Department of Health and Human Services


OFFICE 

INSPECTOR GENERAL


MEDICAID EXPANSIONS FOR


PRENATAL CARE: STATE AND LOCAL


IMPLEMENTATION


7f. 

Richard P. Kusserow 

INSPECTOR GENERAL 

OEI-06-90-00160 
EXECUTIVE SUMMARY


Ths inspection descnoes State and loca effort to implement eligtoilty expansions 

for Medicaid-covered prenata cae and to overcome barers to accssibilty and 

avaiabilty of prenatal cae. 

BACKGROUN 

Aimed at reducing the incidence of inant mortality and low birweight, Federal 

legislation allows more women to meet the income criteria for Medicaid-covered 

prenatal care. States are now mandated to set income eligIoilty at 133 percent of 

the Federal povert level, guarantee contiuous eligtoilty unti 60 days post partum 

extend the presumptive eligtoilty period up to 60 days for States choosing ths 

option, use special pregnancy-related application form, use application sites other 

than where Aid to Famies with Dependent Chidren applications are processed, and

eliate paternty establihment as a precondition to receive Medicaid-covered 

prenatal care. Additional Federal options allow States fleXloilty to set an income 

standard up to 185 percent of the Federal povert level, use of presumptive eligibilty 

to provide temporary ambulatory care while formal Medicaid determations are 

being made, and to disregard assets when makig eligibilty determinations. 

MEODOLOY 

We conducted site visits in 19 communties withi eight states (Alabama, Arkansas 

Colorado, Florida, Maryland, New Jersey, New Hampshie, and Pennylvania). 

Providers, eligtoilty supervsors and workers, and prenatal clients were intervewed 

and a number of implementation issues were identifed. We also conducted a 

national telephone survey of 51.State and Distrct of Columbia offcials responsible 

for implementig the eligtoilty expansions. Along with self-reported inormation, we 

analyzed applicable Federal and State laws, policies and procedures, plus reviewed 

outreach materials and application forms. 

FIINGS 

(All figs ar based on info17tin as of Jan 1991)

Al State Have Set Their Income Stadad at 133 Percent of the Federa 

Povert Leel. In Addition, Man Oters Have Endors Optiona ElgIoilty 

Exanions. 

. 46 States waive the asset/resource test. 
Some State Are Takg Positie Steps to Addres Problems with Acc and 

Awibilty of Medcad-Cered Prnata Cae. 

. Comprehensive client outreach materials 

. Streamled and simplied application processes 

Provider participation incentives 

Alternative health care providers


. Case managers and enhanced prenatal care packages 

Integrated data collection 

Potential Cost Reductons Wil Exce $97 Mion if Neonata Intensive Cae Is 

Reduce by Just 1 Percent. 

RECOMMATIONS 

Deelop A Comprehee Oueach Strteg. 

Simplif and Streaml th Applitin Pres 

Develop Incenes to Inceae Prvi Parttin. 

Clri Poli and Monior Impletin of Medid Exnsns. 

Deelop Data Collctn Syst and Evalutin Preses to Mease Pres th Eligiil Exnsns and Fut Prm Effect 

Esblih a Celied Authori wi Ful Resnsil for Impleg
 Exansns.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................................................... y 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................... . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . 

TABLE OF CONTENTS 

INODUCTON 

Purpse. .. . . . 


Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 


Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 


FIINGS 

(Al fi lI baed Of infom as of It1 1991) 

Al States Have Set Thei Inmme Stada at 133 Pert of the Federa Pov Le 

Adtion, Ma Oth Ha Endors OptiDB Elgibilty ions . . . . . . . . . . . . . . . . . .. 

Howr, Signcat Prble Prnt New Elgible Women frm Recivg cUd RdPn .............................................. 5 

Client Outreach Is Inadequate 

Women Are Not Completing the Cumbersome Application Proces. . . . . . . . . . . . . . . 


States Have Difculty Reciting Prenatal Care Providers. . . . . . 


Adintrative Complexties Discourage Broader Use of Presumptive Eligibilty


Lack of Staffg Hiders Procing of New Elgibles in Most States


States Request More Timely Inormation and Tring from HCFA . . . . . . . . . . . . . . . . .. 


HCFA and !dost State Caot !deaur the Prgr and Impa of the &pions ...... .. 11 

Some State Ar Takg Positi Steps to Addr Prblem with Aa and Avabilty of cUd-C Prnata Ca 

Several States Have Develope Comprehensive Clent Outreach Materials


Several States Have Streamlined and Simplified Their Application Proces. . . . . . . . 


Some States Offer Provider Incentives to Increae Panicipation . . . . . . . . . . . . . . . . . 


Many States Use Alternative Providers


Some States Use Cae Managers and Provide Enhanced Prenatal Care Packages. . . 

Some States Have Integrted Data Collecion Points to Evaluate Future Outcomes. . . . . .. 16 

Potenti Cot Reductons Wi Ex $9 Mion if Neonata Intensiv 

Is Reduce by Just 1 Pernt. 
INTRODUCTION


PUROSE 

Ths inspection describes State and local effort to implemnt eligibilty expansions for 

Medicaid-covered prenatal care and to overcome barrers to accessibilty and 

availabilty of prenatal care. 

BACKGROUN 

Congressional concern about the health status of pregnant women has led to 

signcant Federal and State Medicaid eligibilty expansions in recent years. (See Appendix B.) The impetus for these reforms stems from 1) the United States' poor showing among other nations in regard to infant mortalityl; 2) concern over the 

excessive health care costs to maintain low birhweight babies vis-a-vis the low cost of 

providing prenatal care%; 3) growig numbers of low income women who are 

uninsured for pregnancy-related health care ; and 4) unsatisfactory progress in


achievig the 1990 Health Objectives for the Nation


Today, states are Federally mandated to extend pregnancy-related care to women who have incomes up to 133 percent of the Federal povert level, with an option to use 185 percent of the Federal povert level. (See Appendix C.) Other Federal

mandates affecting ths group are: 

eliminating paternty establishment as a precondition to receive Medicaidcovered prenatal care; 

guaranteeing continuous eligtoilty throughout pregnancy until the end of the 

month in which 60 days postpartum occurs, regardless of income changes; 

applying at sites other than where Aid to Family with Dependent Children

(AFDC) applications are normally processed (effective July 1, 1991); 

using specific application forms for Medicaid-covered prenatal care (effective 

July 1, 1991); and 

extending the time period for presumptive eligibilty if a State chooses this 

option to provide temporary ambulatory care while a formal Medicaid 

application is being processed (effective July 1, 1991). 

States also have the option to waive an asset test when determining a pregnant 

woman s income. 
5) offerig traing and techncal assistance to states wishig to unplement 

presumptive eligibilty, targeted case management, servces for pregnant teenagers using EPSDT, additional care to high-risk mothers and inants through freedom-ofchoice waivers, as well as other available options. 

Durg 1990, HCFA developed a marketig gude for HCFA Regional Offces to use with State legislative, governent, and fiance staff; held thee multi-regional/tate maternal and inant health conferences; and entered into a contract with the 

American College of Gyecologists and Obstetricians (ACOG) and the Public Health 

Servce (PHS) to develop gudes to promote provider recrutment and retention. 

Healthy Start 

The Healthy Start program targets 10 project areas with exceptionally high rates of

infant mortality. Some of the specifc objectives of this intiative are: 1) enrollg more women in prenatal care durig their fist trimester; 2) decreasing the number of low birhweight babies; and 3) decreasing the infant mortality rate. 

The Secretary s Task Force on Minori Health 

The Task Force on Minority Health was created to 1) identif and coordinate HHS


programs that serve minority populations ; 2) address barrers to improved health
 among minority populations; 3) identify successfu models of health interventions in 

specific minority populations; and 4) recommend actions to increase the number of


minorities served by HHS, plus ways to improve the quality of servces aleady


delivered to these groups'. One of the major areas of Task Force concern is the
 delivery of servces to pregnant women. 

Recent Ofce of Inspector Genera (OJQeport 

A recent management advisory report "Access to Medicaid-Covered Prenatal Care 

(OEI, October 1990), presents preliar fidigs regarding barrers to State and

local implementation of Medicaid prenatal care expansions. Effective techniques used by states to implement these expansions were also highlighted. Another study assessed the implementation of the Comprehensive Perinatal Care Program (CPCP), 

an intiative of the PHS (OEI, May 1990). The OIG recommended that the PHS 

reexamine its method of allocating CPCP funds to assure community and migrant 

health centers in areas with high inant mortality rates receive this support. Finaly, another study examined a local program to reduce infant mortality. Findings 

indicated that successful implementation strategies should include targeting client 

outreach, conducting risk assessments, ensuring adequate clinical servces, and fostering indigenous community leadership (OEI, July 1989). 
FINDINGS


Th fo an ba on Douuati u of JanUl 1991.

~ AI STATE HAVE SE 1H INroME STANAR AT 133 PERCE 

OF TH FEER POVETY LE IN ADDmON, MA 

HAVE ENRSED OPTONAL EIGmll EXANSIONS. 

An Overheg Majori of St Have Waived th Aset/Resour Tes an Ar 

Guaranteig Cont Elil. 

Fort-six States have waived the asset/resource test and 45 States guarantee 

contiuous eligtoilty unti the end of the month in which 60 days postpartum occurs. (Since the tie of our data collection, States are now mandated to 

contiue benefits unti the end of the month in which 60 days postpartum 

occurs. ) 

Twen10ur States Voluri Ered th Mandte Fedl Incme Standrd Used 

to Deter Eligiil. 

Eighteen States use an income standard up to 185 percent of the Federal


povert level to determe eligibilty; one State is using 155 percent of the 

Federal povert level; four at 150 percent of the Federal povert level; and one 

at 140 percent of the Federal povert level. 

Twen-si State Ar Usig Presptie Elil to Prvi Temporary Amultory Prta Care (Over one-thd of the States without presumptive eligtoilty 

report expedited formal eligtoilty determinations. 

Appendi E compares States' implementation of the eligtoilty expansions , as of January 1991. Shown are implementation dates for presumptive eligtoilty, asset test waiver, contiuous eligibilty, and Federal income standards used to 

determne eligtoilty, plus an indication of States reportg expedited eligtoilty determations. 

~ HOWEVE SIGNICA PROBLE PREVE NEWLY EUGmLE WOME FROM RECEIVG MEICAVE PREATAL 

Cl Oueach Is Inate 

Few States have coordinated. ongoing. and targeted client outreach. Although the majority of State respondents (84 percent) report some efforts to heighten awareness of the eligtoilty expansions, it is neither intensive nor extensive. Most 

States rely on the 'welfare grapevie" (81 percent) as a primary means of 
want(ing) to disclose their income (not) really want(ing) prenatal care anyway 

and women tending to be afraid of anything offial 

Lengthy. complex forms . Only 17 States use an application form tailored for 

Medicaid-covered prenata care. Formal applications ca vary in length from 

one page to over 30 pages. One respondent from a State using a 34-page 

application form described it as somewhat complex 


In several local welfare offces, some women only wanting Medicaid-covered 

prenatal care felt coerced into applyig for additional public assistance programs. 

Their frstrations are exemplified by such statements as: (1) wasn t sure what to 

fil out because all I wanted was Medicaid for prenatal care. I didn t want Food 

Stamps or AFDC. I didn t even start filing (the applicatin form) out. I looked II or
 through it and said ' GADS We knew we weren t going to need this 

(Medicaid-covered prenatal care) once my husband had a job. The social worker at 

social services kept pushing us to sign up for other programs and all we wanted was 

(Medicaid-covered prenatal care). All this pushing made me not want to go back; 

they didn t seem to understand all we wanted was (Medicaid-covered prenatal 

care). 

Multiple application sites and appointments. During our local visits, 87 percent of the presumptively eligible women reported changing sites to reapply for 

continued Medicaid-covered prenatal care, with 91 percent of this group going to a local welfare agency. In most caes, these women were not able to complete

this task on the same day they were determined presumptively eligtole. Before 

an intervew with a formal application intake worker, they either made an 

appointment and returned another day or first attended an orientation. 

As pointed out by one State respondent, Appointments for formal applicatin are 

set arbitrarily and the women do not get to choose their appointment tie. This 

additional step is especially burdensome for working women and parents who 

must rearrange their work schedules. Over half of 92 local supervsors, eligibilty workers, and providers confied ths delay as a problem for women seeking 

prenatal care. Even though most local sample States (6 out of 8) report outstationing eligibilty workers in places where women are more likely to seek 

prenatal care, we did not observe its widespread use. The majority of eligibilty workers (31 out of 41) and supervsors (9 out of 15) confirmed this finding. 

Also, while over hal of the State respondents report outstationing eligibilty workers, it is usually at selected sites. 

Welfare stigma " Qosely associated with requiring women to go to the local 

welfare office to formally apply for Medicaid-covered prenatal care is the fear 

of being thought of as a welfare recipient. Such comments by State respondents 

The welfare stigma is a big problem. Underemployed, intact families don t want 
concern is expressed in such statements as: 
 OB's are settg quotas on the


number of Medicaid clients they will acceptll 25 percent
 Iwe have) less than a


physician partipatin rate lin our State)"; and 'Doctors claim they have plenty of 

paying customers so they don t need Medicaid patients. " 

Several State respondents think providers' attitudes toward IIwelfare women" limit 

their acceptance of Medicaid patients. They believe providers view women as 

enterig prenatal care later in their pregnancy than non-welfare patients, not 

being as cooperative, and not keeping their appointments as well. 

Some providers have problems with presumptive eligibilty. Eight of the 26 State

respondents from presumptive eligibilty States report problems with some 

providers not making presumptive eligibilty determinations; 10 of these 26 say 

some providers are not willng to accept presumptive eligibilty cards. 

During the site visits, we found that restricting presumptive eligibilty coverage to ambulatory care was a problem in some instances. If the need arises for hospital

inpatient care (for such complications as miscarrage, premature delivery, or an 

ultrasound), a presumptively eligible woman is not covered. As pointed out by one provider affected by this situation and who no longer accepts presumptively eligible women 'Most providers feel morally obligated to offer the full-range of


services for women once they are in (his/her) care. My fit three presumptively
 eligible patients all had to be admited to the hospital: one delivered, one needed a
 & C 
 dilatin and curettage); and one miscarrd. 

Limited access to eligtoilty verification systems !tampers provicter partfcipation


and creates biling problems. Although 92 percent of the States have an


automated verication system, only 53 percent allow provider access. One-third
 of the States report ths is a problem for providers. Also, restricting provider


access increases the lieliood of bilg errors, especially for servces rendered durig the presumptive eligibilty period. 

Reimbursement rates are low and reimbursement turnaround is slow 

. Eighty-two 

percent of State respondents say low reimbursement rates contribute to provider dissatisfaction; over 50 percent say slow turnaround for reimbursements is also a 

disincentive. 

Liabilty issues hinder participation. Six-nine percent of the State respondents think providers don t participate in Medicaid-covered prenatal care because of the high cost of liabilty insurance. Also, 61 percent of the State offcials say providers' perception that Medicaid clients are more likely to sue makes it 

diffcult to recrut providers.

eligtoilty incorrectly so that 
 workers must identify rejected cases and redetermine 

eligibilit. "


Despite these complaints about slow policy communcation and lack of trainng, 80 percent of the State respondents do fid HCF A helpful in providing technical 

assistance. Also, when policy guidance is issued, 71 percent of State respondents report it is usually clearly wrtten. 

However, when asked how HCF A could be even more helpfu, the State offcials 

request clearer and less complicated policy statements; pre-printed State Plan 

amendments; and, as one administrator indicated 'HCFA should coordinate the 

sharing of informatin among States. 

HCFA AN MOST STATE CANOT MEUR TH PROGRE 

IMACf OF TH EXANSIONS. 

Stte-Reported Data on Prm Parttin Appers Incomple and of Qunable Acccy. 

Respondents from 22 States could not or did not estimate the number of new 

eligibles served, or to be served, in 1990 and/or 1991. (See Appendix G.) Only 17 State representatives could report the total number of formal applications

made by new eligibles for any (or all) of the past four years. Additionally, 10 of the 26 respondents from presumptive eligibilty States do not keep data on the 

number of women currently presumptively eligible. Also, just 11 representatives from presumptive eligtoilty States submitted the number of presumptively eligible women who were subsequently denied formal eligtoilty. 

Along with some of the State respondents, we question the accuracy of this incomplete program participation data. A cursory examination of Appendix G raises several concerns about the validity of the provided data. 

Several of the States with large populations do not report data, and in other States some of the estimates do not seem to be consistent 

with the size of their Medicaid populations. 

We are concerned that the reported increases in non-AFC 

women may include not only new eligibles but also signifcant 

numbers of AFC-eligible women who are being enrolled more 

rapidly under the new, less restrictive eligibilty requirements. This 

concern was supported by the four State representatives who 

submitted data on the number of new eligibles who later qualified for AFC. For example, in one State over two-thirds of the new 
postparum cae (Ginsburg, Lewis-Idema, and Pettigrew 1989), it is not surprising 

they cannot report th inormation. Even when they can, only 16 State 

respondents could identi the agency collectig the number of prenatal visits. 

Only 20 State representatives claim they can provide information about the 

trester a newly eligible woman enrolls in prenatal care. Of these, only three 

States actually submitted this requested data. Also, almost one-fourth of the 

State respondents say they do not capture race/ethcity for the new eligibles. 

(See Appendix F. 

Local sites also reflect problems with collecting data. Almost two-thirds of 

51 local supervsors and providers do not have access to completely 

computeried data collection systems. Even when they do, new eligibles are not 

usually distinguished from AFC-eligible pregnant women. 

SOME STATE AR TAKG POSIT STS TO ADDRE 

PROBLE OF ACC AN AVAIIL OF MEICAI-CVE 

PREATAL CAR12


Severl States Have Deelope Comprehe Cl Oueach Materls. 

Unique logos are being used to heighten awareness of the benefits of receiYi 

early and continuous prenatal care. Distictive logos used to identify a State 

outreach campaign are "HealthStart" (New Jersey), "Healthy Start" (Ohio 

Wisconsin, and Massachusetts), "Baby Your Baby" (Utah); "MICHcare 

(Michigan); and "Baby Care" (Colorado). These themes are found throughout all 

their outreach materials.


Materials descnoe the benefits and availabilty of prenatal care. In a 

Massachusetts' "Healthy Start" brochure, Medicaid-covered prenatal care servce 

is not referred to as a welfare program but rather as a way to receive health 

insurance for pregnancy-related care. It also lists a toll-free telephone number so pregnant women can locate a doctor or nurse-midwife and provides 

information about food assistance programs and other community resources. 

Current income eligibilty levels are clearly stated in brochures developed by 

Michigan. From ths inormation, a woman can quickly see if she meets the 

income and family-size qualifications used to determne eligibilty for Medicaidcovered prenatal care. Documentation required at the time of application and available enhanced servces (transportation to provider sites and educational 

classes) are also listed. A separate two-sided leaflet describes Michigan s 24-hour 

prenatal care telephone lie which provides information about servce benefits 

and availabilty, as well as information on WIC. 
Arkansas and Louisiana to simpli the application process; however, the women are stil requied to change application sites. 

Some States are e'iediting formal eligtoilty determinations once alLhe reQu documentation is received. Over one-third of the States report expedited formal

determations, with Alaska and Oregon reporting five day processing times. Other States claiming to expedite formal determinations are Virginia (10 days), Vermont (10 days), West Virginia (13 days), Arona (14 days), Minnesota 

(15 days), and Washigton (15 days). 

Eligtoilty workers are being outstationed by some States. Some of the 

alternative sites that States are using to outstation eligibilty workers include: 

high-volume hospitals (Florida, Louisiana, Mississippi, Missouri, North Carolina Texas, and the District of Columbia); perinatal clinics (California); and WIC sites and health offces (Vermont). Ths approach puts eligibilty workers in locations where pregnant women are most likely to seek prenatal care and, also, separates the application site from the welfare offce, thus helping diffse the ''welfare 

stigma. 

Some States Ofer Prvi Incenes to Inceae Parttin. 

Special efforts are being made to recruit providers. Currently, 75 percent of the 

States report effort to encourage new providers to accept women eligible for 

Medicaid-covered prenatal care. Many States are conducting educational training to dispel negative provider attitudes toward ''welfare '' women. States are meeting with medical societies and physician groups, forming task groups and conducting
 provider surveys to identify barrers to provider participation.


Connecticut has provider-relation representatives to assist with problems 

encountered with Medicaid patients; Minnesota has hired a staff person 

designated to handle provider problems. Maryland and Texas use nurses to recruit providers. Michigan has billng representatives who help doctors file 

Medicaid claims. 

Some States have increased reimbursement rates and provide assistance with liabilty protection. The state of Washington allows higher reimbursement rates 

for primary care clinics located in distressed areas. Louisiana reimburses at 90 percent of private insurance rates. Maine offers $5000 - $10,000 supplements toward medical insurance if obstetricians and gyecologists agree to practice in 

areas where there are provider shortages. A state legal defense fund to help with malpractice litigation has been established in Missouri. Florida extends 

sovereign immunity (legal protection) to providers of Medicaid servces. 
POT COST REUCTONS Wl EXCE $97 MION 

NENATAL INSIV CA IS REUCE BY JUST 1 PERCE. 

The li between inant mortlity, low birweight, and lack of adequate prenatal 

care has been well-documented (Chdren s Defense Fund 1989; Committee on 

Governent Operations 1988; GAO 1987). A woman who does not receive 

early and continuous prenatal cae triples her risk of deliverig a low birhweight 

baby (GAO 1987). Among low birhweight babies, about half require expensive 

neonatal intensive care, costing from $12,000 to $150 000 per child (Offce of 

Technology Assessment 1987). Unfortunately, low birweight babies are 

40 times more likely to die durig their fist week of lie (GAO 1987). Even if 

low birhweight babies survve, they are at signficantly increased risk of suffering 

lielong physical or mental disabilties. 

Low Birhweight Babie Are Ver Costly. 

Low birthweight babies account for a very disproportionate share of the costs of 

maternity care paid for by Medicaid. As shown in Figue 1, the Alan 

Guttmacher Institute (Torres and Kenney 1989; Kenney, Torres, Dittes, and 

Macias 1986) has estimated that six percent of all Medicaid-subsidized deliveries 

require expensive neonatal intensive care which comprise fully 30 percent of 

Medicaid maternity care costs. The average cost of neonatal intensive care is 

$15 814, as contrasted with a normal birweight delivery which costs $2 948. 

Figue 2


LBW DELIVERIES 

CAUSE DISPROPORTIONATE COSTS 

Percent


100 94%


Percent of Cost 

2f/o	 Percent of 

Deliveries 

Normal	 LBW 

Delivery Delivery 

Source: Alan Guttmacher Institute figure based on the estimated


cost for delivery and care for a baby (Kenney et ai, 1986).

FJI 2


RE MEAD LOW 8IRTHGHT


BABIES SAVES LIVES AND MONEY


Low Biweig,t Baby


verage Medicaid


delivery cost 

$1,950 

$97.1 million 

Amount saved if number of low 

birthweight babies requiring 

neonatal intensive care is 

reduced just 

Normal Size Baby 

Average Medicaid 

delivery cost 

$3,533 

According to an Alan Guttmacher 

Institute study (Torres et al. 1989; 

Kenney et al. 1986), Medicaid subsidizes deliveries for about 630,000 low income 

women each year. Six percent of all 

Medicaid deliveries require neonatal 

intensive care and cost an average of 

$18,950 amounting to a total cost of 

$716 milion. If the number of low 

birthweight babies requiring neonatal intensive care is reduced by just 

$97.1 milion wil be saved. 
testing, and even grocery stores, laundromats, and shopping centers to 

locate new eligibles. 

- Use communty residents, women who have received Medicaid-covered 

prenatal care and AFC recipients in the Federal Jobs Opportunty 

and Basic Skils (JOBS) program as outreach workers. 

~ HCFA 
 could 

. Collaborate with the National Center for Education in Maternal and 

Child Health, supported by PHS, to serves as a repository and distnoution 

center for State and nationally-developed Medicaid-covered prenatal care 

outreach materials. The HCF A central offce, coordinating with regional 

HCF A and PHS staff, would need to periodically identify, collect, and 

issue a compendium of inormation to the National Center. State 

Medicaid and Maternal and Child Health directors would need to be 

notified of available materials and subsequent updates. 

. Clarify that matching Federal funds are available to assist with State 

effort to conduct client outreach. 

. Coordinate outreach effort with the Healthy Start National Public 

Information Campaign. Such effort should stress the benefits of 

Medicaid-covered prenatal care as preventive health care rather than 

welfare-related assistance. 

~ States 
 could 

. Create a unique and readily identifiable theme and "logo" for the prenatal care campaign. 

. Establish a statewide toll-free hotline, coordinated with existing MCH hotlines, to provide information about access and availabilty of Medicaidcovered prenatal care. 

Simpli and Streame the Application Proc. 

~ HCFA should: 

. Ensure, in reviewing and approving State Plans, that States comply with the requirements to: 

- Use outreach locations other than welfare offces to accept and begi processing applications for Medicaid-covered prenatal care. 
- Provide sufcient reimbursement to ensure adequate numbers of 

providers are available to deliver Medicaid-covered prenatal care. 

- Specify the noninstitutional obstetrical payment rates in Medicaid State 

Plan amendments. 

- Provide payment for servces rendered by certified nurse practitioners 

or certifed family nurse practitioners if they are authoried under State 

law to perform those servces. 

~ PHS should: 

. Use loan repayment and the National Health Servce Corp recruitment 

programs to increase the number of doctors, nurses, and other health 

professionals servng pregnant women. 

~ States sbould: 

. Survey providers to assess bow many are both available and willng to deliver Medicaid-covered prenatal care. 

. Set reimbursement rates for Medicaid-covered prenatal care at a level 

suffcient to ensure that an adequate number of providers are available to deliver this care. 

. Promote expanded use of alternative health care providers to deliver 

routine Medicaid-covered prenatal care. 

. Assess the feasibilty of assisting providers with liabilty insurance 

increase their partcipation in delivering Medicaid-covered prenatal care. 

. Alow provider access to state eligtoilty verication systems. 

~ HCFA 
 could 

. Develop a legislative proposal to guarantee temporary Medicaid coverage until the end of the presumptive eligibilty period. This coverage would allay provider apprehensions of havig to continue care for women later 

found ineligible for full Medicaid benefits. 

. Develop a legislative proposal authoriing full Medicaid benefits for 

pregnancies deemed at high-risk during the presumptive eligibilty period. 
. Pending the development of such a system to track participation rates 

consider using probabilty samples to estimate the number of newly

eligible women enrolled in Medicaid-covered prenatal care. 

. Work with MCH, ACF, State Medicaid directors and State public health 

offcials to develop minimum reportng requirements to measure the 

effects of the eligibilty expansions on improved birh outcomes. Minimal 

data elements should include: the health status of all partcipants 

(substance abuser or medically high-risk pregnancy); demographic 

inormation (age, race, marital status, income, family size, educational 

level, and employment status); trimester enrolled for prenatal care; the 

number of prenatal care visits completed; bir outcomes (live or dead); 

and the baby s birhweight. Also, to avoid duplication of effort, HCF A should coordinate with the PHS Interagency Committee on Infant 

Mortality (ICIM), Data and Surveilance subgroup in its development of a 

Federal maternal and infant health data strategy. 

~ States should: 

. Develop either a centralized data collection system or enter into formal

agreements with other agencies to assure access to information needed 

for evaluating outcomes. 

~ HCFA 
 could 

. Work with MCH, ACF, State Medicaid directors, State public health offcials, and the State Bureaus of Vital Statistics to assess the potential of linking existing databases, e.g., eligtoilty, medical payments, vital statistics, to measure both participation rates and outcome measures. 

. Plan and seek funding for a multi-year evaluation of the effectiveness of 

the eligibilty expansions on improved birth outcomes. The evaluations 

should be structured to permit separate analysis of women considered at high risk (substance abusers, medically high-risk, etc. 

~ States 
 could 

. Conduct an evaluation of implementation effort and their subsequent impact on lowering infant mortality rates and the incidence of low 

birthweight babies. This could be done in conjunction with HCF A and 

other appropriate agencies.

ENDNOTES


In 1986, the United States place eighteenth worldwide for overall infant monality, behind such 

nations as Spain, Singapore, and Hong Kong. When considered alone, the black infant monality rate place the U.S. twenty-eighth, behind Cuba, Bulgaria, and Czehoslovakia, and tied with Poland, Hungary, Portugal, and Costa Rica (Children s Defense Fund 1989). 

Children s Defense Fund (1989) projec that between 1989 and the year 200, approximately $6

bilion will be spent in first-year costs alone to care for low birthweight infants whose mothers 

recive inadequate care during pregnancy. 

In 1985, one out of four women of childbearing age had either no insurance or, if insured, were not covered for maternty care. The uninsured women were almost three times more likely to 

get delayed prenatal care than women with private health inurance (Children s Defense Fund 1989). 

Goals directly related to prenatal care, low birthweight, and infant monality are: 1) reducing the national infant monality rate to no more than nine deaths per 1 00 live births; 2) reducing infant monality rates for specfic subgroups and regions to no more than 12 deaths per 1, live birhs; 3) reducing the national incidence of low birthweight to no more than five percent of all births; 4) reducing the incidence of low birthweight for specfic subgroups and regions to no more than nine percent; 5) enrollng 90 percent of all pregnant women in prenatal care in their first trimester; 6) enrolling viually all women in a regionali system of primary, secndary, and tertiary care for prenatal, maternal, and perinatal health servce; and 7) ensuring all women have appropriately attended deliveries (Children s Defense Fund 1989). 

The Minority Health Initiative categori Blacks, Hipanics, Asian and Pacific Islanders, and
 American Indians/Alaskan Natives as the predominate U.S. minority populations.


To develop the Minority Health Initiative, an interdepartmental workshop wa held to identify and recmmend how to improve exiting HHS servce and how to reach increaed numbers of 

minorities. Representatives from each Operating Diviion (OPDIV and Staff Diviion (STAFIV were members. In addition, key informants from each predominate minority group met for an informal discuion to exchange idea on how servce delivery of HHS programs to minority populations can be improved. A report wa submitted to the Secetary on the Minority Health Initiative as an internal HHS docment on November 13, 199. 

Subsequent to our field work, OBRA-90 mandated use of specal application form for Medicaid-covered prenatal care. Appendix F ilustrates some of the problems this new legislation wa designed to resolve. 

Transponation servce are available by invoking Section 1902(a)(8) of the Socal Security Ac which guarantee an individual the opportunity to apply for medical asistance and be helped

with reaonable promptnes; Section 1902(a)(19) requires that this gurantee be safegurded and that eligibilty for care and servce will be provided in a way that is consistent with simplicity of administration and in the best interest of the recpient; and Section 1903(a)(17) provides that Federal matching funds are available for activities deemed necsary for the proper and effcient administration of the State Plan. However, the State must 1) use the leat costly mode of 

transportation and 2) use any other available funding source(s) which provide transponation 

without charge, e.g., church groups or charitable organizations. 
Appendi 

Appendi B: 

Appendi C:


Appendi D:


Appendi E: 

Appendi F: 

Appendi G: 

Appendi H: 

Appendi I: 

Appendix J: 

APPENDICES


Glossary of Terms 

Signcant Legislative Changes 

1991 Federal Povert Guidelines for Pregnant Women 

Methodology of Local Site Selection 

Coverage Options for Pregnant Women, as of January 1991 

Comparison of Select Information on Formal Eligibilty Forms 

as of January 1991 

State Reported Statistics--Estimations for 1990, 1991 

References 

Sumary of HCF A' s Comments to Specific Recommendations 

and OIG's Response 

Departmental Comments: Health Care Financing 

Administration, Public Health Servce, Administration for 

Children and Families, and the Assistant Secretary for Planning 

and Evaluation 
APPENDIX A


GLOY OF 

Ai to Fam with CI (AF: Cah payments to eligible neey famies with dependent chdren to cover 00ts for foo, shelter, clothig, and other items of daily livig deemed 

necry by each State. 

Ambulto Cu Refers to outpatient servce. 

Asun Test Wai Asts and resource, e.g., a car, home, capital gain, gif, or loan 

(Federal Regiter, Februry 20, 1991), are not counted when calculating a woman s income to 

determe eligibilty for Medcaid-cvered prenatal care. 

Contiuo1l EI"bDity Guarantee coverage for Medcaid serVce from the time a pregnnt women 

is formally accpted until the end of the month in which her 60 days post panum ocrs. 

Fe Pov Le A simplied version of the Federal Goernment' s statistical povert theshold used by the Bureau of Census in accrdnce with Secon 673(2) of OBRA-81. The port income 

guidelies are used by the HHS for administrative purpes. e., persons are clasifed as being either 

above or below a set standard to determe eligibilty for public asistance. Effecive Februry IS, 1991, the 
 base-line povert threshold for a family of one is S6,620; a family of two, S8 88; a family of three, Sl1 14O a family of four, S13,40; a family of five, $15,66 a family of six $17 920; a family of 

seven, S20,18O a family of eight, $2244 and for each additional member above eight, S2,60 per person. Financial eligibilty for Medicaid-cvered prenatal cae is based on percentage multiples, e. 

130 percent or 185 percent of the guidelines (Federal Regiter, Februry 20, 1991). 

High-Rik or Ha-tRe Prt Women For th study, women who are substance abusers medcall high-rik, teenagers, and women in their mid-thes or above are include in th category. 

Int Monaty Rate A ratio used to repon the number of deaths among innts under one year of age per 1,00 lie binh. 

Prta Ca As defied by the Alan Guttmacher Intitute (1987:14), it is .poor or no care and les-th adequate care. Care is considered por if staned in the third trester, or if there had ben onl one prenatal viit and gestation wa 22-29 weeks, two viits and gestation wa 3031 

weeks, thee viits and gestation wa 32-33 weks, or four viits and gestation wa 

34 weeks or longer. Care is considered les than adequate if the fit viit did not oc before the secnd trester, or if there were only three prenatal viits and gestation wa 22-25 weeks, or four viits and gestation wa 2629 weeks, or five viits and gestation wa 3031 weeks, or six viits and gestation wa 32-33 weeks, or seen viits and gestation wa 34-35 weeks, or eight viits and gestation wa 36 weeks or longer. 

Lo Birght: Weight at bin that is les than five and one-half pounds. 

Medcad-C Prta Ca A fied period of time in which a pregnant woman can recive 

Medicaid servce. She is eligible for these servce: 1) by viue of her income and family siz (see Appendix C) or 2) by already being an AFC recpient. Benefits begin from the time a woman is 

determined formally eligible unti the end of the month in which 60 days postpanum occrs. At the end of this time period, if she nee continued Medicaid assistance, she must reapply and meet AFC eligibilty requirements. 
APPENDIX B


SlGNCA IBJSTI QlGES TO EXAN EUGmIL FO MBICAVB PREATAL CA SEVICE 

Title XI of the Sol Sety Act has ben amended through the: (Given th scope of th stu, 

only th ef ct of apions on Jnno/ car ar dicwsed alugh chages aff ct chin as w lL) 

Tax Equity and Fiscal Responsibilty Ac (rFR P.I- 97-248) of 1982 

Deficit Reduction Ac (DEFR P.I- 98-369) of 198 

Conslidated Omnibus Recncition Ac (COBRA P.I- 99-272) of 1985 

Omnibus Budget Recnciiation Ac (OBRA P .L99-509) of 1986 

. Omnbus Budget Recnciation Ac (OBRA P.I-l00203) of 1987 

Medcare CaWtrphic Coverage Ac (MCCA P.I-l0036) of 1988. 

Omnibus Budget Recnciation Ac (OBRA P.I-I01-239) of 1989. 

Omnbus Budget Recnciation Ac (OBRA P.I-I01-SOS) of 199. 

TEFR-8 allowed States to consider pregnant women as an optional eligibilty group under their 

Medcaid progrms. Both DEF-8 and COBRA-85 mandated or permitted eligibilty exansions for new groups of pregnt women. Madated eligibilty included 1) pregnnt women who met Aid 

to Families with Dependent Children (AFC) eligibilty standards for income and resource requiements; 2) a new defition for a two-member family, i.e., the woman s unborn chid could now 

be considered a member of the household; and 3) an exension of 60 days post panum eligibilty to all pregnant women enrolled in an approved Medcaid plan, regardles of eligibilty group. Optional eligibilty exended flexbilty to target pregnant women. 

COBRA-8 als allowed State flexbilty to modif exting Medicaid servce delivery sytems


(National Governors' Asocation 1989). an option, States can use targeted ca management
 As 

without fit obtaing a Federa waiver, thus permttig servce to pregnant women as a target
 grup. Th change lets Sta es offer enhance prenatal care benefit packages to pregnant women
 without havig to offer the same servce to other groups of Medicaid recpients. 

Though OBRA-8, States were given the option to rais the Medicaid income standard to 

100 percnt of the Federal poert level and to waive an aset test when calculating a woman 

income to determe her eligibilty. For States not waivig the aset test, the test used could be the sae as or more liberal th the one under the cah asistance progrms. Additionally, States were gien the option to guntee contiuous eligibilty throughout pregnancy until 60 days post panum, regares of income chages. It al authori a period of presumptie eligibilty in which a pregnt woman ca recive ambulatory care before being formally accpted for Medcaid. Determtion is bas solely on income and pregnancy verification. 

OBRA-8 gave States fuer options to cover all pregnt women with family incomes under 185 percnt of the Federa poert level, as well as to impoe premiums on the eligibilty of a pregnt women whos fa income fell between and 185 percent of the Federal povert level. ISO 

MCCA-8 mandated the income standard be set at 100 percnt of the Federal povert level. It also 

exended contiuous eligibilty to all eligible pregnant women who would lose eligibilty beuse of income changes. 

OBRA-89 mandated the income standard to be set at 133 percent of the Federal povert level, with the option to increae it up to. 185 percent of the Federal povert level. 
APPENDIX C


1"1 FEER POVETY INCOME GUIEL FOR PRAN WOME 

AL STATF CECEP ALASKA AN HAWAl, PLUS D. 

Mandate: 133 Percent of 1991 Federa Povert Income Guidelies 

Famy Siz Anua Income Monthy 

$ 8,804. $ 733. 

810.40 984. 

816. 234. 

17, 822. 485. 

20, 827. 735. 

23, 833. 986. 

839.40 236. 

29, 845. 487. 

For family units with more than 8 members, add $3 005.80 to annual income for 

each additional member. 

Qptional: 150 and 185 Percent of 1991 Federa Povert Income Guidelies 

Famy Siz 150% Annua 185% Anua 

Income Income 

$ 9,930 $12 247 

13,320 16,428 

710 

20, 100 790 

490 28,971 

880 152 

270 333 

660 514 

For famy unts with more th 8 members, add $3390 for 150% and $4181 

for 185 % to anua income for each additional member. 

"Based on income guidline publishe in the Federal Re2ister on 2/20/91. 

C - 1

APPENDIX D


MEDOLOY OF LO SIT P.c0 

A pursive sample was drawn of eight States representig dierent combinations 

the four Federal options to expand eligtoilty for Medicad-covered prenatal cae 

(using 100185 percent of the Federal povert level, using presumptive eligtoilty, 

guaranteemg contiuous eligibilty, and dropping the aset test). Selected were 

Alabama, Arkansas, Florida, Maryland, Pennsylvania, Colorado, New Jersey, and 

New Hampshie. The fit five States have had all four options in place for the 

longest tie; Colorado had recently implemented al these expansions; New Jersey 

had adopted all options but also had permssion from the Health Care Financing 

Admstration to remai at 100 percent of the Federal povert level unti their 

legilatue met in early 1991; and New Hampshie had not yet adopted any optional 

expansions. 

With each State, we selected a mium of two counties with the highest volume 

of Medicad birts and/or the counties identied by the State as havig diculties 

deliverig prenatal care. The 19 counties were Alabama: Autauga, Jefferson, 

Montgomery, and Shelby; Arkansas: Chicot, Desha, and Philips; Colorado: Denver and EI Paso; Florida : Alachua and Hisborough; Maryland: Alleghany and Baltiore City; New Jersey: Ocean and Union; New Hampshire: Hillsboro and Sulvan; and 

Pennsylvania: Delaware and Phiadelphia. 

Next we asked the State agency responsible for implementig eligtoilty expansions 

for Medicad-covered prenatal care to identi their counterpart with each county.

In tur, these local contact were asked to identi supervsors and intake workers for 

both presumptive eligIoilty and formal intae/determation. The State agency also 

assisted in identig one to thee health care providers in each county who had 

seen the most Medicaid-eligIole pregnant women in the prior year. Once the 

providers were selected, we origially asked them to identify and arrange intervews 

with women who were curently receiving, or had received, Medicaid-covered 

prenata cae and who fit the description of a new eligible. (See Appendix A) 

However, due to provider diculty in distingushig new eligtoles from AFCeligibles, we subsquentl asked to contact only women who had accessed Medicaidcovered prenata cae though presumptive eligtoilty rather than though AFC 

(excludig New Hampshie). 

As shown in Table 1, we intervewed a total of 233 persons. In addition, we 

analyzed State and loca policies and procedures and examined available outreach 

materials and application forms. 

D - 1 
APPENDIX E


COVEGE OPTONS FOR PREGNANT WOMEN. AS OF JANUARY 1991


Presumptive Dropped Continuous Eligibilit as a % of 

Eligibilty Asset Eligibilty Povert & Date 

Test Implemented 

Alabama 7/88 7/88 7/88 133% 4/90 

Alaska 1/89 1/89 133% 4/90 

Arizona 1/88 1/88 140% 0/90 

Arkansas 4/87 1 0/88 4/87 133% 4/90 

California 185% 7/89 

Colorado 1/90 6/90 6/90 133% 4/90 

Connecticut 1/89 1/89 185% 1/89 

Delaware 1/88 1/88 133% 4/90 

4/87 4/87 185% 6/90 

Florida 10/87 10/87 10/87 150% 7/90 

Georgia 1/89 1/89 133% 4/90 

Hawaii 1/89 1/89 1/89 185% 1/90 

Idaho 1/89 1/89 1/89 133% 4/90 

Ilinois 5/90 4/87 133% 4/90 

Indiana 0/88 7/88 7/88 133% 4/90 

Iowa 1/90 7/89 185% 7/89 

Kansas 7/88 150% 7/89 

Kentucky. 6/89 8/88 185% 7/90 

Louisiana 1/89 1/89 1/89 133% 4/90 

Maine 0/88 0/88 0/88 185% 0/88 

Maryland 7/87 7/87 7/87 185% 7/89 

Massachusetts 4/88 7/88 7/88 185% 7/88 

Michigan 1/88 1/88 185% 0/88 

Minnesota 7/88 7/88 185% 7/88 

Mississippi 10/87 1 0/87 185% 1988 

Missouri 7/90 7/90 7/90 133% 7/90 

Montana 1/91 7/90 1/91 133% 4/90 

(continued on next page)


E ­
APPENDIX F


COPAIN OF SELCT 1N11N fOUN ON
 FORM EUGI FO. AS OF JAUAY'''' (POR TO OBR-IO)*** 

UNIQUE JOINT NOTICE LENGTH RACE! 

APPLICATION PE & FORMAL ETHNIC 

FOR APPLICATION REFERRAL FORM GROUP 

PREGNANT FORM FOR OTHER 

WOMEN GOVT. 

PROGRAMS 

5 PG 

NO PE 16 PG OPT. 

NO PE 8 PG OPT. 

4 PG 

NO PE 

1 PG 

NO PE 18 PG OPT 

NO PE 5 PG 

NO PE 6 PG 

1 PG 

NO PE 3 PG 

34 PG OPT. 

OPT. 

2 PG 

10 PG 

NO PE 29 PG OPT. 

NO PE 4 PG 

3 PG 

8 PG 

5 PG 

3 PG OPT. 

NO PE 3 PG OPT. 

NO PE 2 PG 

NO PE 11 PG 

15 PG 

14 PG OPT. 
APPENDIX G


Stte Reported Estimated Numbers and Cost to


Serve Non-AFC Medlcald-Covered Women In 1990, 1991


Estimated 1# 

Non-AFDC


Medicad-Covered


Women


1990 1991 

Alaba. 20, 20, 

Alaska. 181 390 

Arzona. 784 

Arkansa + 000 300 

California +


Colorado (1) 225 

Conneccut +


Delaware 824 449 

DC + 350 

Florida + 20, 29,395 

Gergia + 18,738 28,542 

Hawaii + 258 

Idaho 361 415 

Ilinois + 745 734 

Indiana. 12,061 

Iowa + 000 500 

Kaas (1) 000 000 

Kentuck + 972 10. 

Louisiana +


Maine + 472 800 

Maryland + (1) (2) 13, 

11,398 

Mahusett 

Michigan + 500 

Minneota + 11, 

tJlt.illip 19,471 

Change 

34. 

71. 

43. 

52. 

53. 

50. 

15. 

22. 

19. 

G - 1


Estimated Cost to Enroll 

and Deliver PNC to 

Non-AFDC 

Medicaid-Covered 

Women (Milions) 

1990 1991 

$35. $3. 

$13. $17. 

$17. 

$10. $11. 

Change 

32. 

$5. 

$3. 

$1. 

$9. 

$56. 

$18. 

* $14. 

** $3. 

$12. 

$18. 

* $12. 

$10. 

$3. 

$7. 

$2. 

$147. 

$95. 

* $16. 

** $4. 

$18. 

* $18. 

$10. 

$4. 

119. 

86. 

56. 

67. 

19. 

41. 

50. 

15. 

(3) $25. (3) $31. 

60. 

23. 

$2. 
(1) The State report they do not collect data on the number of non-AFDC women served, 

nevertless, might have submitted estimates. 

(2) Cannot distinguish between women certed presumptively eligible and those women who applied 

direc to the loc welfare offce and were certed eligible without being first found presumptively 

eligible. 

(3) Without Administrative Cots (4) Average Monthly II of Women 

(5) Estimates as of 7/9 

(6) Estimates August-May 1990 

Includes Federal and State matching funds


Only Includes State Porton


CN Only


Both CN & MN


CN = Catergorically Needy Individuals receiving Federally-supported financial assistace. 

MN = Medically Neey Individuals who are eligible for medical but not financial assistace. 

NR = States Not Reportng Information 

Note:	 Estimates of parcipation may include AFDCeligible women. 

Estimates of cost in some States might have included Federal and State matching funds in 

their estimates. This table gives baseline estimates. 

G - 3

APPENDIX H


RECE


Brow Sarah. Prenatal Care: Reachinl! Mothers. Reachinl! Infants. Washigton, D.C.: Intitute of 

Medcie, 1988 

Centers for Dis ControL The National Innt Monalitv Surveilance Proiec Public Heath


Report (Vol. 102 No.2:126-22).


Chdren s Defense Fund. The Health of America s Children: Maternal and Child Health Data 

k. Washigton, D. , 1989.


Commttee on Government Operations. Barrers to Prenatal Care: Can the United States Do More 

with Le? Hous Report 100574, Union Calendar No. 34 (April 19,1988). 100th Congres, 2nd 

Sesion. Washigton, D.C.: U.S. Governent Priting Offce, 1988. 

Federal Regiter. Washigton, D.C.: U.S. Governent Printing Offce (Vol. 56, No. 34:669-61). 

Ginburg, Susnn, Deborah Le-Idema, and Ir Pettigrew. Desiminl! Evaluations of the 

ansions of Medicaid Coveral!e for Premant Women and Children: Final ReDon. Rockve Maryland: Profesional Management Asociates, Inc., 1989. (prepared for HHS/Asistant Secetary for Planng and Evaluation. 

Health Care Financig Admitration. Medicaid Statistical Abstract: Results of the State Medicaid Al!encv Infant Monalitv Data Survev 1989. Baltimore, Maryland: Bureau of Data Management and Strategy Offce of Statistics and Data Management, June 5, 199. 

Hi, Ian T. and Jane BreyeL Cordinatinl! Prenatal Care. National Governors Asociation,

Washigton D.C., 198. 

Intitute of Medicie. Prevntinl! Low Birthweil!ht. Washington, D.C.: National Acdemy Pres 198:2627. 

Kenney, Asta Aida Torres, Nancy Dittes, and Jennifer Macias. .Medicaid Exnditures for Maternty and Newrn Care in America. Familv Planninl! PersocCtives 18 (No. 3, May/June): 103-110, 1986. 

Offce of Evaluation and Inpections (OEI). U.S. Department of Health and Human Servce/Offce of Inspecor General. Acc to Medicaid-Covered Prenatal Care: A Manal!ement Advisorv Report. 

OCtober 199. 

Offce of Evaluation and Inpeions (OEI). U.S. Department of Health and Human Servce/Offce of Inpeor GeneraL ComDrehensive Perinatal Care Pr02lm. May 199. 

Offce of Evaluation and Inpeions (OEI). U.S. Department of Health and Human Servce/Offce of Inpeor General. Lol Manal!ement and ImDlementation Stratel!es to Reduce Infant Monalitv: A Manal!ement Advirv Report. July 1989. 

Offce of Technology Asment. Health Technolol! Ca Study 38: Neonatal Intensive Care for Low Birthweil!ht Infants: Cots and Effecivenes. Washington, D.C.: Government Printing Offce, 198. 

H -

APPENDIX I


SUMMAY OF HCFA' S COMMENTS TO SPECIFIC RECOMMENDATIONS


AND OIG'S RESPONSE


SUY: REOMMATION la 

Develop a comprehenive outreach strateg. 

HCF A 
 should 

. Work with PHS, Administration Cor Children and Familes (ACF), State Medicad 

Direcors, and State MCH offcials to develop a minimum set oC standards to enure effecive client outreach to heighten awarenes oC Medicaid-cvered prenatal cae and to 

taget new eligibles. Such guidelines should provide Cor: 

Coordinating Medicaid outreach activities with Materal and Child Health clinics, 

WIC ceter, and community and migrant health center. 

Conducting ongoing, cordinated State and locl ad capaign. 

Displaying Medicad benefits and income eligibilty requirements 
 Cor Medicaid-cvered 

prenatal cae on media materials. 

Using such loctions as churches, housing projec, neighborhood health and receation ceter, provider sites where women go Cor pregancy testing, and even groc stores, laundromats, and shopping center to locte new eligibles. 

Using community residents, women who have recved Medicaid-cvered prenatal cae and AIC recpients in the Federl Jobs Opportunity and Basic Skills (JOBS) program as outreach worker. 

HCFA Comments 

The HCF A doe not concur with the par of the recommendation to develop a minimum set of stadards. Beuse of the considerable differences among States, and their 

Medicad and Maternal and Child Heath progras, we believe it is not appropriate to pursue the development of sets of stadads for outreach activities. However, we could collaborate with the Public Heath Service (PHS), Administrtion for Children and Fames (ACF), State Medicad Directors, and State Matern and Child Heath (MCR) officials to identify common elements of effective tagete and community-wide outrch 

effort, and develop guides for State agencies which ilustrte those elements in pratice. 
The reprt also suggests that HCF A tnougn a national advertsing capaign, stress 

the benefits of prenata ca. HCF doe not concur with ths par of the

recmmendation. Whe we endorse such a capaign, we believe that it should be 

develope and implemente as par of the national public information and education effort 

for the "Heathy Sta" intiative. 

DIG RemoRse


Collaboration is an excellent way to achieve common goals. If an agreement ca be 

reached with the National Center for Education in Matern and Chid Heath to kee an updte fie of Medicad-cvered prenata cae materials and distrbute them upon request, 

ths approch would encourage State sharng and avoid duplication of effort. The HCF A 

centr offce, cordinatig with regional HCF A and PHS sta, would nee to 

periodcay identify, collect, and issue a compendium of information to the National 

Center. State Medicad and Maternal and Child Heath officials would nee to be kept appri of avaiable materials and subseuent updates. 

As a par of the 
 Heathy Sta initiative, a national Heathy Sta National Public 

Information Campaign is being develope in conjunction with the National Ad Council. During a five-yea effort, national attention wil be given to the benefits of prenata cae. 

The DIG encourages HCF A to collaborate in the development of the Heathy Sta 

materials. 

We revise par of our recmmendation to reflect these changes: (See page 21 for
 complete text.)


Collorae with the Natinal Center Jor EduCDn in Matern and Chil Health, supported by PHS, to serve as a reposiory and diriutn center Jor Stae and nanay-dveloped Medica- covered prenata care outreach materils. The HCFA centra oJfice, cordnang with regina HCFA and PHS staf, woul need to pericay idnt, coUect, and isue a compendum oj itonnn to the Natna Center. Stae Medca and Mllern and Chil Heah offici woul need to be kept apprid oj availk maeri and subsequent updes. 

Coordnae outach efforts with the Health, Start Natinal Pulic Informtin CamDaim. Such efforts shoul stss the benejis oj Medica-cvered prena care as preventve healh care 

raher than welfare-related assistance. 

REOMMATION 2a I 

I SUMY: 

Simplify and streamline the application procs. 

HCFA should 

Ensure, in reviewng and approving State plans, that States comply with the requirements 

to: 
Along with trsprttion and less strngent eligibilty requirements, the tagete 

populations nee assistace with chid cae even before they ca consider applying. 

Without chid cae, many of the women wil not be able to accss these services. Since 

HCF A is responsible for Medicad eligibilty and does not presently have a way to handle ths sitution, the OIG recmmends HCFA tae the lead and collaborate with PHS and/or

ACF to assure chid cae availabilty durig the application procss. 

We revise par of our recommendation to reflect these changes: (See page 22 for complete text.) 

Prmote Stle efforts to 1) ensure the newly-d)1eloped appliCDn fonn are not lengthy and 2) expedie processing ti for forml Medicaid eligiil detennnans andor implement 

presumptive eligiUit.


Collorae with PHS and ACF to promote slte efforts to provi for chUd care durig the appliCDn process. 

Y: REO ATION 38 I 

I S 

Develop incentives to increae provider participation. 

HCF A 
 should 

Ensure, in reviewing and approving State plans, that States are complying with the requirements to: 

Provide suffcient reimbursement to enure adequate numbers of provider are available to deliver Medicaid-cvered prenatal care. 

Spefy the noninstitutional obstetrical payment rates in Medicad plan amendments. 

Provide payment for services rendered by ceified nurse practitioner or cetified family nurse practitioners if they are authorize under State law to perform those service. 

HCFA Comments an 01G Response 

HCF A 
 concurs with this par of the recommendation, subject to a revision of the opening statement: (See page 23 for complete text.) 

Contnue to ensure, in re)1iewing and approving Stle plans, that Stles are complying with the requirements to: 

1- S

REOMMATION 

I SUMY: 

Clafy poDey and monitor implementation of Medicaid expanions for prenatal care. 

HCF A 
 should 

. Work closely with State Medicaid directors to identify nee for guidance, tecnical


asistace and training and develop action plans to provide them.


Inform States of new legislative options and mandates in a timely manner to allow for 

prompt implementation. 

Conduct locl site visits to monitor the implementation of the Medicaid eligibilty 

expansions. For example, have each regional offce annually visit a sample of locl 

presumptive eligibilty and formal application sites, as well as service delivery sites. 

HCFA Comments 

HCF A concurs with ths recommendation. HCF A addresses these topics on an ongoing 

basis. These topics are regular agenda items for the Medicad MCH- Technica Advisory Group. On a quarly basis, HCFA' s regional offices reprt to centr office, the progress of individua States in implementing prenata cae intiatives, and any problems encountered by States in their regions. Also, regarding the loc site visits to monitor the 

implementation of Medicad eligibilty expansions, site visits are a par of the current 

formal progra management review protocls. 

SUY: REOMMATION 

Develop data collection systems and evaluation procses to meaure progres of the eligibilty expansions and future program effects. 

HCF A 
 should 

. Work with State Medicaid and MCH directors to develop minimum reporting requirements to track participation rates. Minimal data elements should include: the 

number of women who could be eligible to recve Medicaid-cvered prenatal care; the

number who have been enrolled by various categories, such as AIC, medically neey, and prenatal care only; the number presumptively eligible; and the attrition rate of 

women not completing the application procs. 

Pending the development of such a system to track participation rates, consider using probabilty samples to estimate the number of newly eligible women enrolled in Medicaidcovered prenatal care. 
points in ti. Ths maes it diffcult to sepate claims for mothers frm those for infants, which, in 

tu, maes it diffcult for HCFA to determe what selVice us and expeditu were for newborn. 

In the send pagraph under ths heaing, the phr "diffculty in acing" doe not provide a clea

pictu of the problem involved. State Medicad agencies have ac to their own Medicad claims data. 

The "critica evaluative elements" liste are not nec to pay clai and, therefore, ar not included 

in thes rerd. Ths inormtion would be usfu, but Medicad Sta agencies ar not currtly reui to collect it. 

Relyig on the linkage of infant birt, death, and Medicad clams recrds to produce


evaluative results wil be frustrtig, if not inconclusive. Also, as pointe out by the


HCF A comments, the State Medicad agencies are not currently required to collect the


tys of information neeed to meaure outcomes. For thes very reans, DIG urged
 that steps be taen to ensure the neeed data is captured. Also, HCFA' s own study,


Medicad Statistica Abstrcts: Results of the State Medicad Agency Infant Mortty
 Data Survey: 1989" reports that Medicad agencies have difficulty accessing critica


evaluative elements. This survey was designed to "determne the availabilty of information relate to the heath of pregnant women and infants" (Heath Care Financing Admistrtion 1990: 1). 

Therefore, DIG continues to recmmend that HCF A assure that critica evaluative 

elements are collecte by the States, either though the Medicad agency, PHS or Vita
 Statistics. HCF A should cordinate its effort with the PHS Interagency Committee on
 Infant Mortity (ICIM, Data and Surveilance subgroup. Ths subgroup, under the
 direction of the Centers for Disee Control, is developing a Federa maternal and infant
 heath data strtegy, resulting in a Federa Data and Use Bok.


Ba on HCFA comments, DIG revise its recmmendation. (See page 25 for full text.) 

Work with MCH, ACF, State Medica directors and Stae public healh offici to de,elop minium reportng requirements to measure the effects of the eligiil expansins on impro,ed 

bith outcomes. Minin da elements shoul includ: the healh st of aU partciants (substnce abusers or medically high-ri pregnncy); demogrphic infonnn (age, race, mDri status, income, family si, educa1Ule,el, and employment stus); trester enrolld 

for pre1U care; the number of prenata care ris completed; birth outcomes (l,e or dead; and bay s birth weight. Also, to a,oUl duplicatin of effort, HCFA shoul coordlUe with the PHS 

Interagency Committee on Infant Mort (ICIM), Data and Su",eilnce subgrup in its de,elopment of a Federal matemal and infant heallh dlta straegy. 

COMMS 

I TEHNCAL 

In addition to the comments above, HCFA provided severa tehnica comments which we 

used to make revisions as appropriate. (Te full text of these comments is included in 

Appendix J. 
APPENDIX 

DEPARTMENAL COMMEN: 

HEAm CA FINANCING ADMINISTRTION, PUBUC REAm SERVICE, 

ADMINISTRTION FOR CHILREN AND FAMIUES, AND


THE ASSISTANT SECRETARY FOR PLANING AND EVALUATION


J - 1

: ,, . .: :

TJealth Care 

DEPARTMENT OF HEALTH &. HUMAN VICES Financing Administration PDIG 

DI.,A 

Date


From


Subject 

SEP 1 3 1991 DIG-OI 

DIG-EI Memorandum AIG-MP 

Gai R. Wilensky, Ph.D. "" "\ Admstrator "V EXSEC

OGC/IG 

DAm-s 

OIG Draf Inpection: "Medicad Exanions for Prenata Cae: State and Local 

Implementation," OEI-06-90-00160 

Inpector General


Offce of the Secreta 

We have reviewed the subject draf inpecton which descnoes State and loca


effort to implement eligIoilty expanions for Medicad-cered prenatal cae and to


overcome barers to accssibilty of prenata cae. Mandatory changes in eligibilty


for pregnant women were addressed in the report However, the mai focus of the


report was on the options avaiable to States to increase the accssibilty of prenata


cae.


The report found that al States have set their income stadad for povert


level pregnant women at 133 percent of the Federal Povert Level (FL), as
 required by law. Many States have alo adopted some of the optional eligibilty


expansions, includig waier of the asset/resource test, contiuous eligIoilty,


extension of the FPL, and presumptie eligibilty. However, a number of factors


inbit accss to prenata cae for Medicad-eligible women.


OIG recommends that HCF A develop a comprehensive outreach strategy, 

streame the application process, develop incenti to increase provider 

parcipation, clar policy and monitor implementation of Medicad expanions for 

prenatal cae, and develop data collecton sytems and evuation processes to 

measure the progress of the eligibilty expanions and futue program effects. 

Although HCFA support the general intent of the report we caot concur with 

the detaed recommendations presented by OIG. Our comments on the 

recommendations are attched for your consideration.


Than you for the opportunty to review and comment on th report. believe that the report is a usefu crtique that we wi use as we contiue to 

implement Medicad' s Maternal and Inant Health Intiatie. Pleae advie us if you 

agree' with our position on the report s recommendations at your earliest 

convenience. 

Attachments 

71 " v.1 . r
 '-I .:J C. .:_ .. J 

J 2:i.:.:' :- . 1 
 \ I

Page 2


Though a national ad campaign stress the benefits of Medicad-covered 

prenatal cae as preventive health cae intead of welfare-related 

assistace. Coordinate outreach effort with the Healthy Start 

capaign. 

HCFA Response 

HCF A does not concur with the par of the recommendation to develop a minim 

set of standards. Because of the considerable dierences among States, and their 

Medicad and Maternal and Chd Health program, we believe it is not appropriate 

to purue the development of sets of stadards for outreach actities. However, we 

could collaborate with the Public Health Servce (PHS), Admtration for Chdren 

and Fames (ACF), State Medicad Directors, and State Maternal and Chd 

Health (MCH) offcials to identi common elements of effective tageted and 

community-wide outreach effort, and develop gudes for State agencies which 

ilustrate those elements in practce. 

HCF A alo does not concur with the par of the recommendation to establish a 

centralied resource center. Given lited stag and fiancial resources, we do 

not believe creatig another resource center would be cost-effectie. The National 

Center for Education in Maternal and Chd Health supported by PHS, serves that 

fuction. Regional HCF A and PHS sta could identi inovatie outreach 

material and practce, and then HCF A's centr offce could issue a compendium 

of inormation though the exiting centrald resource center. 

OIG' s recommendation alo includes that HCF A could clar that matchig Federal 

fuds are avaiable to assist with State effort to conduct client outreach. We 

concur with th par of the recommendation. HCF A has frequently clared the 

avaiabilty of matchig fuds for outreach though memoradum, policy 

interpretations, and technca assistace diected to both Medicad and Maternal and 

Chd Health agencies, and we wi contiue to do so. 

The report alo suggests that HCFA could though a national adverting capaign, 

stress the benefits of prenata cae. HCF A does not concur with th par of the 

recommendation. Whe we endorse such a capaign we believe that it should be 

developed and implemented as par of the national public inormation and 

education effort for the ''Heathy Sta" intiatie. 

Recommendation 2


Simpli and streame the application process. 
Page 4


Recommendation 3


Develop incentives to increase provider parcipation. 

HCFA should: 

Ensure, in revjewig and approvig State plan, that States are complyig 

with the requiements to: 

Provide sufcient reimburement to ensure adequate numbers of 

providers are avaable to delier Medicad-covered prenata cae. 

Specif the nonititutional obstetrca payment rates in Medicad 

State plan amendments. 

Provide payment for servces rendered by certed nure 

practtioners or certed fam nure practtioners if they are 

authoried under State law to perform those servces. 

HCFA could 

Develop a legilatie proposal to gutee temporar Medicad coverage 

unti the end of the presumptie eligIoilty period. Th coverage would 

alay provder apprehensions of havig to contiue cae for women later 

found ineligIole for fu Medicad benefits. 

Develop a legislatie proposal authorig fu Medicad benefits for 

pregnancies deemed at high-rik durg the presumptie eligIoilty period. 

Develop a stadad defition of "quaed" provder, designatig the mium number of Medicad recipients who must be anualy served. 

HCF A Response


HCFA agrees that provder recrtment and retention should be a priority of the 

Medi d intiatie. We are cuently formulatig reguations which implement 

obstetrca and pediatric payment rate requiements. 

HCF A defers comment on the two legilatie propos. Al legilatie proposal 

will be considered with the A-19 process with HCF 
Page 6


HCF A should: 

Work with State Medicad and MCH diectors to develop mium 

reportg requirements to track participation rates. Mial data 

elements should include: the number of women who could be eligible to 

receive Medicad-covered prenata cae; the number who have been 

enrolled by vaous categories, such as AFC, medicay needy, and 

prenata cae only; the number presumptiely eligible; and the attrtion 

rate of women not completig the application process. 

Pending the development of such a system to track paricipation rates 

consider using probabilty samples to estiate the number of newly 

eligtole women enrolled in Medicad-covered prenata cae. 

Work with MCH ACF, State Medicad diectors and State public health 

offcial to develop mium reportg requiements to measure the 

effect of the eligtoilty expanions on improved bir outcomes. Mial 

data elements should include: the health status of al parcipants 

(substace abuser or medicay high-risk pregnancy); demographic 

inormation (age, race, maPta status, income, famy size, educational 

level, and employment statu); trester enrolled for prenata cae; the 

number of prenata cae viits completed; bir outcomes (lie or dead); 

and the baby' bir weight. 

HCFA could 

Work with MCH ACF, State Medicad diectors and State public health 

offcial to assess the potential of lig exitig databases, e.g., eligibilty, 

medica payments, vita statitics, to measure both parcipation rates and 

outcome measures. 

Plan and seek fudig for a multi-year evuation of the effectieness of 

the eligibilty expanions on improved bir outcomes. The evaluations 

should be strcted to permt separte analysis of women considered at 

high rik (substace abusers, medicay high-risk, etc. 
Page 8


Providig a technca assistance document on using the two model 

simplied application form. The fist form is under Title V, for use in 

applyig simultaeously under Head Sta Medicad WIC, MCR, 

communty/migrant/ or homeless health center program. And, the 

second form is for use in applyig for Medicad onl. 

Techncal. Comments 

Page 2	 The report's char on th page is confing. A complete briefig on how 

eligibilty groups work is not appropriate in th response to your report; 

however, we wi provde thi inormation to your sta upon request. 

The fist sentence of the last pargraph should be altered to read, 

HCFA is contiuig to implement a Medicad Maternal and Inant 

Health Intiatie..." The sentence, as it curently appear, iners that 

is a new intiatie. Alo, with th sentence, the Technca Advisory 

Group (TAG) is caed the Medicad/CH TAG. It includes 

representaties of both Medicad and Title V agencies. 

Page 12	 Under the headig, ''Furer, HCFA and Most States Lack Centraled 

Data.. " one problem that is not addressed is how Medicad identicatioli 

(ID) numbers are assigned to newborn. In some States, Medicad 

numbers are automaticay .gien to newborn; in other States, only inants 

with high expenses are gien numbers; and, in the remaig States, the 

ID numbers are assigned to chidren at vag points in tie. Th 

makes it dicut to separate clai for mothers from those for inants, 

which in turn makes it dicut for HCF A to determe what servce use 

and exenditues were for newborn. 

In the second paragrph under th headig, the phrase "dicuty accssing" does not provde a clear picte of the problems involved. 

State Medicad agencies have accss to their own Medicad clai data 

The "crticay evuatie elements" lited are not necessar to pay clais 

and, therefore, are not included in these records. Th inormation would 

be usefu but Medicad State agencies are not curently requied to 

collect it. 

Page	 Under the incenties offered by diferent States to encourage prenata 

cae, we suggest that the coupon books issued by Alabama be included. 

Page 18	 Based on the figues gien by OIG in the char number 5 should be 

$99 628 200 not $96 642,000. Alo, number 6 should be $81,055 800 not 

$78 069 600. 
( ? &. 

, ,. . . \;/ / ,.. , , \, \ :;, 

" ....w j(t"JJ IfF 

DEPARME OF REm HUMA SERVICES CL;Lf:- Public Helt 

. ;yJL C/I/ 

Memorandum 

NOV 2 I 199 

From Assistant Secretary for Health 

Subjec Office of Inspector General (OIG) Draft Report " Medicaid 

Expansions for Prenatal Care: State and Local Implementation 

To - Inspector General, OS 

At t a c h e d are the PHS co mm e n t s on the sub j e c t 0 I G r e po r t . The 

report provides useful information on State and local efforts 

implement eligibility expansions for Medicaid- covered prenatal 

care and to overcome barriers to accessibility and availability 

of prenatal care.


We concur with the report s recommendation directed to PHS.


our comments, we identify the actions taken or planned 


implement this recommendation. In addition , we provide general


comments concerning the on- going activities of the PHS


Interagency Committee on Infant Mortality that relate directly to


the issues addressed in this report.


()'h1

Mason, M. , Dr.


Attachment 

PDIG 

cO: 

AIG-II '7 ;"1' 

oc/IG EXSI :J -..
 DASB - -: fT :: 2 

.1. 
A model application developed by DHHS and the Departent of 

Agricul ture for streamlining applications for child assistance


programs has been approved by both Departents and sent to OMS


prior to publication in the Federal Reaister


PHS also recommends that the OIG report point out the recent


work of the National Governors' Association (NGA), in


conjunction with HRSA, in the area of Medicaid reforms.
 Specifically, approximtely 2 years ago, under a cooperative 

agreement with HRSA, NGA prepared reports which indicated that


financing reforms alone were not sufficient to solve problems
 of access to the underserved. HRSA currently has a second 

cooperative agreement with NGA to examne more recent Medicaid 

expansions and reforms. Finally, the report might also note


that SHCDA provides substantial technical assistance to health


centers to help them implement Medicaid reforms. 

OIG Recommendation 

PHS should use loan repayment and the National Health Service


Corps (NHSC ) recruitment programs to increase the numer of 

doctors, nurses, and other health professionals serving


pregnant women.


PHS Comments


We concur. The NHSC program currently meets the intent of this recommendation. The NHSC specifically targets community-based 

systems of care in medically undeserved areas for the placement 

of health professionals who become available through its 

scholarship program, loan repayment program, and the 

recrui tment of volunteers. A high percentage of the patients seen in these primry health care programs are pregnant women

and children. 

The mission of the NHSC is to provide health personnel to urban 

and rural communi ties and underserved or unserved populations 

with the greatest need. NHSC' s goal is the improvement of access to primry care services in these communities and 

populations. 

Essentially, the NHSC has the mission of elimnating federally 

designated health professional shortage areas (HPSA) throughout 

the United States. To this end, the NHSC seeks to provide an 

adequate supply of primry care and mid-level health 

professionals to communities, special population groups and 

public or private non-profit health facilities in HPSAs. 
dwifery Program awarded

$6, 059, 033 in FY 1990 for 36 projects that support preparation 

of nurses who are able to serve as nurse midwives, obstetrical and gyecological practitioners, and pediatric practitioners. 

In all cases, these nurses focus on patient teaching, guidance, 

The Nurse Practitioner and Nurse 


counseling and health screening acti vi ties. 

PHS funds have been used to support traineeships to 
 prove

admnistration and competency of personnel in maternal and child health programs. In FY 1990, $187, 241 was awarded for 

traineeship support in maternal and child health. 

OTHER COMMENTS


Regarding the recommendation directed to HCFA and the States


that they develop a comprehensive outreach strategy, caution


must be exercised in emphasizing outreach acti vi ties. Outreach 

efforts have to be backed up by adequate system capacity.

g

.. /;:) : \.. , :: ;:, !:.. .. ... . ...,.. \ :. . ; .. :... .. . 

&JJti\IS ERVICES / office of Instor Genal 

Pm 

DIG-AS moran DIG-EI I 0 091 t/

Date ( J" v DIG-O! 

AIG-MP Richar . Kuserow I/ From Inpector Genera EX SEC OGC/IG 

DAT f.i 

Implementation," OEI-090-0160 State and Loca Subiect OIG Dra Report "Medicad Exanions for Prenata Cae 

To Mar 
Gerr - -


J) f?( 

I" SlStat Secre TV 11 Jet "YtA iQ;LA Lo/ -,t OST -is:! l ;.CdJ Plang and Evauation t: ' . I 

SEP 2 5 /991 

2 . ­

; i"1 I 

Attached for your reew and comment is a copy of our draft)nspecti l!:report :;; Medicad Exanions for Prenata Cae: State and Loca Implemenultion. 3 . 

Our inpecton descn"bes State and loca effort to implement eligI"bilty exanions for Medicad-cered prenata cae and to overcome barers to accibilty and
 avaabilty of prenata cae. We found tht, as of Janua 1991, ma States have


endorsed the optiona eligI"biIty exanions. Howev, signcat prblems prevent
 newly eligIcle women from receivg Medicad-cered prenata cae: inadequate
 client outreach, a cubersome application proce dicuty recrtig prenata cae
 providers, problems implementig presptie eligIciIty, stag shortges and the
 need for more tiely inormtion and trg frm the Heath Cae Fmacig
 Admitrtion (HCF A). Alo, data collecton is incient to meae progress
 and outcomes some States ar inovtiely implementig the exanions and a
 1 percent decreae in neonata intensive ca ca potenti reduce Medicad costs 

by over $78 mion. 

We recommend actons by HCFA, the Public Heath Servce and the States to 


develop a comprehensive outreach strtegy, sipli and stre=mline the application
 process, develop incenties to increase provder parcipation, cl policy and
 monitor implementation, develop data collecton sytems and evuation processes to
 measure progres and outcomes and establih a State centrd authority to fully
 implement the exanions.


We would apprecite receivg your comments on the dr report withi 30 days of
 the date of thi mf:::oradum


If you have any questions or comments about th report plea e ca me or have
 your sta contact Mata Zita at FT 269-2678.


Attachment