Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICAID  MANAGED  CARE  AND  EPSDT 

JUNE  GIBBS  BROWN 
Inspector  General 
MAY 1997 
OEI-O5-!&00290  OFFICE  OF  INSPECIYOR  GENERAL 
The  mission  of the  Office  of Inspector  General  (OIG),  as mandated  by Public  Law 95 
452, is to protect  the  integrity  of the  Department  of Health  and  Human  Services 
programs  as well as the  health  and  welfare  of beneficiaries  served  by them.  This 
statutory  mission  is carried  out  through  a nationwide  program  of audits,  investigations, 
inspections,  sanctions,  and  fraud  alerts.  The  Inspector  General  informs  the  Secretary 
of program  and  management  problems  and  recommends  legislative,  regulatory,  and 
operational  approaches  to correct  them. 
Office of Evaluation  and Inspections 
The  Office  of Evaluation  and  Inspections  (OEI)  is one  of several  components  of the 
Office  of Inspector  General.  It conducts  short-term  management  and  program 
evaluations  (called  inspections)  that  focus  on issues  of concern  to the  Department,  the 
Congress,  and  the  public.  The  inspection  reports  provide  findings  and 
recommendations  on  the  efficiency,  vulnerability,  and  effectiveness  of departmental 
programs. 
OEIs  Chicago  Regional  Office  prepared  this report  under  the  direction  of William  C. 
Moran,  Regional  Inspector  General,  and  Natalie  Coen,  Deputy  Regional  Inspector 
General.  Principal  OEI  staff included: 
REGION  HJXADQUMTERS 
Joseph  L. Pet&rot  (Project  Leader)  Winnie  Walker 

Jean  DuFresne 

Erin  Fleming 

To  obtain  a copy  of this report,  call the  Chicago  Regional  Office  at  (312)  353-4124.  EXECUTIVE  SUMMARY 
PURPOSE 
This  inspection  examines  the  extent  to which  Medicaid  managed  care  providers  deliver 
Early  and  Periodic,  Diagnostic,  Screening  and  Treatment  (EPSDT)  to Medicaid  children. 
BACKGROUND 
Under  EPSDT,  State  Medicaid  agencies  must  provide  eligible  children  services  that 
include  comprehensive,  periodic  health  assessments  beginning  at birth  and  continuing 
through  age  20.  All medically  appropriate  immunizations  are  required.  Age  appropriate 
assessments  must  be  provided  at intervals  following  defined  periodicity  schedules. 
State  Medicaid  agencies  have  turned  to managed  care  to rein  in escalating  health  care 
costs,  difficult  to  do in a fee-for-service  environment,  while  ensuring  health  care  access 
for  Medicaid  enrollees.  Medicaid  managed  care  has grown  exponentially.  Between  1983 
and  1995, Medicaid  managed  care  enrollment  increased  from  750,000 to 9.8 million  and 
now includes  over  400 managed  care  plans. 
FINDINGS 
Fewer  than one in three  Medicaid  children enrolled in managed  care  plans receive  timely 
EPSDT  services.  Six of ten receive  none at all. 
Based  on  our  review,  we estimate  that  only  28 percent  of Medicaid  managed  care 
children  receive  all of the  EPSDT  screens  called  for by the  periodicity  schedule  used  in 
their  State.  Sixty percent  of Medicaid  managed  care  children  do not  receive  any EPSDT 
services  called  for  in the  States  periodicity  schedules.  Older  adolescents  receive 
significantly  fewer  required  EPSDT  services  than  other  children.  We  find  no  significant 
differences  in EPSDT  performance  between  health  maintenance  organizations  and 
primary  care  case  management  plans,  or between  large  or small  managed  care  plans. 
We find  there  is no  difference  in EPSDT  performance  if a break  in managed  care 
enrollment  occurred. 
Most  of the  visits Medicaid  children  make  to managed  care  plans  are  sick visits.  In our 
review  of medical  records,  when  children  made  sick visits  to managed  care  providers, 
only  the  symptoms  that  generated  the  sick visit were  treated,  with very  few exceptions. 
There  were  few visits  treating  conditions  discovered  as a result  of a previous  EPSDT 
screen. 
Children receive  significantly more  EPSDT  services from Medicaid  managed  care  plans 
when states inform the managed  care  plans which children are  due for EPSDT. 
A comparison  of the  EPSDT  results  in Michigan  and  Nevada  to the  others  in our  sample  shows that  there  is a very  strong  statistical  difference  in managed  care  plan  performance. 
These  States  identify  children  currently  due  for EPSDT  screens  to their  managed  care 
plans  and  closely  monitor  EPSDT  performance  by managed  care  plans  for  these  children. 
In our  sample,  54 percent  of the  Medicaid  children  enrolled  in these  plans  received  all of 
their  EPSDT  services  compared  to  19 percent  of those  enrolled  in other  managed  care 
plans. 
RECOMMENDATIONS 
The  Health  Care  Financing  Administration  should revise their EPSDT  reporting 
requirements  and data  collection to emphasize  the number  of children who receive  all of 
their EPSDT  screens  in a timely fashion. 
Current  EPSDT  reporting  methods  obscure  the  low EPSDT  rates  we found,  especially 
for  adolescents.  The  Health  Care  Financing  Administration  (HCFA)  should  revise  their 
EPSDT  data  collection  so States  identity  children  of different  ages who  receive  all of the 
required  EPSDT  screens.  The  HCFA  and  the  States  should  monitor  the  age groups  to 
determine  where  progress  is being  made  and  where  additional  efforts  are  required.  This 
revision  will improve  EPSDT  data  collection  for both  fee-for-service  and  managed  care 
programs. 
The  Health  Care  Financing  Administration  should encourage  States  to actively not@ 
managed  care  plans of enrollees  due for EPSDT  exams  and to follow up if EPSDT 
services are not rendered  shortly thereafter. 
Our  study  dramatically  demonstrates  the  value  added  to EPSDT  performance  when 
States  continue  to track  and  monitor  plan  performance  at the  individual  patient  level. 
The  Health  Care  Financing  Administration  should work with States  to ensure  timely 
managed  care  EPSDT  reporting. 
Current  State  EPSDT  reports  to HCFA  do not  distinguish  services  rendered  by managed 
care  plans.  The  HCFA  collects  combined  managed  care  EPSDT  and  fee-for-service 
EPSDT  information  from  States  annually.  In  1994, HCFA  surveyed  the  States  and 
discovered  that  States  collect  EPSDT  data  from  managed  care  plans  in inconsistent  ways. 
All managed  care  plans  should  report  EPSDT  services  to States  in a timely  and  uniform 
manner.  At  present,  managed  care  plans  subcontract  with  numerous  individual 
providers.  Consequently,  reporting  of EPSDT  services  is inconsistent,  not  always timely, 
and  underreporting  may  occur.  Without  consistent  reporting  of EPSDT  data, 
determining  whether  States  meet  participation  goals  becomes  problematic. 
ii  The Health  Care  Financing  Administration  should emphasize  to States  the need to 
define and clarify EPSDT  requirements  in their Medicaid  contracts  with managed  care 
plans. 
Our  study  confirms  the  findings  of earlier  studies  pointing  out  the  lack  of contractual 
specificity  regarding  EPSDT  in States  Medicaid  contracts  with  managed  care  plans. 
AGENCY  C0MMENl.S 
We received  comments  from  HCFA  and  the  Acting  Assistant  Secretary  for  Health. 

Their  comments  are  included  in Appendices  B and  C respectively.  Both  fully  agree  with 

the  recommendations.  The  Acting  Assistant  Secretary  for  Health  suggested  additional 

recommendations.  These  additional  suggestions  are  quite  consistent  with  the 

recommendations  in our  report.  We suggest  that  HCFA  consider  them  in developing 

their  implementation  plan. 

We  made  appropriate  revisions  to the  report  based  on their  technical  comments. 

... 
111  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVESUMMARY 

INTRODUCTION..  ..............................................  1 

FINDINGS  .....................................................  7 

One  in three  receive  timely  EPSDT  ................................  7 

 
State  monitoring  improves  EPSDT  performance  .......................  9 

 
RECXXMMENDATIONS  ...........................................  11 

AGENCYCOMMENTS  ...........................................  13 

APPENDIX 

A:  Variance  table  .............................................  A-l 
B:  HCFA  comments  .............................................  B-l 
C:  Assistant  Secretary  for  Health  comments  ..........................  C-l  INTRODUCTION 
PURPOSE 
This  inspection  examines  the  extent  to which  Medicaid  managed  care  providers  deliver 
Early  and  Periodic,  Diagnostic,  Screening  and  Treatment  (EPSDT)  to Medicaid  children. 
BACKGROUND 
EPSDT 
Congress  created  the  EPSDT  program  in  1967to provide  initial  and  periodic 
examinations  and  medically  necessary  follow-up  care  for  Medicaid-eligible  children, 
The  Omnibus  Budget  Reconciliation  Act  of  1989 (OBRA  1989) expanded  EPSDT  to 
cover  most  Medicaid-eligible  children  under  age 21.  In July  199C, the  Health  Care 
Financing  Administration  (HCFA)  established  participation  goals  for EPSDT  requiring 
that  States  screen  80 percent  of eligible  children  by  1995.  Medicaid  provides  health  care 
coverage  for  more  than  20 million  children.  In  1992, the  Assistant  Secretary  for Planning 
and  Evaluation  estimated  that  less than  half  of Medicaid  eligible  children  receive  any 
Medicaid  reimbursed  services  in a given year. 
Under  EPSDT,  State  Medicaid  agencies  must  provide  eligible  children  services  that 
include  comprehensive,  periodic  health  assessments  beginning  at birth  and  continuing 
through  age  20.  All medically  appropriate  immunizations  are  required.  Age  appropriate 
assessments,  known  as screens, must  be  provided  at intervals  following  defined 
periodicity  schedules.  Additional  examinations  are  also  required  whenever  anyone 
suspects  the  child  may  have  a health  problem.  Medicaid  also  covers  treatment  for  all 
medically  necessary  services  discovered  during  EPSDT  screening.  Preventive,  restorative 
and  emergency  dental  care  is also  covered  by EPSDT. 
Poor  children  and  their  parents  comprise  73 percent  of the  Medicaid  population,  but 
account  for  only  a third  of Medicaid  expenditures.  The  balance  is spent  on the  aged  and 
disabled.  Overall,  the  younger  Medicaid  patients  require  less care  and  less costly  services 
than  the  aged  and  disabled,  and  very  little  long-term  care. 
State  Medicaid  agencies  have  turned  to managed  care  to rein  in escalating  health  care 
costs,  difficult  to do in a fee-for-service  environment,  while  ensuring  health  care  access 
I  States mustprovide for medical, vision, hearing and dental screens. An EPSDT medical screen must include:  a comprehensive health 
and developmental history, including a physical and mental health assessment; a comprehensive unclothedphysical;  appropriate immunizations; 
laboratory tests, buluding  lead blood  level assessment appropriate for  age and tik  factors,  and;  health education,  including  anticipatory 
guiailnee. 
1  for  Medicaid  enrollees.  The  Federal  Government  encourages  the  switch  to managed 
care  by approving  Medicaid  experiments  in some  States  that  require  Medicaid  recipients 
enroll  in managed  care  plans. 
Medicaid  hfanaged  Care 
Medicaid  managed  care  has  grown  exponentially.  Between  1983 and  1995, Medicaid 

managed  care  enrollment  increased  from  750,000 to 9.8 million.  In  1983, less than  one 

percent  of Medicaid  enrollees  were  covered  by managed  care  programs.  By 1995, 

Medicaid  managed  care  covered  nearly  1 in 3 Medicaid  recipients.  Between  1993 and 

1994, an  additional  3 million  Medicaid  recipients  joined  managed  care  programs,  a  1 year 

rise  of 63 percent,  and  in  1995 almost  4 million  more  Medicaid  enrollees  had  managed 

care  health  care  coverage.  By June  1995, 44 States,  Puerto  Rico  and  the  District  of 

Columbia  had  contracted  with  403 Medicaid  managed  care  plans  to serve  almost  10 

million  recipients. 

Managed  care  aims  to reduce  unnecessary  services, lower  health  care  costs, increase 

access  to services  and  monitor  the  quality  of medical  care  provided  to its beneficiaries. 

At  one  type  of managed  care  plan  - a health  maintenance  organization  (HMO), 

gatekeepers  direct  patients  to needed  care,  usually  within  the  managed  care  plan.2 

The  HMOs  receive  a contracted  amount  from  the  State,  a fixed  capitated  rate  per 

member,  to provide  for  the  health  care  of its Medicaid  members.  The  HMOs  do not 

submit  individual  claims  for  payment  for  services  rendered  to the  State.  Roughly  75 

percent  of Medicaid  recipients  in managed  care  belong  to HMO-type  plans. 

A second  type  of managed  care  program,  Primary  Care  Case  Management  (PCCM),  also 

uses a gatekeeper  to refer  patients  for  necessary  services.  The  PCCMs  are  reimbursed  a 

fixed  amount  for  case  management  services  only.  Individual  medical  services  are  billed 

on a fee-for-service  basis  by the  individual  provider  of services. 

Although  some  basic  tenets  of managed  care  - to provide  preventive  medical  services  and 

education  - mirror  those  of the  EPSDT  program,  some  factors  work  against  Medicaid 

managed  care  plans  delivering  EPSDT  services  to Medicaid  children.  Managed  care 

plans  receiving  a capitated  rate  have  a financial  incentive  to deliver  fewer  services.  Since 

EPSDT  candidates  are  generally  healthy,  not  providing  required  preventive  and/or 

educational  services  can  represent  a short  term  way for  managed  care  plans  to avoid 

expenses  at minimum  risk.  To  discourage  these  tendencies,  some  States  build  EPSDT 

performance  measures  into  their  contracts  with managed  care  plans.  In  addition, 

Federal,  State  and  managed  care  plan  quality  assurance  activities  work  to  ensure  that 

managed  care  plans  and  providers  fulfill  their  contractual  obligations  to deliver 

appropriate  medical  services. 

The  on-again,  off-again  nature  of welfare  and  Medicaid  entitlement  is at odds  with 

2  Other types of numagzd  care plans -Prepaid Health Plans and Health Insumnce  Organization  -are similar to HMOs.  For the 
purpose  of this evaluation, we treat these types of managed  care organizations like HMOs. 
2  managed  health  care  delivery.  Some  patients  are  enrolled  for very  short  periods  of time 
and  do not  receive  any  services  from  their  managed  care  plan.  Some  managed  care 
plans  or Medicaid  patients  may not  see  any benefit  in establishing  a medical  relationship 
that  will be  short-lived.  Likewise,  many  Medicaid  patients  use the  emergency  care  system 
for  their  health  care  needs  and  are  unfamiliar  with  preventive  approaches  that  managed 
care  plans  use. 
Dtmmenhg  EPSDT  Services  in a Mznaged  Care  Setting 
In  1991, the  Office  of Inspector  General  issued  a report  entitled  Early  and  Periodic 
Screening,  Diagnosis,  and  Treatment  - Performance  Measurement  OEI-07-90-00130,  that 
found,  among  other  EPSDT  reporting  problems,  that  children  enrolled  in Medicaid 
managed  care  plans  were  considered  to have  received  their  EPSDT  services  strictly  on 
the  basis  of their  enrollment.  Since  that  time,  HCFA  changed  their  policy  and  now 
requires  that  States  report  specific  EPSDT  encounter  data  for  children  covered  by 
managed  care  plans  as well as fee-for-service. 
In  1994, HCFA  reported  that  States  capture  EPSDT  data  from  its capitated  plans  in 
different  ways.  Some  States  require  HMOs  submit  dummy claims  which  their  systems 
would  process  for  tally  purposes.  Two States  require  different  reporting  standards 
depending  on  the  capabilities  of the  HMO  to provide  data.  Massachusetts  reconciles 
HMO  reported  amounts  by auditing  a sample  of medical  records.  States  rely  on PCCMs 
to report  EPSDT  services  accurately  to ensure  prompt  payment  for  services. 
Annually,  HCFA  collects  combined  managed  care  EPSDT  and  fee-for-service  EPSDT 
information  from  States  on Form  HCFA-416.  This  report  emphasizes  the  ratio  of 
EPSDT  encounters  to the  total  EPSDT  eligible  population.  The  HCFA-416  does  not 
capture  the  number  of Medicaid  managed  care  children  who  received  all of the  EPSDT 
visits required  by the  State  for  that  year.  Also,  since  States  report  combined  managed 
care  EPSDT  and  fee-for-service  EPSDT  information  to HCFA,  no  definitive  comparisons 
of EPSDT  performed  by fee-for-service  providers  and  managed  care  programs  exist. 
EPSDT  and  Managed  Care  Contmcts 
State  contracts  with  managed  care  plans  often  do not  specify  EPSDT  requirements.  A 
1995 Childrens  Defense  Fund  study  of  100 Medicaid  1991 managed  care  contracts  found 
that  less than  half  delineated  EPSDT  responsibilities.  In September  1996, HCFA  issued 
Integrating EPSDT  and Medicaid  Managed  Care, which  also  indicates  that  some  State 
contracts  with  managed  care  plans  do not  adequately  spell  out what  EPSDT  services  are 
required.  This  HCFA  report  cites  the  managed  care  contract  with  States  as the  blueprint 
for  patient  care,  and  recommends  that  States  define  and  specify  EPSDT  program 
requirements.  By mandating  managed  care  plan  performance  in the  State  contract, 
managed  care  plans  would  be  more  likely  to specify  similar  EPSDT  details  when 
contracting  with  individual  providers. 
Managed  care  plans  who  contract  with  individual  providers  must  rely  on  those  providers 
3 
 for  accurate  data.  A University  of North  Carolina  study  of EPSDT  services  in North 
Carolina  indicated  many  problems  with  providers  inaccurate  reporting  of services.  A 
managed  care  plan  in Wisconsin  reported  to us that  1 of 5 providers  they  audited  had 
EPSDT  documentation  problems. 
SCOPE  AND  METHODOIDGY 
This  inspection  analyzes  how well Medicaid  managed  care  plans  deliver  timely  EPSDT 
services  to children.  We  did not  examine  managed  care  services  to children  with  special 
health  care  needs.  There  are  several  studies  of this  area  already  proposed  or underway. 
Likewise,  we did not  focus  on  specific  EPSDT  requirements  like  immunizations,  which 
has been  studied  extensively.3  We  make  no  comparisons  of the  individual  managed  care 
plans  sampled  in this  inspection. 
Data  Gathering 
We base  our  findings  on data  we collected  from  several  sources,  including  interviews  with 

State  and  managed  care  officials,  and  a review  of a national  sample  of medical  records 

for  children  enrolled  in managed  care  programs.  We used  SAS and  SUDAAN 

quantitative  software  plans  to assist in our  analysis  and  projections. 

We  interviewed  State  personnel  and  Medicaid  managed  care  plan  managers  for  the  plans 

chosen  in our  sample.  These  interviews  focused  on  access  and  barriers  to  providing 

EPSDT,  including  outreach  and  transportation  activities,  EPSDT  contractual 

arrangements,  and  reporting  and  verifying  services. 

We  examined  medical  records  for  a national  sample  of children  covered  by Medicaid 

managed  care  plans. 

To  draw the  sample,  we first  stratified  managed  care  plans  treating  Medicaid-enrolled 

children  as of January  1, 1994 into  two groups  - PCCM  model  and  HMO  model.  These 

two strata  then  were  further  stratified  into  two more  strata  - Medicaid  enrollees  of 50,000 

or more,  and  less than  50,000 Medicaid  enrollees.  We  compiled  our  stratified  list using 

HCFA  data  published  in the  Medicaid  Managed  Care  Enrollment  Report  as of June 

30, 1994. 

We  then  randomly  selected  six plans  from  the  large  HMO  strata,  and  two from  the  small 

HMO  strata.  Two large  PCCM  plans  and  two small  PCCM  plans  were  also  randomly 

selected  for  a total  of twelve  plans  from  all strata.  This  sampling  methodology  ensured 

that  we have  accurate  representation  from  both  large  and  small  plans,  as well  as 

3 
An April, 1996  Ofice  of Inspector General report, Childrens Dental Services Under Medicaid:  Access and Utilization (OEI-09-
93-W240)  focused  on EPSDT  dental services 
4  adequate  representation  from  PCCM-type  models  for  comparison  purposes.  The  12 

managed  care  plans  in the  sample  represent  10 different  States. 

The  12 plans  selected  in the  sample  provided  us with  the  names  of all children  in their 

plans  who  met  the  criteria  of being  in Medicaid  and  under  age  21, and  who  were 

enrolled  in their  plan  for  any  period  of time  between  January  1, 1994 and  December  31, 

1995.  From  each  plan,  we randomly  selected  30 names,  a total  sample  of 360 children. 

Twenty-two  children  were  subsequently  dropped  from  the  sample  when  we found  they 

had  less than  4 months  of managed  care  enrollment  and  had  received  no  EPSDT 

services.  Final  projections  were  based  on the  remaining  338 children  in the  sample. 

To  account  for  the  sampling  plan  and  provide  results  that  accurately  reflect  the 

distribution  of cases  in the  population  studied,  all percentages  in the  report  reflect  the 

proper  weighting  of the  data.  This will also be  true  of the  totals  presented.  When  we 

present  sample  based  results,  we identify  them. 

Reviewing  the Midcal  Records 
To  examine  the  extent  of EPSDT  services  actually  being  performed,  we reviewed  the 
medical  records  for this  sample  to see if EPSDT  was reported  accurately,  whether 
EPSDT  services  were  provided  in line  with  periodicity  schedules,  and  to make  a national 
projection  of EPSDT  services  rendered.  We  did not  address  issues  of quality  of care.  In 
instances  where  rendering  of EPSDT  services  was in doubt  based  on  the  medical  records, 
we credited  the  services  as having  been  rendered.  We  credited  EPSDT  as being 
performed  whenever  screens  were  performed  or if subsequent  treatment  resulting  from 
EPSDT  screens  took  place. 
We  reviewed  the  managed  care  medical  records  and  the  States  fee-for-service  data  for 
each  child  for  at least  6 months  prior  to and  after  the  study  period.  In this way, if the 
EPSDT  services  fell outside  of our  study  timeframe,  we would  credit  them  as being 
performed.  By reviewing  the  fee-for-service  billings,  we were  able  to  credit  any EPSDT 
services  rendered  out  of plan. 
During  the  study  timeframe  of  1994 and  1995, children  might  require  multiple  EPSDT 
services  depending  on  their  age  and  the  States  periodicity  schedule.  For  example,  an 
infant  requires  six EPSDT  screens  the  first year  of life in most  States.  But  a 17 year  old 
may  require  an EPSDT  visit annually  or less frequently,  depending  on  the  State.  Our 
analysis  accounted  for  these  variables.  In determining  the  age  of the  child,  we used  the 
age  as of January  1, 1995.  If not  enrolled  on that  date,  we used  the  age  at the  period  of 
coverage. 
OtherData  Gathered 
We  also  conducted  interviews  with  27 physicians  randomly  chosen  from  the  plans 
directories.  We  limited  these  interviews  to pediatricians,  family  practitioners  and 
internists  since  these  providers  would  most  likely be  the  primary  physicians  for  children  receiving  EPSDT.  The  physician  discussions  covered  contractual  arrangements  with  the 
managed  care  plan  and  knowledge  of the  EPSDT  (or by its local  name)  program. 
We  contacted  all States  to  obtain  copies  of any standard  contract  they  use with  Medicaid 
managed  care  providers.  We  analyzed  these  contracts  to determine  the  extent  of 
EPSDT-specific  requirements. 
Our  review  was conducted  in accordance  with  the  QuaZityStandards  for Inspections  issued 
by the  Presidents  Council  on Integrity  and  Efficiency. 
6 
 FINDINGS 

Fewer  than one in three  Medicaid  children enrolled in managed  care  plans receive  timely 
EPSDT  services.  Six of ten receive  none  at all. 
Based  on  our  review,  we estimate  that  only  28 percent  of Medicaid  managed  care 
children  receive  all of the  EPSDT  screens  called  for by the  periodicity  schedule  used  in 
their  State.  Another  12 percent  of children  enrolled  in managed  care  receive  some,  but 
not  all of the  EPSDT  services  they  should.  Sixty percent  of Medicaid  managed  care 
children  do not  receive  any EPSDT  services  called  for  in the  States  periodicity  schedules. 
When  we separate  these  data  into  age  cohorts,  we estimate  older  adolescents  enrolled  in 
Medicaid  managed  care  receive  significantly  fewer  required  EPSDT  services  than  other 
children. 
Age  of Child  Receive  all  Receive  some  Receive  no 
EPSDT  EPSDT  EPSDT 
Birth  - age  5  30%  22%  48% 
ages  6 - 14  32%  1%  67% 
ages  15 - 20  14%  0  86% 
all ages  28%  12%  60% 
Our  results  approximate  those  recently  found  by the  Oregon  Medical  Professional 

Review  Organization  (OMPRO)  in a review  of Washington  Medicaid  managed  care 

EPSDT  performance.  The  OMPRO  used  the  Medicaid  Health  Plan  Employer  Data  and 

Information  Set  (HEDIS),  a voluntary  standardized  performance  measurement  tool  for 

managed  care  plans,  to review  immunizations  in infants,  and  EPSDT  screens  for 

4-6 years  old  and  12-21 years  old.  They  found  that  26 percent  of the  4-6 year  old 

children  and  16 percent  of the  adolescents  received  EPSDT  services  in a 12 month 

period. 

We  tested  for  other  variables  that  might  affect  delivery  of EPSDT  services.  We find  no 

significant  differences  between  HMO  and  PCCM  plans  or between  large  or small 

managed  care  plans.  We  find  there  is no  difference  in EPSDT  performance  if a break  in 

managed  care  enrollment  occurred.  Besides  the  age of the  child  discussed  above,  the 

only variable  that  is significant  is the  States  EPSDT  monitoring,  which  is discussed  in the 

next  finding. 

The  mean  age  of the  children  in the  sample  is 7 years.  The  sample  averaged  16 months 

enrollment  in Medicaid  managed  care.  The  children  averaged  2.75 visits  (including  .8 

7  EPSDT  services)  to the  managed  care  plan  during  the  study  period. 
Medical  Record  Reviews 
Most  of the  visits Medicaid  children  make  to managed  care  plans  are  sick visits, based  on 
our  review  of medical  records.  In a few exceptions,  we found  these  visits were  expanded 
to become  full EPSDT  services.  3ut  in most  cases,  only  the  symptoms  that  generated  the 
sick visit were  treated.  Likewise,  we found  few visits treating  conditions  discovered  as a 
result  of a previous  EPSDT  screen. 
As could  be  expected,  documentation  of EPSDT  services  varied  greatly  between  States, 
managed  care  plans,  and  providers.  Frequently,  we found  more  complete  EPSDT 
documentation  when  providers  used  preprinted  forms  that  detail  the  appropriate  services 
for  a child  at  a given  age.  These  forms  correspond  to the  States  periodicity  schedule 
and  are  usually  provided  by the  managed  care  plan  to individual  providers.  One  plan 
color-coded  the  forms  to make  each  age cohort  distinctive  in order  to  alert  the  provider 
that  different  services,  tests,  guidance  and  observations  are  required  for  each  age group. 
However,  many  medical  records  failed  to detail  all of the  EPSDT  components.  Lead 
testing  was absent  from  many  records.  Frequently,  vision  and  dental  examinations  do not 
appear  to be  performed,  although  in some  States,  dental  services  are  not  part  of the 
managed  care  contracts.  If health  education,  growth  and  development  and  anticipatory 
guidance  for  the  child  to the  responsible  adult  were  provided,  they  were  seldom  part  of 
the  medical  record.  One  managed  care  plan  said that  in a capitated  environment,  there 
are  few incentives  for  providers  to provide  the  full range  of services.  Another  managed 
care  plan  pointed  out  that  with  capitated  payments,  there  was little  incentive  to report 
EPSDT  services  timely. 
The  philosophy  of some  States  and  managed  care  plans  may work  against  EPSDT 
services  being  provided.  One  managed  care  plan  explained  it is the  parents 
responsibility  to ensure  their  children  receive  all the  necessary  screens.  In that  plan, 
individual  physicians  do not  know what  families  have  chosen  them  as their  primary  care 
provider  until  that  family  makes  an  appointment  for  services.  One  State  said  that  using 
primary  care  physicians  as gatekeepers  is a way to  ease  the  physician  community  into 
accepting  managed  care. 
State  Contract3 
As stated  in our  background,  studies  show that  States  vary  widely  in emphasizing  EPSDT 
in their  managed  care  contracts.  Our  survey  tends  to  confirm  these  earlier  findings. 
Forty-one  States  responded  to our  request  for  contract  information.  Nine  of these  States 
do not  contract  with  any managed  care  plans  for  services  to Medicaid  children.  We 
found  13 States  spell  out  managed  care  EPSDT  responsibilities  in detail  in their  contracts 
with  managed  care  plans,  and  Oregon  does  the  same  without  mentioning  EPSDT  by 
name.  Three  States  are  in the  process  of revising  their  managed  care  contracts.  The 
other  States  managed  care  contracts  mention  the  EPSDT  requirement  without  providing 
8 
 specific  detail. 
E~orts  to &mote  EPSDT 
Medicaid  providers  face  many  obstacles  in attracting  Medicaid  patients  for 

non-emergency  health  care.  Barriers  include  the  on-again,  off-again  nature  of Medicaid 

coverage,  transient  addresses  and  phone  numbers,  the  high  number  of no-show 

appointments,  and  convincing  parents  of the  need  for  preventive  care  for  healthy 

children.  Some  States  specifically  require  managed  care  plans  to provide  transportation 

to patients  and  conduct  outreach  activities  to overcome  some  of these  barriers. 

In addition  to sending  reminder  postcards  and  phone  calls to parents  and  providing 

needed  transportation  to EPSDT  exams,  managed  care  plans  and  individual  providers 

have  taken  many  innovative  steps  to foster  EPSDT  screens  and  treatments.  One  Nevada 

physician  distributes  coupons  for McDonalds  Happy  Meals  to every  parent  who  brings 

in a child  for  an EPSDT  screen.  He  reports  buying  more  than  500 coupons  this year. 

The  restaurant  sells the  coupons  to him  at a bulk  discount  rate.  Another  physician 

provides  drug  store  discount  coupons  for  those  receiving  their  EPSDT  exams.  One 

managed  care  plan  held  a lottery  to win a big wheel  bicycle.  Chances  to win this 

prominently  displayed  prize  were  distributed  when  children  came  for  their  EPSDT 

screens. 

Providers  routinely  distribute  promotional  material  including  EPSDT  refrigerator 

magnets,  coloring  books,  and  coupons  for baby  shoes  and  diapers.  Managed  care  plans 

may  send  a nurse  for  a personal  home  visit to newborns.  While  most  of these  attractions 

are  aimed  at infants  and  small  children,  one  managed  care  plan  is starting  a teen  health 

plan. 

Managed  care  plans  and  school-based  health  centers  are  beginning  to work  together. 

Some  States  require  or encourage  coordination  between  managed  care  plans  and  school-

based  health  centers,  community  health  centers  and  local  health  departments  in an 

attempt  to bring  health  care  services  to hard-to-reach  populations. 

Children receive  significantly more  EPSDT  services from Medicaid  managed  care  plans 
when States inform the managed  care  plans which children are  due for EPSDT 
Two States  in our  sample,  Michigan  and  Nevada,  identity  children  who  are  currently  due 
for  EPSDT  screens  to their  managed  care  plans.  Michigan  notifies  their  plans  by an 
electronic  file  transfer  listing  all of the  children  due  that  month.  The  State  requires  each 
plan  to respond  for  each  child  by electronic  file transfer  by months  end. 
For  children  enrolled  in Nevadas  PCCM,  the  State  sends  a listing  of children  due  for 
EPSDT  screens  to the  PCCM,  who  sends  notices  to the  responsible  adult  for  the  child 
advising  of the  need  for EPSDT testing.  They  follow  up  as appropriate.  If the  State  has 
not  received  a bill for  EPSDT  services  within  3 months,  phone  calls to the  responsible 
9 
 adult  are  made. 
A comparison  of the  EPSDT  results  in these  States  to the  others  in our  sample  shows 
that  there  is a very  strong  statistical  difference  in managed  care  plan  performance. 
Managed Care State  received all EPSDT  received me,  not all EPSDT  -wEPm 
Michigaa/Nevada  54%  7%  38% 
All  others  19%  13%  68% 
Administratively,  a large  State  and  a small  State,  have  adapted  EPSDT  monitoring  to 
their  States  environment.  Michigans  monitoring  affects  capitated  managed  care  plans, 
while  Nevadas  tracks  PCCM  performance.  The  approaches  they  take,  while  basically  the 
same,  vary  in terms  of the  number  of children  to be monitored  and  the  systems 
sophistication  of the  States  and  managed  care  plans. 
10 
 RECOMMENDATIONS 
The  managed  care  philosophy  stressing  preventive  services  now  to avoid  costly  expenses 
later  for  medical  care  complements  EPSDT  program  objectives.  Medicaid  managed  care 
plans  are  potentially  very  conducive  to  delivering  EPSDT  services.  Managed  care  plans 
serve  as a medical  home  and  as gatekeeper  to medical  care  and  emphasize  prevention 
and  wellness  for  millions  of children.  Capitated  plans  especially  feature  many  advantages 
over  individual  providers  in being  able  to provide  outreach  and  transportation  to clients. 
They  benefit  from  economies  of scale  and  a steady  funding  stream.  However,  many  of 
our  findings  indicate  that  managed  care  plans  have  not  yet  realized  their  full potential  in 
providing  EPSDT  services. 
The Health  Care  Financing  Administration  should revise their EPSDT  reporting 
requirements  and data  collection to emphasize  the number  of children who receive  all of 
their EPSDT  screens  in a timely fashion. 
Current  EPSDT  reporting  methods  obscure  the  low EPSDT  rates  we found,  especially 
for  adolescents.  The  HCFA  should  revise  their  EPSDT  data  collection  so States  identify 
children  of different  ages who  receive  all of the  required  EPSDT  screens.  This  revision 
will improve  EPSDT  data  collection  for both  fee-for-service  and  managed  care  programs. 
The  HCFA  and  the  States  should  monitor  the  age groups  to determine  where  progress  is 
being  made  and  where  additional  efforts  are  required. 
States  currently  report  only  the  number  of children  receiving  at least  one  screen  during 
the  defined  time  period.  Since  the  EPSDT  requirements  vary with  State  and  age, revised 
reporting  data  should  identify  not  only  the  number  of children  who  receive  an  EPSDT 
screen,  but  also  the  number  of EPSDT  screens  those  children  should  be  receiving. 
Presently,  EPSDT  reporting  presents  data  in a way to suggest  that  most  children  receive 
EPSDT  services.  One  State  advised  us that  reporting  HCFA-416  data  always shows us 
over  100 percent.  Weve been  stuck  at 52 percent  forever.  This  anomaly  occurs 
because  current  reporting  overemphasizes  the  greater  number  of required  medical 
services  provided  to very young  children. 
We  support  States  using  Medicaid  HEDIS  as a measurement  tool  to  evaluate  the  nature 
of EPSDT  services  performed  in managed  care  settings.  States  should  be  encouraged  to 
evaluate  both  HMO  and  PCCM  type  plans.  Our  study  shows that  more  than  half  the 
children  enrolled  in Medicaid  managed  care  plans  receive  no  EPSDT  services,  regardless 
of plan  type. 
The  HCFA  should encourage  States to actively notify managed  care  plans of enrollees 
due for EPSDT  exams  and to follow up if EPSDT  services are  not rendered  shortly 
thereafter. 
11 
 Our  study  dramatically  demonstrates  the  value  added  to EPSDT  performance  when 
States  continue  to track  and  monitor  plan  performance  at the  individual  patient  level.  In 
some  States,  this  responsibility  may belong  at the  County  level,  but  regardless,  the 
technique  should  be  emulated.  The  techniques  used  in Michigan  and  Nevada  could  serve 
as models  for  States  to identify  the  children  due  for,  and  receiving  timely  EPSDT  screens. 
Beginning  in  1997, Virginias  Medicaid  Management  Information  System  will notify 
PCCMs  twice  annually  of children  due  for EPSDT  exams. 
The  HCFA  should work with States  to ensure timely managed  care  EPSDT  reporting. 
The  breakout  of managed  care  EPSDT  services  from  fee-for-service  is important.  The 
HCFA  needs  specific  data  to determine  whether  managed  care  is living  up  to its promise 
of access  and  care  to children,  who  represent  more  than  half  the  total  Medicaid 
population. 
Current  State  EPSDT  reports  to HCFA  do not  distinguish  services  rendered  by managed 
care  plans.  The  HCFA  collects  combined  managed  care  EPSDT  and  fee-for-service 
EPSDT  information  from  States  annually.  Immunization  records  may  lag behind  as well. 
In  1994, HCFA  discovered  that  States  collect  EPSDT  data  from  managed  care  plans  in 
inconsistent  ways. 
All managed  care  plans  should  report  EPSDT  services  to States  in a timely  and  uniform 
manner.  At  present,  managed  care  plans  subcontract  with  numerous  individual 
providers.  Consequently,  reporting  of EPSDT  services  is inconsistent,  not  always  timely, 
and  underreporting  may  occur.  Without  consistent  reporting  of EPSDT  data, 
determining  whether  States  meet  participation  goals  becomes  problematic. 
The  HCFA  should emphasize  to States the need to define and clarify EPSDT 
requirements  in their Medicaid  contracts  with managed  care  plans. 
Our  study  confirms  the  findings  of earlier  studies,  including  HCFAs,  pointing  out  the 
lack  of contractual  specificity  regarding  EPSDT  when  States  contract  with  managed  care 
plans  to provide  Medicaid  services.  In omitting  EPSDT  programmatic  details  from 
managed  care  contracts,  States  have  less leverage  in persuading  managed  care  plans  to 
deliver  timely  EPSDT  services  and  fewer  ways to evaluate  individual  plan  performance. 
The  HCFA  needs  to continue  working  with  States  to provide  examples  of effective 
contracts. 
12 
 AGENCY  COMMENT!3 
We  received  comments  from  HCFA  and  the  Acting  Assistant  Secretary  for  Health. 

Their  comments  are  included  in Appendices  B and  C respectively.  Both  fully agree  with 

the  recommendations.  The  Acting  Assistant  Secretary  for  Health  suggested  additional 

recommendations.  These  additional  suggestions  are  quite  consistent  with  the 

recommendations  in our  report.  We  suggest  that  HCFA  consider  them  in developing 

their  implementation  plan. 

We made  appropriate  revisions  to the  report  based  on their  technical  comments. 

13 
 APPENDIX  A 
VARIANCETABLE 
A-l  VARIANCE  AND  ESTIMATED 
 CONFIDENCE  INTERVALS 
Estimate  Standard 
Error 
Medicaid  managed  care 
children  who  receive  all  28.10%  8.30%  11.83%  44.37% 
required  EPSDT  services 
Medicaid  managed  care 
children  who  receive  some  11.52%  1.79%  8.01%  15.03% 
required  EPSDT  services 
Medicaid  managed  care 
children  who  receive  no  60.38%  13.37%  47.01%  73.75% 
required  EPSDT  services 
A-2 
 APPENDIX  B 
HCFA  COMMEiNTS  ON DRAFI  REPORT 
B-l  DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  Health Care Financing Administration 
The Administrator 
Washington, D.C.  20201 
4%  9 1997
2 
DATE: 
TO: 	 June Gibbs Brown 
Inspector General 
FROM: 	 Bruce C. Vladec 
Administrator 
SUBJECT: 	 Office of Inspector General (OIG) Draft Report: Medicaid Managed Care 
and EPSDT, (OEI-05-93-00290) 
We reviewed the above-referenced report that examined the Early aqd Periodic 
Screening, Diagnosis, and Treatment (EPSDT) services Medicaid children enrolled in 
managed care plans receive. 
Our detailed comments on the report recommendations are attached for your 
consideration.  Thank you for the opportunity to review and comment on this report. 
Attachment 
B-2  Comments of the Health Care Financing Administration  (HCFA) 

on Office of Inspector General (OIG) 

Draft Report: Medicaid Managed Care and EPSDT. 

(OEI-05-93-00290) 

OIG Recommendation 
HCFA should revise its Early and Periodic Screening, Diagnosis, and Treatment 
(EPSDT) reporting requirements and data collection to emphasize the number of children 
who receive all of their EPSDT screens in a timely fashion. 
HCFA Response 
We concur.  HCFA convened a Workgroup of representatives from the public and private 
sectors to assess and recommend changes to the current EPSDT reporting and data 
collection tool, the HCFA-416.  The Workgroup will focus on, among other issues: 
(1) developing an instrument that will collect more consistent, meaningful data from 
states regarding the furnishing of EPSDT services, especially services provided under 
managed care arrangements; (2) reviewing the effectiveness of periodic&y schedules that 
VW by state to determine if there is a better way to measure each states participation 
goal against the actual periodicity  requirement in the state; and (3) determining if Health 
Plan Employer Data and Information Set (HEDIS) measures will be a useful tool in 
measuring EPSDT services in managed care settings. 
It should be noted the current HCFA-416 collects data that identifies children of different 
ages.  It also uses the periodicity  schedule of the American Academy of Pediatrics to 
measure the number of screens children should be receiving in order to adjust the figure 
(i.e., 6 screens for the less than 1 year old, 50 screens for the 15-20 years old who should 
receive one every other year). 
.. _
OIG Recommendation 
HCFA should encourage states to actively notify managed care plans of enrollees due for 
EPSDT exams and follow-up if EPSDT services are not rendered shortly thereafter. 
HCFA Response 
We concur.  We will address this as part of the follow-up activities resulting from George 
Washington Universitys  recently released study of Medicaid managed care contracts, or 
as part of the Medicaid Managed Care Teams outreach efforts. 
B-3 
 Page 2 
OIG Recommendation 
HCFA should work with states to ensure timely managed care EPSDT reporting. 
HCFA Resuonse 
We concur.  This issue has been an ongoing concern of HCFA and wiIl be addressed  by 
the Workgroup mentioned above. 
OIG Recommendation 
HCFA should emphasize to states the need to define and clarify EPSDT requirements  in 
their Medicaid contracts with managed care plans. 
HCFA Resnonse 
We concur.  In addition to encouraging states through ongoing technical assistance, 
HCFA will continue to encourage states through its review and approval of new and 
existing waivers to include speci&  EPSDT programmatic requirements in their contracts 
with managed care programs. 
Technical Comments 
Page 2, Paragraph  1 - The enrollment figures published in the (1995) Medicaid Managed 
Care Enrollment Report contain double counts.  The figures have been revised to 
estimate unduplicated  figures.  As a result, total Medicaid managed care enrollment as of 
June 30,1995,  is estimated to be 9.8 million., or 29.4 percent of the total Medicaid 
population.  This 9.8 million figure represents a growth of about 2 million beneficiaries 
from the previous year. 
.. _ 
HCFA recently published the 1996 enrollment figures.  The total Medicaid managed care 
enrollment as of June 30, 1996, is reported to be 13.3 million (see HCFAs Home Page 
on the World Wide Web for the full report). 
The reference to managed care plans to which people are being enrolled should be 
changed to managed care programs.  The term programs more accurately describes the 
variety of systems into which people are enrolling.  Of the 403 Medicaid managed care 
arrangements in 1995,48  are primaty  care management programs and 355 are some form 
of managed care organization. 
B-4  Page 3 
Page 2, Paragraph 2, frost sentence - We suggest the following to replace the first 
sentence:  Managed care aims to reduce the utilization  of services that are not medically 
necessary,  lower health care costs, increase access to services, and provide a vehicle to 
better monitor the quality of care provided to beneficiaries. 
Page 2, Paragraph 3 - Managed care plan is more accurately managed care program. 
Page 2, Paragraph 4 - Quality assurance activities at the Federal, state government, and 
plan levels are designed to ensure Medicaid beneficiaries  are provided access to the 
services to which they are entitled and that providers and managed care organizations  are 
fXfilhng  their contractual obligations.  This point should be made more clearly in the 
discussion of fraudulent activities. 
Page 3, Paragraph  1 - Mention should be made that the contracts discussed in the 1995 
Childrens Defense Fund study were from 1991.  Since that time, increased attention has 
been focused on child health, which is likely reflected in newer contracts.  In the second 
sentence, please change showed to indicated, since no contract language was provided in 
Integrating EPSDT and Medicaid Managed Care. 
Page 4, Paragraph 2 - Managed care plan is more accurately managed care program. 
Page 7, Paragraph 3 - The Medicaid HEDIS was issued by the National Committee for 
Quality Assurance, not HCFA. 
Page 9, Paragraph 4 - Federally Qualified Health Centers (FQHCs) have protections not 
realized by school-based health centers, community health centers, and local health 
departments.  States are required to provide Medicaid beneficiaries with access to 
FQHCs, which is not the case for the other entities.  Either this distinction should be 
clear, or FQHCs should be removed from this provider list. 
Page 9, Last Paragraph - Nevada has a Health Maintenance Organization program, which 
means the state pays managed care organizations a capitated fee to provide a defined set 
of services to the Medicaid beneficiaries  enrolled in the plans.  In the description of 
Nevadas approach, mention is made of bills not being received by the state.  In a 
capitated situation, bills are never received by the state.  Please clarify Nevadas 
approach. 
It would be useful if the OIG report indicates what age groupings would provide more 
useful information than those currently used. 
It would be more accurate if the report used managed care program rather than managed 
care plan. 
B-S 
 APPENDIX  C 
k%%STANT  SECRETARY  FOR  HEALTH  COMMENTS  ON  DRAFT  REPORT 
C-l  DEPAkTMENTWHEALTHAND-S=w- Offica of the socwtrry 
As&ant  Se~crutmfroyr Hodth 
offiwofPublkcarldmd 
Wmhiqton  D.C.  20201 
MAR27l997 
TO: 	 June QibbeBrow 
In8pwtorGulcral 
FROhfz  Acting Awhtant  Sac- forHealth 
SUBJECT 	 OIG Drd  Repoh  Medicaid Managed Care and EPSDT 
OBI-05-93-00290 
Thankyou fortheoppommityto review andcommenton theinitialdraf?lbspectionreport: 
fhfedicaidManagedCareundEPSDT.O&OS-9340290. Thestudymakw an important 
contniiutionto the evolvinglmowlalge of theu8eof man@  camplansin providingnewswry 
prcvmti~e  and treatmat tices  to Medicaidrecipients. 
I havelimitedmy commentato twoapccificareaa:(1) Report Findings; and (2) Additional 
Recmmaxlad~.  Ovexall, I agree fhlly with your recommuxi8tiom  aud have inoludedscverai 
cI~on88ndariditi~  ttcainm~ons  for yau  conaidadion.  I look Wwml  to your 
Mm-
U.S. Publk Hedth  Suvb 
c-2  Page 2 -Ms. June Gibbs Brown 
Was the study limited to managed  care or PCCM providm  that were under contract, or 
o&wise  expectal, to provide the f%Uarray of EPSBT services? If not, what procedures 
were used to determine additional services acquiredby be&cities  outside of the 
designated provida  or plan? 
Second, various pxwentive sdgs  arc not well documented and are difEcult to 
identie  in the medical record. For example, health education andcoweeliag  are 
commoaly not documulted in the medical record during clinic vilJi&especially for 
sensitive or illegal activities. This does not. howeva, indicate 8 total d  of the8e 
6ervice6.The rtxamnendation  of collecting f&rre dataon am  BPSDT 
rcportillg for?&izlcludingutlls ofhealth e&at-i*  courl8eHn&d  rmtiw 
guidaucc, fbr all Msdioaid tnaeficisrics (m&r 21) would solve this rcp@g  problem. 
3, 	 Intereetingly, no st&tical  differarces were obsav&l between maoaged OQCand PCCM 
beneficiaries. I would have hypothesized thatPKM  pzuvidar had a higher mte of 
suocws due to the financial and treatmentincentives mt  in the fbc-far_arvice 
reimbursementsystem. This tiding  raises iasuear&al  to the efIisctleof the Stati: or the 
individual in the acquisition of such BcIvicts.The man@  care plan and Strte bear 
direct msponaibifity in providing many of these caabiing services. 
A8part of your evalt&ioll of effbrta used by providers to iucrmcp8ticnt  compliance, 
were you able @mihte  the use of tmqof@on  ~c&J&  locrbkn df pmvider, or 
iltxamibility of aeEviH+tshat may dvcrstly  effect m  to &X+ceB? 
c-3  Page 3 -Ms. June Gibbs Brow 
1. 	 The advantages of managed care, as part of the introductoqr paragraph of the 
Recommendations section, have yet to be reahed  or demonsti4  specifically, 
outreach programs, transportation services, and stressing preventive se&es  to avoid 
costly expense8late? fir medical care. I nxomm end revisions bared on our curznt 
state of knowledge on these issues, 
2. 	 In Recommendation #1, require additional data r+ting  within specific catcgorier:of 
BPSDTClQviccafor each age group. These categmiea include: complcta phy+cal exam; 
vision and he&n&  dental; dcve~opmentaland bahpvioral screaning; PI-O+UW 
(laboratory and inmnhtions);  md health education and anticipatory guidance. 
3. 	 In Recommedation  #!2,the State must continue to not@ beneficiari=  of the availability 
of EPSDT services, how to obtain them, and transportation and scheduling assistance. 
Additionally, if the State contractason&es to partial providers, they must develop a 
mechanism to coIlect EPSDT data from all 8ourcc.1o1f cam; thus, demonstrating 
compliance with providing the fill range of EPSDTservices. 
4. 	 In Rccummendation #3, the development and implem&ation  of a aandsrdized reporting 
form is vital to the State8and HCFAecflbrts in monitoriq  ~qticipotiop goal+ The lack 
of mtaPingfuhlealthinfhuhion is fiutk  complicated by theloss of l@dipsid 
reimbureemacnltaimafilestlnnu@theuseof caphtai paymenptqjram& Thi6 form 
6hould include the broai range of wxvicea availabk to eligibk  bu~eficiaiics, as dimwed 
above.~lemcntltionofsuchrEonnshwldbelinLc4toHCPAr1915(b)or111s 
Dt?momdoll w8ivern. 
5. 
6. 
. 
7 
C-4