DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
Center for Medicaid, CHIP and Survey & Certification 
 
CMCS Informational Bulletin 
 
  
DATE:  March 30, 2012 
 
FROM:  Cindy Mann, Director 
  Center for Medicaid, CHIP and Survey & Certification (CMCS) 
 
SUBJECT:  Medicaid Lead Screening and EQRO protocols  
 
This Informational Bulletin is meant to inform you of a pending revision to our policy regarding 
lead screening for Medicaid-eligible children and an opportunity to comment on proposed 
changes to Medicaid Managed Care External Quality Review Protocols.   
 
Medicaid Lead Screening 
 
Although substantial improvements have been made in reducing lead in the environment, lead 
poisoning continues to be a significant problem for some low-income children.  To improve 
screening of children most at risk for lead exposure, CMS plans to align its Medicaid lead 
screening policy with current recommendations of the Centers for Disease Control and 
Prevention (CDC). The new approach encourages targeted screening in States that have 
sufficient data to demonstrate that universal screening is not the most effective method of 
identifying exposure to lead.  In addition to being consistent with CDCs recommendations, this 
change will allow States limited resources to be targeted to children most needing the services. 
 
The CDC outlined its new lead screening policy in a report entitled Recommendations for Blood 
Lead Screening of Medicaid Eligible Children Ages 1-5 years: An Updated Approach to 
Targeting a Group at High Risk in the Morbidity and Mortality Weekly report (MMWR) which is 
available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5809a1.htm.  The report included 
three recommendations:  1) Update blood lead screening policies for Medicaid-eligible children; 
2) Improve rates of blood lead screening for Medicaid-eligible children determined to be at 
increased risk for lead exposure; and 3) Design and implement updated surveillance and 
evaluation strategies.  In October 2009, CMS and CDC released a joint memorandum 
announcing the new CDC recommendations and noted that CMS and CDC were working to 
update our Medicaid lead screening policy.   
 
Given the information in the CDC report supporting the decrease in the number of children ages 
1 to 5 with elevated blood lead levels and the importance of State and local data, adopting the 
CDC recommendations will allow States limited resources to be targeted to those children most 
needing these services.  In addition, we believe providers will be more willing to screen children 
in a targeted group where data supports the risk of lead poisoning rather than being asked to 
universally screen all Medicaid eligible children and seeing little results.  We will also be 
  increasing our efforts to ensure that Medicaid eligible children who need to be screened for lead 
poisoning receive the necessary blood lead screening test.    
 
CMS has historically followed CDC recommendations on lead screening for Medicaid eligible 
children, and this shift in approach is consistent with past practices.  However, we understand 
that this change will not be without challenges.  CDC and CMS are developing a process by 
which State Medicaid Agencies would apply to CDC and CMS for approval to discontinue 
universal screening and move to the targeted approach.  State Medicaid Agencies will need to 
partner with their State Health Departments and/or lead screening programs to collect and share 
data needed to support such a change and also to provide new screening guidelines to providers.  
In States where data on lead exposure are not sufficient, universal screening will need to be 
continued.  We will continue to work closely with States as they work through this transition and 
will provide further guidance as needed. 
 
The CMS and CDC have developed a preliminary process for State Medicaid Agencies to 
request to move their Medicaid eligible children into a State specific targeted lead screening 
approach, and we expect to finalize the process in the coming months.  Because a targeted 
approach will involve data from State Health Departments, we encourage Medicaid agencies 
who have not already done so to begin working with their State Health Department.  Medicaid 
agencies and State Health Departments will need to ensure that the appropriate data sharing and 
other cooperative arrangements are in place so that, when the new process is implemented, the 
State can ensure that Medicaid eligible children are appropriately screened for lead poisoning 
according to the States assessment of need.  If you have any questions please feel free to contact 
Cindy Ruff at 410-786-5916 or Cynthia.Ruff@cms.hhs.gov.   
 
Revisions to Managed Care External Quality Review Protocols for Public 
Comment 
 
The Balanced Budget Act of 1997 (BBA) required State Medicaid agencies that contract with 
Medicaid managed care organizations (MCOs) to develop a State quality assessment and 
improvement strategy that is consistent with standards established by the Department of Health 
and Human Services (HHS).  The BBA also requires HHS to develop protocols for use in the 
performance of independent, external review of the quality and timeliness of, and access to, care 
and services provided to Medicaid beneficiaries by Medicaid MCOs and prepaid inpatient health 
plans (PIHPs). CHIP managed care plans also are required to conduct EQRs, as required by the 
Childrens Health Insurance Program Reauthorization Act of 2009 . 
  
We published proposed substantial updates to the CMS EQR protocols in a Federal Register 
Notice on February 17, 2012, available at http://www.gpo.gov/fdsys/pkg/FR-2012-02-
17/pdf/2012-3790.pdf.  The draft revised EQR Protocols are available for viewing and download 
at the CMS Medicaid.gov website: 
http://www.cms.gov/PaperworkReductionActof1995/PRAL/list.asp - and click on the link CMS-
R-305.  Public comments are due April 17, 2012.