DEPARTMENT OF HEALTH AND HUMAN SERVICES 
OFFICE OF INSPECTOR GENERAL 
WASHINGTON, DC  2020l 
NOV 12 2014 
TO: 	 Marilyn Tavenner 
Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Suzanne Mll.R!in 
Dep.Yty Irtspe.etor General 
for Evalliation and Inspections 
SUBJECT: 	 Recommendation Followup Memorandum Report:  CMS Needs To Do More To 
Improve Medicaid Children's Utilization ofPreventive Screening Services, 
OEI-05-13-00690 
This memorandum report describes the steps that the Centers for Medicare & Medicaid Services 
(CMS) has taken to encourage children's participation in Medicaid's Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT) screenings and to ensure that providers deliver 
complete medical screenings.  The Office oflnspector General (OIG) issued a report in 2010 
recommending improvements in both areas. 
SUMMARY 
Medicaid is required to provide a comprehensive and preventive child health benefit-known as 
the EPSDT benefit-for eligible children under the age of 21.  Services provided under the 
EPSDT benefit are intended to screen, diagnose, and treat eligible children at early, regular 
intervals to avoid or minimize childhood illness.  A 2010 OIG report found that children were 
not receiving all required EPSDT screenings.  In addition, OIG also found that children who 
received medical screenings were not receiving all the components of a complete medical 
screenmg. 
We found that CMS has taken some actions toward encouraging participation in EPSDT 
screenings and toward encouraging the delivery of all components of medical screenings, but 
that it has not fully addressed OIG's recommendations.  Further, we found that children's 
participation in EPSDT medical screenings remained lower than established goals.  Page 2  Marilyn Tavenner 
 
BACKGROUND 
 
Every State Medicaid program must offer the EPSDT benefit.  In 2013, 32 million children were 
eligible for EPSDT.1  The EPSDT services cover four health-related areas:  medical, vision, 
hearing, and dental.2    
 
Each State establishes its own schedule for each type of screening.  These schedules outline the 
frequency of each type of screening, which varies by a childs age.  For medical screenings, 
States schedules vary as to the number required.  Typically, States require multiple medical 
screenings for infants and children ages 1 to 2. For children 3 or older, States typically require 
one medical screening every 1 to 2 years. 
 
Unlike the other three types of screenings, medical screenings have components specifically 
required by statute. Complete medical screenings under the EPSDT benefit must include the 
following five components:  (1) a comprehensive health and developmental history (including 
assessment of both physical and mental health development); (2) a comprehensive unclothed 
physical examination; (3) appropriate immunizations; (4) appropriate laboratory tests and 
(5) health education.3  Medical screenings are often called well-child or well-care visits. 
 
EPSDT Reporting Requirements 
The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) strengthened EPSDT by 
establishing State reporting requirements and mandating that the Secretary of Health and Human 
Services (the Secretary) set participation goals for the States.4, 5 In response to OBRA 1989, the 
Secretary required annual reporting via the Annual EPSDT Participation Report Form CMS-416 
(which we refer to as the CMS-416) and established an overall goal of 80 percent beneficiary 
participation in EPSDT for each State annually.6    
 
The CMS-416 provides basic information on participation in EPSDT and is used to assess the 
effectiveness of EPSDT.  States must report to CMS information about the number of children 
who (1) receive medical screenings, (2) are referred for corrective treatment, and (3) receive 
dental services.  States report this information at an aggregate level and for seven different age 
groups. States are to report only complete medical screenings, i.e., those that include all 
                                                 
1  CMS, Annual EPSDT Participation Report Form CMS-416  (National), 2013.  Accessed at 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-
Diagnostic-and-Treatment.html on June 18, 2014.  

2 Social Security Act,   1905(r), 42 U.S.C  1396d(r).  Note  that where the statute refers to screening services in 
 
1905(r)(1), it  is describing medical screenings.  For claritys sake, we refer to screening services as medical 

screenings. 

3  Social Security Act,  1905(r)(1)(B), 42 U.S.C.  1396d(r)(B). 
 
4 OBRA 1989, P.L. No. 101-239, Title VI   6403(b)(3) (adding Social Security Act,  1902(a)(43)(D), 42  U.S.C. 

 1396a(a)(43)(D)). 
 
5 OBRA 1989, P.L. No. 101-239, Title VI   6403(c) (amending Social Security Act,  1905(r), 42  U.S.C.  1396d, 

by adding annual participation  goals at the end of that section). 

6  CMS, State Medicaid Manual, Pub. No. 45,   5360(A) and (B).  Beneficiary participation in medical screenings is
  
measured using the participant ratio.  This is calculated  by  dividing the number of eligible children receiving at least 

one medical screening by the number of eligible children who should receive at least one  medical screening 

according to the screening schedules for their respective States.  
  
 
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 3  Marilyn Tavenner 
 
five components.  States are not required to report any information about vision or hearing 
screenings. 
 
Quality Measures for Childrens Health Care 
The Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA) included 
provisions to strengthen the quality of care provided and health outcomes of children in 
Medicaid and the Childrens Health Insurance Program (CHIP).7 CHIPRA required the 
Secretary to create a set of childrens health care quality measures (known as the Child Core Set) 
for voluntary use by State Medicaid programs and CHIP.8 States that choose to participate 
submit their results to CMS.  CHIPRA also required the Secretary to annually collect, analyze,  
and make publicly available the information that States report regarding these measures.9 The 
Secretary prepares a report using data available to CMS.10  Of the 24 measures that were created 
for the Child Core Set, 3 measures track well-child or well-care visits for 3 different age groups.   
 
Previous OIG Report on EPSDT 
A May 2010 OIG report found that children were not receiving all required EPSDT screenings.11   
Specifically, 76 percent of children in nine States did not receive all required medical, vision, 
and hearing screenings.12  Forty-one percent of children did not receive any required medical 
screenings, and more than half of children did not receive any required vision or hearing 
screenings. In addition, OIG also found that children were not receiving complete medical 
screenings. Nearly 60 percent of children who received medical screenings lacked at least one 
component of a complete medical screening.   
 
OIG made four recommendations to CMS for increasing participation in EPSDT screenings and 
increasing the completeness of medical screenings.  See Table 1 for a complete list of OIG 
recommendations and CMSs response.     
 
   
                                                 
7 CHIPRA, P.L. No. 111-3. 

8  CHIPRA, P.L. No. 111-3,    401(a)  (adding Social Security Act  1139A, 42  USC   1320b-9a); 74  Fed. Reg. 
 
68846 (Dec. 29, 2009). 

9 Social Security Act  1139(A)(c)(2), 42  USC   1320b-9a(c)(2)  (added  by   401(a)  of CHIPRA). 

10 Department of Health and Human Services (HHS),  Childrens Health  Insurance Program Reauthorization Act 
 
Annual Report on the Quality of Care for Children in Medicaid  and CHIP, September 2010.  Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-
Care/Downloads/2010_Secretary_Report.pdf on  August 6, 2014.   

11  OIG, Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, 

OEI-05-08-00520, May 2010. 
    
12 This  report excluded dental screenings because at the time of the review, CMS was conducting a detailed review
  
of dental screenings and services. 
 
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 4  Marilyn Tavenner 
 
Table 1: OIGs previous EPSDT-related recommendations and CMS response   
OIG Recommendations   CMS Response  
CMS stated that it would consider this 
recommendation, but also said that it needed 
Require States to report vision and hearing screenings  
to assess the financial impact on States and 
the feasibility of collecting the data. 
Collaborate with States and providers to develop effective strategies to 
Concur  
encourage beneficiary participation in EPSDT screenings  
Collaborate with States and providers to develop education and incentives 
Concur  
for providers to encourage complete medical screenings  
Identify and disseminate promising State practices for increasing childrens 
participation in EPSDT screenings and providers delivery  of complete  Concur  
medical screenings  
Source: OIG, Most Medicaid Children in Nine States Are Not Receiving All Required Preventive  Screening Services, OEI-05-08-00520, May 2010.  
 
METHODOLOGY 
 
Scope 
This review focused on the actions that CMS has taken to address OIGs recommendations for 
increasing participation in EPSDT screenings and increasing the delivery of complete medical 
screenings. We also determined whether childrens underutilization of EPSDT services 
continues to be a challenge for States. 
 
Data Collection and Analysis  
To determine the actions that CMS has taken to address OIGs recommendations, we conducted 
structured interviews and reviewed related documents.  Specifically, we interviewed the CMS 
staff responsible for EPSDT and four representatives from a national workgroup that CMS 
created to address EPSDT issues. We asked about the actions CMS has taken since 2010 related 
to encouraging childrens participation in EPSDT screenings and encouraging providers to 
deliver all of the components of a complete medical screenings.  Our interviews occurred 
between December 2013 and February 2014.  We also reviewed documents provided by CMS or 
workgroup representatives, including informational bulletins, strategy guides, Web seminars, and 
workgroup reports. 
 
To determine whether the underutilization of EPSDT services continues to be a challenge, we 
reviewed States CMS-416 reports from 20062013.  We used 2006 data as the baseline for 
OIGs previous review. We also reviewed the national CMS-416 reportsi.e., reports that 
aggregate all States datafrom  20062013.  Finally, we reviewed the 2013 Annual Report on 
the Quality of Care for Children in Medicaid and CHIP.13    
 
   
                                                 
13 The 2013 report describes outcomes for the Child Core Set for fiscal year (FY)  2012.  See HHS,  2013 Annual 
Report on the Quality of Care for Children  in Medicaid and CHIP, September 2013.  Accessed at  
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2013-Ann-
Sec-Rept.pdf  on  June 18, 2014.   
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 5  Marilyn Tavenner 
 
Standards 
This study was  conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS 
  
CMS Has Taken Actions Toward Encouraging Participation in EPSDT Screenings and 
Encouraging the Delivery of Complete Medical Screenings  
After the May 2010 OIG report, CMS convened a National EPSDT Improvement Workgroup in 
December 2010.  CMSs goals for this workgroup were to identify the most critical areas for 
improvement in EPSDT, discuss steps to increase the number of children who access EPSDT  
services, and improve data reporting.  The workgroup included State representatives, childrens 
health providers, consumer representatives, and other stakeholders with expertise in Medicaid, 
childrens health, and data analysis.   
 
CMS hired a contractor in September 2011 to help the workgroup gather data about beneficiary 
participation in EPSDT screenings and the delivery of complete medical screenings.  The 
contractor interviewed eight States and the District of Columbia about improving beneficiary 
participation in screenings and the delivery of complete medical screenings.14 For beneficiary 
participation in screenings, the contractor asked about States promising practices, challenges, 
and lessons learned. For delivery of complete medical screenings, the contractor asked States for 
promising practices to improve the delivery of complete medical screenings.  The contractor also 
held a focus group with pediatricians to gain their perspective on the delivery of complete 
medical screenings and any barriers they face to doing so.  
 
CMS has disseminated strategies aimed at improving participation in EPSDT screenings. In 
February 2014, CMS released a strategy guide titled Paving the Road to Good Health: 
Strategies for Increasing Medicaid Adolescent Well-Care Visits.15 CMS designed this guide 
primarily for State Medicaid agencies.  The guide presents six strategies for promoting 
adolescent well-care visits (i.e., medical screenings).  The guide also provides examples of State 
and program models that use the strategies presented (i.e., best practices).  The second strategy 
offered in the guideto incentivize providers, adolescents, and parents to encourage preventive 
careclosely aligns with a suggestion made in OIGs 2010 EPSDT report.   
 
In addition, CMS funded a new EPSDT resource page that was launched on the contractors Web 
site in December 2013. The resource page provides State policymakers, Medicaid officials, and 
other stakeholders with State-specific information on a variety of EPSDT-related topics, 
including State initiatives to improve access to required screenings and treatment services for 
children. As of August 2014, this Web site did not include information from all States.  Since 
December 2013, CMS and its contractor have held a series of Web seminars and roundtables to 
                                                 
14  The contractor interviewed these eight  States:  Connecticut, Illinois, Iowa, Mississippi, Nevada, New Mexico, 
 
New York, and South Dakota. 
 
15 CMS, Paving  the Road to  Good Health:  Strategies for Increasing Medicaid Adolescent Well-Care Visits, 

February 2014.  Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Downloads/Paving-the-Road-to-Good-Health.pdf on June 18, 2014. 

CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 6  Marilyn Tavenner 
 
promote the resource page, provide technical assistance, and discuss various EPSDT-related 
topics. 
 
CMS has made efforts to improve the delivery of some of the components of complete medical 
screenings. Since January 2013, CMS has participated in an initiative named Birth to 5: Watch 
Me Thrive!, aimed at encouraging developmental and behavioral screenings in children from  
birth to age 5. Such screenings are part of a comprehensive health and developmental history,  
which is one component of a complete medical screening.  The initiative is a coordinated effort 
across seven agencies within HHS and one agency within the Department of Education to 
encourage support for children, families, and their providers.  CMS had a lead role in developing 
the screening guide for primary care providers.  This initiative launched publicly in March 2014.    
 
In addition, CMS disseminated in March 2013 an informational bulletin aimed at increasing 
mental health screenings.  Like developmental and behavioral screenings, mental health 
screenings are part of a comprehensive health and developmental history.  Specifically, the 
March 2013 bulletin addressed the prevention and early identification of mental health and 
substance use disorders.16  CMS developed this bulletin to inform States about resources 
available to help them  meet the needs of children under EPSDT, specifically related to services 
for such disorders. 
 
Lastly, CMS disseminated in June 2014 an EPSDT guide for StatesCoverage in the Medicaid 
Benefit for Children and Adolescentsthat is intended to help States, health care providers, and 
others to understand the scope of services that are covered under EPSDT.17 The guide did not 
establish new EPSDT policy but instead compiled various CMS-issued EPSDT guidance into 
one document.  Within the guide, CMS reiterates the five components of a medical screening and 
provides an example of a State payment methodology that is intended to encourage providers to 
perform all five components. 
 
CMS has assessed the feasibility of requiring States to report vision and hearing screenings. 
CMS staff reported making multiple efforts to learn about the feasibility of requiring States to 
report vision and hearing screenings. For instance, CMSs contractor completed a feasibility 
study to determine whether collecting data on vision and hearing screenings was possible.  From  
2010-2013, CMS staff also participated in a Federal Interagency Task Force on Childrens 
Vision and Eye Health. As part of the task force, CMS also worked with States to assess 
whether it would be feasible for States to report vision screenings. 
 
The contractors feasibility study found that requiring States to report these screenings would not 
be feasible. The study found that such a requirement would burden States and that data might 
not be available. Separately, CMS staff indicated that one reason data might not be available is  
   
                                                 
16 CMS, CMCS [Center for Medicaid & CHIP Services]  Informational Bulletin:  Prevention and Early 
Identification of Mental Health and Substance Use Conditions, March 27, 2013.  Accessed at 
http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-03-27-2013.pdf  on June 18, 2014.   
17 CMS, EPSDT-A Guide for States:  Coverage in the Medicaid  Benefit for Children and  Adolescents, June 2014.  
Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/  
EPSDT_Coverage_Guide.pdf on  October 1, 2014. 
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 7  Marilyn Tavenner 
 
that there are no standard billing codes for vision and hearing screenings for children under 
age 3. Without standard billing codes, States may be unable to count the number of screenings 
performed.  Additionally, CMS staff indicated that another reason for the lack of data is that  
these screenings may occur in schools and therefore it is difficult to document their occurrence.  
 
Although the contractors study raised concerns as to the feasibility of reporting vision and 
hearing screenings, CMS has stated that it has plans to continue stressing the importance of these 
screenings. In August 2014, CMS said that it was planning to create additional Web pages 
focusing on vision and hearing screenings and that these pages would emphasize the importance 
of collecting data on these screenings and reporting the data to CMS. 
 
Further, CMS stated that it is working with stakeholders on developing a measure regarding the 
quality of childrens vision screenings. 
 
Childrens Participation in EPSDT Medical Screenings Remained Lower Than Established 
Goals 
According to the national FY 2013 CMS-416 report, overall, 63 percent of beneficiaries received 
EPSDT screenings during the FY.18 This is below the Secretarys goal of 80 percent 
participation. In fact, only two States met the Secretarys goal in 2013.   
 
The underutilization of medical screenings is an ongoing concern, despite a slight increase in 
participation between 2006 and 2013. Since 2006, the States, overall, have not met the 
Secretarys goal. Only 8 States had 80 percent participation at least once between 2006 and 
2013. The national participation ratio improved from 56 percent in 2006 to 63 percent in 2013 
with most of the gain occurring between 2006 and 2008.  Figure 1 demonstrates the trend in 
national EPSDT participation from 2006 to 2013. 
 
   
                                                 
18 As  of June 2014, CMS-416 data were  not available for eight States:  Arizona, Connecticut, Florida, Maryland, 
Maine, Missouri, New Hampshire, and  North Carolina. 
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 8  Marilyn Tavenner 
 
Figure 1: CMS-416 National Participation Ratios, 2006-2013  
90% 
80% 
70% 
60% 
National 
50%  Participation 
Ratio 
40%  Goal 
30% 
20% 
10% 
0% 
2006  2007  2008  2009  2010  2011  2012  2013 
   
Note: As of June 2014, data  from 2012 were missing from Connecticut and  data from 2013 were missing from Arizona, Connecticut, Florida, Maryland, 
Maine, Missouri, New Hampshire, and North Carolina.  
 
Source:  OIG analysis of CMS-416 reports, 20062013. 
 
Three measures from the Child Core Set corroborate the CMS-416 data showing underutilization 
of well-child visits. Of these three measures, twoone for well-child visits during a childs first 
15 months, and the other for well-child visits from ages 3-6 yearsclosely align with the overall 
participation ratio.19  These age groups demonstrated 60 and 66 percent participation, 
respectively. Each measure had more than 40 States reporting.  The third measurefor 
adolescent well-care (12-21 years)demonstrated only 44 percent participation, with more than 
40 States reporting.20    
 
CONCLUSION 
 
Since the 2010 OIG report, CMS has taken a number of steps to encourage participation in 
EPSDT screenings and to encourage the completeness of medical screenings.  CMS has 
collaborated with States and providers and promoted adolescent well-care visits.  It has also 
promoted mental health screenings for all children and behavioral and developmental screenings 
for children from birth to age 5.  Finally, CMS discussed an ongoing effort to stress the 
importance of collecting data on vision and hearing screenings and reporting these data to CMS.  
These efforts are in line with OIGs recommendations.  
 
   
                                                 
19 The measure of well-child  visits for the first 15 months is  defined as the percentage of children with six or more 

visits.  The measure of well-child  visits for children aged  36 years is defined as the percentage  with  one or more 
 
visits. 

20 The measure of adolescent well-care is defined as the percentage  of children with one or more visits. 

CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)  Page 9  Marilyn Tavenner 
 
In general, CMSs efforts to encourage participation in EPSDT screenings for particular age 
groups and to encourage the mental health assessmenta component of a comprehensive health 
and developmental historyare promising, but they do not fully address all OIG 
recommendations.  We found no evidence that CMS has worked to encourage beneficiary 
participation for children of all ages, specifically children under age 12.  Additionally, CMS has 
done very little to encourage providers to complete all five components of a complete medical 
screening. Further, at the time of our review it was too soon to know whether CMSs efforts 
would correspond to increases in beneficiary participation.   
 
Although CMSs contractor found that it is not feasible for States to report vision and hearing 
screenings, CMS has indicated ongoing activitiesi.e., additional Web pages and a possible 
measure vision screeningsthat it plans to pursue through 2015.  With regard to the possible 
measure for vision screenings, CMS has not indicated the mechanism (e.g., the CMS-416 report) 
through which this would be reported or whether States would be required to report it.  Lastly, 
CMS has not indicated any effort to create a measure regarding hearing screenings.   
 
Given that CMS has not yet fully addressed all OIG recommendations, coupled with evidence 
that children continue to receive fewer medical screenings than required, CMS must continue to 
focus on EPSDT screenings. Although a successful EPSDT benefit involves multiple actors 
such as physicians, parents, and Statesdoing their parts, CMSs interactions with States to 
promote EPSDT screenings remain vital to EPSDTs success.  Specifically, OIG considers all 
four of the recommendations from the 2010 report to remain open.  We recommended that CMS:  
(1) require States to report vision and hearing screenings, (2) collaborate with States and 
providers to develop effective strategies to encourage beneficiary participation in EPSDT 
screenings, (3) collaborate with States and providers to develop education and incentives for 
providers to encourage complete medical screenings, and (4) identify and disseminate promising 
State practices for increasing childrens participation in EPSDT screenings and increasing 
providers delivery of complete medical screenings.   
 
This report contains no new recommendations and is being issued directly in final form as a 
result. If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-05-13-00690 in all correspondence. 
 
CMS Needs To  Do More To  Improve Childrens Utilization  of Preventive Screening  Services (OEI-05-13-00690)