U.S. Department of Health and Human Services 
 
 
Office of Inspector General 
 
More Than One-Third of 
Medicaid-Enrolled Children in 
Five States Did Not Receive 
Required Blood Lead 
Screening Tests  
Christi A. Grimm 
Principal Deputy Inspector General 
October 2021, OEI-07-18-00371  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
Report in Brief 
 
O ctober 2021, OEI-07-18-00371 
More Than One-Third of Medicaid-Enrolled 
Why OIG Did This 
Review  Children in Five States Did Not Receive Required 
There is no safe level of lead 
Blood Lead Screening Tests  
exposure; even low-level blood 
lead concentrations during  Medicaids Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit 
childhood have been  covers preventive medical servicesincluding blood lead screening testsfor 
associated with behavioral and  enrolled children.  Previous OIG work regarding 
physical impairments.  Children  EPSDT screenings and annual EPSDT participation 
Key Takeaway 
exposed to lead may suffer  reports have identified deficiencies with blood lead 
stunted cognitive development  In the 5 States we reviewed,  level testing.  Specifically, OIG found that many 
and delayed reproductive  38 percent of 1 million  enrolled children did not receive all required 
development.  In the longer  Medicaid-enrolled children  components of complete medical screenings, 
term, elevated blood lead  did not receive a blood lead  including blood lead screening tests, potentially 
levels have been linked to  screening test at 12 months  leaving them vulnerable to the toxic effects of lead 
increased incidence of  or 24 months of age, as  exposure. 
hypertension and coronary  required by Medicaids 
What OIG Found 
heart disease as well as higher  schedule. 
rates of violent crime and  Many Medicaid-enrolled children in five States did 
arrests in adulthood.   not receive required blood lead screening tests on 
Prevention is key to avoiding  schedule during FYs 201518.  Specifically, more than one-third of the 1 million 
the permanent developmental  children who were required to receive a 12-month and a 24-month blood lead 
effects of lead exposure on  screening test received neither test.  Additionally, of the approximately 209,000 
children.  Scheduled blood  children who had been continuously enrolled in Medicaid from birth through age 3, 
lead screening tests can  1 in 5 children in the selected States had never received a blood lead screening test 
support early detection of  by 3 years of age.  Finally, stakeholders we interviewed called for consistent 
elevated blood lead levels,  requirements for blood lead screening tests and practitioners reported challenges 
timely followup, and improved  with providing blood lead screening tests for Medicaid-enrolled children. 
outcomes for children.   
What OIG Recommends 
How OIG Did This  To address challenges that contribute to low participation rates in the blood lead 
Review  testing component of the EPSDT benefit, we recommend that CMS: 
We selected five States for 
1. monitor national EPSDT performance data for blood lead screening tests and
which we reviewed Medicaid 
target efforts toward low-performing States to develop action plans for
claims data and supplemental 
increasing the provision of blood lead screening tests, according to Medicaids
health department data for 
schedule;
fiscal years (FYs) 201518.  We 
examined the extent to which  2. ensure consistency across CMS guidance related to actionable blood lead
Medicaid-enrolled children  reference values (i.e., the blood lead level at which public health actions should
received required blood lead  be initiated) and blood lead screening test definitions; and
screening tests.  We also 
3. coordinate with partners to develop and disseminate to State Medicaid agencies
interviewed stakeholders and 
educational resources that reaffirm requirements and schedules for blood lead
surveyed practitioners to 
screening tests.
identify challenges in 
providing blood lead 
CMS concurred with all of our recommendations. 
screening tests, followup 
services, and treatment for 
 
Medicaid-enrolled children.   
TABLE OF CONTENTS 
 
 
BACKGROUND  1 
Methodology  5 
FINDINGS  7 
More than one-third of Medicaid-enrolled children in 5 States did not receive a blood lead  7 
screening test at 12 months or 24 months of age, as required by Medicaids schedule 
For those children who had been continuously enrolled in Medicaid from birth through age  9 
3, 1 in 5 children in the selected States had never received a blood lead screening test by 
3 years of age 
Stakeholders called for consistent requirements for blood lead screening tests and  9 
practitioners reported challenges with providing tests for Medicaid-enrolled children  
CONCLUSION AND RECOMMENDATIONS  11 
Monitor national EPSDT performance data for blood lead screening tests and target efforts  11 
toward low-performing States to develop action plans for increasing the provision of blood 
lead screening tests, according to Medicaids schedule 
Ensure consistency across CMS guidance related to actionable blood lead reference values  12 
and blood lead screening test definitions  
Coordinate with partners to develop and disseminate to State Medicaid agencies  12 
educational resources that reaffirm requirements and schedules for blood lead screening 
tests 
AGENCY COMMENTS AND OIG RESPONSE  13 
DETAILED METHODOLOGY  14 
APPENDICES   18 
A. Requirements and Guidance for Blood Lead Screening Tests, Followup Services, and 18 
Treatment
B. States Rates of Blood Lead Screening Tests 20 
C. Survey Responses From Practitioners in the Sample 22 
D. Agency Comments 23 
ACKNOWLEDGMENTS AND CONTACT  26 
ABOUT THE OFFICE OF INSPECTOR GENERAL  27 
ENDNOTES   28   
BACKGROUND 
 
 
Objectives 
1.  To determine the extent to which children enrolled in Medicaid received 
required assessments of blood lead levels (i.e., blood lead screening tests) 
during fiscal years (FYs) 201518 
2.  To identify challenges that practitioners faced in providing blood lead 
screening tests, followup services, and treatment for Medicaid-enrolled 
children 
 
Medicaids Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit 
provides comprehensive, preventive medical screening services for millions of children 
annually.1  Under this benefit, States must provide enrolled children with services 
including laboratory testing and blood lead screening tests at early, regular intervals.2  
Previous OIG work on EPSDT services has identified deficiencies.  Specifically, OIG 
found that some enrolled children did not receive all required components of 
complete medical screenings including blood lead screening tests, potentially leaving 
them vulnerable to the toxic effects of lead exposure.3 
Lead exposure is often attributed to a childs home environment (e.g., lead-based 
paint and dust in old houses, or contaminated soil) or the area in which a child lives 
(e.g., industrial areas).4, 5  But sources of lead exposure are widespread and not tied to 
specific areas of the Nation; cases have been chronicled from coast to coast.6, 7, 8  
Children can also be exposed to lead through food, water, toys, and consumer 
products in their homes.9, 10, 11  Many of these exposure sources can present particular 
hazards for young children as they become mobile, begin to explore their 
environments, and engage in hand-to-mouth activity.12  Cumulative exposures can 
have lasting impacts on childhood development.13   
There is no safe level of lead exposure; even low-level blood lead concentrations 
during childhood have been associated with behavioral and physical impairments.14  
Children exposed to lead may suffer stunted cognitive development (e.g., reduced 
academic performance and increased impulsivity), and delayed reproductive 
development.15  In the longer term, elevated blood lead levels (EBLLs) have been 
linked to increased incidence of hypertension and coronary heart disease, as well as 
to higher rates of violent crime and arrests in adulthood.16, 17, 18  Prevention is key to 
avoiding the permanent developmental effects of lead exposure on children.19  
Scheduled blood lead screening tests can support early detection of EBLLs, timely 
followup, and improved outcomes for children.   
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Background | 1  Early and Periodic Screening, Diagnostic, and Treatment 
Services 
Medicaids EPSDT benefit provides comprehensive, preventive medical screening 
services for millions of children annually to avoid and reduce childhood illnesses.20, 21  
States must establish periodicity schedules that set the frequency for EPSDT services 
to occur in consultation with recognized medical organizations involved in pediatric 
health care such as the American Academy of Pediatrics (AAP).22, 23  Components of 
EPSDT medical screenings include a comprehensive health and developmental history; 
physical exam; age-appropriate immunizations; laboratory tests (including blood lead 
screening tests appropriate for age and risk factors); and health education.24   
When conditions or illnesses are identified through screenings, EPSDT covers 
necessary treatment, services, and other medical assistance to correct or ameliorate 
the issues, regardless of whether such corrective services are covered under State 
plans.25   
Centers for Medicare & Medicaid Services Requirements and 
Activities Regarding Blood Lead Screening Tests and Diagnosis of 
Elevated Blood Lead Levels 
The CMS State Medicaid Manual requires enrolled children to receive blood lead 
screening tests at 12 and 24 months of age.26  These tests include the collection of a 
blood sample via a capillary blood draw (i.e., fingerstick) or venipuncture (i.e., blood 
collected from a vein).  If a capillary draw identifies a blood lead level (BLL) equal to or 
greater than 10 g/dL (micrograms per deciliter), a confirmatory test must be 
conducted using venipuncture to verify the childs level.  
CMS issued updated guidance on blood lead screening tests via two Informational 
Bulletins published in 2012 and 2016.  The 2012 guidance allowed States to request 
approval from CMS to implement a targeted blood lead screening program in lieu of 
universal blood lead screening test requirements for all Medicaid-enrolled children 
ages 12 months and 24 months.27  To date, only Arizona has been approved for a 
targeted program.  CMSs 2016 guidance cited the current Centers for Disease Control 
and Prevention (CDC) actionable blood lead reference value of 5 g/dL, which is the 
level at which the CDC recommends that public health actions be taken.28  CMS did 
not revise the policy in The State Medicaid Manual to reflect this change.  CMS also 
stated in the bulletin that completion of a risk assessment questionnairesometimes 
referred to as lead screening questionswould not satisfy the Medicaid blood lead 
testing requirement.   
CMS has engaged in additional activities with Federal partners and professional 
organizations related to blood lead screening test requirements.  Some activities 
included a session at the 2016 CMS Quality Conference and a webinar as part of 
National Lead Poisoning Prevention Week in 2018.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Background | 2  Other Guidance Related to Blood Lead Screening Tests and 
Followup for Elevated Blood Lead Levels 
CMS suggests that States referencealong with Medicaid EPSDT requirements
other practice guidelines related to lead screening and followup for EBLLs.29  These 
include guidance developed by CDC as well as the AAPs Bright Futures: Guidelines for 
Health Supervision of Infants, Children, and Adolescents.  See Appendix A for a table of 
the EPSDT requirements and CMS-suggested guidance related to blood lead 
screening tests and followup for EBLLs.   
CDC 
CDC guidance recommends that practitioners follow Medicaid guidelines for blood 
lead screening of Medicaid-enrolled children.30  CDC also advises practitioners to use 
screening questions, outreach, and parental education to minimize a childs exposure 
to lead prior to testing.  When testing indicates confirmed blood lead levels above 5 
g/dL in children, CDC recommends that practitioners initiate public health actions 
(e.g., followup testing within 3 months).31   
AAP 
AAP guidance regarding lead screening and followup for EBLLs emphasizes 
prevention and risk assessment as key factors in reducing childhood lead exposure.  
One prevention effort is AAPs anticipatory guidance, which outlines discussion points 
to educate parents about lead exposure, minimize risks, and develop a plan to create 
a lead-safe environment for children.32  This effort also includes the use of 
environmental assessments and risk assessments at designated intervals of the Bright 
Futures/AAP periodicity schedule, and screenings for Medicaid-enrolled patients at 
12 months and 24 months of age.33, 34  When practitioners identify blood lead levels 
above 5 g/dL in a child, AAP recommends followup services such as finding and 
removing environmental sources of lead, and observing the childs diet and nutritional 
status.35   
State Reporting on Blood Lead Screening Tests and Lead 
Surveillance Activities  
State EPSDT Reports 
Each year, CMS requires States to submit EPSDT reports that track the expected and 
actual number of EPSDT screening services provided to Medicaid-enrolled children in 
different age groups.36, 37  Form CMS-416 allows States to count instances of certain 
medical screening procedures, including blood lead screening tests, as proxies for 
reporting complete medical screenings.  In 1990, the Secretary of the Department of 
Health and Human Services established a target goal of 80-percent EPSDT 
participation by 1995, but States have typically fallen short.38, 39  Although the EPSDT 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Background | 3  participation goal applies broadly to initial or periodic screening services and is not 
specific to blood lead screening tests, annual EPSDT reporting suggests that there is 
room for improvement in blood lead screening tests.  When the number of blood 
lead screening tests reported nationally in 2018 on Form CMS-416 is compared to the 
number of eligible children, the data suggest that only about 46 percent of children 
between 12 months and 24 months of age received a blood lead screening test.40, 41  
This reporting methodology introduces imprecision; rates could be impacted if any 
child has more than one Medicaid identification number, or if any child receives 
multiple blood lead screening tests during a period of enrollment.  Furthermore, 
EPSDT reporting may not capture all instances of blood lead screening tests in cases 
in which tests were not billed to Medicaid.  Sometimes, Medicaid-enrolled children 
may receive testing through participation in Head Start, WIC, or other programs 
funded by State and local health agencies.  In addition to tracking screening services, 
CMS requires States to count the total number of children referred for corrective 
services and/or treatments in cases in which screenings identified illnesses or 
conditions (e.g., an EBLL identified through a blood lead screening test).   
State Lead Surveillance Programs 
Some State and local health departments receive grant funding from CDC for 
activities such as establishing programs to prevent childhood lead poisoning.42  These 
programs promote education, enhanced blood lead screening efforts, and referrals 
for medical and environmental intervention in cases of childhood lead exposure.43  
The programs often play a role in State surveillance efforts as well, including the 
collection and reporting of blood lead screening test data to ensure that children with 
EBLLs receive followup and case management.44  For all States included in this review, 
practitioners and/or laboratories are required to report the results of any childs blood 
lead screening test, regardless of BLL, for lead surveillance purposes.  CDC currently 
funds 35 programs in States and some large cities, and requires quarterly reporting of 
lead surveillance data as a condition of the grant.45, 46  CDC applies standard 
definitions and classifications for terms such as screening test in its collection of 
States lead surveillance data.47  See Exhibit 1 on the next page for selected State 
activities to prevent childhood lead exposure and improve blood lead screening test 
rates. 
 
 
 
 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Background | 4  Exhibit 1: Following our FYs 2015-18 review period, selected States engaged 
in activities to prevent childhood lead exposure and support lead 
surveillance efforts. 
State  Activity 
 
CA  In 2020, California enacted legislation to improve the provision of blood lead screening tests 
  
among children enrolled in Medicaid Managed Care plans.48  The Department of Public 
Health collaborated with the Department of Health Care Services on a strategy to identify 
providers with low rates of performing blood lead screening tests for Medicaid-enrolled 
children and to improve screening practices among these providers.49 
NY  In 2019, the New York State Public Health Law was amended to lower the definition of an 
EBLL from 10 ug/dL to 5 ug/dL.50  New York City implemented a campaign to prevent lead 
poisoning, including an initiative to increase the number of children that receive blood lead 
screening tests.51 
OH  During Healthy Homes Awareness Month in 2019, staff from the Ohio Department of Health 
visited physicians offices and offered trainings to increase the provision of blood lead 
screening tests for at-risk children.  The Department of Health also received $10 million from 
the Ohio State Medicaid agency to fund lead hazard control projects.52  
PA   In 2019, the State implemented an initiative to increase childrens access to blood lead 
screening tests.  The Pennsylvania Department of Health also collaborated with the State 
Medicaid agency on a data-matching project to improve lead surveillance data and the 
provision of screenings for Medicaid-enrolled children.53 
TX  In 2019, the Texas lead poisoning prevention program collaborated with the University of 
Texas on a data project to assess the completeness of State lead surveillance data.  The 
collaboration also included production of a series of educational modules for providers on 
compliance related to blood lead screening tests, reporting, and followup.54 
Source: OIG review of State activity documentation, 2021. 
Methodology 
This study includes an evaluation of Medicaid claims and blood lead testing data from 
State health departments, a practitioner survey, and stakeholder interviews.  We did 
not conduct a medical record review to determine the rate of EBLLs among children 
who received blood lead screening tests or the efficacy of treatment; this material can 
be found in a future OIG companion report.   
To assess the extent to which children in five selected States received required blood 
lead screening tests, we collected Medicaid Management Information System data for 
FYs 2015-18.  Specifically, we collected fee-for-service claims, managed care 
encounter claims, and eligibility data from the States of California, New York, Ohio, 
Pennsylvania, and Texas.  We also collected blood lead testing data from the selected 
States health departments for the same time period.  Together, the combined data 
comprised blood lead screening tests that Medicaid-enrolled children received in 
medical office visits, labs, and in other settings (e.g., tests administered at public 
health fairs) for the cumulative period of review. 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Background | 5  We conducted several analyses of the combined Medicaid and State health 
department data.  To account for BLL tests that occurred at the required 12- and 
24-month time periods, and off-schedule tests that occurred for a subset of children, 
we determined the percentages of Medicaid-enrolled children who received:  
1)  a blood lead screening test on schedule at 12 months and at 24 months of 
age; and  
 
2)  a blood lead screening test at any point before 3 years of age. 
 
For the above analyses, we identified evidence of blood lead tests within each of the 
time periods.  From the Medicaid data, we used a blood lead test procedure code 
detailed in the Form CMS-416 instructions to States for annual reporting.  From the 
State health department data, we counted dates of service for blood lead tests.  The 
analyses also contained other criteria that precluded comparison to aggregate blood 
lead test data in annual EPSDT reporting.  See Detailed Methodology for further 
details regarding our analyses. 
To collect information regarding challenges in the provision of blood lead screening 
tests, followup services, and treatment, we surveyed practitioners and conducted 
stakeholder interviews.  We surveyed 706 practitioners in the selected States about 
lead screening and diagnosis practices, and any barriers to the provision of blood lead 
screening tests, followup services, and treatment.  We received responses from 
193 practitioners, which was a simple final response rate of 27 percent (see 
Limitations below).55  We interviewed stakeholders from government agencies and 
professional organizations regarding blood lead screening tests and outreach to 
practitioners, parents, and caregivers.  We reviewed the survey responses and 
interview data to identify common themes.   
Limitations.  It is possible that some children in our review received blood lead 
screenings that were not submitted to Medicaid or reported to State health 
departments.  Therefore, this study may underestimate the number of children who 
received blood lead screenings.  In addition, we relied on State health departments to 
match the data and did not verify the accuracy of their efforts. 
In the weeks and months following the deployment of the practitioner survey, the 
COVID-19 pandemic impacted day-to-day operations in practitioners offices in some 
States and many practitioners did not respond to repeated requests to complete the 
survey.  Because of the low survey response rate of 27 percent, results of the 
practitioner survey are not generalizable. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
 
 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Background | 6   
FINDINGS 
 
More than one-third of Medicaid-enrolled children in 5 States 
did not receive a blood lead screening test at 12 months or 
24 months of age, as required by Medicaids schedule 
More than one-third of Medicaid-enrolled children in the five selected States did not 
receive a required blood lead screening test on schedule.  That is, 38 percent of the 
approximately 1 million children who should have received a 12-month test and a 
24-month test received 
neither test (see Exhibit 5 in 
Exhibit 2: In selected States, many children 
Detailed Methodology).  
Medicaids schedule requires  did not receive blood lead screening tests at 
that enrolled children be  required intervals. 
screened for lead exposure 
38% of Medicaid-enrolled children 
via blood testing at 12 months 
did not receive a 12-month or a 
and 24 months of age.   
24-month blood lead screening test. 
For more information 
regarding our review of 
Medicaid claims and blood  Source: OIG analysis of Medicaid claims data, 2021. 
lead testing data from State 
health departments, please see Detailed Methodology.  See Appendix B for more 
information on individual State rates of blood lead screening tests.   
Fifty percent of Medicaid-enrolled children in 5 States did not 
receive a blood lead screening test at 12 months of age, as 
required by the schedule 
Of the 1.8 million Medicaid-enrolled children who should have received a blood lead 
screening test at 12 months of age in the selected States, more than 900,000 children 
did not receive a test.  The scheduled 12-month blood lead screening test is 
important to identify early exposure and to establish primary prevention efforts.  For 
children who drink formula, and may thereby ingest greater quantities of tap water, 
this initial required test could aid practitioners in timely detection of EBLLs in cases in 
which water is the source of lead exposure.  Early testing also offers practitioners an 
opportunity to educate parents on lead exposure risks and to discuss how to create a 
lead-safe environment for children as they learn to crawl and walk.   
For more details regarding States rates of blood lead screening tests for children at 
12 months of age, see Appendix B.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Findings | 7  Nearly two-thirds of Medicaid-enrolled children in 5 States did 
not receive a blood lead screening test at 24 months of age, as 
required by the schedule 
Of the 1.9 million Medicaid-enrolled children who should have received a blood lead 
screening test at 24 months of age, more than 1.2 million children did not receive a 
test.  In all 5 States, a smaller 
proportion of children  Exhibit 3: In all 5 States, a higher proportion 
received this second required  of Medicaid-enrolled children received a 
blood lead screening test,  blood lead screening test at 12 months of 
compared to the number of  age than at 24 months of age. 
children who were tested at 
12 months of age.   
As children age, the number of 
scheduled medical office visits 
for EPSDT screenings typically 
decreases.  Therefore, during 
their second year of life, 
Medicaid-enrolled children may 
have fewer opportunities to be 
examined by practitioners and 
fewer opportunities to receive 
their second required blood lead 
screening test.   
For young children who often 
exhibit hand-to-mouth 
behaviors, the scheduled 
24-month blood lead screening 
test is critical; as children gain 
mobility, they face increased 
risks of encountering lead in dirt 
and dust, toys, and consumer 
products around the home.  The 
Source: OIG analysis of Medicaid claims data, 2021. 
second scheduled test also provides 
practitioners with another opportunity to educate parents and to discuss the impacts 
of diet and nutrition on childhood lead absorption. 
For more details regarding States rates of blood lead screening tests for children at 
24 months of age, see Appendix B.  
 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Findings | 8  For those children who had been continuously enrolled in 
Medicaid from birth through age 3, 1 in 5 children in the 
selected States had never received a blood lead screening test 
by 3 years of age 
Of the approximately 209,000 children with continuous Medicaid enrollment from 
birth to 3 years of age in 
the 5 States, 21 percent of 
Exhibit 4: In selected States, some children 
the children had not 
were never tested for elevated blood lead 
received a blood lead 
levels before their third birthday. 
screening test before their 
third birthday (see 
21% of children with continuous 
Appendix B).   
enrollment in Medicaid from birth 
did not receive a blood lead 
Children included in this 
screening test by 3 years of age. 
analysis had 3 years of 
continuous Medicaid 
enrollment and therefore  Source: OIG analysis of Medicaid claims data, 2021.
had more time to receive a 
blood lead screening test than children included in the 12- and 24-month analyses. 
Still, many were never tested. 
Stakeholders called for consistent requirements for blood lead 
screening tests and practitioners reported challenges with 
providing tests for Medicaid-enrolled children   
Through interviews with stakeholders (e.g., government agencies and professional 
organizations) and surveys of practitioners, we gathered insights and challenges 
related to providing blood lead screening tests and followup services for 
Medicaid-enrolled children.  Although CMS does not establish clinical guidelines, 
stakeholders called for CMS to adopt an actionable blood lead reference value (i.e., a 
blood lead level at which public health actions should be initiated), as the blood lead 
reference values published in the CMS State Medicaid Manual and the 2016 
Informational Bulletin are not consistent.  Stakeholders also called for consistent 
definitions related to blood lead screening tests.  Furthermore, surveyed practitioners 
reported logistical challenges and other barriers related to providing blood lead 
screening tests for Medicaid-enrolled children.  See Appendix C for response rates to 
individual survey questions. 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Findings | 9  Stakeholders called for consistency across CMS guidance related 
to actionable blood lead reference values and blood lead 
screening test terminology  
Stakeholders described opportunities for CMS to adopt consistent blood lead 
reference values and blood lead screening definitions across CMS requirements and 
guidance.  Stakeholders reported challenges related to the lack of a consistent 
actionable blood lead reference value.  Although the CMS State Medicaid Manual 
defines a BLL of 10 g/dL as actionable, CMS Informational Bulletin references CDCs 
actionable BLL of 5 g/dL.  Therefore, practitioner reimbursement for activities to 
identify the source of a childs lead exposure could be limited by some State Medicaid 
agencies to only those cases in which a child has an actionable BLL of 10 g/dL or 
above.  Stakeholders agreed and shared that discrepancies in what qualifies as an 
actionable BLL can limit a childs access to followup services and interventions.  
Stakeholders also noted that CMS requirements and guidance lack definitions for 
blood lead testing terms.  For example, the CMS State Medicaid Manual does not 
include definitions for the terms test, screening test, and confirmed elevated BLL, 
which are included in CDCs standard lead surveillance definitions.    
Practitioners reported logistical challenges and other barriers 
related to providing blood lead screening tests  
Surveyed practitioners reported challenges with parental followup related to 
scheduled lab appointments, which can limit practitioners abilities to screen for 
EBLLs.  Practitioners noted that children frequently miss scheduled lab appointments 
where they would receive initial and/or followup blood lead screening tests because 
these tests often require an additional office visit.  If Medicaid-enrolled children do 
not attend lab appointments to obtain testing on schedule, practitioners may not be 
aware of EBLLs, leaving children vulnerable to the toxic effects of lead exposure.   
Practitioners also reported that parents occasionally decline blood lead screening 
tests and followup tests for children.  During the first few years of life, a child attends 
frequent medical office visits for preventive care EPSDT screenings and typically 
receives immunizations at each appointment.  Parents may not want to subject their 
child to a capillary or venous blood draw on top of the multiple immunizations that 
may occur during an office visit.  When parents decline screenings during scheduled 
EPSDT medical office visits, practitioners could miss screenings at later dates, causing 
Medicaid-enrolled children to fall behind schedule for critical BLL testing. 
 
 
 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Findings | 10   
CONCLUSION AND RECOMMENDATIONS 
 
 
During the timeframe of this work, CMS took steps to coordinate with partners in 
support of blood lead screening test requirements for Medicaid-enrolled children.  
Some activities included the development of a 2016 Informational Bulletin, a session 
at a CMS Quality Conference, and a webinar as part of National Lead Poisoning 
Prevention Week.   
Despite these efforts, our review determined that CMS must continue to focus its 
attention on the blood lead screening test component of EPSDT.  To date, only one 
State has been approved for a targeted lead screening program,56 and most 
Medicaid-enrolled children are required to receive blood lead screening tests at 12 
months and 24 months of age, per Medicaids schedule.  However, we found that 
many Medicaid-enrolled children did not receive required blood lead screening tests 
on schedule.  In fact, half of the children in selected States did not receive their first 
required blood lead screening test at 12 months of age, and more than 60 percent of 
children did not receive their second required test at 24 months of age.    
Via stakeholder interviews and practitioner surveys, we identified several factors that 
may contribute to low participation rates in the BLL testing component of EPSDT.  We 
determined that existing CMS guidance is lacking consistency in actionable blood 
lead reference values and definitions to help guide the provision of blood lead 
screening tests, diagnosis of EBLLs, and followup services.  Additionally, we 
determined that missed lab appointments and declined blood lead screening tests 
present serious challenges to timely testing for and diagnosis of EBLLs.   
On the basis of these findings, we recommend that CMS implement strategies to 
address these challenges.  Specifically, we make three recommendations to CMS: 
Monitor national EPSDT performance data for blood lead 
screening tests and target efforts toward low-performing States 
to develop action plans for increasing tests, according to 
Medicaids schedule 
CMS should actively monitor national EPSDT performance data for blood lead 
screening tests to identify low-performing States.  For low-performing States in the 
lowest quartile, CMS should request that States develop action plans to improve 
blood lead screening test rates.  CMS should also alert States if they are at risk of 
entering the lowest quartile.  The plans should include State-specific objectives to 
improve screening rates and ensure Medicaid-enrolled children receive BLL testing on 
schedule.  The plans should also establish reasonable timelines for States to meet 
outlined objectives and allow CMS to track progress over time.  The plans could 
promote the use of innovative strategies (e.g., linking Medicaid claims with State 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Recommendations | 11  health department data to identify testing deficiencies; launching point-of-care 
testing initiatives to support blood lead screening tests in medical office settings).57, 58  
Finally, the plans could encourage States to report promising strategies to improve 
rates of blood lead screening tests.   
Ensure consistency across CMS guidance related to actionable 
blood lead reference values and blood lead screening test 
definitions 
CMS should adopt consistent blood lead reference values and definitions for blood 
lead screening tests across CMS guidance.  To accomplish this, CMS should ensure 
the actionable blood lead reference value across its guidance aligns with the CDCs 
actionable blood lead reference value.  Furthermore, CMS should consider 
incorporating the CDCs standard lead surveillance definitions across CMS guidance.  
Coordinate with partners to develop and disseminate to State 
Medicaid agencies educational materials that reaffirm 
requirements and schedules for blood lead screening tests  
CMS should continue to coordinate with Federal agencies (e.g., CDC) and medical 
organizations (e.g., AAP) to develop educational materials to share with State 
Medicaid agencies.  To support early identification and improved outcomes for 
children exposed to lead, the materials should clearly communicate Medicaids 
requirements and testing schedule, and the materials should highlight the current 
actionable blood lead reference value.  CMS could share these materials and reaffirm 
its support for improved blood lead screening test rates by developing an 
Informational Bulletin or holding a workshop for State Medicaid agencies.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Recommendations | 12   
AGENCY COMMENTS AND OIG RESPONSE 
 
CMS concurred with all of our recommendations.  
In response to our first recommendationfor CMS to monitor national EPSDT 
performance data for blood lead screening tests and target efforts toward low 
performing States to develop action plans for increasing tests, according to 
Medicaids scheduleCMS stated that it would monitor national EPSDT performance 
data for blood lead screening tests in order to identify States performing in the lowest 
quartile.  CMS will request that States performing in the lowest quartile develop an 
action plan, and CMS will provide technical assistance, as necessary. 
In response to our second recommendationfor CMS to ensure consistency across 
CMS guidance related to actionable blood lead reference values and blood lead 
screening test definitionsCMS stated that it recognizes the need for consistent 
guidance, and will work to ensure that CMS guidance reflects the current blood lead 
reference value established by the CDC. 
In response to our third recommendationfor CMS to coordinate with partners to 
develop and disseminate to State Medicaid agencies educational materials that 
reaffirm requirements and schedules for blood lead screening testsCMS stated that 
it has undertaken considerable outreach efforts around Medicaid blood lead 
screening requirements, and remains committed to working with both Federal and 
State partners to ensure that all children enrolled in Medicaid and CHIP receive 
required blood lead screening tests.  CMS will continue to engage with its partners 
and identify educational and outreach materials available to help states reaffirm 
requirements and schedules for blood lead screening tests. 
OIG appreciates CMSs steps to address deficiencies in childhood blood lead 
screening tests for Medicaid-enrolled children, and continues to encourage CMSs 
efforts to engage both Federal and State partners in protecting children from toxic 
lead exposure. 
Appendix D provides the full text of CMSs comments. 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Agency Comments and OIG Response | 13  DETAILED METHODOLOGY 
 
State Selection 
For this evaluation of blood lead screening tests, and a forthcoming companion 
medical record review of followup services and treatment for children with elevated 
blood lead levels (EBLLs), we selected five States: California, New York, Ohio, 
Pennsylvania, and Texas.  These States had among the highest number of children 
with confirmed EBLLs, based on National Childhood Blood Lead Surveillance Data 
from the Centers for Disease Control.  We selected these States to ensure that we 
would have a large enough population of children with EBLLs to sample from for our 
medical record review.   
Medicaid Claims and State Health Department Data Analysis 
Population Selection 
This study included Medicaid-enrolled children born between January 1, 2013, and 
December 31, 2016, from California, New York, Ohio, Pennsylvania, and Texas.  We 
examined the population of children with at least 6 months of continuous Medicaid 
enrollment who were eligible to receive a blood lead screening test at 12 months of 
age and at 24 months of age.  We also evaluated the population of children with 
continuous Medicaid enrollment starting at birth who received a blood lead screening 
test by 3 years of age.   
Data Collection 
Medicaid Claims.  We collected Medicaid Management Information System 
fee-for-service and managed care encounter claims from Fiscal Years (FYs) 2015 
through 2018, as well as all of the dates of Medicaid eligibility for the defined 
population in the selected States.  The data included eligibility information and all 
incurred outpatient claims (i.e., all claims that practitioners submitted) for our 
population of children.  
State Health Department Data.  Medicaid-enrolled children may receive blood lead 
screening tests that are not billed to Medicaid.  To capture tests that were not 
submitted to Medicaid but were reported to State health departments, we requested 
blood lead testing data from each of the selected States.  Specifically, unique 
identifiers of 2,284,414 Medicaid-enrolled children were sent to respective State 
health departments.  The health departments matched these children to blood lead 
testing databases and returned relevant blood lead screening tests to OIG.   
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Detailed Methodology | 14  Blood Lead Screening Rate Analysis 
Eligibility.  From the Medicaid claims, we identified children for the 12-month and 
24-month screening rate analyses who were continuously enrolled in Medicaid and
eligible to receive a blood lead screening test for 3 months preceding and 3 months
following their first and second birthdays, respectively.  For instance, children in the
12-month analysis had to have been continuously enrolled in Medicaid from 9
months of age to 15 months of age.  This approach provided a reasonable buffer for
children to meet the EPSDT requirement.  Children in the combined 12-month and
24-month analysis (i.e., finding 1 on page 8) had to have continuous Medicaid
enrollment from 9 to 15 months of age and 21 to 27 months of age.  Therefore,
children included in the combined analysis were also represented in the respective
12-month and 24-month analysis populations (see Exhibit 4 below).  Children
included in the 3-year analysis had to have been continuously enrolled in Medicaid
from birth to 3 years of age.  Children with a populated date of death variable were
excluded from all analyses.
Exhibit 5: Children in the combined 12-month and 24-month analysis were 
also represented in the respective 12-month and 24-month analysis 
populations of Medicaid-enrolled children.  
12-month analysis: Combined analysis:  24-month analysis:
906,497 out of  383,506 out of  1,207,236 out of 
1,807,450 enrolled  1,016,811 children  1,868,147 enrolled 
children (50 percent)  (38 percent) with  children (65 percent) 
did not receive a blood  both 12-month and  did not receive a blood 
lead screening test  24-month Medicaid lead screening test 
enrollment received
no tests 
Source: OIG analysis of Medicaid claims data, 2021. 
Data Analysis.  To identify blood lead screening tests for enrolled children in the 
cumulative Medicaid claims data, we referenced the CMS Form-416 instructions for 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Detailed Methodology | 15  States.  Form-416 criteria allow States to report blood lead screening tests as claims 
with a blood lead test medical procedure, accompanied by certain diagnoses, or by 
reporting data collected from the use of a measure developed by the National 
Committee for Quality Assurance.59  We broadly defined a blood lead screening test 
as any instance of a blood lead test procedure code, regardless of diagnosis, to 
facilitate matching with State health department data. 
For Medicaid-enrolled children who were eligible for one of the respective analyses 
(e.g., the 12-month analysis) but did not have a qualifying blood lead screening test 
claim, we looked for blood lead screening tests in State health department data.  
Specifically, we looked for evidence of dates of service for blood lead tests.  These 
data were merged with Medicaid data to determine a more complete screening rate 
and account for tests received during medical office visits, in labs, and in other 
settings in which tests may not have been billed to Medicaid (e.g., tests administered 
at public health fairs or schools).  See Appendix B for States screening rates.   
Unit of Measure.  The findings in this study are expressed in terms of unique children 
and the number of required blood lead screening tests enrolled children received 
before age 3.  For this reason, we do not report our analysis broken out by fiscal year 
as this would limit our ability to track a child over time.  It is possible for a child to 
have multiple Medicaid identification numbers within a State.  Therefore, prior to 
analysis, we created an arbitrary, unique identifier per child based on Social Security 
numbers.  This approach reduces the probability of reporting the same child more 
than once.  
 Data Validation and Quality Assurance 
We performed extensive data validation and quality assurance checks, including:  
 null analysis of selected variables compared to Medicaid Statistical Information
System threshold tolerances;60
 independent, peer review, and quality assurance checks of all analyses; and
 incorporation of each States timeliness of reporting guidelines into analysis.
Through this validation process, we concluded that the data were usable for the 
analyses conducted for this study.   
Practitioner Survey 
Population Selection 
For the 5 States included in this evaluation, we identified 35,116 unique National 
Provider Identifiers (NPIs) for Medicaid-enrolled practitioners who billed for well-child 
medical procedure office visits from FY 2015 through FY 2018.    
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Detailed Methodology | 16  Sample 
From this population, we selected a simple random sample of 150 practitioners 
enrolled in Medicaid in each of the 5 States, as identified in the Medicaid claims 
analysis.  Thirty-five of the selected NPIs were associated with businesses and 9 of the 
selected NPIs were deactivated or associated with practitioners who had retired.  This 
resulted in a final sample size of 706 practitioners.   
Survey of Practitioners 
We administered a survey to the sampled practitioners regarding practices and 
barriers related to childhood blood lead screening tests, followup services, and 
treatment for Medicaid-enrolled children.  We asked the practitioners about topics 
including: (1) when and how they typically conduct blood lead screenings for 
Medicaid-enrolled children; (2) any barriers they face when screening and providing 
services for Medicaid-enrolled children; and (3) their experiences with guidance and 
educational resources related to blood lead screenings.  We collected the survey data 
from February to June 2020. 
To distribute the survey, we mailed practitioners a letter and a paper copy of the 
survey informing them of the effort.  We also sent an email with a link to a web-based 
survey.  We made multiple attempts to contact practitioners via mail, email, phone, 
and facsimile. 
We received responses from 193 practitioners for a final response rate of 27 percent.  
The weighted response rate, based on responses within each State, was 25 percent.  
To evaluate practices and barriers related to childhood blood lead screening tests, 
followup services, and treatment for Medicaid-enrolled children, we analyzed the 
193 survey responses.  Due to the low response rate, and item nonresponse for 
individual questions, results of the survey are not generalizable.  See Appendix C for 
response rates to individual survey questions. 
Stakeholder Interviews 
To gather information regarding childhood lead exposure, blood lead screening tests, 
and outreach to practitioners, parents, and caregivers, we conducted structured 
interviews with stakeholders.  The interview respondents included specialists from the 
Pediatric Environmental Health Specialty Unit Network and the Agency for Toxic 
Substances and Disease Registry, and officials from the American Academy of 
Pediatrics and the Childrens Environmental Health Network.   
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Detailed Methodology | 17   
APPENDIX A 
 
Requirements and Guidance for Blood Lead Screening Tests and 
Followup for Elevated Blood Lead Levels 
The following tables provide an overview of requirements and guidance from CMS, the CDC, 
and AAP regarding blood lead screening tests, followup services, and treatment for children.  
Risk Assessment /  Blood Lead Screening Tests  Additional 
Screening Questions  Considerations 
CMS State  All children are 
All children enrolled in Medicaid are required to 
considered at risk and 
Medicaid  receive a screening blood test at 12 months and 
must be tested for lead 
ManualI  at 24 months.  Children between 36 months and 
poisoning.
72 months of age must receive a screening 
blood lead test if they have not been screened 
previously.  A blood lead test result equal or 
greater than 10 ug/dL obtained by capillary 
specimen (fingerstick) must be confirmed using a 
venous sample.
CMS 2016  Completion of a risk assessment  All children enrolled in Medicaid are required to  To align the Medicaid 
questionnaire does not meet the  receive blood lead screening tests at ages 12  lead screening policy 
Informational 
Medicaid requirement.   months and 24 months.  In addition, any child  with that of the CDC, 
BulletinII 
between 24 months and 72 months of age with  CMS expanded its lead 
no record of a previous blood lead screening test  screening policy in 
must receive one.  The Medicaid requirement is  2012 to allow states to 
met only when the two blood lead screening  request approval from 
tests (or a catchup) are conducted.  CMS to implement a 
targeted lead screening 
program.  
CDCIII  Clinicians roles should include  The CDC recommends that Medicaid-enrolled 
screening questions, outreach,  children be screened at ages 12 months and 24 
and education to minimize  months, and once between 36 months and 72 
exposures prior to blood lead  months for those without prior screening. 
testing.IV 
AAPV  The Bright Futures/AAP  A blood lead test is only recommended if the risk  Universal screens or 
Periodicity Schedule recommends  assessment comes back positive or as  blood lead level tests 
a risk assessment at the following  appropriate based on universal screen  are no longer 
well-child visit intervals: 6  requirements for patients with Medicaid or in  recommended except 
months, 9 months, 12 months, 18  high prevalence areas.  for in high prevalence 
months, 24 months, and at 3, 4, 5,  areas with an increased 
and 6 years of age.  risk factor. 
Sources: I) CMS, The State Medicaid Manual, Chapter 5: Early and Periodic Screening, Diagnostic and Treatment Services, section 
5123.2.D.  Accessed at https://go.usa.gov/xU2VG on October 29, 2017.  
II)CMS, CMCS Informational Bulletin, Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Childrens Health
Insurance Program, November 30, 2016.  Accessed at https://go.usa.gov/xHF8p on August 26, 2020.
III)CDC, Recommendations for Blood Lead Screening of Medicaid-Eligible Children Aged 1-5 Years: An Updated Approach to
Targeting a Group at High Risk, August 7, 2009.  Accessed at https://go.usa.gov/xFx5u on August 10, 2020.
IV)CDC, Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention, January 4, 2012.  Accessed at
https://go.usa.gov/xU58B on July 16, 2018.
V)AAP, Detection of Lead Poisoning, 2016.  Accessed at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-
exposure/Pages/Detection-of-Lead-Poisoning.aspx on July 15, 2018.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix A | 18  Blood Lead Reference Level Recommended Recommended Treatment 
Followup 
CMS State  10 ug/dL (see Recommended  If a child is found to have blood lead levels 
Treatment) equal to or greater than 10 ug/dL, providers are 
Medicaid 
to use their professional judgment with 
ManualI 
reference to CDC guidelines covering patient 
management and treatment, including followup 
blood tests and initiating investigations to 
determine the source of lead, where indicated.
CMS 2016  The bulletin references the CDC,  States should have  Under the EPSDT benefit, Medicaid provides 
which recommends 5 ug/dL is the  guidance and  comprehensive coverage for any service 
Informational 
threshold level at which public  resources available to  described in section 1905(a) of the Social 
BulletinII 
health actions be taken  support providers,  Security Act needed that is medically necessary 
families and other  to correct or ameliorate defects in physical and 
stakeholders who work  mental illnesses or conditions identified by the 
to obtain appropriate  screening services.  States have an affirmative 
services for children  obligation to ensure that Medicaid-eligible 
with EBLLs.  children and their families are aware of the 
services that are a part of the EPSDT benefit 
and have access to required screenings and 
necessary treatment services. 
Medicaid also provides reimbursement for lead 
investigations in the home or primary residence 
of a child with an EBLL. 
CDCIII  The CDC uses a blood lead  The CDC provides a  The CDC provides a summary of 
reference value of 5 ug/dL, which is  schedule for followup  recommendations for followup and case 
based on National Health and  blood lead testing for  management of children based on confirmed 
Nutrition Examination Survey data  blood lead levels  blood lead levels ranging from <5 ug/dL to 
from 2007-2008 and 2009-10.   ranging from 5-9  70 ug/dL.  Services range from anticipatory 
ug/dL to 45 ug/dL.IV  guidance and environmental investigations for 
lower ranges to abdominal x-rays and chelation 
for higher ranges.IV 
AAPV  The current reference value is  Recommended treatment includes finding and 
5 g/dL or greater for case  eliminating the source of lead, instruction in 
management.  personal and household hygiene measures, 
optimizing the childs diet and nutritional 
status, and close followup. 
Sources: I) CMS, The State Medicaid Manual, Chapter 5: Early and Periodic Screening, Diagnostic and Treatment Services, section 
5123.2.D.  Accessed at https://go.usa.gov/xU2VG on October 29, 2017. 
II) CMS, CMCS Informational Bulletin, Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Childrens Health
Insurance Program, November 30, 2016.  Accessed at https://go.usa.gov/xHF8p on August 26, 2020.
III) CDC, Blood Lead Levels in Children.  Accessed at https://www.cdc.gov/nceh/lead/prevention/blood-lead-levels.htm on August 28, 2020.
IV) CDC, Summary of Recommendations for Follow-up and Case Management of Children Based on Confirmed Blood Lead Levels.  Accessed
https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm on December 14, 2017.
V)AAP, Treatment of Lead Poisoning.  Accessed at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-
exposure/Pages/Treatment-of-Lead-Poisoning.aspx on August 28, 2020.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix A | 19   
APPENDIX B 
 
States Blood Lead Screening Test Rates 
Table B-1: Number of Medicaid-enrolled children in 5 States who did not receive a blood 
lead screening test* at 12 months of age 
Number of   Number of Enrolled Children  Percentage of Enrolled Children Who 
Enrolled Children  Who Did Not Receive a Test*  Did Not Receive a Test 
12-Month Eligibility**
California  713,086  414,538  58.13% 
New York  334,404  105,798  31.64% 
Ohio  211,951  106,007  50.01% 
Pennsylvania  175,233  67,510  38.53% 
Texas  372,776  212,644  57.04% 
Total  1,807,450  906,497  50.15% 
Table B-2: Number of Medicaid-enrolled children in 5 States who did not receive a blood 
lead screening test* at 24 months of age 
Number of   Number of Enrolled Children  Percentage of Enrolled Children Who 
Enrolled Children  Who Did Not Receive a Test*  Did Not Receive a Test 
24-Month Eligibility**
California  713,659  521,497  73.07% 
New York  373,130  165,539  44.36% 
Ohio  220,288  147,801  67.09% 
Pennsylvania  174,224  106,002  60.84% 
Texas  386,846  266,397  68.86% 
Total  1,868,147  1,207,236  64.62% 
Source: OIG analysis of Medicaid claims data, 2021. 
*For these analyses, we counted blood lead test procedures within Medicaid claims data and dates of service for BLL tests identified by
State health departments to determine whether Medicaid-enrolled children received required blood lead screening tests on schedule at
12 months and at 24 months of age.
**12-month and 24-month eligibility analyses included children with continuous enrollment 3 months preceding and 3 months following
12 months of age, and 3 months preceding and 3 months following 24 months of age.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix B | 20  Table B-3: Number of Medicaid-enrolled children in 5 States who did not receive a blood 
lead screening test* by 3 years of age  
Number of   Number of Enrolled Children  Percentage of Enrolled Children Who 
Enrolled Children  Who Did Not Receive a Test*  Did Not Receive a Test 
3 Years of Continuous Eligibility** 
California  63,204  19,599  31.01% 
New York  68,077  5,139  7.55% 
Ohio  46,383  12,070  26.02% 
Pennsylvania  23,671  4,315  18.23% 
Texas  8,013  2,758  34.42% 
Total  209,348  43,881  20.96% 
Source: OIG analysis of Medicaid claims data, 2021. 
*For this analysis, we counted blood lead test procedures within Medicaid claims data and dates of service for BLL tests identified by State
health departments to determine whether Medicaid-enrolled children received a BLL test within 3 years of age.
**The 3-year eligibility analysis included children with continuous Medicaid eligibility from birth to age 3.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix B | 21   
APPENDIX C 
 
 
Survey Responses From Practitioners in the Sample 
Table C-1: Number of Practitioners in Sample Who Reported That They Have Experienced 
Barriers Related to Screening Children for Lead* (n=156) 
Barriers  California  New York  Ohio  Pennsylvania  Texas  Total 
Number of 
Practitioners 
Missed appointments  11  16  15  22  30  94 
Lapses in Medicaid coverage  6  6  4  4  21  41 
Parents decline screening  7  5  4  9  9  34 
Requires travel to offsite  3  2  4  10  3  22 
location 
Informational and/or  2  2  2  1  6  13 
educational barriers for parents 
Other  4  1  0  4  2  11 
Requires additional  2  0  2  1  5  10 
appointments 
Shortage of clinical staff and/or  2  0  1  2  2  7 
resources 
Source: OIG analysis of survey responses from 193 practitioners, 2021. 
*Practitioners could select multiple barriers and are represented in more than one category.  Among respondents, 114 practitioners
selected at least one barrier, including Other.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix C| 22  APPENDIX D:  AGENCY COMMENTS
DATE:  September 21, 2020 
TO:  Christi A. Grimm  
Principal Deputy Inspector General 
Office of Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
Centers for Medicare & Medicaid Services 
SUBJECT:  Office of Inspector General (OIG) Draft Report: More than One-Third of 
Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead 
Screening Tests (OEI-07-18-00371) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report. CMS is committed to working 
with both federal and state partners to ensure that all children enrolled in Medicaid and the 
Childrens Health Insurance Program (CHIP) receive required blood lead screening tests. 
The amount of lead in blood is referred to as blood lead level, which is measured in micrograms 
of lead per deciliter of blood (g/dL), and the Centers for Disease Control and Prevention (CDC) 
currently uses a blood lead reference value of 5 g/dL to identify children with elevated blood 
lead levels (EBLLs). Lead exposure can affect nearly every system in the body and often goes 
undetected because, at low levels of exposure, it may display no obvious symptoms. 
Comprehensive screening and surveillance ensures that lead-poisoned infants and children 
receive the necessary medical and environmental follow-up as soon as possible, and also allows 
for the development of neighborhood-based efforts to prevent lead poisoning. 
As young children are especially vulnerable to lead exposure, all children enrolled in Medicaid 
or Medicaid expansion CHIP (M-CHIP) are required to receive blood lead screening tests at 12 
months and 24 months of age, or a catch-up blood lead screening test at up to 72 months of age if 
there is no record of a previous blood lead screening test. CMS has clarified for states that the 
completion of a risk assessment questionnaire does not meet the requirement, and that the 
Medicaid requirement is met only when the 12- and 24-month blood lead screening tests, or a 
catch-up blood lead screening test, are conducted. Separate CHIP programs (S-CHIP) do not 
have the same requirements for universal lead screening as Medicaid; however, CMS encourages 
states to align their CHIP and Medicaid screening policies. At this time, all S-CHIP states cover 
blood lead screening tests and medically necessary care for children with identified EBLLs.   
As noted in the OIGs report, the Early and Periodic Screening, Diagnostic and Treatment 
(EPSDT) benefit covers the required blood lead screening tests as well as any medically 
necessary care for children with identified EBLLs. In addition, Medicaid will provide 
reimbursement for lead investigations in the home or primary residence of a child with an EBLL 
if the investigation is conducted by a credentialed health practitioner who meets the 
qualifications established by the state and is undertaken to identify the source of lead exposure. 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  
Appendix D | 23 APPENDIX D:  AGENCY COMMENTS
States have an affirmative obligation to ensure that Medicaid enrolled children and their families 
are aware of the services that are a part of the EPSDT benefit and have access to required 
screenings and necessary treatment services.  
State Medicaid agencies are required to submit EPSDT data annually to CMS using the Form 
CMS-416, which includes the number of blood lead screening tests for children enrolled in 
Medicaid, from birth to age six. According to data reported on the Form CMS-416, the number 
of children enrolled in Medicaid who receive blood lead screening tests varies considerably from 
state to state. Further, because the Form CMS-416 only captures Medicaid claims and encounter 
based data, it underrepresents the actual number of children who received blood lead screening 
tests. For example, it does not capture screenings that are not paid for by Medicaid, such as 
screenings performed by clinics using CDC funding or funded by state health departments. CMS 
encourages states to review their most recent Form CMS-416 data submission and any other 
available data sources, including CDC surveillance data, to better understand their states blood 
lead screening rate. 
In support of state efforts to improve blood lead screening rates for children, CMS issued an 
informational bulletin1 in November 2016 to remind states of the screening requirements for 
children enrolled in Medicaid and CHIP and the current recommended blood lead reference 
value for taking action. The informational bulletin also included information on steps that states 
could take to improve lead screening efforts in order to reach children at risk of EBLLs. For 
example, CMS encouraged states to include lead screening requirements in their managed care 
contracts in order to emphasize its importance and ensure that additional monitoring occurs 
through the annual state report required by 42 CFR 438.66. CMS also recommended that states 
ensure that their provider manuals and educational materials include information on lead 
screening that is clearly written and consistent with Medicaid and CHIP requirements. CMS is 
committed to working with states to improve blood lead screening rates for children enrolled in 
Medicaid and CHIP, and appreciates the opportunity to comment on the OIGs report.  
OIGs recommendations and CMS' responses are below. 
OIG Recommendation 
Monitor national EPSDT performance data for blood lead screening tests and target efforts 
toward low-performing states to develop action plans for increasing tests, according to 
Medicaids schedule. 
CMS Response 
CMS concurs with this recommendation and will monitor national EPSDT performance data for 
blood lead screening tests in order to identify states performing in the lowest quartile. CMS will 
request that states performing in the lowest quartile develop an action plan, and will provide 
technical assistance as necessary.  
OIG Recommendation 
Ensure consistency across CMS guidance related to actionable blood lead reference values and 
blood lead screening test definitions. 
1 https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.pdf 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Appendix D | 24 APPENDIX D:  AGENCY COMMENTS
CMS Response 
CMS concurs with this recommendation. CMS recognizes the need for consistent guidance, and 
will work to ensure that CMS guidance reflects the current blood lead reference value established 
by the CDC.  
OIG Recommendation 
Coordinate with partners to develop and disseminate to state Medicaid agencies educational 
materials that reaffirm requirements and schedules for blood lead screening tests. 
CMS Response 
CMS concurs with this recommendation. As noted in the OIGs report, CMS has undertaken 
considerable outreach efforts around Medicaid blood lead screening requirements, and remains 
committed to working with both federal and state partners to ensure that all children enrolled in 
Medicaid and CHIP receive required blood lead screening tests. CMS will continue to engage 
with our partners and identify educational and outreach materials available to help states reaffirm 
requirements and schedules for blood lead screening tests.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371   Appendix D | 25  
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Dana Squires served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Katharine Fry, Haley 
Lubeck, and Anna Pechenina.  Office of Evaluation and Inspections staff who provided 
support include Althea Hosein, Kevin Manley, and Christine Moritz.   
We would also like to acknowledge the contributions of other Office of Inspector 
General staff including Lonie Kim and Julie Taitsman. 
This report was prepared under the direction of Brian Whitley, Regional Inspector 
General for Evaluation and Inspections in the Kansas City regional office. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Acknowledgements and Contact | 26   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network 
of audits, investigations, and inspections conducted by the following operating 
components: 
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  About the OIG | 27  ENDNOTES 
1 In FY 2018, more than 42 million children were eligible to receive Medicaids EPSDT benefit and nearly 5 million of these 
children were between the ages of 12 months and 24 months.  CMS, Early and Periodic Screening, Diagnosis and Treatment, 
2018 annual reporting data.  Accessed at https://go.usa.gov/xUWaP on August 3, 2020. 
2 Social Security Act (The Act)  1905(r). 
3 Previous OIG work that included a sample of 345 children in 9 States found that almost 40 percent of 197 children who 
received EPSDT medical screenings were missing appropriate laboratory tests.  Among the children missing lab tests, almost 60 
percent of children ages 1 and 2 did not receive blood lead screening tests as required by Medicaid.  OIG, Most Medicaid 
Children in Nine States Are Not Receiving All Required Preventative Screening Services, OEI-05-08-00520, May 2010.  Accessed at 
https://go.usa.gov/xU4gG on October 29, 2017. 
4 AAP Council on Environmental Health, Prevention of Childhood Lead Toxicity, Pediatrics, Vol. 138, No. 1, July 2016.  
Accessed at https://pediatrics.aappublications.org/content/138/1/e20161493 on July 24, 2020. 
5 C.M. Aelion and H.T. Davis, Blood lead levels in children in urban and rural areas: Using multilevel modeling to investigate 
impacts of gender, race, poverty, and the environment, Science of the Total Environment, Vol. 694, December 2019.  Accessed 
at https://doi.org/10.1016/j.scitotenv.2019.133783 on October 20, 2020. 
6 M.B. Pell and Joshua Schneyer, Reuters, Reuters finds 3,810 U.S. areas with lead poisoning double Flints, November 14, 
2017.  Accessed at https://www.reuters.com/article/us-usa-lead-map/reuters-finds-3810-u-s-areas-with-lead-poisoning-
double-flints-idUSKBN1DE1H2 on January 18, 2018. 
7 Luis Ferre-Sadurni, The New York Times, 11,168 Children Tested Positive for Lead. The City Didnt Inspect the Homes, 
September 26, 2019.  Accessed at https://www.nytimes.com/2019/09/26/nyregion/nyc-lead-exposure.html on August 6, 2020. 
8 Lauren Schroeder, Los Angeles Times, 1.4 million California kids have not received mandatory lead poisoning tests, January 
8, 2020.  Accessed at https://www.latimes.com/california/story/2020-01-08/california-children-tested-positive-for-lead-
poisoning on July 7, 2020. 
9 Annie Gasparro and Sharon Terlep, The Wall Street Journal, Toxic Heavy Metals Found in Some Baby Food, Congressional 
Report Says, February 4, 2021.  Accessed at https://www.wsj.com/articles/toxic-heavy-metals-found-in-some-baby-food-
congressional-report-says-11612451332 on February 5, 2021. 
10 AAP Council on Environmental Health, Prevention of Childhood Lead Toxicity, Pediatrics, Vol. 138, No. 1, July 2016.  
Accessed at https://pediatrics.aappublications.org/content/138/1/e20161493 on July 24, 2020. 
11 A U.S. Government Accountability Office (GAO) review of consumer products purchased through third-party sellers on 
e-commerce websites identified counterfeit products such as travel mugs and cosmetics that had been found to contain
hazardous substances including lead.  GAO, Intellectual Property: Agencies Can Improve Efforts to Address Risks Posed by
Changing Counterfeits Market, January 2018.  Accessed at https://go.usa.gov/xGR6a on August 12, 2020.
12 Eric M. Roberts, M.D., Ph.D., et al., Assessing Child Lead Poisoning Case Ascertainment in the US, 1999-2010, Pediatrics, Vol. 
139, No. 5, May 2017.  Accessed at https://doi.org/10.1542/peds.2016-4266 on December 6, 2017. 
13 AAP Council on Environmental Health, Prevention of Childhood Lead Toxicity, Pediatrics, Vol. 138, No. 1, July 2016.  
Accessed at http://pediatrics.aappublications.org/content/pediatrics/138/1/e20161493.full.pdf on August 17, 2018. 
14 Low-level exposure even at blood lead concentrations below 5 g/dL has been associated with diminished intellectual 
abilities and lower birth weights in children.  See AAP Council on Environmental Health, Prevention of Childhood Lead 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Endnotes | 28  Toxicity, Pediatrics, Vol. 138, No. 1, July 2016.  Accessed at 
http://pediatrics.aappublications.org/content/pediatrics/138/1/e20161493.full.pdf on August 17, 2018. 
15 U.S. Environmental Protection Agency, Integrated Science Assessment for Lead, June 2013.  Accessed at 
https://go.usa.gov/xUgUs on October 26, 2017. 
16 Ibid. 
17 Brian B. Boutwell, et al., Aggregate-level lead exposure, gun violence, homicide, and rape, PLoS One, Vol. 12, No. 11, 
November 2017.  Accessed at https://doi.org/10.1371/journal.pone.0187953 on January 29, 2018. 
18 John Paul Wright, et al., Association of Prenatal and Childhood Blood Lead Concentrations with Criminal Arrests in Early 
Adulthood. PLoS Med, Vol. 5, No. 5, May 2008.  Accessed at https://doi.org/10.1371/journal.pmed.0050101 on October 28, 
2017. 
19 AAP Council on Environmental Health, Prevention of Childhood Lead Toxicity, Pediatrics, Vol. 138, No. 1, July 2016.  
Accessed at http://pediatrics.aappublications.org/content/pediatrics/138/1/e20161493.full.pdf on August 17, 2018. 
20 In FY 2018, more than 42 million children were eligible to receive Medicaids EPSDT benefit and nearly 5 million of these 
children were between the ages of 12 months and 24 months.  See CMS, Early and Periodic Screening, Diagnosis and  
Treatment, 2018 annual reporting data.  Accessed at https://go.usa.gov/xUWaP on August 3, 2020. 
21 Medicaid-enrolled children under the age of 21 are eligible to receive EPSDT services. 
22 The Act  1905(r)(1)(A)(i). 
23 The Act  1905(r)(1)(B)(iv). 
24 The Act  1905(r)(1)(B). 
25 The Act  1905(r)(5). 
26 The State Medicaid Manual also states that children between the ages of 36 months and 72 months should also receive a 
blood lead test if they have not been previously screened for lead.  See CMS, The State Medicaid Manual, Chapter 5: Early and 
Periodic Screening, Diagnostic and Treatment Services, section 5123.2.D.1.  Accessed at https://go.usa.gov/xU4hY on October 
29, 2017.  
27 The policy change helped align the CMS lead screening policy with that of the CDC.  See CMS, CMCS Informational Bulletin, 
Targeted Lead Screening Plans, June 2012.  Accessed at https://go.usa.gov/xF29W on June 7, 2021. 
28 The Informational Bulletin also stated that any child between ages 24 months and 72 months with no record of a previous 
blood lead screening test must receive one.  See CMS, CMCS Informational Bulletin, Coverage of Blood Lead Testing for 
Children Enrolled in Medicaid and the Childrens Health Insurance Program, November 2016.  Accessed at 
https://go.usa.gov/xHF8p on August 13, 2020.   
29 CMS, The State Medicaid Manual, Chapter 5: Early and Periodic Screening, Diagnostic and Treatment Services, section 
5123.2.D.  Accessed at https://go.usa.gov/xU2VG on October 29, 2017. 
30 CDC guidance also recommends that practitioners follow local and State screening guidelines.  In jurisdictions without 
formal State or local recommendations, CDC recommends that children receive blood lead screening tests at 12 and 24 
months of age, and once between 36 months and 72 months of age for those without a prior test.  CDC, Low Level Lead 
Exposure Harms Children: A Renewed Call for Primary Prevention, January 2012.  Accessed at https://go.usa.gov/xU58B on July 
16, 2018.   
31 The CDC, Childhood Lead Poisoning Prevention, Recommended Actions Based on Blood Lead Level.  Accessed at 
https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm on June 4, 2021.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests 
OEI-07-18-00371  Endnotes | 29   
32 Joseph F. Hagan, Jr., M.D., FAAP, et al., AAP, Bright Futures Guidelines for Health Supervision of Infants, Children, and 
Adolescents (Fourth Edition), 2017. 
33 AAP does not recommend universal blood lead testing except in high prevalence areas with increased risk factors for lead 
exposure.  The current Bright Futures/AAP Periodicity Schedule includes a risk assessment at the following well-child visit 
intervals: 6 months, 9 months, 12 months, 18 months, 24 months, 36 months, 48 months, 60 months, and 72 months of age.  
The recommendation notes that a blood lead screening test should be conducted only if the risk assessment comes back 
positive.  See AAP, Detection of Lead Poisoning, 2016.  Accessed at https://www.aap.org/en-us/advocacy-and-policy/aap-
health-initiatives/lead-exposure/Pages/Detection-of-Lead-Poisoning.aspx on July 15, 2018.  
34 Bright Futures/AAP, Recommendations for Preventive Pediatric Care Periodicity Schedule, March 2021.  Accessed at 
https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf on June 4, 2021. 
35 AAP, Treatment of Lead Poisoning, 2016.  Accessed at https://www.aap.org/en-us/advocacy-and-policy/aap-health-
initiatives/lead-exposure/Pages/Treatment-of-Lead-Poisoning.aspx on July 15, 2018. 
36 CMS, The State Medicaid Manual, Chapter 5: Early and Periodic Screening, Diagnostic and Treatment Services, section 
5320.2.C.  Accessed at https://go.usa.gov/xU2VG on October 29, 2017. 
37 CMS, 2700.4 Instructions for Completing Form CMS-416, Annual Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) Participation Report, 2020.  Accessed at https://go.usa.gov/xHF9x on June 4, 2021. 
38 The Act  1905(r), 42 U.S.C.  1396d(r).  
39 CMS, The State Medicaid Manual, Chapter 5: Early and Periodic Screening, Diagnostic and Treatment Services, section 
5360.B.  Accessed at https://go.usa.gov/xU2VG on October 29, 2017. 
40 The 2018 national EPSDT report noted that about 2 million blood lead screening tests were provided to almost 4.5 million 
enrolled children between 12 months and 24 months of age.  See CMS, Early and Periodic Screening, Diagnosis and Treatment, 
2018 annual reporting data.  Accessed at https://go.usa.gov/xUWaP on August 3, 2020. 
41 CMS instructs States to count the total number of blood lead screening tests provided to eligible children under the age of 6 
with at least 90 continuous days of enrollment during a fiscal year, using unduplicated claims.  The instructions also note that 
followup blood tests administered to children who have been diagnosed with or are being treated for lead poisoning should 
not be counted.  See CMS, 2700.4 Instructions for Completing Form CMS-416, Annual Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) Participation Report, 2020.  Accessed at https://go.usa.gov/xHF9x on June 4, 2021. 
42 Lead Contamination Control Act of 1988, Pub. L. No. 100-572,  3, 102 Stat. 2887 (1988). 
43 Adrienne S. Ettinger, et al., CDCs Lead Poisoning Prevention Program: A Long-standing Responsibility and Commitment to 
Protect Children From Lead Exposure, Journal of Public Health Management and Practice, Vol. 25, Suppl. 1, 2019.  Accessed at 
https://go.usa.gov/x7YAk on September 17, 2020. 
44 CDC, Childhood Lead Poisoning Prevention: Data and Statistics.  Accessed at https://go.usa.gov/xGVTg on September 24, 
2020. 
45 CDC, Childhood Lead Poisoning Prevention, Learn More about CDCs Childhood Lead Poisoning Data.  Accessed at 
https://go.usa.gov/xGVT2 on September 24, 2020. 
46 CDC, Childhood Lead Poisoning Prevention, Funding Information.  Accessed at https://go.usa.gov/xFx6z on June 4, 2021. 
47 CDC, Childhood Lead Poisoning Prevention, Standard Surveillance Definitions and Classifications, July 2019.  Accessed at 
https://go.usa.gov/xAugN on January 24, 2020. 
48 A.B. 2276 (Cal. 2020).  Accessed at 
https://leginfo.legislature.ca.gov/faces/billCompareClient.xhtml?bill_id=201920200AB2276&showamends=false on July 28, 
2021. 
 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Endnotes | 30 
   
 
49 California Department of Public Health, Californias Progress in Preventing and Managing Childhood Lead Exposure, 2020.  
Accessed at 
https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/CDPH%20Document%20Library/CLPPBReport2020.pdf on July 28, 
2021. 
50 N.Y. Comp. Codes R. & Regs. Tit 10  67-1.2.  Accessed at https://regs.health.ny.gov/content/section-67-12-lead-screening-
and-follow-children-health-care-providers on July 28, 2021. 
51 City of New York, Lead Free NYC Initiatives, 2020.  Accessed at https://www1.nyc.gov/content/leadfree/pages/initiatives on 
July 28, 2021. 
52 Ohio Department of Health, 2019 Ohio Lead Advisory Council Annual Report.  Accessed at 
https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/childhood-lead-poisoning/media/olac-annual-report on July 
28, 2021.  
53 Pennsylvania Department of Health, 2019 Childhood Lead Surveillance Annual Report, January 2021.  Accessed at 
https://www.health.pa.gov/topics/Documents/Environmental%20Health/2019%20Childhood%20Lead%20Surveillance%20Annu
al%20Report.pdf on July 28, 2021. 
54 Texas Department of State Health Services, Minutes from a meeting of the Strategic Planning Committee to Eliminate 
Childhood Lead Poisoning, August 2019.  Accessed at https://dshs.texas.gov/lead/SPC/SPC_Minutes_08-21-19.pdf on July 28, 
2021. 
55 The weighted response rate, based on responses in each State, was 25 percent.    
56 States that have sufficient data to demonstrate that universal screening is not the most effective method of identifying 
exposure to lead may request to implement a targeted lead screening plan for Medicaid-enrolled children, rather than 
continuing to universally screen all Medicaid-enrolled children at ages 1 and 2.  See CMS, CMCS Informational Bulletin, 
Targeted Lead Screening Plans, June 2012.  Accessed at https://go.usa.gov/xF29W on June 7, 2021. 
57 Shelley A. Bruce, et al., Using Medicaid Data to Improve Childhood Lead Poisoning Prevention Program Outcomes and 
Blood Lead Surveillance, Journal of Public Health Management and Practice, Vol. 25, Suppl. 1, 2019.  Accessed at 
https://go.usa.gov/xAnX6 on January 8, 2021. 
58 Benjamin Carnahan, M.D., et al. Point-of-Care Testing Improves Lead Screening Rates at 1- and 2-Year Well Visits, The 
Journal of Pediatrics, March 2021.  Accessed at https://doi.org/10.1016/j.jpeds.2021.02.067 on April 7, 2021. 
59 The National Committee for Quality Assurances (NCQAs) Health Effectiveness Data and Information Set measure for lead 
screening in children examines the percentage of children who had one or more blood lead test(s) by their second birthday.  
NCQA, Lead Screening in Children, 2021.  Accessed at https://www.ncqa.org/hedis/measures/lead-screening-in-children/ on 
July 16, 2021. 
60 Medicaid Statistical Information System (MSIS) threshold error tolerances allow between 0.1 and 5.0 percent missing, 
unknown, or invalid codes for the variables used in this analysis.  CMS, MSIS File Specifications and Data Dictionary, 2012.  
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood Lead Screening Tests  
OEI-07-18-00371  Endnotes | 31