Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

 

 

MOST MEDICAID CHILDREN IN 

NINE STATES ARE NOT 

RECEIVING ALL REQUIRED 

PREVENTIVE SCREENING 

SERVICES 

Daniel R. Levinson 

Inspector General 

May 2010 

OEI-05-08-00520 
INTRODUCTION EXECUTIVE SUMMARY 

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 

children’s 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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EXECUTIVE SUMMARY 

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 EPSDT’s 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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EXECUTIVE SUMMARY 

 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 children’s 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. 
 TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

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

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 
 

 

 INTRODUCTION 

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 

children’s participation in EPSDT screenings and the completeness 

of EPSDT medical screenings. 

BACKGROUND 

Earlier studies have reported ongoing problems with Medicaid’s 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 benefit’s 

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, Children’s Health Under Medicaid: A National Review

of Early and Periodic Screening, Diagnosis, and Treatment 1999–2003, 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: Medicaid’s 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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INTRODUCTION 

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

Medicaid’s 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 Medicaideligible 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 

 2 

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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INTRODUCTION 

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 child’s 

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 clarity’s 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 

child’s development. 

18 CMS, Manual, § 5123.2(C). 

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INTRODUCTION 

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 physician’s 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 children’s 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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INTRODUCTION 

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. 

 5 

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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INTRODUCTION 

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 

 6 

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 child’s age based upon his or her age as 

of September 30. The age groups are: under 1, 1–2, 3–5, 6–9, 10–14, 15–18, and 19–20. 

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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INTRODUCTION 

were at or below 50 percent.41 In fact, only one State achieved the 

Secretary’s 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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INTRODUCTION 

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 child’s 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 children’s 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 child’s 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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INTRODUCTION 

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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INTRODUCTION 

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 children’s 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 children’s 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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INTRODUCTION 

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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 FINDINGS 

Three out of four children did not receive all 

required medical, vision, and hearing screenings 

In 9 selected 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 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 

No screenings

38%

Missing types of 

screenings

33%

All types of 

screenings, but 

incorrect number

4%

All screenings

21%

Insufficient 

documentation

4%

Chart 1: Required 

Screenings 

Received, by 

Percentage of 

Children 

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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FINDINGS 

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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FINDINGS 

Nearly 60 percent of children who received 

EPSDT medical screenings lacked at least one 

component of a complete medical screening 

Fifty-five percent,45 or nearly 

2 million children in the 9 selected 

States, received medical 

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. 

Complete screening, 

41%

One missing 

component, 30%

Two missing 

components, 18%

Four missing 

components, 2%

Three missing 

components, 9%

Chart 2: Number 

of Missing 

Components, by 

Percentage of 

Children Who 

Received Medical 

Screenings 

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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FINDINGS 

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. 

0% 10% 20% 30% 40% 50% 60% 70%

Missing any component

Complete physical

examination

Appropriate

immunizations

Health education

(Anticipatory guidance)

Health and

developmental history

Appropriate lab tests

Percentage of Children

Chart 3: Of 

Children Who 

Received Medical 

Screenings, 

Percentage 

Missing Each 

Component 

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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FINDINGS 

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 child’s 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 1–5 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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FINDINGS 

 17 

NDINGS 

the 6-month visit and the 1-year visit. By collecting a thorough health 

history, the provider determined that the increase was due likely to a 

diet high in sugary drinks and offered guidance to move the child to a 

more appropriate diet. 

Staff from all selected States’ 

Medicaid agencies (hereinafter 

referred to as officials) 

identified efforts to increase 

the number of children who receive screenings, as well as increase the 

completeness of medical screenings. 

Staff from all selected States’ 

Medicaid agencies (hereinafter 

referred to as officials) 

identified efforts to increase 

the number of children who receive screenings, as well as increase the 

completeness of medical screenings. 

All nine States reported strategies to improve 

participation in EPSDT screenings and the 

completeness of EPSDT medical screenings 

Officials from all nine States reported efforts to improve participation in 

EPSDT screenings, but barriers remain 

Officials from all selected States identified at least one of three 

strategies to improve participation in EPSDT: direct communication to 

eligible families, outreach, and incentives. Despite these strategies, 

officials from all States identified barriers to improving participation in 

EPSDT screenings. 

Officials from all selected States identified at least one of three 

strategies to improve participation in EPSDT: direct communication to 

eligible families, outreach, and incentives. Despite these strategies, 

officials from all States identified barriers to improving participation in 

EPSDT screenings. 

Direct communication. 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 

child’s 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 child’s 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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FINDINGS 

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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FINDINGS 

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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 RECOMMENDATIONS 

Most children are not fully benefiting from EPSDT’s 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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RECOMMENDATIONS 

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 

 21 

53 GAO, Medicaid Preventive Services. 

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RECOMMENDATIONS 

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 children’s 

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 EPSDT’s screening services. This 

effort should focus on practices designed to ensure that families are 

aware of EPSDT screening services and methods to encourage children’s 

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 

 22 

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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RECOMMENDATIONS 

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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RECOMMENDATIONS 

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 CMS’s technical 

comments. 

For the full text of CMS’s comments, see Appendix D. 

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APPENDIX ~ 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 child’s 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 

 25 

 APPENDIX ~ A 

57 Centers for Medicare & Medicaid Services (CMS), Manual, §§ 5123.2(A)-(E). 

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APPENDIX ~ A 

to give information to the child and the child’s 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 child’s development (anticipatory 

guidance). 

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Detailed Methodology

 APPENDIX ~ B 

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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APPENDIX ~ B 

State-provided data. If a child’s birthday was during the first 

6 months of 2007, then we used the age he or she became in 2007. If 

a child’s 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 child’s 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 child’s age. To do this, we used each 

State’s 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, 3–8, and 9–21. We 

determined each child’s 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, Children’s Health Under Medicaid. 

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APPENDIX ~ 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 

3–8 941,968 55 408,501 60 1,350,469 115 

9–21 964,891 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 child’s 12-

month determined age to provide additional context. For 82 children, 

the sample period was 26 months because the State’s 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 children’s 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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APPENDIX ~ B 

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 record’s 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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APPENDIX ~ 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 State’s laboratory schedule to 

determine what, if any, lab tests were required at a child’s 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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APPENDIX ~ B 

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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APPENDIX ~ C 

Estimates and Confidence Intervals 

Table C-1: Estimates of Medical Record Review Results Analysis 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who did not receive all required Early and 

Periodic Screening, Diagnostic, and Treatment (EPSDT) medical, 

vision, and hearing screenings 

345 75.7 70.7%—80.6% 

Number of children who did not receive all required EPSDT medical, 

vision, and hearing screenings 345 2,731,975 2,553,012—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 

number of screenings 345 4.3 2.4%—6.2% 

Percentage of children whose medical records had insufficient 

documentation 345 3.6 1.5%—5.6% 

Percentage of children who received at least one, but not all, EPSDT 

screenings 345 37.8 32.4%—43.2% 

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% 

Number of children who received at least one medical screening 345 1,986,492 1,786,186—

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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who did not receive hearing screenings and did 

not receive medical screenings 242 55.7 49.0%—62.4% 

Source: OIG analysis of results of a review of medical records, 2009. 

 APPENDIX ~ C 

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APPENDIX ~ C 

Table C-3: Estimates of Medical Record Review Results Analysis for Children 

Who Did Not Receive Vision Screenings 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who did not receive vision screenings and did 

not receive medical screenings 222 60.1 53.9%—67.2% 

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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who received medical screenings but did not 

receive all components 197 59.5 52.0%—66.8% 

Percentage of children who received medical screenings and received 

complete screenings 197 41.4 35.9%—46.9% 

Percentage of children who received medical screenings but did not 

receive one component 197 29.9 22.9%—36.9% 

Percentage of children who received medical screenings but did not 

receive two components 197 17.9 11.8%—24.0% 

Percentage of children who received medical screenings but did not 

receive three components 197 9.1 4.5%—13.6% 

Percentage of children who received medical screenings but did not 

receive four components 197 2.0 0.6%—5.1%* 

Percentage of children who received medical screenings but did not 

receive the appropriate laboratory tests component 197 38.2 30.7%—45.6% 

Percentage of children who received medical screenings but did not 

receive the health and developmental history component 197 21.0 14.7%—27.4% 

Percentage of children who received medical screenings but did not 

receive the complete unclothed physical examination component 197 8.2 3.9%—12.5% 

Percentage of children who received medical screenings but did not 

receive the appropriate immunizations component 197 12.8 7.6%—17.9% 

* Confidence interval calculated with an exact method based on the binomial distribution. 

continued on next page 

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APPENDIX ~ C 

Table C-4: Estimates of Medical Record Review Results Analysis for Children 

Who Received Medical Screenings, continued

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who received medical screenings but did not 

receive the health education (including anticipatory guidance) 

component 

197 20.7 14.4%—27.0% 

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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who did not receive medical screenings and did 

not receive vision and hearing screenings 148 86.4 81.1%—91.8% 

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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of children who received medical screenings and were 

required to receive tuberculosis tests but did not receive them 115 69.1 59.9%—78.3% 

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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of one- and two-year-olds who received medical screenings 

but did not receive mandatory blood lead tests 56 57.4 42.4%—72.4% 

Source: OIG analysis of results of a review of medical records, 2009. 

OEI-05-08-00520 MOST MEDICAID CHILDREN IN NINE S TATES ARE N OT RECEIVING ALL REQUIRED P REVENTIVE S CREENING S ERVICES 35 
A P PEN 0 x o 


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

CMS Response ;~ ~ 8 .~' 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. 

OEI·05·08·00520 MOST MEDICAID CHILDREN IN NINE STATES ARE NOT RECEIVING ALL REQUIRED PREVENTIVE SCREENING SERVICES 36 
 

 

APPENDIX ~ D 

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APPENDIX ~ D 

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APPENDIX ~ D 

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 ACKNOWLEDGMENTS 

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. 
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 OIG’s 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.