Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
       
 
 
 
 
MOST M  EDICAID CHILDREN IN 
 
N S A N
INE  TATES  RE  OT 
 
 
R A R
ECEIVING  LL  EQUIRED 
 
P   S
REVENTIVE  CREENING 
 
S  
  ERVICES
 
Daniel R. Levinson  
Inspector General 
 
May 2010 
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 E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
1. To determine the extent to which children in nine selected States 
received required Medicaid Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) screenings. 
2. To determine the extent to which children in nine selected States 
received all of the required components of EPSDT medical  
screenings. 
3. To describe nine selected States efforts to increase EPSDT-eligible 
childrens participation in EPSDT screenings and the completeness 
of EPSDT medical screenings. 
BACKGROUND 
Medicaid provides a comprehensive and preventive child health benefit 
for children under the age of 21, known as the EPSDT benefit.  Services 
provided under the EPSDT benefit are intended to screen, diagnose, and 
treat children eligible for EPSDT services at early, regular intervals to 
avoid or minimize childhood illness.  The EPSDT services cover 
four health-related areas:  medical, vision, hearing, and dental.  This 
study focuses on medical, vision, and hearing screenings. 
Only medical screenings have components specifically required by the 
statute.  Complete medical screenings under the EPSDT benefit must 
include the following five components:  a comprehensive health and 
developmental history, a comprehensive unclothed physical 
examination, appropriate immunizations, appropriate laboratory tests, 
and health education. 
We reviewed medical records in 9 States for a sample of 345 children 
enrolled in Medicaid in 2007.  We also conducted structured interviews 
with State Medicaid staff responsible for the EPSDT benefit in nine 
States. 
FINDINGS 
Three out of four children did not receive all required medical, 
vision, and hearing screenings.  In 9 States, 76 percent of children, or 
2.7 million children, did not receive 1 or more of the required EPSDT 
medical, vision, or hearing screenings.  Forty-one percent of children did 
not receive any required medical screenings.  In addition, more than half 
of children did not receive any required vision or hearing screenings.   
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Nearly 60 percent of children who received EPSDT medical 
screenings lacked at least one component of a complete medical 
screening.  Fifty-five percent, or nearly 2 million children in 9 selected 
States, received medical screenings.  Of these 2 million children, 
59 percent did not receive all five required components of a medical 
screening during a 1-year period.  Children were missing appropriate 
laboratory tests most often; 38 percent of children who received medical 
screenings did not receive this component. 
All nine States reported strategies to improve participation in EPSDT 
screenings and the completeness of EPSDT medical screenings.  
Officials from all selected States Medicaid agencies identified strategies 
to increase both the number of children who receive screenings as well 
as the completeness of medical screenings.  Officials from all selected 
States identified at least one of three main strategies to improve 
beneficiary participation in EPSDT:  direct communication to eligible 
families, outreach, and incentives.  In addition, officials from all selected 
States reported strategies to increase the number of complete 
screenings, primarily through education and incentives for providers.   
RECOMMENDATIONS 
Most children are not fully benefiting from EPSDTs comprehensive 
screening services.  Two primary factors contributed to this problem.  
First, children did not receive the correct number of each type of 
screening.  Second, when children received medical screenings, they 
were often incomplete.  These two factors taken together indicate that 
very few children received the correct number of complete medical 
screenings and the correct number of vision and hearing screenings.   
In addition, while all States reported strategies to improve both the 
number of screenings and the completeness of medical screenings, these 
strategies do not appear to have the desired effect.  The disconnect 
between States efforts to improve the EPSDT program and the low 
number of children receiving required screenings is difficult to account 
for, but indicates that additional efforts are required.   
Therefore, we recommend that CMS: 
  require States to report vision and hearing screenings,  
  collaborate with States and providers to develop effective 
strategies to encourage beneficiary participation in EPSDT 
screenings,  
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E X E C U T I V E   S U M M A R Y  
  collaborate with States and providers to develop education and 
incentives for providers to encourage complete medical 
screenings, and  
  identify and disseminate promising State practices for 
increasing childrens participation in EPSDT screenings and 
providers delivery of complete medical screenings. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
For the first recommendation, CMS stated that it will consider how 
hearing and vision screenings could be included as part of revised or 
new data collection efforts.  However, CMS indicated that it will need to 
assess the effect that new data collection requirements might have on 
States financial resources as well as consider the difficulty States 
might have in obtaining data on services that are provided outside 
traditional provider settings.  We agree that CMS should assess the 
costs of any new data collection requirements for vision and hearing 
screenings and States ability to collect these data.  However, we 
continue to think that requiring States to report vision and hearing 
screenings will enable CMS to better monitor participation in these 
screenings.   
CMS concurred with our other three recommendations and indicated its 
commitment to improving beneficiary and provider participation in 
EPSDT.  CMS stated that in collaboration with States and national 
experts, it has begun efforts to improve the provision of EPSDT services.   
 
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 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
Three out of four children did not receive all required medical, 
vision, and hearing screenings. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
Nearly 60 percent of children who received EPSDT medical 
screenings lacked at least one component of a complete medical  
screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 
 
All nine States reported strategies to improve participation in  
EPSDT screenings and the completeness of EPSDT medical 
screenings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
 
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 
  Agency Comments and Office of Inspector General Response . . . 23 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 
  A:  Components of a Complete Medical Screening. . . . . . . . . . . . . 25 
  B:  Detailed Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 
  C:  Estimates and Confidence Intervals. . . . . . . . . . . . . . . . . . . . . 33 
  D:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 
 
    
   
 I N T R O D U C T I O N  
OBJECTIVES 
1. To determine the extent to which children in nine selected States 
received required Medicaid Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) screenings. 
2. To determine the extent to which children in nine selected States 
received all of the required components of EPSDT medical 
screenings. 
3. To describe nine selected States efforts to increase EPSDT-eligible 
childrens participation in EPSDT screenings and the completeness 
of EPSDT medical screenings. 
BACKGROUND 
Earlier studies have reported ongoing problems with Medicaids EPSDT 
benefit, which includes preventive screening services for eligible 
children under the age of 21.  A 1997 Office of Inspector General (OIG) 
report found that 60 percent of children in a managed care setting did 
not receive required screenings.1  Also, the National Health Law 
Program in 2005 concluded that since its inception, the EPSDT benefits 
success in screening and treating eligible children has not met 
expectations.  For example, in 2003, only 15 percent of children under 
5 years of age were reported to have received blood lead tests.2  Most 
recently, in August 2009, the Government Accountability Office (GAO) 
noted low participation of children in EPSDT.3   
Low-income children with public insurance are more likely to be in poor 
health.4  Research has confirmed a relationship between low-income 
and chronic health issues, such as depression and obesity,5 iron 
 
1 OIG, Medicaid Managed Care and EPSDT, OEI-05-93-00290, May 1997. 
2 National Health Law Program, Childrens Health Under Medicaid:  A National Review 
of Early and Periodic Screening, Diagnosis, and Treatment 19992003, May 2005. 
3 GAO, Medicaid Preventive Services:  Concerted Efforts Needed to Ensure Beneficiaries 
Receive Services, GAO-09-578, August 2009. 
4 Christie Provost Peters, EPSDT:  Medicaids Critical but Controversial Benefits 
Program for Children, National Health Policy Forum, Issue Brief No. 819, 
November 20, 2006.  Accessed at http://www.nhpf.org on September 20, 2009. 
5 Elizabeth Goodman, The Role of Socioeconomic Status Gradients in Explaining 
Differences in US Adolescents Health,  American Journal of Public Health, Vol. 89, No. 10, 
October 1999.  Accessed at http://www.ajph.org on September 11, 2009. 
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deficiency,6 and poor cognitive development.7  Identifying and 
addressing these issues through preventive screening in childhood may 
have greater effects on adult health than addressing them later in life.8 
The EPSDT benefit and preventive care continue to be a priority among 
policymakers.  In 2006, congressional committee chairmen sent a letter 
to the Secretary of Health & Human Services (the Secretary) to clarify 
which changes in Medicaid, as a result of the Deficit Reduction Act of 
2005, were not intended to alter EPSDT coverage and that EPSDT 
remains a required Medicaid benefit.9 
Medicaids EPSDT Benefit 
The EPSDT benefit provides a comprehensive and preventive child 
health program for children under the age of 21.  Every State Medicaid 
program must offer the EPSDT benefit.   
The EPSDT-eligible children include all children who are categorically 
eligible for Medicaid based on income guidelines established in Federal 
law.10  States may choose to extend EPSDT benefits to all Medicaid-
eligible children under the age of 21.11  In 2007, 31.5 million children 
were eligible for EPSDT.12 
Services provided under the EPSDT benefit are intended to screen, 
diagnose, and treat children eligible for EPSDT services at early, 
regular intervals to avoid or minimize childhood illness.  The EPSDT 
services cover four health-related areas:  medical, vision, hearing, and 
 
6 Katherine Alaimo, et al., Food Insufficiency, Family Income, and Health in US 
Preschool and School-Aged Children,  American Journal of Public Health, Vol. 91, No. 5, 
May 2001.  Accessed at http://www.ajph.org on September 11, 2009.  
7 Sanders Korenman, et al., Long-Term Poverty and Child Development in the United 
States:  Results from the NLSY, Children and Youth Services Review, Vol. 17, No. 1/2, 
1995.  Accessed at http://www.sciencedirect.com on September 11, 2009. 
8 Jack P. Shonkoff, W. Thomas Boyce, and Bruce S. McEwen, Neuroscience, Molecular 
Biology, and the Childhood Roots of Health Disparities, JAMA, 2009, p. 1.  Accessed at 
http://jama.ama-assn.org on September 3, 2009. 
9 Grassley Specifies Intent of Two Medicaid Provisions in Deficit Reduction Act.  U.S. 
Senate Committee on Finance.  (Letter from Senator Charles Grassley and Representative 
Joe Barton to Michael O. Leavitt, Secretary, Health & Human Services.)  Accessed at 
http://finance.senate.gov on October 2, 2009. 
10 Social Security Act,  1902(a)(10)(A)(i), 42 U.S.C.  1396a(a)(10)(A)(i), and Social 
Security Act,  1905(a)(4)(B), 42 U.S.C.  1396d(a)(4)(B). 
11 Centers for Medicare & Medicaid Services (CMS), State Medicaid Manual, 
Pub. No. 45, ch. 5,  5010(A). 
12 CMS, Annual EPSDT Participation Report Form CMS-416 (National), 2007.  Accessed 
at http://www.cms.hhs.gov on September 2, 2009.   
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dental.13  This study focuses on medical, vision, and hearing 
screenings.14 
Medical screenings.  Only medical screenings have components 
specifically required by the statute.  Complete medical screenings under 
the EPSDT benefit must include the following five components:15  
  a comprehensive health and developmental history (including 
assessment of both physical and mental health development); 
  a comprehensive unclothed physical examination; 
  appropriate immunizations, as established by the Advisory 
Committee on Immunization Practices, according to age and health 
history;16 
  appropriate laboratory tests (including blood lead level assessment 
appropriate for age and risk factors); and 
  health education (including anticipatory guidance).17 
For a more thorough description of the five components of a medical 
screening, see Appendix A. 
For a medical screening to be considered complete, immunization 
history must be reviewed and immunizations administered when 
appropriate.  At each screening, a provider should check a childs 
immunization record and update when appropriate.  Immunizations 
should be provided following the recommendations of the Advisory 
Committee on Immunization Practices.18 
In addition, for a medical screening to be considered complete, 
laboratory tests (hereinafter referred to as lab tests) must be 
administered when appropriate.  Each State establishes its own 
 
13 Social Security Act,  1905(r), 42 U.S.C.  1396d(r).  Note that where the statute refers 
to screening services in  1905(r)(1), medical screenings are described.  For claritys sake, 
we refer to screening services as medical screenings. 
14 This study will not examine dental screenings because CMS was conducting a detailed 
review of dental screenings and services while this study was underway.   
15 Social Security Act,  1905(r)(1)(B), 42 U.S.C.  1396d(r)(B). 
16 CMS, Manual,  5123.2(C). 
17 Anticipatory guidance is intended to assist in understanding what to expect in the 
childs development. 
18 CMS, Manual,  5123.2(C). 
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I N T R O D U C T I O N  
guidelines for which lab tests are required at each medical screening.19  
Lab tests may include the test itself or an assessment for risk, which 
States often require to determine if a lab test should be performed.  The 
only federally required lab test is a blood lead test, required at 12 and 
24 months.20  
Vision and hearing screenings.  Vision and hearing screenings may or 
may not be performed at the same time as a medical screening.  While 
States may require that vision and hearing screenings occur during a 
medical screening,21 it is not a Federal requirement.22  In some cases, 
vision and hearing screenings, particularly for school-aged children, 
may be performed in settings outside a physicians office.  However, if 
States require vision and hearing screenings during the medical 
screening, they must be documented.23 
Diagnosis and treatment.  In addition to including screenings, EPSDT 
includes other necessary health care and diagnostic and treatment 
services to address concerns identified during medical, vision, hearing, 
or dental screenings.24  These include, but are not limited to, inpatient 
and outpatient hospital services, home health care services, case 
management services, eyeglasses, and hearing aids.25   
EPSDT Screening Schedules 
Each State establishes its own periodicity schedules for each type of 
screening.  Periodicity schedules outline the frequency of each type of 
screening, which varies by age.  Each State must develop these 
schedules in consultation with recognized medical organizations 
involved in childrens health care.26  Guidance from CMS states that 
screenings must be provided at intervals which meet reasonable 
 
19 CMS, Manual,  5123.2(D).  See also CMS, Manual,  5123.2(A)(2) (requiring a lab test 
to screen for iron deficiency). 
20 Social Security Act,  1905(r)(1)(B)(iv), 42 U.S.C.  1396d(r)1)(B)(iv), and CMS, 
Manual,  5123.2(D)(1). 
21 CMS, Manual,  5123.2(F). 
22 Social Security Act,  1905(r)(2) and 1905(r)(4), 42 U.S.C.  1396d(r)(2), and 
 1396d(r)(4). 
23 CMS, Manual,  5310(A). 
24 Social Security Act,  1905(r)(2)(B), 1905(r)(3)(B), 1905(r)(4)(B), and 1905(r)(5). 
25 Social Security Act,  1905(r)(2)(B), 1905(r)(3)(B), 1905(r)(4)(B),  1905(r)(5), and 
1905(a). 
26 CMS, Manual,  5140(A). 
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standards of medical practice.27  In addition, CMS requires an initial 
screening following enrollment in Medicaid.28 
State periodicity schedules for medical screenings vary in the number 
of medical screenings required.  The American Academy of Pediatrics 
(AAP) recommends multiple medical screenings per year for children 
under age 2 and one screening per year after age 2.  State 
requirements range from four to seven medical screenings for infants 
under age 1 and two to three medical screenings per year for 1- and 
2-year-olds.  For children 3 or older, States typically require one 
medical screening every 1 to 2 years.  
State periodicity schedules for other screening types also vary.  States 
generally follow AAP recommendations that vision and hearing 
screenings occur with the same frequency as medical screenings.   
EPSDT State Requirements 
CMS requires States to notify all eligible families of available services 
and the need for appropriate immunizations.29, 30  At a minimum, this 
must occur within 60 days after the date of the initial determination of 
eligibility for Medicaid and a determination of eligibility after a period 
of ineligibility.  CMS allows flexibility in the notification methods 
employed by States.31  
In addition, services provided during a screening visit must be recorded 
and records must be available to verify those services.  CMS instructs 
States that providers of EPSDT services must agree to keep records 
necessary to disclose the extent of services furnished and information 
regarding payment of claims.32  Some States publish forms for 
providers to complete during EPSDT medical screenings to assist with 
documentation.  The forms generally have a section for each of the five 
components; are age specific; and list development and nutrition 
questions, appropriate lab tests, and immunizations. 
 
27 CMS, Manual,  5140(A). 
28 CMS, Manual,  5140(C). 
29 Social Security Act,  1902(a)(43)(A), 42 U.S.C.  1396a(a)(43)(A). 
30 The legislation states that eligible people under the age of 21 are to be notified, but the 
Manual,  5121(B), clarifies that States are to inform eligible families of the availability of 
EPSDT. 
31 CMS, Manual,  5121(A). 
32 CMS, Manual,  5310(A). 
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Further, the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) 
strengthened EPSDT by establishing State reporting requirements for 
EPSDT and mandating that the Secretary set participation goals for the 
States.33, 34  In response to OBRA 1989, the Secretary required annual 
reporting via the Annual EPSDT Participation Report Form CMS-416 
(CMS-416) and established a goal of 80-percent beneficiary participation 
in EPSDT for each State.35 
The CMS-416 provides information, focused primarily on medical 
screenings, about beneficiary participation in EPSDT screenings.  
Specifically, States report the expected and total number of screenings 
received at an aggregate level and for seven different age groups.36  
CMS instructs States to use certain Current Procedural Terminology 
(CPT) codes as a proxy for reporting EPSDT screenings.37  However a 
State may use a different method of counting EPSDT screenings, if one 
exists.38  States are to report only complete medical screenings that 
include all five age-appropriate components.39  States do not have to 
report on vision and hearing screenings on the CMS-416. 
According to CMS-416 reports, States have continued to fall short of the 
80-percent beneficiary participation goal established by the Secretary.  
Beneficiary participation is measured using the participant ratio, which 
is calculated by dividing the number of eligible children receiving at 
least one EPSDT medical screening by the number of eligible children 
who should receive at least one EPSDT medical screening.  In 2007, 
58 percent of those children expected to receive a medical screening 
received at least one across all States.40  Participation rates in 14 States 
 
33 OBRA 1989, P.L. 101-239, Title VI,  6403(b), Social Security Act,  1902(a)(43)(D),  
42 U.S.C.  1396a(a)(43)(D). 
34 OBRA 1989, P.L. 101-239, Title VI,  6403(c), Social Security Act,  1905(r), 42 U.S.C. 
 1396d. 
35 CMS, Manual,  5320.2(C) and 5360(B). 
36 Each State uses its own periodicity schedule to determine the expected number of 
screenings.  States are instructed to determine each childs age based upon his or her age as 
of September 30.  The age groups are:  under 1, 12, 35, 69, 1014, 1518, and 1920. 
37 The CPT codes are a numeric coding system consisting of descriptive terms that are 
used primarily to describe medical services and procedures furnished by physicians and 
other health care practitioners. 
38 CMS, Instructions for the CMS Form-416:  Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) Report. 
39 CMS, Manual,  5360(D). 
40 CMS, Annual EPSDT Participation Report Form CMS-416 (State), 2007.  Accessed at 
http://www.cms.hhs.gov on September 22, 2009. 
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were at or below 50 percent.41  In fact, only one State achieved the 
Secretarys goal in 2007.   
METHODOLOGY 
Through a review of medical records, this review determined the extent 
to which children enrolled in Medicaid for all of 2007 in nine selected 
States received required Medicaid EPSDT screenings and all of the 
required components of EPSDT medical screenings.  In addition, this 
review describes nine selected States efforts to increase beneficiary 
participation in EPSDT screenings and the completeness of EPSDT 
medical screenings.  This information was collected in structured 
interviews with State officials responsible for the EPSDT benefit.  See 
Appendix B for a detailed methodology. 
Scope 
This study assesses medical, vision, and hearing screenings for children 
in the nine selected States.  The medical record review did not include 
an assessment of the quality of care or the medical necessity of the 
services.  In addition, it did not include whether services were billed 
correctly; therefore, we did not estimate potential overpayments.  
Finally, we did not focus on the diagnostic or treatment aspects of 
EPSDT.  Therefore, we did not determine whether children were offered 
appropriate followup care based on information identified in the 
screenings. 
Sample 
State selection.  To determine which States to select, we used States 
2006 CMS-416 submissions.  We ranked 39 States and the District of 
Columbia by number of EPSDT-eligible children and participant ratio 
and then summed the 2 rankings to create a combined score for each 
State.  To provide us with a range of State sizes and EPSDT 
participation, we chose the five States with the lowest combined score 
and the five States with the highest combined score.  The States 
initially selected for this study included:  Arkansas, Florida, Idaho, 
Illinois, Missouri, North Carolina, North Dakota, Texas, Vermont, and 
West Virginia.   
 
41 CMS, Annual EPSDT Participation Report Form CMS-416 (State), 2007.  Accessed at 
http://www.cms.hhs.gov on September 22, 2009. 
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Beneficiary sampling frame.  We created a sampling frame of children 
who fit three characteristics:  (1) enrolled in Medicaid for all of 2007, 
(2) eligible for the EPSDT benefit for all of 2007, and (3) expected to 
receive at least one EPSDT medical screening in their sample periods.  
The sample period is a 14-month period based on a childs birthday and, 
therefore, is different for each child.  The sample period is described in 
more detail below. 
To create the sampling frame, we used Medicaid eligibility data from 
the selected States and States periodicity schedules.  We used the 
eligibility data to exclude children who were not enrolled in Medicaid or 
not eligible for the EPSDT benefit for all of 2007.  We also used the 
eligibility data to determine the age of each EPSDT-eligible child.  Once 
we determined childrens ages, we used States periodicity schedules to 
exclude any child not expected to receive an EPSDT medical screening 
at that age.  We combined all of the remaining children from the 
10 originally selected States into 1 sampling frame. 
Beneficiary sample.  After creating the sampling frame of children 
expected to receive EPSDT medical screenings, we selected a stratified 
random sample of 360 children.  We stratified by age and delivery model 
(fee-for-service or managed care).  After selecting our sample, we 
excluded 11 children because of ongoing provider investigations by OIG 
or State Medicaid Fraud Control Units.42  Because of these exclusions, 
North Dakota was no longer represented in the sample because the only 
sampled child from the State had a provider under investigation.  As a 
result, nine States were included in our review.  We dropped an 
additional four children because further research deemed them 
ineligible for EPSDT.  The final sample consisted of 345 children.  
Data Collection 
Medical record request.  For the sample of 345 children, we asked States 
to furnish provider contact information for providers that billed 
EPSDT-related codes during the childs sample period.43   
For 82 sampled children, who were expected to receive medical 
screenings every other year based on their ages and their States 
 
42 A State Medicaid Fraud Control Unit is a State government entity, annually certified 
by the Department of Health & Human Services, that conducts a statewide program for the 
investigation and prosecution of health care providers that defraud the Medicaid program. 
43 Providers were typically physicians.  However, providers in one State included school 
districts because they billed Medicaid for vision and hearing screenings. 
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periodicity schedules, we used a 26-month sample period.  For all 
sampled children, the sample periods included at least 6 months of 
2007.  Collectively, the sample periods for all sampled children are 
referred to as the study period. 
For the 345 children, States reported that 98 children did not have any 
providers that billed EPSDT-related CPT codes during their sample 
periods.  We considered these children to be missing all EPSDT 
screenings.  For the remaining 247 children, we requested, by mail, 
complete medical records from each provider.   
For the 247 children for whom we requested medical records, we 
received responses from all providers.  However, for 14 children, we did 
not receive enough information to determine whether they received 
screenings.  We retained these children in the sample and classified 
their records as having insufficient documentation.   
Structured interviews.  We interviewed State Medicaid staff responsible 
for oversight of the EPSDT benefit from the nine selected States via 
telephone.  We inquired specifically about activities that the States used 
to encourage beneficiary participation in EPSDT and complete EPSDT 
medical screenings in 2007.  In addition, we asked about any barriers to 
increasing beneficiary participation or complete EPSDT medical 
screenings that States encountered.  These interviews took place during 
November and December 2008. 
Data Analysis 
To determine the extent to which children received EPSDT services, 
each child was assigned to one of four OIG staff reviewers who reviewed 
medical records to determine whether a child received all, some, or none 
of the required EPSDT screenings.  We also reviewed medical records to 
determine what types of screenings were received (medical, vision, or 
hearing) and whether all five components of a medical screening 
occurred.  Reviewers used State periodicity schedules to determine the 
types and numbers of screenings children were required to receive. 
We used the results of our review, including the 98 children with no 
EPSDT-related billing, to calculate the percentage of children missing 
all, some, or none of the required screenings.  We also did an analysis by 
type of screening received.  We considered a child to have received a 
medical screening even if the screening did not include all five 
components.  Among the subpopulation of children who received 
medical screenings, we also calculated the percentage of children 
missing each of the five required components of a medical screening. 
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To describe State efforts to increase EPSDT participation and 
completeness of medical screenings, we analyzed all State interviews 
and categorized the responses by topic (e.g., education, incentive, 
barrier) and by the intended target of the effort (provider or eligible 
family).  We counted the number of States with responses in each 
category. 
Unless otherwise noted, we projected the results from our review to the 
population of children in nine selected States who were enrolled in 
Medicaid and the EPSDT benefit for all of 2007 and who were expected 
to receive at least one EPSDT medical screening based on age.  See 
Appendix C for a list of 95-percent confidence intervals for all statistical 
projections. 
Data Limitations 
Because we did not stratify the sample by State, we were not able to 
calculate participation for individual States.  Therefore, we were unable 
to assess whether State efforts to increase childrens participation in 
EPSDT had an effect.  In addition, the results of this study cannot be 
extrapolated nationally.  Because of this and other methodological 
differences, the results of this study cannot be directly compared to the 
CMS-416 data. 
We did not verify childrens enrollment status for the times in their 
sample period that fell outside 2007 (all children had at least  
6 months of their sample period in 2007).  In these cases, we could have 
counted a screening as missing, when, in fact, it should not have been 
because the child was not enrolled in Medicaid.  However, nearly  
40 percent of the EPSDT claims we reviewed were for dates of service 
outside 2007, indicating that children were generally enrolled in 
Medicaid during their sample periods. 
The estimates for the percentage of children who did not receive vision 
and hearing screenings may be marginally overstated.  One of the nine 
selected States does not require that vision and hearing screenings be 
documented during the medical screenings.  In fact, officials from this 
State reported that doctors were aware that vision and hearing 
screenings occurred in schools and, therefore, the screenings were 
usually not noted in medical records.  However, the children from this 
State make up less than 1 percent of the nine-State sampling frame. 
Finally, the projections are only for children who were enrolled in 
Medicaid and eligible for the EPSDT benefit for all of 2007.  The sample 
excludes children who were enrolled in Medicaid for only part of 2007.  
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For this reason, the study results cannot be projected to all Medicaid 
children in the nine selected States.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency. 
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Three out of four children did not receive all  In 9 selected States, 76 percent of 
required medical, vision, and hearing screenings  children, or 2.7 million children, did 
not receive 1 or more of the 
 
required EPSDT medical, vision, or 
hearing screenings during their sample period.  Thirty-eight percent of 
children did not receive any EPSDT screenings during their sample 
periods.  Moreover, only 21 percent of children received all screenings.  
However, this percentage does not take into account the completeness of 
medical screenings; this is addressed in the next finding.  Chart 1 
illustrates the extent to which children received required EPSDT 
screenings, by percentage of children.44  
 
Chart 1:  Required 
Screenings 
All types of 
Received, by  Missing types of 
screenings, but 
Percentage of  screenings incorrect number
33%
Children  4%
 
All screenings
21%
Insufficient 
documentation
4%
No screenings
38%
  Source:  OIG analysis of results of a review of medical records, 2009. 
An additional 37 percent received at least one, but not all, required 
EPSDT screenings based on their States periodicity schedules.  The 
percentage of children who received some, but not all, required EPSDT 
screenings includes children in two categories:  (1) children who 
received all types of screenings (medical, vision, hearing), but received 
the incorrect number of screenings according to the States periodicity 
schedules, and (2) children who were missing types of screenings.   
 
44 The 76 percent of children that did not receive 1 or more required screenings is 
depicted in Chart 1 as 75 percent because of rounding. 
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Four percent of children fall into the first category, those who receive all 
types of screenings, but an incorrect number of screenings.  This 
includes only children under the age of 3, as they are the only children 
for whom States periodicity schedules mandate multiple screenings per 
year.  For example, a child in this category could be a child under 1 who 
received four medical, vision, and hearing screenings when the State 
periodicity schedule recommends that six of each type occur.   
Thirty-three percent of children fall into the second category, those who 
received some screenings, but not all types.  For example, an 8-year-old 
child whose periodicity schedule recommends one of each type of 
screening could have received a medical and vision screening, but not a 
hearing screening.   
Below is specific information on children who did not receive screenings, 
broken out by the type of screening not received. 
Four out of ten children did not receive any required medical screenings 
Forty-one percent of children did not receive any required medical 
screenings.  Children who did not receive medical screenings were likely 
to be missing all other types of screenings.  Indeed, 86 percent of 
children who did not receive medical screenings did not receive vision 
and hearing screenings.  There appears to be a link between not 
receiving a medical screening and not receiving a vision and hearing 
screening.   
More than half of children did not receive any required vision or hearing 
screenings 
Sixty percent of children did not receive any vision screenings and 
67 percent of children did not receive any hearing screenings.  Further, 
over half of children who did not receive vision or hearing screenings 
also did not receive medical screenings.  Specifically, 60 percent of 
children who did not receive vision screenings and 56 percent of 
children who did not receive hearing screenings did not receive medical 
screenings.
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Nearly 60 percent of children who received  Fifty-five percent,45 or nearly 
EPSDT medical screenings lacked at least one  2 million children in the 9 selected 
States, received medical 
component of a complete medical screening 
screenings during the study 
period.  Of these 2 million 
children, 59 percent did not receive all five required components of a 
medical screening during the study period:  a comprehensive health and 
developmental history, a comprehensive unclothed physical exam, 
appropriate immunizations, appropriate lab tests, and health education.  
More than a quarter of children who received medical screenings were 
missing only one component of a complete medical screening.  Chart 2 
illustrates the number of missing components, by percentage of children 
who received medical screenings.   
Chart 2:  Number    Four missing 
components, 2%
of Missing 
Three missing 
Components, by 
components, 9%
Percentage of 
Children Who 
Received Medical 
Screenings  Two missing  Complete screening, 
components, 18% 41%
 
One missing 
component, 30%
  Source:  OIG analysis of results of a review of medical records, 2009. 
 
 
 
45 As noted in the first finding, 41 percent did not receive medical screenings.  An 
additional 4 percent of children had insufficient documentation in their medical records to 
determine screenings received. 
 
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Of the five components, children were missing appropriate lab tests most 
often 
While each of the five components was missing for at least some 
children who received medical screenings, more children were missing 
appropriate lab tests.46  Thirty-eight percent of children who received 
medical screenings did not receive appropriate lab tests.  Chart 3 
illustrates this, along with the percentage of children missing each of 
the other components of a medical screening. 
 
Chart 3:  Of 
Appropriate lab tests
Children Who 
Received Medical 
Screenings, 
Health and
Percentage  developmental history
Missing Each 
Component  
Health education
 
(Anticipatory guidance)
Appropriate
immunizations
Complete physical
examination
Missing any component
0% 10% 20% 30% 40% 50% 60% 70%
Percentage of Children
  Source:  OIG analysis of results of a review of medical records, 2009 
 
Appropriate lab tests.  Low receipt of lab tests is highlighted by 
examining two lab tests in particular:  blood lead tests and tuberculosis 
(TB) tests.  Blood lead tests are the only federally mandated lab test for 
EPSDT medical screenings.47  However, other lab tests, such as TB, 
cholesterol, or a complete blood count, must be performed depending on 
State requirements. 
 
46 The difference is statistically different from other components at the 95-percent 
confidence level in a multiple comparison test using a Bonferroni threshold of 0.0125. 
47 Social Security Act,  1905(r)(1)(B)(iv), 42 U.S.C.  1396d(r)(1)(B) (iv). 
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Fifty-seven percent of 1- and 2-year-olds did not receive a blood lead test 
as required.48  CMS considers all children at risk for lead toxicity and 
requires all children to receive blood lead tests at 12 and 24 months.49   
Children with high blood lead levels are at risk of decreased 
intelligence, academic failure, and behavior problems.50   
Further, 69 percent of children required by their State to receive a TB 
assessment did not receive one.  Five of the nine selected States require 
a TB assessment at certain ages.  The disease can affect any part of the 
body and can be fatal if left untreated.51  Infection in children is a signal 
of poor health conditions and a sign that preventive care needs 
improvement.52   
Other components.  The percentage of children who received medical 
screenings and were missing each of the other required components, 
although smaller than the percentage missing lab tests, is still a 
concern.  For example, 21 percent of these children did not have their 
health and development history assessed and 21 percent of these 
children did not receive health education.   
One example from the sampled medical records highlights issues that 
can arise from inadequate health education.  One 4-month-old child was 
documented to be overfed during the exam, and the childs family was 
given guidance to improve this.  During the two previous medical 
screenings, there was no health education documented.  Had the 
provider given information on proper feeding for infants during previous 
medical screenings, the overfeeding might have been avoided.   
A second example demonstrates the benefits of gathering a health 
history and providing health education.  In this case, the child went 
from the 50th percentile to the 95th percentile in height/weight between 
 
48 Because this percentage is based on a small sample size, the estimate is less precise 
than other estimates presented in this report because of a larger standard error.  See 
Appendix C for a complete list of confidence intervals.    
49 CMS, Manual,  5123.2(D)(1). 
50 Centers for Disease Control and Prevention (CDC), Recommendations for Blood Lead 
Screening of Medicaid-Eligible Children Aged 15 Years:  An Updated Approach to 
Targeting a Group at High Risk, 58(RR09); 1-11, August 7, 2009.  Accessed at 
http://www.cdc.gov on October 2, 2009. 
51 CDC, Tuberculosis (TB).  Accessed at http://www.cdc.gov on October 2, 2009. 
52 American Academy of Pediatrics, Red Book Online, Section 3:  Summaries of 
Infectious Diseases.  Tuberculosis.  Accessed at http://aapredbook.aappublications.org on 
September 11, 2009. 
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FF II NNN DDD III NNN GGG SSS      
tthhee  66--mmoonntthh  vviissiitt  aanndd  tthhee  11--yyeeaarr  vviissiitt..    BByy  ccoolllleeccttiinngg  aa  tthhoorroouugghh  hheeaalltthh  
hhiissttoorryy,,  tthhee  pprroovviiddeerr  ddeetteerrmmiinneedd  tthhaatt  tthhee  iinnccrreeaassee  wwaass  dduuee  lliikkeellyy  ttoo  aa  
ddiieett  hhiigghh  iinn  ssuuggaarryy  ddrriinnkkss  aanndd  ooffffeerreedd  gguuiiddaannccee  ttoo  mmoovvee  tthhee  cchhiilldd  ttoo  aa  
mmoorree  aapppprroopprriiaattee  ddiieett..  
SSttaaffff  ffrroomm  aallll  sseelleecctteedd  SSttaatteess  
All nine States reported strategies to improve 
MMeeddiiccaaiidd  aaggeenncciieess  ((hheerreeiinnaafftteerr  
participation in EPSDT screenings and the 
rreeffeerrrreedd  ttoo  aass  ooffffiicciiaallss))  
completeness of EPSDT medical screenings 
iiddeennttiiffiieedd  eeffffoorrttss  ttoo  iinnccrreeaassee  
tthhee  nnuummbbeerr  ooff  cchhiillddrreenn  wwhhoo  rreecceeiivvee  ssccrreeeenniinnggss,,  aass  wweellll  aass  iinnccrreeaassee  tthhee  
ccoommpplleetteenneessss  ooff  mmeeddiiccaall  ssccrreeeenniinnggss..  
OOffffiicciiaallss  ffrroomm  aallll  nniinnee  SSttaatteess  rreeppoorrtteedd  eeffffoorrttss  ttoo  iimmpprroovvee  ppaarrttiicciippaattiioonn  iinn  
EEPPSSDDTT  ssccrreeeenniinnggss,,  bbuutt  bbaarrrriieerrss  rreemmaaiinn  
OOffffiicciiaallss  ffrroomm  aallll  sseelleecctteedd  SSttaatteess  iiddeennttiiffiieedd  aatt  lleeaasstt  oonnee  ooff  tthhrreeee  
ssttrraatteeggiieess  ttoo  iimmpprroovvee  ppaarrttiicciippaattiioonn  iinn  EEPPSSDDTT::    ddiirreecctt  ccoommmmuunniiccaattiioonn  ttoo  
eelliiggiibbllee  ffaammiilliieess,,  oouuttrreeaacchh,,  aanndd  iinncceennttiivveess..    DDeessppiittee  tthheessee  ssttrraatteeggiieess,,  
ooffffiicciiaallss  ffrroomm  aallll  SSttaatteess  iiddeennttiiffiieedd  bbaarrrriieerrss  ttoo  iimmpprroovviinngg  ppaarrttiicciippaattiioonn  iinn  
EEPPSSDDTT  ssccrreeeenniinnggss..  
DDiirreecctt  ccoommmmuunniiccaattiioonn.  Officials from all selected States indicated that 
States communicate directly with eligible families at multiple times 
while a child is EPSDT-eligible.  As required by Federal law, officials for 
each State noted that their State provided either an initial letter or 
beneficiary handbook upon enrollment in Medicaid.  These documents 
inform the family what services are available to them, including 
EPSDT.  However, officials from all selected States indicated that 
States also provided additional notices to families at one or more of the 
following times:  when a screening is due, annually (usually around the 
childs birthday), when data indicate there is no EPSDT billing for the 
child, or when a child has missed a scheduled appointment.  Officials 
from one State also indicated that a notice of when screenings are due is 
printed on a childs Medicaid identification card. 
In addition, an official from one State described a system to help 
determine when communication to families is needed.  Officials in this 
State reported that they established a no-reimbursement billing code 
that providers can bill to Medicaid when beneficiaries miss 
appointments so that the State can track these instances and 
communicate directly with these families.   
Outreach.  Officials from all selected States also reported outreach 
efforts aimed at the public and other State agencies.  These efforts 
included:  outreach focused on special populations, such as high-risk 
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F I N D I N G S  
individuals and adolescents; media campaigns; participation in health 
fairs and food drives; and outreach in churches or schools.  Officials 
noted the importance of collaborating with other State agencies in 
charge of Head Start, public health, and education.  Some of these 
collaborations include data-sharing agreements that allow Medicaid 
staff to identify children who need screenings. 
Incentives.  Officials from four States discussed incentive programs 
aimed at providers and families to increase participation.  Examples of 
provider incentives include additional payments to providers that 
exceed the average screening rate by 5 percent and 10 percent, 
pay-for-performance programs for preventive screenings for children 
under the age of 5, and increased reimbursement rates for preventive 
screenings.  In addition, these officials indicated that some managed 
care organizations provide small incentives (e.g., diaper coupons) to 
families for bringing children to EPSDT screenings.   
Barriers.  However, officials from all selected States identified barriers to 
getting children to visit a doctor for preventive screenings.  The most 
frequently cited barriers were cultural or family attitudes and 
circumstances.  The officials indicated that some parents think 
preventive screenings are not necessary, believe children need to go to 
the doctor only when sick, and have concerns about taking time off 
work.  Other barriers cited include limited access to providers, incorrect 
beneficiary contact information, and failure of beneficiaries to keep 
appointments. 
Officials from all nine States reported strategies to increase the number of 
complete medical screenings 
Officials from all selected States reported efforts to increase the number 
of complete medical screenings, primarily through education and 
incentives.  Officials from all selected States indicated that States 
provide education to providers about screening requirements.  In 
addition, officials from some States reported incentive programs used to 
increase the number of complete screenings.  
Education.  The officials from all selected States identified attempts to 
inform and educate providers about EPSDT screening requirements.  
The officials reported educating providers in a variety of ways, including 
provider toolkits with information about the five components, online 
information and training opportunities, provider handbooks and 
bulletins, and in-person training or conferences.  Despite these efforts, 
officials in three States reported that some providers remain unaware of 
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what a complete medical screening entails or do not believe all 
components are necessary. 
As a further reminder of the required components, four States have 
standardized forms for providers to use during visits that contain all 
components of a medical screening.  Although actual use of 
State-provided EPSDT screening forms is unknown, it may be low.  
Records from sampled children in the four States with standardized 
forms showed that only 40 percent of the sample records used the forms.  
Incentives.  In addition, officials from four States reported tracking some 
components of the medical screening separately and offering incentives 
to providers.  Officials noted that tracking some components separately 
enables the State to maintain a focus on them.  In addition, officials 
described incentive programs that States or managed care organizations 
offer, including one that offers a bonus to providers if their percentages 
of children immunized are above a set goal and a payment reduction 
when immunization percentages are below the goal. 
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 R E C O M M E N D A T I O N S  
Most children are not fully benefiting from EPSDTs comprehensive 
screening services.  Two primary factors contributed to this problem.  
First, children did not receive the correct number of each type of 
screening.  In fact, only 21 percent of children received all required 
medical, vision, and hearing screenings.  Second, when children 
received medical screenings, they were often incomplete.  Specifically, 
59 percent of children who received medical screenings did not receive 
complete medical screenings.  These two factors taken together indicate 
that considerably less than 21 percent of children received the correct 
number of complete medical screenings and the correct number of vision 
and hearing screenings.  This conclusion is supported by OIG and other 
organizations that have established a body of work that indicates low 
beneficiary participation in EPSDT covering at least a decade.  
Although all States reported strategies to improve both the number of 
screenings and the completeness of medical screenings, these strategies 
do not appear to have the desired effect.  The disconnect between States 
efforts to improve the EPSDT program and the low number of children 
receiving required screenings is difficult to account for, but indicates 
that additional efforts are required.  When choosing which additional 
efforts to implement, special emphasis should be placed on strategies 
that States show to be effective or strategies in States with high 
participation ratios. 
To increase participation in EPSDT screenings and increase the 
completeness of medical screenings, we make the following four 
recommendations.  CMS should: 
Require States to report vision and hearing screenings 
Currently, States do not report vision and hearing screenings to CMS on 
the CMS-416 or in any other way.  By requiring these data, CMS could 
better monitor participation in these screenings.  Once tracking systems 
for reporting are in place, CMS could establish a baseline participation 
rate and perhaps a goal to increase participation in vision and hearing 
screenings.  Further, the requirement would likely drive States to 
develop guidance for providers to assist them with proper 
documentation and billing so that the State could report these 
screenings to CMS.  Lastly, requiring these data would enable CMS and 
States to identify problem areas and work to find solutions. 
While we recognize that States may not currently have mechanisms for 
tracking vision and hearing screenings, we make this recommendation 
as a first step in obtaining usable data about these screenings.  
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Requiring that vision and hearing screening data be reported to CMS 
will enable CMS to determine the number of States that do not have 
data available and the quality of the data in the States where they are 
available.  It may also enable CMS to determine the barriers to 
collecting these data.  Having this information, CMS could begin 
working with States to improve reporting.  Although obtaining quality 
data is likely a multiyear process, as stated above, we believe that 
reporting is a necessary first step that would enable States and CMS to 
monitor the delivery of vision and hearing screenings.  
To collect data on vision and hearing screenings, CMS could revise the 
CMS-416 data collection form to include vision and hearing screenings 
or it could work with States to develop an alternative method of 
tracking these screenings and reporting to CMS.  In response to 
recommendations in a 2009 GAO report, CMS indicated a willingness to 
review and revise the CMS-416.53  We suggest that CMS consider 
making these changes as part of that review and revision process. 
Collaborate with States and providers to develop effective strategies to 
encourage beneficiary participation in EPSDT screenings 
CMS and States should collaborate to develop appropriate education for 
families.  In addition to alerting families of the EPSDT benefit, States 
could focus education and outreach efforts on the importance of 
preventive care.  Officials from multiple States discussed a concern that 
families do not emphasize preventive care.  Due to this concern, a 
culture that supports preventive care needs to be developed.  
CMS should also collaborate with providers, such as through national or 
local pediatric medical organizations.  Collaborating with providers may 
identify the best way to work with families.  It may involve ideas about 
how to reach out to families to encourage preventive care or ideas for 
small incentives that might encourage more children to participate.  
Collaborate with States and providers to develop education and incentives 
for providers to encourage complete medical screenings 
CMS and States should collaborate with national or local pediatric 
medical organizations and regional or State provider groups to educate 
providers on the necessity and importance of each of the five 
components of a medical screening.  The education could clarify what is 
expected during a medical screening and what is considered appropriate 
 
53 GAO, Medicaid Preventive Services. 
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documentation.  Strong working relationships between States and 
providers and their associations are critical for supporting providers 
participation in delivering EPSDT services.54  In addition, provider 
input is important for developing effective education techniques.   
Additionally, CMS should work with States to develop incentives for 
providers to encourage complete medical screenings.  This could include 
exploring ways to revise billing practices to encourage complete 
screenings.  One example of revising billing practices could involve 
billing separate codes for each component of a medical screening (at 
lesser amounts), and if all five components were billed on the same date 
of service, the provider would receive payment up to the current 
reimbursement amount. 
Identify and disseminate promising State practices for increasing childrens 
participation in EPSDT screenings and providers delivery of complete 
medical screenings 
CMS should identify and disseminate promising practices among States 
to ensure that children benefit from EPSDTs screening services.  This 
effort should focus on practices designed to ensure that families are 
aware of EPSDT screening services and methods to encourage childrens 
participation in EPSDT screening services.  For example, this may 
include information about incentives offered by States or managed care 
organizations within a State to families to encourage participation.  
In identifying promising practices, CMS should also identify and 
disseminate promising approaches to working with providers to increase 
the completeness of medical screenings.  Officials from the selected 
States described some approaches that appear, at face value, to be 
promising.  Perhaps this could be a starting point for this effort.  Those 
ideas included initiatives focused on various components, States 
experiences with the development and adoption of standardized forms, 
and the creation of incentive programs.  
To accomplish these tasks, CMS could consider an initiative similar to 
the recently completed EPSDT dental reviews for developing promising 
practices.  As a result of that initiative, CMS published a National 
Dental Summary that included promising and notable practices for 
 
54 National Academy for State Health Policy, New Opportunities and Continuing 
Challenges:  A Report from the NASHP EPSDT Forum.  July 2008.  Accessed at 
http://www.nashp.org on November 3, 2009. 
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improving access to dental services.55  CMS has also indicated a 
willingness to collect promising practices from States to ensure children 
receive preventive services.56 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS indicated that it concurred, in part, with our first recommendation 
to require States to report vision and hearing screenings.  In its 
comments, CMS stated that it will consider how hearing and vision 
screenings could be included as part of any revised or new data 
collection efforts currently in progress.  CMS stated that it is 
implementing new reporting requirements based on two laws enacted 
in 2009 and that it will consider our recommendation as part of these 
efforts.  However, CMS indicated that it will need to assess the effect 
new data collection requirements might have on States financial 
resources as well as consider the difficulty States might have in 
obtaining data on services that are provided outside traditional 
provider settings. 
We agree that CMS should assess the costs of any new data collection 
requirements for vision and hearing screenings and States ability to 
collect these data.  However, we continue to think that requiring States 
to report vision and hearing screenings will enable CMS to better 
monitor participation in these screenings.  Requiring these data would 
enable CMS to identify which States do not have data available, 
determine the quality of the data that are available, and identify 
barriers to collecting these data.  With this information, CMS could 
begin working with States to improve reporting.  Although obtaining 
quality data is likely a multiyear process, we continue to believe that 
reporting is a necessary first step that would enable States and CMS to 
monitor the delivery of vision and hearing screenings.   
CMS concurred with our other three recommendations and indicated its 
commitment to improving beneficiary and provider participation in 
EPSDT.  CMS stated that in collaboration with States and national 
experts, it has begun efforts to improve the provision of EPSDT 
services.  CMS also stated that it is developing an internal work plan to 
 
55 CMS, 2008 National Dental Summary, January 2009.  Accessed at 
http://www.cms.hhs.gov on November 3, 2009. 
56 GAO, Medicaid Preventive Services. 
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R E C O M M E N D A T I O N S  
improve EPSDT guidance for State Medicaid agencies.  In addition, 
CMS held two events in 2009 to obtain input from State Medicaid 
programs and national organizations and to hear their 
recommendations on how to improve EPSDT.  Further, CMS stated 
that it intends to create a National EPSDT Improvement Workgroup in 
2010, which will include State Medicaid agencies, providers, and other 
stakeholders.  CMS expects this workgroup to recommend a 
multifaceted approach to improving EPSDT, including strategies that 
ensure accountability on the part of providers.  The workgroup is also 
expected to determine whether there are opportunities to identify and 
share promising practice information. 
We made revisions to the draft report based on CMSs technical 
comments.   
For the full text of CMSs comments, see Appendix D. 
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 A P P E N D I X   ~   A  
Components of a Complete Medical Screening 
A complete medical screening is one in which each of the five required 
components is delivered.57  The required components are:  
1.  Comprehensive health and developmental history.  This includes a physical 
and mental developmental assessment and an assessment of nutritional 
status.  Providers are expected to assess the childs usual functioning as 
reported by a familiar person, review all information and make an objective 
judgment as to whether the child is within the expected range, ensure that 
assessments are culturally sensitive and valid, refrain from making a 
premature diagnosis and instead report only that a condition was referred or 
that a type of diagnostic or treatment services is needed, and consult child 
development resources when concerns or questions remain. 
2.  Comprehensive unclothed physical examination.  The physical examination 
should note obvious physical defects and include an examination of all organ 
systems.  In addition, physical growth, including height and weight, must be 
included.  Results should be compared to what is considered normal for that 
age.   
3.  Appropriate immunizations.  Immunizations should be provided when 
medically necessary and appropriate for age and health history according to 
the recommendations of the Advisory Committee on Immunization Practices. 
4.  Appropriate laboratory tests.  CMS requires a blood lead test at the ages of 
12 and 24 months.  Additional appropriate laboratory tests should be 
determined by each State for particular age and population groups.  CMS 
instructs States to develop their minimum laboratory screening requirements 
in consultation with State medical organizations or by referencing recognized 
and accepted clinical practice guidelines.  CMS provides examples of tests for 
States to consider, such as hematocrit, urinalysis, tuberculosis (TB) skin 
testing, sexually transmitted disease screening, and cholesterol screening.    
States often require a risk assessment to determine whether a lab test should 
be performed.  A risk assessment may include questions such as Does the 
child live in a home with peeling or chipped paint built prior to 1978? (lead 
risk assessment) or As far as you know has your child been around anyone 
sick with TB? (TB risk assessment).   
5.  Health education (including anticipatory guidance).  Providers are instructed 
to use the screening as context for providing health education.  Providers are 
 
57 Centers for Medicare & Medicaid Services (CMS), Manual,  5123.2(A)-(E). 
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A P P E N D I X   ~   A  
to give information to the child and the childs family about the benefits of 
healthy lifestyles and practices as well as accident and disease prevention 
(health education).  This component is also intended to assist in 
understanding what to expect in the childs development (anticipatory 
guidance). 
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 A P P E N D I X   ~   B  
Detailed Methodology 
Sample 
State selection.  To review the Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) benefit, we selected 10 States for review.  To 
determine which States to include in this study, we used States 
2006 Annual EPSDT Participation Report Form CMS-416 (CMS-416) 
submissions to the Centers for Medicare & Medicaid Services (CMS).  
Data from 2006 were the most recent CMS-416 data available at the 
time of State selection.  The 2006 CMS-416 data for Kentucky and 
Maine were not available from CMS; therefore we excluded these 
States.  We also excluded States that had more than 90 percent 
enrollment in either fee-for-service (FFS) or managed care, based on the 
CMS-416, to ensure representation from both service delivery models.  
This removed nine States.58  We ranked the remaining 39 States and 
the District of Columbia by number of children eligible for the Medicaid 
EPSDT and by participant ratio.  We then summed the two rankings to 
create a combined score for State selection.  To provide us with a range 
of State sizes and EPSDT participation, we chose the five States with 
the lowest combined scores and the five States with the highest 
combined scores.   
Beneficiary sampling frame.  We created a sampling frame of 
EPSDT-eligible children in the 10 originally selected States expected to 
receive at least one EPSDT medical screening based on their ages.  We 
used Medicaid eligibility data from the selected States and States 
periodicity schedules to determine which children were required to 
receive screenings. 
First, we requested 2007 Medicaid State Information System (MSIS) 
eligibility files from CMS.  For States with available MSIS data, we 
used these data to determine those children enrolled in Medicaid and 
eligible for the EPSDT benefit for the entire year.  For the four States 
for which MSIS data were unavailable or incomplete, we requested 
directly from the States a list of children enrolled in Medicaid and 
eligible for the EPSDT benefit for all of 2007.   
Second, we determined the age of each EPSDT-eligible child, using 
the demographic information from the MSIS eligibility files or the 
 
58 These States included Alaska, Arizona, Colorado, Mississippi, Oregon, South Carolina, 
South Dakota, Tennessee, and Wyoming. 
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A P P E N D I X   ~   B  
State-provided data.  If a childs birthday was during the first 
6 months of 2007, then we used the age he or she became in 2007.  If 
a childs birthday was in the last 6 months of 2007, then we used the 
age he or she became on his or her last birthday, in 2006.  For 
example, if a child turned age 6 on April 3, 2007, we determined the 
child to be 6 years old.  If a child turned age 6 on September 3, 2007, 
we determined the child to be 5 years old.  Hereinafter, when we refer 
to a childs age, we mean the age we determined the child to be in this 
step. 
Third, we determined whether a child was required to receive an 
EPSDT service based on the childs age.  To do this, we used each 
States periodicity schedule in effect during 2007.  Although States 
periodicity schedules may change from year to year, the requirements 
remained the same across the study period in the selected States.   
Finally, we combined all of the remaining children from the original 
10 selected States into 1 sampling frame. 
Beneficiary sample.  The final sample consisted of 345 children.  After 
creating the sampling frame, we selected a stratified random sample of 
360 children.  We stratified the sample by service delivery model (FFS 
or managed care) and age group.  We stratified by service delivery 
model because a previous Office of Inspector General (OIG) report on 
EPSDT found problems in managed care.59  We stratified by age 
because research suggested vulnerabilities by age in EPSDT.60  We used 
three age groups for representation:  under age 3, 38, and 921.  We 
determined each childs service delivery model based on the model each 
child was enrolled in for at least 6 months of 2007.  We selected 
60 children from each of the 6 strata.   
From the sample of 360 children, we dropped 11 children because of 
ongoing investigations into their provider(s) by OIG or State Medicaid 
Fraud Control Units.  One State was dropped at this time because of an 
ongoing provider investigation by OIG, resulting in nine States.  We 
dropped an additional four children because further research deemed 
them ineligible for EPSDT.  Table B-1 shows the population of children 
within the sampling frame, the six strata, and the final number of 
children in each stratum. 
 
59 OIG, Medicaid Managed Care and EPSDT. 
60 National Health Law Program, Childrens Health Under Medicaid. 
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A P P E N D I X   ~   B  
Table B-1:  Sample Stratification 
Managed Care  FFS  Total 
Age 
Group 
Population  Sample  Population  Sample  Population  Sample 
< 3        669,281           58        240,185           60         909,466         118 
38        941,968           55        408,501           60      1,350,469         115 
921        964,891           57        583,126           55      1,548,017         112 
     Total     2,576,140         170     1,231,812         175      3,807,952         345 
Source:  OIG Sample stratification, 2009. 
Data Collection 
Medical record request.  For the 345 children, States reported that 
98 children did not have any providers who billed EPSDT-related 
Current Procedural Terminology (CPT) codes during their sample 
periods.  Therefore, for the remaining 247 children, we requested 
medical records from all providers who billed an EPSDT-related CPT 
code.  We requested medical records for a 14-month period of time from 
providers for these 247 children.  This period of time included 
documentation for 1 month before and 1 month after each childs 12-
month determined age to provide additional context.  For 82 children, 
the sample period was 26 months because the States periodicity 
schedule required 1 screening within a 2-year period.   
The initial medical record request was sent by mail.  We made two 
additional attempts by mail and two attempts by telephone to obtain 
the records.  We made the last written request by signature-required 
certified mail.  We received responses from all providers.   
However, we did not receive enough information for 14 children to 
determine whether they received screenings.  For these children, at 
least one of their providers either responded that the child was not a 
patient or that the provider retired and did not retain records or 
responded only with the signed certified-mail receipt from the last 
written request. 
Test review.  To test the medical record review instrument and to ensure 
uniformity among the multiple OIG staff reviewers, we conducted a 
preliminary review of childrens medical records.  Beyond the original 
sample of 360 children, we selected an additional 30 children for the test 
review and requested their medical records as outlined above.  Each 
child was assigned to one of four OIG staff reviewers.  Each reviewer 
reviewed the first 15 medical records received.  As a group, we analyzed 
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the results of the review.  We then made necessary revisions to the 
review instrument and discussed the results to resolve any reviewer 
inconsistencies.   
Data Analysis 
We reviewed medical records to determine whether a child received all, 
some, or none of the required EPSDT screenings.  The reviewers used 
the periodicity schedule established by the State in which each child 
resided to determine the required number of medical screenings at his 
or her determined age.  For vision and hearing screenings, we used 
State periodicity schedules to determine whether a child was required to 
receive a screening at his or her age.  We then analyzed the documents 
in the medical records to determine the types of screenings that 
occurred.   
We also reviewed the medical records to determine the completeness of 
medical screenings.  We considered a medical screening complete only if 
the medical record included documentation of all five required 
components.   
Quality assurance.  We selected both a purposive sample and a random 
sample of children to review for quality assurance during and after the 
review of medical records.  On a weekly basis during the review of 
medical records, reviewers chose the two to four most difficult of their 
assigned medical records for a quality assurance check.  Difficult 
records may have been illegible or the assigned reviewer had concerns 
about the sufficiency of the records documentation.  The other 
reviewers then analyzed the records for the selected children, and we 
discussed the results each week to resolve any reviewer inconsistencies 
and changed the results if necessary.  At the end of the review of 
medical records, an additional random sample of children was selected 
for a similar quality assurance review.  In total, all reviewers 
participated in a quality assurance check for 35 children, or 14 percent 
of children for whom medical records were requested. 
Analysis of medical record review results.  We used the results of the 
review of medical records, including the 98 children without 
EPSDT-related billing, to calculate the percentage of children missing 
all, some, or none of the required screenings.  We counted the number of 
children who received all required screenings, the number of children 
who received some screenings, and the number of children who did not 
receive any screenings and divided each total by the number of children 
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A P P E N D I X   ~   B  
in the sample, including children whose medical records had insufficient 
documentation.  
We used the results to count the number of children who did not receive 
each type of screening.  We then divided the totals for each type of 
screening by the total number of children in the sample. 
We considered a child to have received a medical screening even if the 
screening did not include all five components.   
In addition, for the children whose medical records did not indicate that 
they received vision or hearing screenings and who were not required to 
receive those screenings, we considered those children to have met the 
vision and hearing requirements. 
To determine the percentage of children who were missing components 
of a medical screening over the course of a year, we first excluded any 
children who did not receive any medical screenings during the sample 
period.  We also excluded children whose records had insufficient 
documentation.  This left 197 children for analysis.   
We used the results to determine how many of the five components a 
child did not receive during the sample period.  We determined whether 
each child was missing 0, 1, 2, 3, or 4 of the components.  Then, we 
divided each group of children by the total number of children who 
received medical screenings.  We also determined whether the lab test 
component was not received more often than any other component.  
Using the Bonferroni method for multiple comparisons, a difference was 
statistically significant if the confidence interval of the difference did 
not contain zero using an alpha of 0.05 divided by 4, or 0.0125. 
We attempted to be as generous as possible when reviewing records for 
documentation of the components.  For the health and developmental 
history component, we looked for any documentation indicating that a 
developmental assessment (both mental and physical health history) 
and an assessment of nutritional status occurred.  Similarly, for the 
immunization component, we considered the component complete if 
there was any indication that providers checked to be sure a child was 
up-to-date on immunizations or administered immunizations.  For the 
lab test component, we used each States laboratory schedule to 
determine what, if any, lab tests were required at a childs age.  If no lab 
test was required, we considered the laboratory component complete.  If 
lab tests were required, we looked for any indication that the required 
lab tests were assessed or performed.  Lastly, for the other two 
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components, we looked for any documentation (physician notes, 
checkmarks on forms, etc.) that the provider attempted to address the 
component. 
To determine the percentage of children missing each component, we 
counted the number of children who lacked each component during an 
entire year and divided that by the total number of children who 
received medical screenings. 
As part of the analysis of the laboratory component, we also analyzed 
the results for two different lab tests.  To determine the percentage of 
children who were missing blood lead tests, we counted the number of 
children who did not receive required blood lead tests and divided that 
by the number of children required by Federal law to receive blood lead 
tests.  To determine the percentage of children who were missing 
tuberculosis (TB) tests, we counted the number of children who did not 
receive required TB tests and divided that by the number of children 
required by their States to receive TB tests. 
Generally, we found no significant differences in EPSDT participation 
between children in FFS and managed care or between age groups.  
Therefore, we did not present the results in the report. 
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A P P E N D I X   ~   C  
 A P P E N D I X   ~   C  
Estimates and Confidence Intervals 
Table C-1:  Estimates of Medical Record Review Results Analysis 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who did not receive all required Early and 
Periodic Screening, Diagnostic, and Treatment (EPSDT) medical,  345  75.7  70.7%80.6% 
vision, and hearing screenings 
Number of children who did not receive all required EPSDT medical,  2,553,012
345  2,731,975 
vision, and hearing screenings  2,910,938 
Percentage of children who received all EPSDT screenings  345  20.8  16.1%25.5% 
Percentage of children who did not receive any EPSDT screenings  345  37.8  32.4%43.3% 
Percentage of children who were missing types of screenings  345  33.5  28.1%38.9% 
Percentage of children who had all types of screenings, but an incorrect 
345  4.3  2.4%6.2% 
number of screenings 
Percentage of children whose medical records had insufficient 
345  3.6  1.5%5.6% 
documentation 
Percentage of children who received at least one, but not all, EPSDT 
345  37.8  32.4%43.2% 
screenings 
Percentage of children who did not receive any medical screenings  345  41.4  35.9%46.9% 
Percentage of children who did not receive any vision screenings  345  59.6  53.9%65.2% 
Percentage of children who did not receive any hearing screenings  345  66.6  61.4%71.9% 
Percentage of children who received at least one medical screening  345  55.0  49.5%60.6% 
1,786,186
Number of children who received at least one medical screening  345  1,986,492 
2,186,798 
Source:  Office of Inspector General (OIG) analysis of results of a review of medical records, 2009. 
 
Table C-2:  Estimates of Medical Record Review Results Analysis for Children 
Who Did Not Receive Hearing Screenings 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who did not receive hearing screenings and did 
242  55.7  49.0%62.4% 
not receive medical screenings 
Source:  OIG analysis of results of a review of medical records, 2009. 
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Table C-3:  Estimates of Medical Record Review Results Analysis for Children 
Who Did Not Receive Vision Screenings 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who did not receive vision screenings and did 
222  60.1  53.9%67.2% 
not receive medical screenings 
Source:  OIG analysis of results of a review of medical records, 2009. 
 
Table C-4:  Estimates of Medical Record Review Results Analysis for Children 
Who Received Medical Screenings 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who received medical screenings but did not 
197  59.5  52.0%66.8% 
receive all components 
Percentage of children who received medical screenings and received 
197  41.4  35.9%46.9% 
complete screenings 
Percentage of children who received medical screenings but did not 
197  29.9  22.9%36.9% 
receive one component 
Percentage of children who received medical screenings but did not 
197  17.9  11.8%24.0% 
receive two components 
Percentage of children who received medical screenings but did not 
197  9.1  4.5%13.6% 
receive three components 
Percentage of children who received medical screenings but did not 
197  2.0  0.6%5.1%* 
receive four components 
Percentage of children who received medical screenings but did not 
197  38.2  30.7%45.6% 
receive the appropriate laboratory tests component 
Percentage of children who received medical screenings but did not 
197  21.0  14.7%27.4% 
receive the health and developmental history component 
Percentage of children who received medical screenings but did not 
197  8.2  3.9%12.5% 
receive the complete unclothed physical examination component 
Percentage of children who received medical screenings but did not 
197  12.8  7.6%17.9% 
receive the appropriate immunizations component 
* Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
 
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Table C-4:  Estimates of Medical Record Review Results Analysis for Children 
Who Received Medical Screenings, continued 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who received medical screenings but did not 
receive the health education (including anticipatory guidance)  197  20.7  14.4%27.0% 
component 
Source:  OIG analysis of results of a review of medical records, 2009. 
 
Table C-5:  Estimates of Medical Record Review Results Analysis for Children 
Who Did Not Receive Any Medical Screenings 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who did not receive medical screenings and did 
148  86.4  81.1%91.8% 
not receive vision and hearing screenings 
Source:  OIG analysis of results of a review of medical records, 2009. 
 
Table C-6:  Estimates of Medical Record Review Results Analysis for Children 
Who Received Medical Screenings and Were Required to Receive Tuberculosis 
Tests 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of children who received medical screenings and were 
115  69.1  59.9%78.3% 
required to receive tuberculosis tests but did not receive them 
Source:  OIG analysis of results of a review of medical records, 2009. 
 
Table C-7:  Estimates of Medical Record Review Results Analysis for Children 
Who Received Medical Screenings and Were Required to Receive Blood Lead 
Tests 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of one- and two-year-olds who received medical screenings 
56  57.4  42.4%72.4% 
but did not receive mandatory blood lead tests 
Source:  OIG analysis of results of a review of medical records, 2009. 
 
OEI-05-08-00520  MOST MEDICAID CHILDREN IN NINE STATES ARE NOT RECEIVING ALL REQUIRED PREVENTIVE SCREENING SERVICES  35  x  o 

A  P  PEN  0 
Agency Comments 
DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
Ad11linistrator 
Washington, DC 20201 
DATE: 
MAfi  18  20m 
TO: 	 Daniel R, Levinson 

Deputy Inspector General 

FROM: 	 Charlene Frizzeta 

Acting Administrator 

SUBJECT:  Office of Inspector General (OIG) Draft Report:  Most Medicaid Childreil Are 

Not Receiving All Required Preventive Screening Services (OEI -05-08-00520) 

The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 

comment on the Office oflnspector General (OIG) draft report, 

The CMS is committed to improving access to services fot Medicaid eligible children, and to 

ensuring that children receive the full scope ofservices .available under the Medicaid Early and 

Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. We COncur with most ofthe 

recommendations in thIs report and are undertaking efforts in conjunction with States ahd 

national experts to improve the provision ofEPSDT services. In addition, we have attached 

technical comments on the draft report,  .  (~;  ~ 

C'  ~ ,;s1J

OIG Recommendation  C'lr,;  ~ ("'11

,."u  () 
Require States to report vision and hearing screenings, 
 ~'''"!  \!)  ~>1
X)7~  :r.- <~ 

8 
CMS Response  ;~  ~ 
.~'  N 
The CMS concurs, in part, with this recommendation,  CMS is undertaking broader eff~rts, N 
which are described below, to strengthen the EPSDT program. As OIG notes in its report, this 
could include reviewing the data collected on the Form CMS-416 to ensure that the data 
accurately measure children's access to the preventive and follow up services to which they are 
entitled under EPSDT, Additionally, we will assess opportunities to improve our data collection 
and reporting to better measure the quality of and access to services provided to children under 
EPSDT,  As we continue to implement the child health care quality measure program and annual 
quality reporting provisions established by the Children's Health Insurance Program 
Reauthorization Act of2009, and the electronic health records incentive provisions of the 
American Recovery and Reinvestment Act of2009, we will consider how hearing and vision 
screenings could be included as part of any revised or new data collection effort. 
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 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Ann Maxwell, Regional 
Inspector General for Evaluation and Inspections in the Chicago 
regional office, and Thomas F. Komaniecki, Deputy Regional Inspector 
General.   
Nicole Hrycyk served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Chicago regional 
office who contributed to the report include Benjamin Dieterich, Patrick 
Joyce, Meghan Kearns, and Lauren Rosapep; central office staff who 
contributed include Heather Barton, Scott Manley, and Megan Ruhnke.  
 
OEI-05-08-00520  MOST MEDICAID CHILDREN IN NINE STATES ARE NOT RECEIVING ALL REQUIRED PREVENTIVE SCREENING SERVICES  40   
Office of Inspector General 
http://oig.hhs.gov 
 
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: 
Office of Audit Services 
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 assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
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.  
Office of Investigations 
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. 
Office of Counsel to the Inspector General 
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.