objective is to fid and treat the problems dicovered 
by the screenig servces early, before they become more complex and 
costly to treat.

Page 2, "Vision and Hearg Servces" section, second paragraph. We suggest thi 
paragraph be amended to read: 
mium: 
Hearig Servces include, at a 
hearg 
diagnosis and treatment for defects in hearg, including 
aids. 
Page 2  Dental SeIVces" section, first paragraph. We suggest this paragraph be 
amended to read: 
Dental Servces which are provided at intervals that meet reasonable 
, as determed 
standards of dental practice by the State afer consultation 
with recogned dental organitions involved in chid health cae, and at 
determe the exitence of a 
such other intervals as medically necessar to 
mium: 
, at a 
suspected illess or condition. Dental servces include
relief of pai and infections, restoration of teeth, and 
maintenance of dental health. 
Page 3  EPSDT Reporting Form" section, fist paragraph. We suggest the fourh item 
this paragraph be 
the list of inclusions to the report  thid sentence of 
given in the 
amended to- read: 
total number of eligibles provided chid health screenig 
supervsion. 
E - 4