DEPARTMENT OF HEALTH & HUMAN SERVICES  
Health Care Financing Administration  
Center for Medicaid and State Operations  
7500 Security Boulevard  
Baltimore, MD 21244-1850  
October 22, 1999  
Dear State Medicaid Director:  
The Department of Health and Human Services (HHS) is committed to ensuring that all 
of America's children are free of lead poisoning. The purpose of this letter is to present 
you with the findings of a General Accounting Office (GAO) lead screening report to 
clarify the legal requirements for lead screening for children in Medicaid, and to update 
you on the activities of an HHS taskforce created to control lead poisoning.  
Lead poisoning remains a significant health concern for young children. As you know, 
the General Accounting Office (GAO) released a report in January 1999 entitled "Lead 
Poisoning: Federal Health Programs are Not Effectively Reaching At-Risk Children." 
This report highlighted the low number of Medicaid eligible children who have been 
screened for lead poisoning as well as the number of states that are not adhering to 
Federal Medicaid lead screening policy. It is critical that State Medicaid programs adhere 
to the Federal Medicaid policies for lead screening and provide the medically necessary 
follow-up services as part of Early and Periodic Screening, Diagnostic and Treatment 
(EPSDT) services.  
GAO Report Findings  
Research indicates that although Medicaid-eligible children represent approximately 60 
percent of all children in this country with lead poisoning. That is why state Medicaid 
programs are required by Federal law and policy to cover screening blood lead tests for 
all children. And yet, the GAO report found that only 20 percent of Medicaid-eligible 
children had received any screening blood lead tests. The report also identified problems 
with regard to state Medicaid coverage of case management services and the one-time 
investigation to determine the source of lead in children who are lead poisoned. 
Additionally, the report raised issues concerning the reliability of state Medicaid data on 
blood lead screening and the effect of Medicaid managed care programs on lead testing 
and data. For your information, we have enclosed a copy of the Executive Summary and 
the Department's responses to GAO's recommendations (Enclosure 1) ( Note: Enclosure 1 
is not available in electronic format). The full report may be downloaded from the GAO 
website at www.gao.gov. 
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Page 1  State Medicaid Director 1   Click here to download the report in pdf format.  
(www.afhh.org/res/res_pubs/he99018.pdf) 
Lead Screening Requirements in Medicaid  
Even as the average blood lead level of children in this country continues to decline, lead 
poisoning among Medicaid-eligible and other vulnerable children remains a concern. As 
part of the definition of EPSDT services, the Medicaid statute requires coverage for 
children to include screening blood lead tests appropriate for age and risk factors. The 
Health Care Financing Administration (HCFA) has interpreted this language to require 
that all children enrolled in Medicaid should receive a screening blood lead test at 12- 
and 24-months of age because this is the age when all children are most at risk. Children 
over the age of 24 months, up to 72 months of age, for whom no record of a previous 
screening blood lead test exists, should also receive a screening blood lead test. In 
addition, states should cover any follow-up services within the scope of the Federal 
Medicaid statute, including diagnostic or treatment services determined to be medically 
necessary. Such services would include both case management services and the one-time 
investigation to determine the source of lead for children diagnosed with elevated blood 
lead levels.  
Part 5 of the State Medicaid Manual states that "investigations to determine the source of 
lead may be reimbursable . . . under certain circumstances." We are taking this 
opportunity to clarify this information. The term "may" does not mean this is an optional 
service. The intent was that certain medical circumstances must be present before the 
investigation is reimbursable as a Medicaid service, i.e., the child must have an elevated 
blood lead level. In addition, the scope of the investigation is limited. HCFA only 
reimburses for a health professional's time and activities during an on-site investigation 
of a child's home (or primary residence). Medicaid funds are not available for testing of 
environmental substances such as water, paint or soil. We will revise the State Medicaid 
Manual in the near future to make this requirement more explicit. In the meantime, we 
are bringing it to your attention now so that any misunderstanding is corrected.  
Lead Screening Taskforce Update  
HCFA has undertaken a comprehensive Departmental initiative to increase lead screening 
of Medicaid and other vulnerable children. We would also like to improve access to, and 
the provision of, needed follow-up services for children who are found to be lead 
poisoned. In addition to HCFA, the initiative includes the Centers for Disease Control 
and Prevention (CDC), the Health Resources and Services Administration (HRSA), and 
the Administration for Children and Families (ACF) with assistance from the 
Environmental Protection Agency and the Department of Housing and Urban 
Development.  
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Page 2  State Medicaid Director  2   This group has developed a detailed strategy and timeline to implement five activities 
that are central to the GAO's findings:  
  ensure compliance with Federal policies;  
  develop state-specific data;  
  develop a process for waiving universal blood lead screening for Medicaid 
children;  
  develop a strategy for educating providers and the public about lead poisoning so 
that resources are focused on children who are the most likely to need help; and  
  promote working relationships with federally-funded programs involved in 
childhood lead poisoning issues and other activities.  
We also enclose information about HCFA's strategy for assuring that states are adhering 
to Federal Medicaid policies on lead screening and the provision of medically necessary 
follow-up services as well as describing the Departmental initiative in more detail. 
Finally, we discuss methods for sharing best practices. (See Enclosure 2)  
We have discussed some of these issues and our activities with the National Association 
of State Medicaid Directors' (NASMD) Executive Committee at their meeting in March. 
This will also be an agenda topic at NASMD's Fall meeting. Please feel free to contact 
Cindy Ruff at 410-786-5916 (e-mail: cruff@hcfa.gov) for further information.  
Thank you for your attention to this very important matter.  
Sincerely,  
/s/  
Timothy M. Westmoreland  
Director  
Enclosures  
cc:  
All HCFA Regional Administrators  
All HCFA Associate Regional Administrators for Medicaid and State Operations  
Lee Partridge  
American Public Human Services Association  
3
                                                 
Page 3  State Medicaid Director 3   Joy Wilson  
National Conference of State Legislatures  
Matt Salo  
National Governors' Association  
Brent Ewig  
National Association for State and Territorial Health Officials 
4  
                                                 
Page 4  State Medicaid Director 4   Enclosure 2  
TASK FORCE UPDATE  
ON LEAD POISONING PREVENTION 
Ensure Compliance with Federal Medicaid Policy  
Using data from the most recent National Health and Nutrition Examination Surveys 
(NHANES) conducted from 1991 to 1994 and confirmed by (1994/1995) data from 15 
state Medicaid agencies, the GAO report indicates that only 20 percent of Medicaid-
eligible children are being screened for lead poisoning. In addition, a national survey of 
state Medicaid agencies by GAO indicated that many states have not adopted the 
mandatory EPSDT lead screening policy. As indicated in the cover letter, States are to 
provide all Medicaid-eligible children with a screening blood lead test at 12- and 24-
months of age. Children over the age of 24 months up to 72 months of age for whom no 
record of a previous screening blood lead test exists, should also receive a screening 
blood lead test. In addition, any follow-up services, including diagnostic or treatment 
services determined to be medically necessary that are within the scope of the Federal 
Medicaid statute, should also be provided. This would include both case management 
services and the one-time investigation to determine the source of lead for children 
diagnosed with elevated blood levels.  
We intend to review the results of GAO's national survey and follow-up with those states 
which, based on the survey answers, appear not to be adhering to our policies on lead 
screening, coverage of case management services and coverage of investigations to 
determine the source of lead. We, along with our Regional Offices, are eager to work 
with States to ensure compliance with the law and program regulations.  
According to GAO, approximately 42 percent of Medicaid-eligible children received 
their medical services through managed care arrangements. These health delivery 
systems are ideal for the provision of coordinated preventive services including lead 
screening. However, GAO found mixed results with respect to the effectiveness of 
managed care and lead screening and concluded that improvements are needed. Managed 
care plans and providers need to be made aware of the Federal lead screening 
requirements. We encourage all states that contract with managed care organizations to 
provide EPSDT services to Medicaid-eligible children to consider including specific 
language on lead screening requirements in your contracts. George Washington 
University's Center for Health Policy Research, under a contract with CDC, has 
developed optional contract specifications, including model language for lead screening. 
If you would like more information on this, you may contact the George Washington 
University website at www.gwumc.edu/chpr.  
While Medicaid covers the medical services that a child with lead poisoning needs, there 
remain other (non-medical) type services, such as housing, lead abatement and 
environmental investigation of the source of lead, that may also be needed in these cases. 
Case management services, which are claimed as a medical service, can be used to reach  beyond the bounds of the Medicaid program to coordinate access to a broad range of 
services, regardless of whether the Medicaid program is funding the service to which 
access is gained. We encourage you to work with state and local agencies to develop 
interagency agreements to ensure that Medicaid children receive all the necessary 
services not covered under the Medicaid program. We (HCFA) will be working with our 
HRSA and CDC counterparts, as part of the Departmental initiative, to assist you in this 
effort and to develop model interagency agreements that you can use.  
Recently, Rhode Island was approved to expand its statewide 1115 Medicaid 
demonstration waiver to cover the cost of replacing windows in the homes of children 
diagnosed with lead poisoning. While replacing windows is not a covered item under the 
"regular" Medicaid program, Rhode Island was able to obtain HCFA approval for this 
because it financed the program with Medicaid savings created through other aspects of 
its 1115 waiver. This innovative program is expected to improve the health of lead 
poisoned children by removing the major source of contamination from their homes. We 
will be happy to provide any technical assistance that states need in developing similar 
innovative 1115 proposals for services for Medicaid children who are lead poisoned.  
Develop State-Specific Data  
Data on lead screening of Medicaid children is very difficult to capture on a national 
level for many reasons. In many states, public health departments provide lead screening 
to Medicaid-eligible children but do not bill the Medicaid agencies for these tests. State 
Medicaid agencies have no way of knowing these tests have been provided if no bill is 
received. For those Medicaid children served by managed care plans, encounter-type data 
and information is often not submitted to the state Medicaid agency. The laboratories 
(both public and private) that actually perform blood lead tests have a wealth of data, 
including prevalence data. However, while CDC grantees obtain data from public and 
private laboratories, it is not always statewide data, eligibility information is not always 
included in the submission, and this information is not usually shared with the Medicaid 
agency. As you can see, much work is needed in this area.  
We are currently working on several ways to improve data collection for lead screening. 
We are revising the form HCFA-416, the annual EPSDT reporting form, to include a line 
requiring states to report the number of screening blood lead tests provided to children 
under the age of 6. The HCFA-416 collects data on EPSDT services for children 
receiving services in both fee-for-service and managed care arrangements. States should 
begin reporting this new data on April 1, 2000, which will be data for fiscal year 1999. 
The revision to the form is consistent with recommendations of GAO and has the support 
of the Administrator of HCFA and several members of Congress.  
At the present time, HCFA is able to collect some data on lead testing from the Medicaid 
Statistical Information System (MSIS) report. As of January 1, 1999, all states are 
required to submit this report. Nevertheless, we expect that it will take several years 
before MSIS will contain complete and reliable data for Medicaid-eligibles in both the 
fee-for-service and managed care systems.   We also intend to work with CDC and HRSA to address the data collection/sharing issues 
and problems. As you know, in a letter dated October 22, 1998, HCFA joined CDC and 
HRSA to launch a coordinated strategy aimed at reducing barriers to sharing data 
between Medicaid and health agencies. This strategy also supports innovative approaches 
to the design and implementation of state information systems that foster collaboration 
among these programs. We believe that lead screening data provides an excellent 
opportunity for different state agencies to work together towards a common goal. We 
encourage you to use the model data sharing agreement included in the October letter as a 
framework for developing an agreement to share and link lead screening data with 
relevant state level agencies. Regulations at 42 CFR 431.402 specify the reasons and 
purposes that are allowable administrative costs in the Medicaid program. 42 CFR 
431.402(c) specifies that one such allowable administrative cost is administrative 
activities related to "providing services for recipients." We believe that sharing data, such 
as providing a list of Medicaid-eligible children or of Medicaid-eligible children who 
have received a blood lead test, with other state and local agencies involved in lead 
screening or lead poisoning prevention, would qualify as an allowable administrative 
cost. This linkage would allow the State Medicaid agency and other collaborating 
agencies to develop a data base to identify children who have not received screening 
blood lead tests and those at high-risk for lead poisoning. This type of data sharing or 
linking would fit the purpose of enabling more Medicaid children, particularly those at 
highest risk, to receive necessary services related to lead poisoning and would provide 
states with a match of 50 percent Federal financial participation.  
Finally, we would like to ask you for any information you have on successful lead 
screening programs or interagency agreements which are working well in your states to 
ensure that children are receiving lead screens. We would like to collect "best practices" 
information to share with other states which may be having difficulty in determining the 
best way to screen children and collect and share appropriate data. Please send this 
information to HCFA, Center for Medicaid and State Operations, Family and Children's 
Health Programs Group, Attention: Cindy Ruff, 7500 Security Boulevard, S2-01-16, 
Baltimore, Maryland 21244.  
Develop a Process for Waiving Universal Blood Lead Screening for Medicaid 
Children  
When we revised our lead screening policy in 1998 to reflect the new CDC 
recommendations, we recognized that it may be necessary to revisit our mandatory 
screening requirements as states developed their statewide lead screening plans. In a 
letter to you dated April 13, 1998, we encouraged your participation on the public health 
advisory committee in your state developing the statewide lead screening plan. We 
believe that Medicaid representation on this committee is of great importance to ensure 
that the concerns of the Medicaid population are addressed. According to the CDC, 
children receiving public assistance remain at high risk for lead poisoning, despite the 
general overall drop in lead poisoning rates nationwide.   The GAO recommended that we develop a methodology for waiving Medicaid's 
universal screening requirement. We intend to work with CDC, its Advisory Committee 
on Childhood Lead Poisoning Prevention, and HRSA to develop a protocol and criteria to 
determine whether states have sufficient data and the information necessary to waive the 
universal screening requirement for all Medicaid-eligible children. We acknowledge that 
some states may not have a lead exposure problem or that it may be limited to only 
certain areas of a state. In these instances, mandatory lead screening of all Medicaid 
children may be unnecessary. However, until we have appropriate criteria or a process in 
place, we cannot allow a state to waive the universal lead screening requirement for 
Medicaid-eligible children. That is why we believe your participation in the development 
of these statewide lead screening plans is important.  
Develop a Strategy for Educating Providers and the Public About Lead Poisoning  
As part of the Departmental initiative, HCFA intends to work with other Federal agencies 
to better educate providers and the public about the continuing risk of lead poisoning 
especially for low-income children and those living in older homes. HRSA is already 
involved in educational activities such as the National Childhood Lead Poisoning 
Training and Resource Center and developing a national televideo conference for parents, 
caregivers and advocacy groups as part of its series of productions for Maternal and Child 
Health (MCH) Bureau grantees. CDC is funding the development of materials to educate 
the public and private providers, managed care organizations and parents about the 
importance of lead screening as part of its cooperative agreement with the Center for 
Health Policy Research at George Washington University.  
Promote Working Relationships with Federally-funded Programs Involved in 
Childhood Lead Poisoning Issues and Other Activities  
We will be working with our counterparts on the Departmental workgroup to enhance 
federally-funded activities in lead poisoning prevention, screening, treatment and other 
areas. Many Federal agencies currently play a role and provide funding for childhood 
lead poisoning prevention activities. Through the Departmental initiative, we expect to 
better coordinate and enhance the Federal role. Specifically, HCFA intends to make 
presentations to NASMD and the Medicaid/Maternal and Child Health Technical 
Advisory Group to keep them apprised of lead poisoning issues and the collaborative 
work we are doing with other agencies. HCFA, HRSA and CDC intend to participate on 
key workgroups and committees on the Federal, state and community level. HRSA 
intends to convene an expert panel to explore the impact of lead poisoning on the MCH 
population. CDC will review its grantee performance goals to assure that collaboration 
with WIC, Early Head Start and Community Health Centers is specified.