Report to Congressional Requesters

United States General Accounting Office

GAO

July 2001 MEDICAID

Stronger Efforts

Needed to Ensure

Children’s Access to

Health Screening

Services

GAO-01-749
Page i GAO-01-749 Medicaid EPSDT Services

Letter 1

Results in Brief 3

Background 4

Limited Available Data Indicate Many Children Do Not Receive

EPSDT Services 9

States Have Taken Action to Improve Data Reporting and Delivery

of EPSDT Services 15

HCFA Efforts to Ensure Children’s Access to EPSDT Have Been

Limited 20

Conclusions 23

Recommendations for Executive Action 24

Agency Comments 25

Appendix I Profiles of the Five States Visited 27

Appendix II Examples of State Actions Resulting From EPSDT

 Legal Settlement Agreements 28

Appendix III Comments From the Centers for Medicare and

 Medicaid Services 31

Appendix IV Comments From the State of New York Department

 of Health 33

Appendix V GAO Contacts and Staff Acknowledgments 35

Tables

Table 1: Recommended Number of EPSDT Screens, by Age Group,

for Selected States 7

Table 2: Examples of State Initiatives to Improve Data 15

Table 3: Examples of State Initiatives to Better Ensure Delivery of

Services 17

Contents
Page ii GAO-01-749 Medicaid EPSDT Services

Table 4: Examples of Initiatives to Improve Beneficiary Outreach

and Education 19

Table 5: Background on State and Medicaid Populations and State

Medicaid Managed Care Programs 27

Table 6: Description of Selected EPSDT-Related Lawsuits and

Resulting State Actions to Improve the Provision of

Services 28

Figure

Figure 1: Children in Medicaid as a Proportion of All Children, by

Age Group, 1998 5

Abbreviations

AAP American Academy of Pediatrics

BBA Balanced Budget Act of 1997

CMS Centers for Medicare and Medicaid Services

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

OBRA 89 Omnibus Budget Reconciliation Act of 1989

SCHIP State Children’s Health Insurance Program
Page 1 GAO-01-749 Medicaid EPSDT Services

July 13, 2001

The Honorable Henry A. Waxman

Ranking Minority Member

Committee on Government Reform

House of Representatives

The Honorable John D. Dingell

Ranking Minority Member

Committee on Energy and Commerce

House of Representatives

Medicaid, a joint federal and state program, finances health coverage for

21 million, or more than one in four, of the nation’s children. For many

years, one of its central services has been to screen children for various

conditions so that health problems can be found early and treated before

they worsen. This service, called Early and Periodic Screening, Diagnostic,

and Treatment (EPSDT), calls for states to provide children and

adolescents under age 21 with access to comprehensive, periodic

evaluations of health, developmental, and nutritional status, as well as

vision, hearing, and dental services. Despite the importance of these

services, there is concern that families are not sufficiently informed of

benefits and that enrolled children are not receiving them. In addition, the

adequacy of state efforts to ensure children’s access to these services has

been challenged in court cases throughout the country. These lawsuits

have alleged that state Medicaid programs are not doing an adequate job

of screening children for medical conditions or providing treatment for the

children who need it.

An additional area of concern has been how these services are faring

under managed care plans. Increasingly, state Medicaid programs are

contracting with such plans to provide Medicaid-covered services,

including EPSDT. In many cases, states pay these plans a prepaid fee per

Medicaid enrollee (a “capitated” fee) to provide most medical services.

Managed care plans have traditionally placed an emphasis on preventive

care as a way to provide appropriate care in the most efficient setting, to

avoid or correct health problems before they become more acute or

costly. However, Medicaid beneficiaries in some arrangements are “locked

in” to a particular plan for a period of time—and therefore are restricted to

receiving care solely from providers in that plan. This restriction in

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-01-749 Medicaid EPSDT Services

choice—together with concerns that the prepayment of capitated fees may

create incentives for health care providers to under-provide services to

maximize profit—has raised awareness of the need for assurance that

managed care plans provide required EPSDT services.

To better understand federal and state efforts to ensure that children in

Medicaid receive EPSDT services, you asked that we examine:

1. the extent to which children in Medicaid are receiving EPSDT services;

2. efforts that selected states are taking to improve delivery of EPSDT

services, particularly within managed care; and

3. federal government efforts to ensure that state Medicaid programs

provide covered EPSDT services.

To assess the extent to which EPSDT services were being provided, we

reviewed state reports submitted to the Health Care Financing

Administration (HCFA),1

 the agency that administers Medicaid at the

federal level. We also reviewed major reports and studies on the provision

of EPSDT services. To assess actions or innovative practices that states

had in place or were implementing to provide EPSDT services, we

contacted selected states and visited five—California, Connecticut,

Florida, New York, and Wisconsin. We selected these states to represent

different regions of the country and because they had either relatively high

numbers of children in managed care or a reputation for having an

innovative EPSDT program, or both (see app. I for details on the states we

visited). We also reviewed several major legal settlement agreements and

court orders to identify examples of practices being put in place to

respond to concerns about access to EPSDT services. Finally, to

determine what federal efforts were under way, we reviewed documents

and discussed EPSDT monitoring with HCFA central and regional office

representatives, and we obtained related reports from reviews conducted

since 1995. We conducted our work from September 2000 through June

2001 in accordance with generally accepted government auditing

standards.

 1

In June 2001, HCFA’s name was changed to the Centers for Medicare and Medicaid

Services (CMS). Since our fieldwork was conducted while the agency was known as HCFA,

we are referring to the agency in our report findings by its former name.
Page 3 GAO-01-749 Medicaid EPSDT Services

The extent to which children in Medicaid across the country are receiving

EPSDT services is not fully known, but the available evidence indicates

that many are not receiving these services. A comprehensive view is not

possible because annual state reports to HCFA on the delivery of EPSDT

services are unreliable and incomplete, particularly for children in

managed care. The most reliable evidence comes from studies of specific

EPSDT services, such as lead screening or dental services, and reviews

conducted in a handful of states or covering the medical records of a

relatively small number of patients. For example, prior studies we have

conducted of lead screening and dental care nationwide found that most

children in Medicaid do not receive services, although they are at

significantly higher risk than other children. A Department of Health and

Human Services (HHS) Office of Inspector General study specific to

managed care similarly found that less than one-half of enrolled children

in their sample received any EPSDT screens. These and other studies have

found that several factors contribute to the lack of services. Some involve

program issues, such as inadequate systems for ensuring that services are

provided. Others involve beneficiary issues, such as parents’ being

unaware of the need for or availability of covered services.

The five states we visited were taking actions to improve the compiling

and reporting of data to better monitor whether children were receiving

services. For example, Wisconsin is in the process of linking several state

databases to provide a more complete picture of the care being given to

individual children in multiple settings. As an incentive for managed care

plans to report all health screenings, New York publishes statistics that

compare the performance of these plans on child health-access measures

such as lead screening and well-child visits. The states were also acting to

better ensure that providers and managed care plans delivered required

services and to improve outreach and education to Medicaid children and

families in need of services. California, for example, requires health plans

to contract with local health departments to coordinate care for children,

and Florida mails reminder letters to parents when their children are due

for EPSDT screens.

Federal efforts to ensure that children are receiving services have focused

largely on changing the format and specificity of state reports so that they

can collect reliable information about the extent to which children are

being screened. While these efforts take a positive step, they do not

adequately address the difficulties that states face in obtaining information

about EPSDT service delivery, particularly in capitated managed care

settings in which payments are not directly tied to services provided.

Obtaining accurate data will require additional time and effort by states,

Results in Brief
Page 4 GAO-01-749 Medicaid EPSDT Services

plans, and providers. To identify areas for improvement, some HCFA

regional offices have worked with states to assess EPSDT activities. For

example, HCFA’s San Francisco Regional Office conducted a collaborative

review with California that helped identify such issues as gaps in

informing beneficiaries about EPSDT benefits. HCFA has in recent years

conducted eight studies in other regions or states that included any review

of EPSDT, only four of which focused exclusively on EPSDT. Although

many of the actions taken by one state to improve the delivery of services

may apply to other states, HCFA does not have mechanisms in place for

identifying and highlighting such actions. HCFA has recently signaled a

renewed focus on EPSDT, proposing that it expand its role in overseeing

and promoting state EPSDT activities. A specific plan for how HCFA—

now called CMS—will implement these efforts has not yet emerged.

We are recommending that CMS work with states to develop criteria and a

timetable for assessing and improving the reporting and provision of

EPSDT services. We are also recommending that CMS develop

mechanisms for identifying and highlighting practices that could be used

as models for other states. In commenting on a draft of this report, CMS

generally concurred with our recommendations that the agency work with

states on these criteria and time frames and develop mechanisms for

sharing information among states, but said improvement plans may not be

needed for all states. We clarified our recommendation to indicate that

CMS should determine the need for state improvement plans based on the

outcome of a consistent assessment of all states.

For more than 30 years, federal law has provided comprehensive health

coverage for low-income children through Medicaid.2

 The children eligible

for such care have made up a significant and growing portion of the

nation’s population, as eligibility for Medicaid benefits has expanded to

cover increasing numbers of previously uninsured children. In 1998,

Medicaid covered more than one-third of young children ages 0 through 5,

and more than one-fourth of children under age 21 (see figure 1).3

 The 21

 2

Specifically, the Social Security Amendments of 1967 (P.L. 90-248) enacted the EPSDT

benefit.

3

The Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) required states to cover

pregnant women and children under age 6 in families with incomes at or below 133 percent

of the federal poverty level. The Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508)

required states to phase in coverage (to 2002) of children ages 6 through 18 in families with

incomes at or below 100 percent of the federal poverty level.

Background
Page 5 GAO-01-749 Medicaid EPSDT Services

million children covered by Medicaid that year composed slightly more

than half of the 41 million people in the program while the $32 billion

spent for their care was about 23 percent of the $142 billion spent on the

program by the federal government and states.

Figure 1: Children in Medicaid as a Proportion of All Children, by Age Group, 1998

Source: HCFA.

An increasing number of children are also becoming eligible for EPSDT

services, as federal policy designed to cover the growing number of

uninsured children allows states to provide Medicaid services through the

federally supported State Children’s Health Insurance Program (SCHIP).

To implement SCHIP, states have the option of expanding their Medicaid

programs, developing separate SCHIP programs, or doing some

combination of both. If a state elects Medicaid expansion, it must offer the

same comprehensive benefit package, including EPSDT services, to SCHIP

beneficiaries as it does to Medicaid beneficiaries. In 2000, more than 1

million children were enrolled in SCHIP Medicaid expansion programs and

were therefore also eligible for EPSDT services.

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-5 years old 6-14 years old 15-20 years old All ages
Page 6 GAO-01-749 Medicaid EPSDT Services

Although many coverage, eligibility, and administrative decisions are left

to individual states, the federal government sets certain requirements for

state Medicaid programs. Coverage of screening and necessary treatment

for children is one of these requirements. EPSDT components are

designed to target health conditions and problems for which growing

children are at risk, including iron deficiency, obesity, lead poisoning, and

dental disease. They are also intended to detect and correct conditions

that can hinder a child’s learning and development, such as vision and

hearing problems. For many children, especially those with special needs

because of disabilities or chronic conditions, EPSDT is an important help

in identifying the need for essential medical and supportive services, and

in making these services available.4

The federally required EPSDT components that constitute an EPSDT

“screen” include a comprehensive health and developmental history, a

comprehensive unclothed physical exam, appropriate immunizations,

laboratory tests (including a blood lead-level assessment), and health

education.5

 Other required EPSDT services include

• vision services, including diagnosis, treatment, and eyeglasses;

• dental services, including relief of pain and infections, restoration, and

maintenance;

• hearing services, including diagnosis, treatment, and hearing aids; and

• services for other conditions discovered through screenings, regardless of

whether these services are typically covered by the state’s Medicaid plan

for other beneficiaries.6

While state Medicaid programs must cover EPSDT, they have some

flexibility in determining the frequency and timing of screens. States

develop, in consultation with recognized medical and dental organizations,

their own “periodicity schedules,” which contain age-specific timetables

that identify when physical examinations and certain laboratory tests and

 4

See Children with Disabilities: Medicaid Can Offer Important Benefits and Services

(GAO/T-HEHS-00-152, July 12, 2000).

5

The required components of EPSDT are found in Section 1905(r) of the Social Security Act

(SSA).

6

Section 1905(r) of the Social Security Act requires that EPSDT include services, described

in section 1905(a), that are necessary to correct or ameliorate defects and physical and

mental illnesses and conditions discovered through screening, whether or not those

services are covered by the state’s Medicaid plan.

EPSDT Services Under

Medicaid Are

Comprehensive
Page 7 GAO-01-749 Medicaid EPSDT Services

immunizations should occur. These tables vary somewhat from state to

state. For example, the number of recommended EPSDT screens ranged

from 15 to 29 across the five states we visited (see table 1).

Table 1: Recommended Number of EPSDT Screens, by Age Group, for Selected States

Age Group

American

Academy of

Pediatricsa

Californiab

Fee-forServiceCaliforniab

Managed Care Connecticut Florida New York Wisconsin

Less than 1 8 6 8 8 8 6 6

1-5 6 5 6 6 6 6 7

6-14 7 2 7 7 9c 5 4

15-20 6 2 6 6 6 3 3

All ages 27 15 27 27 29 20 20

Note: Table is based on periodicity schedules effective as of January 2001.

a

The number of screens recommended by the American Academy of Pediatrics (AAP) is included for

reference.

b

California has separate periodicity schedules for fee-for-service and managed care programs.

c

Florida exceeds AAP guidelines because it recommends check-ups at ages 7 and 9 for at-risk

children.

Source: American Academy of Pediatrics and each state’s Medicaid agency.

States have increasingly turned to managed care as a way to deliver

Medicaid services, including EPSDT. From 1991 to 1999, the proportion of

all Medicaid beneficiaries enrolled in managed care—either capitated or in

primary care case management models—rose from about 10 percent to

about 56 percent.7

 Only two states do not have at least some Medicaid

beneficiaries in managed care plans.

Managed care, with its emphasis on preventive and primary care, is

philosophically an ideal model for delivering EPSDT-type services. Under

a capitated managed care model, states contract with managed care plans,

such as health maintenance organizations, and pay a fixed monthly fee per

 7

This proportion represents the Medicaid population enrolled in capitated plans and

programs known as primary care case management models (PCCM). The PCCM model is

similar to a fee-for-service arrangement except that a primary care provider is paid a

monthly, per-capita case management fee to coordinate care for beneficiaries. These

programs are not included as part of our managed care review, but they are included here

because specific calculations of Medicaid enrollees in capitated managed care over time

were not available at the time of our review. Compared to PCCM enrollment, about five

times as many beneficiaries are enrolled in capitated health plans.

The Growth of Medicaid

Managed Care
Page 8 GAO-01-749 Medicaid EPSDT Services

Medicaid enrollee (a capitated fee) to provide most medical services.8 This

model, with its fixed prospective payment for a package of services,

creates an incentive for plans to provide preventive and primary care to

reduce the chance that beneficiaries will require more expensive

treatment services in the future. However, capitated managed care can

also create a financial incentive to underserve or deny beneficiaries access

to needed care. Moreover, Medicaid beneficiaries required to enroll in

managed care may find it difficult to seek alternative care if their plan

providers fail to meet their needs. Because of the potential to underserve,

states must build in safeguards and accountability measures, such as

grievance and appeals processes, to ensure that beneficiaries receive

appropriate care.9

The Congress has given states greater flexibility in moving Medicaid

beneficiaries into mandatory managed care plans. Before the Balanced

Budget Act (BBA) of 1997, a state could require Medicaid beneficiaries to

enroll in managed care only if it first obtained approval from HCFA to

waive certain statutory provisions, such as the freedom to choose

providers. Under HCFA waivers, states have implemented a variety of

mandatory managed care programs, ranging from programs serving

limited populations in just a few counties to state-wide programs covering

all Medicaid beneficiaries, including children with special needs.10 The

BBA gave states new flexibility in implementing mandatory Medicaid

managed care programs, allowing them to implement programs through an

amendment to their state Medicaid plan without first obtaining a HCFA

waiver.11

 8

States often “carve out” services, such as dental, mental health, or pharmacy, from their

managed care benefit package. Providers of these services are generally paid on a fee-forservice basis.

9

See Medicaid Managed Care: Challenge of Holding Plans Accountable Requires Greater

State Effort (GAO/HEHS-97-86, May 16, 1997).

10See Medicaid Managed Care: Challenges in Implementing Safeguards for Children With

Special Needs (GAO/HEHS-00-37, Mar. 3, 2000).

11The BBA exempted certain groups from mandatory enrollment through state plan

amendments. These include children with special health care needs, Indians who are

members of federally recognized tribes, and beneficiaries eligible for both Medicare and

Medicaid. States must still obtain HCFA waivers for mandatory managed care enrollment

of these populations.
Page 9 GAO-01-749 Medicaid EPSDT Services

The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) made

significant changes to improve the provision of EPSDT services to

children in Medicaid. It required that the Secretary of HHS set statespecific annual goals for children’s participation in EPSDT; mandated

state-established periodicity schedules for screening in dental, vision, and

hearing services; required blood lead assessments appropriate for age and

risk factors; and imposed new reporting requirements.

To fulfill the state-specific goal requirement, in 1990 HCFA set a

participation goal of 80 percent by 1995 for every state. To measure

progress towards participation goals and in accordance with the OBRA 89

requirement that states report certain EPSDT statistics, HCFA required,

starting in 1990, that states submit annual EPSDT reports (known as the

form 416). The EPSDT report captures, by age group, the number of

children who (1) received EPSDT health screens; (2) were referred for

corrective treatment; (3) received dental treatment or preventive services;

and (4) were enrolled in managed care plans. Since fiscal year 1999, states

also are required to report the number of blood tests provided to screen

children for lead poisoning.

Lawsuits have been filed in many states alleging shortcomings in the

provision of EPSDT services. According to information from the National

Health Law Program, at least 28 states have been sued by beneficiaries or

advocates since 1995 for failing to provide required access to EPSDT

services. These lawsuits range from single-issue suits—such as coverage

of selected services including mental health services in Maine—to alleged

programwide failures and deficiencies in Texas, Tennessee, and

Washington, D.C. In several instances, the outcomes, including court

orders and settlements agreed to by both parties to remedy known

concerns, illustrate the difficulties states have encountered in providing

services and also suggest strategies to remedy established EPSDT

deficiencies.

Despite statutory reporting requirements, reliable national data are not

available on the extent to which children in Medicaid are receiving EPSDT

services. However, a number of studies of limited scope indicate that

many children in Medicaid are not receiving EPSDT services. These

studies also show that several factors are at work in limiting the successful

delivery of EPSDT services. Some factors are program-related, such as a

lack of providers or systems to ensure access to covered services. Others

are related to beneficiaries themselves, such as the beneficiaries’ lack of

States Are Required to

Report on the Delivery of

EPSDT Services

Legal Settlements

Highlight Challenges in

Many States

Limited Available

Data Indicate Many

Children Do Not

Receive EPSDT

Services
Page 10 GAO-01-749 Medicaid EPSDT Services

awareness about the importance of preventive health care and about

services covered, or their difficulty in maintaining continuity of care with

one provider.

HCFA’s efforts to assemble reliable information about EPSDT

participation in each state have so far been unsuccessful. State-reported

data, upon which HCFA depends, are often not timely or accurate. For

example, states were required to submit their fiscal year 1999 reports by

April 1, 2000. As of January 2001, 15 states had not submitted their 1999

reports and another 15 states’ reports had been returned by HCFA because

they were deficient. HCFA and state officials acknowledge long-standing

difficulties that states face in their efforts to collect complete and reliable

data, which are used as the basis for the EPSDT reports. These difficulties

continue despite HCFA’s attempts to improve the reliability of state

EPSDT reports by revising the report format and guidance.

One reason for the continued difficulty involves collecting data on EPSDT

services provided under managed care. Under the more traditional fee-forservice approach, data on service delivery are often relatively easy to

collect as part of the payment process because states pay providers for

each service for which they bill the state. Under capitated managed care,

however, states pay the managed care plan a prospective monthly perenrollee fee that is not tied to the individual services provided. As a result,

data on service utilization (often referred to as “encounter data”) are not

necessarily captured. Instead, states have to rely on managed care plans to

collect and report these data separately. Managed care plans, particularly

those that also pay their participating providers on a capitated basis, often

have difficulty collecting and reporting complete and accurate data.

States face continuing challenges in determining how to minimize the

administrative burden on managed care plans and providers while still

collecting information at the level needed to administer the program. For

example, to facilitate the collection of EPSDT data, California uses a

special EPSDT form for providers to use in documenting the components

of EPSDT services provided. California’s managed care contracts also call

for managed care plans to collect the EPSDT forms from their providers

and submit detailed encounter data to the state. However, the state has

had difficulty enforcing these requirements across the several layers of

contractors involved in its managed care delivery system. For example, in

the Los Angeles area, the state contracts with two large managed care

organizations that subcontract with multiple commercial and nonprofit

health plans, such as Blue Cross, that further subcontract with a network

Reliable and

Comprehensive National

Data Do Not Exist
Page 11 GAO-01-749 Medicaid EPSDT Services

of providers. Most of these contracts are on a capitated basis. State

officials said that some of the health plans had difficulty collecting the

required encounter data and that one plan had never submitted the

required data. Also, they said that capitated providers of health plans had

little incentive to fill out and submit the EPSDT form because their

payments are not linked to it. The state’s Medicaid agency has not imposed

sanctions against noncompliant plans or providers, restrained in part by its

reluctance to lose any providers given the shortage of providers willing to

serve children in Medicaid.

Although problems are more extensive with managed care data than with

fee-for-service data, most of the states we visited had some difficulty

obtaining complete and accurate data from fee-for-service providers as

well. Florida illustrates the kinds of difficulties that can be encountered.

Providers in Florida are required to use a specific EPSDT code and a claim

form to document the components of EPSDT services they provide.

However, according to state officials, providers often choose to use other

codes instead. For example, providers may submit a claim under a

comprehensive office-visit code for a new patient that pays a higher rate

than an EPSDT screen or they may submit claims under other

comprehensive office-visit codes that require less documentation.12

Compounding these difficulties are limitations in claims processing

systems used by states for fee-for-service programs or by managed care

plans. In Florida, for example, if a child receives laboratory work from one

provider and the remaining components of a screening from another

provider, some managed care plans’ data systems do not combine the

services to correctly reflect that a full screening for the child has been

provided. Similarly, some states have problems tracking referrals and

follow-up treatment services. This tracking difficulty may explain why, in

 12For example, under Florida’s current Medicaid fee schedule for physicians, the payment

rate for an EPSDT screen (code W9881) is $69.12. The payment rate for a comprehensive

office visit of a new patient is $87.24 if it involves medical decision-making of high

complexity (CPT code 99205) and $69.12 if it involves medical decision-making of

moderate complexity (CPT code 99204).
Page 12 GAO-01-749 Medicaid EPSDT Services

HCFA’s 1998 compilation of state reports, seven states reported that no

children had been referred for corrective treatments.13

While HCFA’s data cannot present a reliable and comprehensive picture of

the extent to which children in Medicaid receive EPSDT services, other

studies indicate that many of these children are not receiving such

services. These other studies have been narrow in scope, allowing analysts

to overcome the kinds of problems that so far have thwarted attempts to

gather comprehensive data. They have focused on specific EPSDT services

or reviews of a sample of patients’ medical records. For example, in recent

years we have conducted reviews of screening rates for lead poisoning and

dental care, basing our analysis primarily on data from national health

surveys.14 Both studies found low screening rates for these specific

services among low-income populations served by Medicaid. For lead

poisoning, about 19 percent of children in Medicaid aged 1 through 5 were

screened—a serious concern, because these children are almost five times

more likely than others to have a harmful blood lead level. The screening

rate for potential dental problems was similar, with about 21 percent of

low-income children aged 2 to 5 having had a dental visit in the previous

year. Older children fared somewhat better, with 36 percent of low-income

children aged 6 to 18 having had a dental visit within the previous year.

Studies by others have shown similar results. A 1997 study by HHS’ Office

of Inspector General, which examined a sample of 338 children’s medical

records from 12 health plans in 10 states, estimated that only 28 percent of

 13Determining whether children are receiving medically necessary treatment services is an

even more difficult proposition, as providers determine appropriate medical treatment

services based on the health condition of the individual child. The federally required

EPSDT reports do not require information to track whether treatment services were

provided or whether referrals for treatment resulted in any provided services. Most states

we visited had no formal mechanisms for comprehensively tracking whether referrals for

treatment resulted in provided services. Instead, they relied largely on small sample

reviews of medical records to monitor whether children were receiving needed treatment

services.

14Lead Poisoning: Federal Health Care Programs Are Not Effectively Reaching At-Risk

Children (GAO/HEHS-99-18, Jan. 15, 1999), and Oral Health: Dental Disease Is a Chronic

Problem Among Low-Income Populations (GAO/HEHS-00-72, Apr. 12, 2000). The first study

used data from the National Health and Nutrition Examination Survey, which is conducted

by the National Center for Health Statistics of the Centers for Disease Control and

Prevention. The study also used data from HCFA’s State Medicaid Research Files. The

second study used data from the Medical Expenditures Panel Survey, which is conducted

by the Agency for Healthcare Research and Quality.

Some Studies Show

Screening Rates Are Low
Page 13 GAO-01-749 Medicaid EPSDT Services

children enrolled in Medicaid managed care received all prescribed

EPSDT screens and that 60 percent received no screens at all.15 In several

states, organizations responsible for external quality review of the

Medicaid program have conducted sample medical record reviews of

children enrolled in fee-for-service programs as well as those in managed

care, and they have found similar results. For example, a study by

Minnesota’s external quality review organization found that nearly half of

the children in managed care plans whose files were reviewed had not

visited a clinic in the previous year, and only 6 percent of those due for an

EPSDT screen had received a comprehensive screen.16 A study in

Washington State found that for the sampled files of children in managed

care, 32 percent of infants (birth to 15 months) and 20 percent of children

age 3 to 6 years received screenings for all aspects of EPSDT. The

screening rates for children in fee-for-service care were also low—7

percent for infants and 24 percent for children age 3 to 6 years.17

Studies such as those cited above have collectively identified a number of

reasons why many children in Medicaid are not receiving EPSDT services.

Some of these reasons involve program-related matters, such as limited

provider participation in Medicaid. For example, low provider

participation in Medicaid has been noted as a particular problem in dental

and mental health. Our earlier study found that a shortage of dentists

willing to treat Medicaid patients was the major factor contributing to the

low use of dental services.18 Similarly, a study by the Economic and Social

Research Institute for the Kaiser Commission on Medicaid and the

 15Medicaid Managed Care and EPSDT, Office of the Inspector General, HHS (OEI-05-93-

00290, May 1997).

161999 External Quality Review Study Child and Teen Checkups Participation Rate Review

Final Report, FMAS Corp. for the Minnesota Department of Human Services, August 2000.

172000 EPSDT Report—External Review for Washington Medical Assistance

Administration, OMPRO. This study covered only those children who had 12 months or

more continuous Medicaid eligibility—a longer period than the average eligibility of

Medicaid children. Screening rates for such children are expected to be higher than rates

for Medicaid children as a whole because children who have been eligible for a longer time

are more likely to receive preventive care.

18Our study defined “substantial participation” in Medicaid as seeing 100 or more Medicaid

patients a year—about 10 percent of a dentist’s normal caseload. Thirty-one states provided

information to us on the extent to which their dentists participated in Medicaid. None of

these states reported that more than half of its dentists saw 100 or more Medicaid patients

a year; most states reported that fewer than one-fourth of their dentists did so.

Several Factors Contribute

to Children Not Receiving

Services
Page 14 GAO-01-749 Medicaid EPSDT Services

Uninsured found shortages of mental health and substance abuse

professionals willing to treat Medicaid patients.19

Other program-related factors include inadequate methods for ensuring

access to services. Our study of lead screening found problems with

providers’ missing opportunities to perform follow-up tests when children

returned for other care. Lawsuits brought in a number of states have also

highlighted such problems as inadequate systems for informing

beneficiaries about the availability of EPSDT services and poor

coordination by managed care plans and state agencies. Several advocacy

groups we interviewed echoed concerns that states and managed care

plans do not adequately inform beneficiaries about the broad scope of

EPSDT services or about beneficiary appeal rights. These groups also

questioned the adequacy of the provider networks for serving children in

Medicaid.

In addition to these program-related factors, some beneficiary-related

factors have also been found to limit screening services. For example,

many Medicaid beneficiaries change eligibility status over short periods of

time, and they may move frequently, making it more difficult to maintain

continuity in their medical care.20 Researchers have also found that parents

whose children are eligible to receive services under Medicaid tend to be

less aware of the importance of preventive care than the general

population. Those who try to obtain preventive care face other barriers. In

our reports on oral health and screening for lead poisoning, we noted

several other contributing factors, such as difficulty in getting time off

from work, finding child care, arranging transportation to the provider,

and overcoming language differences. These factors may contribute to a

higher rate of broken appointments—a major concern among providers,

particularly dentists. An American Dental Association survey reported that

about one-third of Medicaid patients failed to keep appointments. A 1999

study conducted for the Florida Medicaid agency found that the top three

reasons given by survey respondents for missing pediatric appointments

were not having a ride to the appointment, the child no longer being sick,

and forgetting an appointment.

 19Medicaid Managed Care for Persons with Disabilities: A Closer Look, Marsha Regenstein

and others, The Economic and Social Research Institute for the Kaiser Commission on

Medicaid and the Uninsured, April 2000.

20For example, the average period of Medicaid eligibility reported by all states combined

was less than 9 months in 1998.
Page 15 GAO-01-749 Medicaid EPSDT Services

The five states we visited have implemented a variety of initiatives

intended to improve the provision of EPSDT services to children in

Medicaid, including those in managed care. The state and health plan

efforts we identified fall into three general categories: (1) improving data;

(2) better ensuring that plans deliver services; and (3) improving

beneficiary outreach and education. Although in most cases states and

health plans could not provide information on their specific impact, these

initiatives represented efforts that state and plan officials cited as helping

to better ensure that children receive EPSDT services.

The five states we visited have taken a number of steps to improve the

quality of the data they collect—especially from managed care programs—

to monitor the utilization of services and to compile EPSDT reports to

HCFA. These steps have not yet solved the states’ data and reporting

problems; however, by moving toward more timely and reliable encounter

data, states can better assess progress toward participation goals, identify

specific plans or providers experiencing problems, and target corrective

measures. As table 2 shows, these steps involve four main types of actions:

requiring plans to submit detailed encounter data, validating those data,

linking data with other sources, and reporting summary data in print or on

the Internet. For example, to encourage health plans to report complete

and accurate data, and to publicize comparative data, New York publishes

summary statistics on individual plans on its health department Web site.

Table 2: Examples of State Initiatives to Improve Data

Type of action Description of initiatives

Submitting encounter data Some states have implemented systems and requirements for health plans to submit data from

each encounter with patients. California, Connecticut, New York, and Wisconsin are states we

visited that require health plans to submit detailed encounter data, including delivery of ESPDT

services. Several officials told us that health plans that pay their providers on a fee-for-service

basis, although they themselves are paid on a capitated basis, experience fewer problems with

their encounter data because the data are based on claims information.

Validating data A data validation process can provide information on the limitations of reported data. All five

states we visited require annual external audits of health plan data. California, for example,

contracts with an external quality review organization to develop baseline and annual

assessments of health plans, including EPSDT services such as immunizations and well child

visits. These external evaluations include a limited chart review, validating coding and data

entry, and audits of computer systems.

Linking data from various sources States can help close gaps in data on the provision of services by linking databases and

information from numerous data sources. To ensure that the state has complete data on the

care provided to children in Medicaid, Connecticut and Wisconsin are finding ways to link planreported encounter data with data from various data sources, such as local health departments

or other state records. For example, as part of its new EPSDT encounter data system,

Wisconsin is in the process of linking its EPSDT database to other health databases such as the

statewide immunization registry and the lead screening database.

States Have Taken

Action to Improve

Data Reporting and

Delivery of EPSDT

Services

Improved Data Reporting
Page 16 GAO-01-749 Medicaid EPSDT Services

Type of action Description of initiatives

Publishing data How states use the data they collect can motivate health plans to pay more attention to the

quality of the data they gather and submit to the state. New York, for example, publishes

summary encounter statistics—including several EPSDT measures such as well child visits and

lead screening—for each managed care plan on its health care Web site. This report, Quality

Assurance Reporting Requirements, allows plan-to-plan comparisons. According to state and

plan managers, such publicity is a strong incentive for health plans to report complete and

accurate encounter data.

These states’ experiences demonstrate that gathering complete and

reliable encounter data is a long-term effort. Wisconsin, for example,

worked collaboratively with capitated managed care plans for 4 years to

formulate a uniform encounter data set and reporting system that all plans

are required to use. Wisconsin’s system did not become functional until

May 2000 and has not yet produced its first report to HCFA. New York has

required managed care plans to submit encounter data for the past 6 years,

but state Medicaid officials said the first few years of data were unreliable.

The data became more reliable around the fourth year, after state officials

worked with health plans to improve their data collection and verification

efforts.21

States have also put into action a number of initiatives to help ensure that

managed care plans and health providers deliver screening and treatment

services to children enrolled in Medicaid. The broad package of benefits

offered under EPSDT can result in confusion and potential under-service if

health plans and providers are not clearly informed of their

responsibilities to provide EPSDT services. In California, for example,

officials said some health plans were not performing screens according to

the state’s managed care periodicity schedule. Plan providers were

confused, they said, because the state’s Medicaid fee-for-service

periodicity schedule called for fewer screens than its managed care

periodicity schedule (15 compared to 27) and physicians often served both

fee-for-service and managed care patients. In addition, a recent HCFAsponsored study of Medicaid managed care contracts in more than three

dozen states found that states often fail to spell out the full range of

 21While officials told us the encounter data are now reliable, through 1999 New York did

not report actual encounters in their annual report to HCFA because health plans were

categorized as “continuing care providers” that were assumed to provide full EPSDT

screens. Their data were therefore overstated. Officials expect to report actual managed

care encounters in their 2000 data submission.

Ensuring Service Delivery
Page 17 GAO-01-749 Medicaid EPSDT Services

EPSDT services that plans are responsible for providing.22 The study

concluded, among other things, that while states routinely expect

managed care plans to provide the full range of EPSDT service obligations,

they do not always explain in contracts what this means and may not

require contractors to educate beneficiaries about the benefit package

offered under EPSDT.

To better ensure EPSDT service delivery, the states we visited have taken

action in several areas (see table 3). Some of these actions have involved

states’ laying out expectations for managed care plans or providers

through extensive specification of responsibilities in contracts or provider

education. Other actions have involved the monitoring of health plans, the

use of incentives and sanctions for provision of services, and requirements

for plans to coordinate care with public health departments. States have

also increased reimbursement rates for EPSDT services. For example, in

1995, to encourage fee-for-service providers to screen more children,

Florida more than doubled its reimbursement rate for a comprehensive

EPSDT screen. The examples in table 3 represent a few of the promising

actions these states and health plans have implemented.

Table 3: Examples of State Initiatives to Better Ensure Delivery of Services

Type of action Description of initiatives

Detailed contract requirements Specific and comprehensive contract language helps ensure that health plans know their

responsibilities and can be held accountable for delivering EPSDT services. Connecticut’s

contract, for example, contains three pages of specific EPSDT requirements, including

requirements for (1) EPSDT screens, (2) services such as scheduling appointments,

arranging transportation, and providing interpreters for enrollees with limited English

proficiency, and (3) coordinating with other assistance programs, such as Head Start. The

contract also contained a 27-page appendix of EPSDT periodicity schedules and

guidance.

Provider education Policies and procedures governing EPSDT, as well as the EPSDT benefit package itself,

can vary substantially from the typical commercial policy. As a result, provider education is

an essential health plan activity. Florida conducts provider training and outreach, including

coverage of EPSDT services and promotional materials, through 11 area EPSDT

coordinators. Wisconsin holds annual conferences for providers and others to discuss

topics such as EPSDT policies, processes, and barriers to providing services.

Increased state monitoring Monitoring of individual plan performance allows states to identify the need for specific

corrective actions. New York uses encounter data to compare each health plan to

statewide averages and the plan’s own prior year performance. Plans performing below

statewide averages or showing decreased performance are required to implement

corrective actions that are monitored by the state to ensure improvement. Connecticut

established an independent Children’s Health Council to, among other things, help

 22Final Report: Federal EPSDT Coverage Policy, The George Washington University, Center

for Health Services Research and Policy, December 2000.
Page 18 GAO-01-749 Medicaid EPSDT Services

Type of action Description of initiatives

monitor delivery of EPSDT services. The Council’s responsibilities include operating a

complaint hotline, analyzing health plan encounter data, and publishing newsletters and

reports on the delivery of EPSDT services.

Use of incentives and sanctions States can build incentives and sanctions into contracts to help ensure that health plans

deliver EPSDT services. New York rewards plans that do better in providing EPSDT

services by assigning them a higher proportion of new enrollees who do not make a

specific choice when they enroll. Each year, Wisconsin recoups payments for screens if

health plans do not achieve an 80 percent screening rate. State officials expect to recoup

$1 million to $2 million per year from plans that did not meet the 80 percent goal in 1998

and 1999.

Required contracts with local health

departments

Close coordination between public health departments and Medicaid agencies can help

ensure continuous, efficient care for those who receive services from different providers.

To better coordinate care, California requires health plans to subcontract with the local

health department in each county for public health services, including immunizations and

other EPSDT services. Similarly, New York requires health plans to have agreements with

local health departments and to coordinate public health related activities, such as

outreach and reporting for immunizations.

Increased provider reimbursement Higher Medicaid fees can attract new providers or motivate existing providers to see more

patients. In Florida, reimbursement for an EPSDT screen in the fee-for-service program

increased 116 percent in 1995 (from $30.00 to $64.82). After the fee increase and other

concurrent initiatives, such as provider education, screening rates doubled—from 32

percent to 64 percent.

The third area in which states have taken action is in educating and

encouraging parents to better ensure that their children receive EPSDT

services. Beneficiary outreach and education is typically a responsibility

shared between the states and the health plans. At certain times in the

process, the states may have primary responsibility for informing

beneficiaries about covered services, such as when new beneficiaries are

enrolled. Once a beneficiary is enrolled in a health plan, the state may

require the plan to take measures to inform parents and families about

covered services and how to access them. Officials from states and plans

we visited reported a number of initiatives to better inform beneficiaries

about EPSDT services (see table 4). These generally fell into four

categories: designing clear and informative member handbooks, creating

helpful and easy-to-understand materials to supplement member

handbooks, developing programs to reach special populations such as

children with disabilities, and conducting community outreach activities.

For example, to encourage Medicaid beneficiaries, including those in

managed care, to take advantage of preventive care, Florida mails

reminder letters to families when their children are due for EPSDT

screens.

Improving Beneficiary

Outreach and Education
Page 19 GAO-01-749 Medicaid EPSDT Services

Table 4: Examples of Initiatives to Improve Beneficiary Outreach and Education

Type of action Description of initiatives

Designing member handbooks Member handbooks provide information on what services are covered, how to access

care, and what to do in the event of questions or problems. One plan’s handbook in

Wisconsin discussed the importance of preventive care under HealthCheck, the state’s

EPSDT program, and listed the elements of an EPSDT screen that a beneficiary should

expect to receive, such as a physical exam, hearing and vision tests, and complete

immunizations.

Creating additional informational materials States and health plans produce a variety of special publications to supplement member

handbooks and promote health issues. For example, one plan in New York distributes

special calendars for expectant and new mothers. The calendars provide useful

information on what to expect during pregnancy, offer early-childhood tips, and have

space for recordkeeping and doctor appointments. Florida sends reminder letters to all

Medicaid enrollees, including those in managed care who are due for EPSDT

screenings. Florida also created a “Child Health Checkup” card for families’ use in

tracking scheduled EPSDT screenings, similar to what a family might use to track a

child’s immunizations.

Reaching special populations Health plans use a variety of initiatives to reach special populations. For example, most

plans we visited publish outreach material in foreign languages to reach non-Englishspeaking members. To attract adolescent members—another difficult group to reach—

one plan in Wisconsin operates teen clinics that offer free pizza and gift certificates. New

York awards grants to health plans to develop innovative delivery models. Grants for

2001 included initiatives to improve screening tools and treatment of children with

disabilities.

Conducting community outreach activities Health plans conduct a variety of activities to promote health issues, including EPSDT

services, in their communities. For example, one managed care plan in California

created community advisory committees that include health plan members, advocates,

and providers in an effort to facilitate communications with members and strengthen ties

within the community. In Connecticut, one health plan conducts home visits, obtaining

neighborhood and community assistance in connecting with families.

In addition to these efforts in the five states we visited, children’s

advocates also informed us that several states have implemented

initiatives as part of settlement agreements arising from EPSDT-related

lawsuits. Settlement documents and court orders from selected EPSDT

lawsuits contain information on a number of state initiatives to improve

delivery of EPSDT services. For example, Pennsylvania established a

series of 18 performance standards and health outcome measures and

incorporated them into managed care contracts. Standards and interim

targets were established for the percentage of children to receive

immunizations and EPSDT screens, and measures were established for

treatment and prevention of asthma, anemia, and lead poisoning.

Appendix II contains further information on the basis for selected lawsuits

and actions taken by states in response.
Page 20 GAO-01-749 Medicaid EPSDT Services

HCFA, now called CMS, is currently reevaluating how best to carry out its

role in helping to ensure that children receive access to EPSDT services.

In recent years, HCFA’s efforts have focused largely on trying to improve

the guidance to states about reporting the extent to which children are

being screened. Attempts to improve reporting have been time-consuming,

and progress has been slow. Because HCFA’s focus has been mainly on

improving the format and specificity of the state EPSDT reports, it has

placed little emphasis on the extent to which states are improving the

underlying data or meeting HCFA’s EPSDT participation goals. At the

regional office level, where much of the responsibility for working with

states resides, a few offices have begun to help states identify problems

and promote state progress in increasing children’s use of services.

However, because most regional offices have focused their resources on

priorities other than EPSDT, these efforts have not been widespread. In

January 2001, HCFA’s central office proposed to regional offices and other

stakeholders that the agency work more closely with states to improve

both reporting and children’s use of services, but a specific plan for how to

do so has not yet been developed.

Recognizing that progress in providing services is difficult to assess

without good data as a starting point, HCFA has centered its monitoring

efforts largely on revising the guidance and format in order to improve

state EPSDT reports. These revisions were largely aimed at capturing

more reliable and more consistent EPSDT information while minimizing

the burden on states in completing the reports. For example, in 1999

HCFA changed the EPSDT report to, among other revisions, require new

information on dental services and blood lead tests, and to add more

precise definitions of certain required data elements. It also allowed states

to use their own periodicity schedules to determine their participation and

screening rates.

While these revisions have changed the reporting requirements, they have

done little to address the continuing difficulties states face in their efforts

to gather reliable and complete data. As our review of the five states

showed, these problems require determined efforts at the state level, and

because of the complexities associated with collecting managed care

encounter data, such efforts take considerable time to accomplish. In the

meantime, these EPSDT reports do not provide an accurate or complete

picture of most state EPSDT programs, nor do they allow for reasonable

national estimates of EPSDT screening and participation rates or for

meaningful comparisons between states.

HCFA Efforts to

Ensure Children’s

Access to EPSDT

Have Been Limited

HCFA Is Acting to Improve

State Reports, but

Progress in Improving the

Underlying Data Is Slow
Page 21 GAO-01-749 Medicaid EPSDT Services

Although HCFA’s efforts to improve data collection are important, by

themselves they do not represent a strategy for helping states meet EPSDT

goals. In part because HCFA acknowledges the limitations of the state

EPSDT reports, the agency has done little to address how well states are

doing in meeting the goal of providing EPSDT services to 80 percent of

children enrolled in Medicaid. The existing reports show that most states

are considerably below this goal. However, even if issues regarding data

and reporting are adequately addressed, improved EPSDT reports, taken

alone, will not provide HCFA with sufficient program detail to perform

other oversight duties, such as helping states identify and correct specific

problems or share information on lessons learned from other states and

model state practices.

A few HCFA regional offices have conducted reviews of state EPSDT

programs. HCFA regional officials reported to us that eight such studies

have been completed since 1995. Four included EPSDT as one element of

a broader review of a state’s Medicaid managed care program; four

focused exclusively on EPSDT. While these EPSDT and managed care

assessments varied widely in their methodology and coverage of EPSDT

issues, they have helped illuminate policy and process concerns and

innovative practices of states. They have also identified needed actions to

improve children’s access to EPSDT care. For example:

• In Oklahoma, an EPSDT-focused study conducted jointly by HCFA’s

Dallas Regional Office and state Medicaid officials found several ways to

increase screening and improve the quality of data submitted. The team

found that providers relied on a review of a child’s medical chart to

determine whether an EPSDT screen was due—a step they generally took

only when an office visit occurred. As a result, children not visiting for

other reasons were often not screened. The study recommended that the

state establish a system to notify providers when children were due for

screens. The study team also found that Medicaid provider knowledge of

EPSDT services varied widely, and that many providers did not know

about a monetary bonus the state offered to those providers who

increased, to 60 percent or more, the proportion of eligible children who

had EPSDT screens. To increase provider awareness, the study team

recommended that the state annually include a discussion of EPSDT at

provider education meetings.

• In California, an EPSDT-focused study conducted by HCFA’s San

Francisco Regional Office with the cooperation of state Medicaid officials

found that families of children in Medicaid were not being effectively

informed about the availability of services or how to gain access to them.

Studies by Some Regional

Offices Have Identified

Areas for Improvement

and Innovative Practices
Page 22 GAO-01-749 Medicaid EPSDT Services

State officials who responded to the report’s findings acknowledged the

need for a more cohesive effort to provide information about EPSDT

services, and they indicated that the state would work to ensure that

systems are in place to provide adequate information to families of

children in Medicaid. The same HCFA study also singled out commendable

practices including state efforts to coordinate care between Medicaid

managed care plans and community health providers such as county

mental health centers.

• In Michigan, a review of the state’s Medicaid managed care program

conducted by HCFA’s Chicago Regional Office and others included an

assessment of certain EPSDT policies and processes. These included

EPSDT-covered services; processes and responsibilities for outreach,

informing, and providing transportation services to beneficiaries; provider

access and coordination; data reporting; and the achievement of screening

goals. The review contained observations such as problems the state was

having in collecting reliable data for the state EPSDT reports and

differences in the usefulness of health plan member handbooks for

describing how beneficiaries can obtain transportation services covered

under EPSDT. Stated goals of the review were to gather information that

would be useful in improving access and quality in the managed care

program and to identify areas of innovation and best practices that could

be shared with other states.

While these assessments have helped those state programs that were

reviewed and have identified best practices that might be applicable to

other states, HCFA has reviewed only eight states since 1995 and has not

established a mechanism for sharing lessons learned or innovative

practices already in place among states. Since there is no HCFA

requirement to periodically focus on and promote EPSDT on the state

level, the decision to do so resides with management of each HCFA region.

Most regions have not devoted resources to actively monitor or promote

EPSDT. Some regional office staff cited other priority efforts, such as

SCHIP, as diverting their resources. We found that regions typically have

one staff person designated as EPSDT Coordinator, but with multiple

responsibilities other than EPSDT.
Page 23 GAO-01-749 Medicaid EPSDT Services

HCFA has recently begun to reevaluate the adequacy of its role in EPSDT.

In a January 2001 letter to the agency’s regional offices, HCFA’s Director

of the Center for Medicaid and State Operations introduced a proposal to

broaden the agency’s role in promoting state EPSDT activities. In the

letter, the Director sought input to a proposal designed to assure

children’s access to services under the Medicaid program and to assist

states in addressing problems in the collection and reporting of state

EPSDT data.

HCFA officials told us that the goal of the letter was to obtain stakeholder

comments on what HCFA’s focus and direction should be. As of April

2001, HCFA regional staff had reviewed and commented on the letter, as

had representatives from the American Academy of Pediatrics, officials

from HHS’s Health Resources and Services Administration, and the

Maternal and Child Health Technical Advisory Group (an advisory group

made up of 6 to 10 state Medicaid directors). HCFA officials informed us

that stakeholder reaction to the proposed initiative had generally been

positive. The current chair of the Maternal and Child Health Technical

Advisory Group told us that the general tone of the letter represents a

collaborative, partnership approach that would provide for needed

technical assistance while affording the flexibility needed for states to

address conditions and impediments unique to each state.

It is too early to determine whether this initiative will move forward, what

form it will take, or what might result from it. The agency has not yet

established a plan or devoted resources to develop and implement this

proposal. HCFA officials said that they were continuing to solicit

comments and input from stakeholders to develop a plan and that

decisions about resources and implementation would depend on guidance

and direction on agency priorities.

More than a decade ago, the Congress passed legislative changes to help

ensure that millions of low-income children under Medicaid have access to

important health screening and treatment services. In the years since then,

the Congress has placed even more emphasis on providing a health care

safety net by expanding coverage to more and more children who do not

have health insurance. This safety net, however, cannot be considered

fully in place unless there are assurances that the covered health care

services are actually provided. Unfortunately, reported data are unreliable

and incomplete. They are inadequate for gauging Medicaid’s success in

providing screening, diagnostic, and treatment services to enrolled

children. Particularly for children served by managed care plans—a

Recent HCFA Proposal

Aims to Improve EPSDT

Performance, but Specific

Plan Is Not Yet Developed

Conclusions
Page 24 GAO-01-749 Medicaid EPSDT Services

growing segment of the population—current information does not allow a

thorough assessment of progress. However, the available information

indicates that many children are still not receiving health screening

services. Recognizing this concern, some states are taking a more active

role in identifying ways to reach the at-risk population served by Medicaid.

HCFA, now called CMS, has recently indicated increased emphasis on

EPSDT services and can build on these state efforts in several ways while

still giving states the flexibility to administer the program. One way is to

continue the important task of working with states to improve the

reporting of information on service delivery. Many providers, plans, and

states will need to improve their reporting in the long-term so that there

will be a more accurate picture of how well they are doing in providing

these services, especially in a capitated managed care environment. In the

short-term, CMS can take action to obtain a better understanding of the

many different state policies and practices so it can work collaboratively

with states to improve data and reporting, monitor the provision of

services, and better inform and reach beneficiaries. In its position of

setting federal policy and assessing a broad array of state activities

intended to help reach at-risk Medicaid children, CMS can help build on

successful efforts by sharing successes among states and working with the

many different agencies and parties to ensure a coordinated approach to

this care. By signaling a broadening of its interest in state EPSDT efforts,

the agency has taken a positive first step. An important next step is for

CMS to develop a more specific plan and time frames for working with

states to assess their efforts and results in providing services to children in

Medicaid.

To strengthen the federal role in ensuring the delivery of EPSDT services

and to bring greater visibility to ways that states can better serve children

in Medicaid, we recommend that the Administrator of CMS:

• work with states to develop criteria and time frames for consistently

assessing and improving EPSDT reporting and the provision of services,

including requiring that states develop improvement plans as appropriate

for achieving the EPSDT goal of providing health services to children in

Medicaid; and

• develop a mechanism for sharing information among states on successful

state, plan, and provider practices for reaching children in Medicaid.

Recommendations for

Executive Action
Page 25 GAO-01-749 Medicaid EPSDT Services

We obtained comments on a draft of this report from CMS and the five

states we visited. CMS commented that, as noted in the draft report, the

problem is complex and not subject to an easy resolution (CMS’s

comments are included in app. III). CMS agreed that more could be done

to work with states to help ensure children’s access to services and

compliance with federal requirements and stated that the agency’s

regional offices are already starting to work with some states where

problems exist. CMS partially agreed with our recommendation that it

work with states to develop criteria and time frames for assessing and

improving EPSDT reporting and the provision of services, including

developing state-specific improvement plans for achieving EPSDT goals.

While acknowledging the importance of working with states to improve

the provision of services, CMS indicated that it was not certain that

improvement plans for all states were necessary as part of this effort.

Because of the unreliability of EPSDT reports, we believe that a more

consistent assessment across all states is necessary to provide greater

insight into states’ progress in achieving EPSDT goals. Depending on the

assessment outcomes, improvement plans may not be needed for every

state. We have clarified our recommendation accordingly. CMS agreed

with our recommendation that the agency do more to foster information

sharing and cooperation among states to improve EPSDT. The agency

indicated that, as a first step, it is planning several activities with states,

foundations, and others to promote the value of EPSDT services. The

agency also provided technical comments that we incorporated where

appropriate.

California and Connecticut reviewed our findings concerning their state

programs and said they had no comments. Florida, New York, and

Wisconsin provided technical comments, which we incorporated where

appropriate. New York also commented that the draft did not

acknowledge that compliance rates with screening requirements are

uniformly low, even for children not in Medicaid, and stated that EPSDT

expectations may not be realistic. While some available reports, such as

our past work on lead and dental screening, do show low screening rates

in the aggregate, these reports also show wide variations among states.

Because available data are insufficient to gauge states’ progress in

providing EPSDT services, assessing whether the agency’s 80 percent

screening goal is realistic is difficult. We anticipate that once state EPSDT

data are more reliable, CMS will be in a better position to reevaluate

whether the annual screening goals that it set more than a decade ago are

realistic and achievable. New York also commented that the shortfalls in

the provision of recommended levels of preventive health services

identified in the report apply to all children, not just those served by

Agency Comments
Page 26 GAO-01-749 Medicaid EPSDT Services

Medicaid. Rather than perform a comparative analysis of the provision of

services for children in Medicaid versus others, this report focused on the

provision of EPSDT services to children in Medicaid, which our past work,

as well as the work of others, has shown to be an at-risk population. New

York’s comments are included in appendix IV.

As arranged with your offices, unless you release its contents earlier, we

plan no further distribution of this report until 30 days after its issuance

date. At that time, we will send copies to the Secretary of Health and

Human Services; the Administrator of CMS; appropriate congressional

committees; and other interested parties.

If you or your staff have any questions about this report, please contact me

at (202) 512-7118. Other contacts and major contributors are included in

appendix V.

Kathryn G. Allen

Director, Health Care—Medicaid

 and Private Health Insurance Issues
Appendix I: Profiles of the Five States Visited

Page 27 GAO-01-749 Medicaid EPSDT Services

To obtain information about efforts states were taking to improve EPSDT

services, particularly within managed care, we visited five states. These

states—California, Connecticut, Florida, New York, and Wisconsin—were

selected to represent different regions of the country and because they

had relatively high numbers of children in managed care or a reputation

for having an innovative EPSDT program or both. These states differed

greatly in the size of their Medicaid populations and the number of

participating health plans. Table 5 contains background information on the

states we visited.

Table 5: Background on State and Medicaid Populations and State Medicaid Managed Care Programs

California Connecticut Florida New York Wisconsin

State population, 2000 33,871,648 3,405,565 15,982,378 18,976,457 5,363,675

Total Medicaid enrollment, 2000a 5,036,768 320,617 1,701,128 2,751,385 479,167

Proportion of Medicaid recipients

under 21 years of age, fiscal year

1998b

51% 53% 56% 49% 54%

Managed care enrollment, 2000a,c 2,525,406 229,995 1,016,641 691,422 211,185

Proportion of Medicaid population in

managed care, 2000a,c

50% 72% 60% 25% 44%

Number of health plans participating

in Medicaid managed care, 2000

33e 4 14 29 14

Specific EPSDT screening goals

established in managed care

contracts

None 80 percent annual

screening rate

60 percent

screening rate for

children 0-5 years of

age and

continuously

enrolled for 8

months

None 80 percent

screening rate per

contract year

a

As of June 30, 2000.

b

Fiscal year 1998 is the most recent year for which these data are available.

c

The percentage of the Medicaid population enrolled in managed care includes those enrolled in

primary care case management arrangements, as well as capitated managed care plans.

d

State officials reported contracting with 42 entities to deliver health, dental, and long-term care, and

services to special populations. Thirty-three of these contracts were for health care services.

Sources: U.S. Census Bureau, HCFA, and state Medicaid agencies.

Appendix I: Profiles of the Five States Visited
Appendix II: Examples of State Actions

Resulting From EPSDT Legal Settlement

Agreements

Page 28 GAO-01-749 Medicaid EPSDT Services

Lawsuits have been filed in at least 28 states alleging the states had failed

to adequately provide EPSDT services. The seven cases summarized in

table 6 were suggested by the National Health Law Program’s Director of

Legal Affairs and other EPSDT advocates as examples of states that have

adopted innovative or promising EPSDT practices as a result of lawsuits.

The following information reflects our review of relevant court documents

in each of these cases and, in some instances, follow-up contacts with

state officials to obtain further information about the state’s efforts.

Table 6: Description of Selected EPSDT-Related Lawsuits and Resulting State Actions to Improve the Provision of Services

State Basis for Selected EPSDT Lawsuits and Resulting State Actions

California

(T. L. v. BELSHE, No. CV-S-93-1782

LKKPAN, E.D. Cal., 1995)

Promulgating State Regulations on EPSDT services

Plaintiffs alleged that the state had failed to provide prescribed EPSDT services.

California promulgated EPSDT requirements in state regulations to clarify additional

requirements for coverage for children beyond requirements for adult Medicaid coverage

spelled out in its state Medicaid plan.

California

(EMILY Q. v. BELSHE, CV-98-4181-

WDK, C.D. Cal., May 5, 1999)

Expanded Availability of EPSDT Mental Health Services

Plaintiffs filed a class action lawsuit alleging that the California Department of Health

Services had failed to offer Medicaid-enrolled children the full scope of mental health

services covered under EPSDT. Prior to the lawsuit, California had been institutionalizing

children with severe mental health needs. The plaintiffs alleged that California had violated

EPSDT notification and access requirements by failing to advise the children and their

families about other noninstitutionalization options, such as Therapeutic Behavioral

Services (TBS), which is a type of mental health service for children that involves having a

trained, experienced staff person available on a one-on-one basis to work with the troubled

child in his or her home and community throughout the child’s routine day. In their lawsuit,

the plaintiffs argued that a less disruptive, noninstitutional approach—such as TBS—is a

required EPSDT benefit.

The Court ruled that TBS “could be considered as both preventive and rehabilitative as

contemplated by the [EPSDT] statute, and therefore, when necessary should be a covered

[state plan] benefit.” As a result of the lawsuit, California is now required to offer

noninstitutionalization or “wraparound” services so that mentally ill children can receive

treatment in the community instead of being institutionalized.

Appendix II: Examples of State Actions

Resulting From EPSDT Legal Settlement

Agreements
Appendix II: Examples of State Actions

Resulting From EPSDT Legal Settlement

Agreements

Page 29 GAO-01-749 Medicaid EPSDT Services

State Basis for Selected EPSDT Lawsuits and Resulting State Actions

District of Columbia

(SALAZAR v. DISTRICT OF COLUMBIA,

No. CA-93-452, Jan. 25, 1999)

Appointment of a Court Monitor to Oversee Corrective Action

Plaintiffs filed numerous challenges against the District of Columbia alleging that the

District failed to provide Medicaid benefits, including access to EPSDT services, to its

residents. The lawsuit alleged that the District of Columbia did not notify residents of

EPSDT’s availability and that the District failed to provide EPSDT services when

requested.

In ordering relief, the court appointed a special monitor to oversee implementation of the

corrective action required by the court’s consent decree. Other required actions include

annual EPSDT training for all managed care plans and physicians; establishment of an

EPSDT telephone referral and question hotline for providers and EPSDT recipients; interim

participation goals; and a Spanish EPSDT Helpline.

Maine

(FRENCH v. CONCANNON, No. 97-CV24-B-C, D. Me, July 16, 1998)

Expanded Availability of EPSDT Mental and Behavioral Health Services

Plaintiffs alleged that Maine was failing to comply with EPSDT requirements because the

state was not apprising patients of the availability or providing access to mental health

services under its EPSDT program.

As a result of the lawsuit, Maine agreed to modify the EPSDT informational materials given

to parents and providers to include specific information about screening and treatment

services available to address behavioral health needs. The state also agreed to provide

case management for behavioral and mental health needs, develop a resource directory,

and conduct additional provider education.

Pennsylvania

(SCOTT v. SNIDER, No. 91-CV-7080,

E.D. Pa., Dec. 2, 1994)

Increased Outreach to New Mothers and Setting Performance Standards

The plaintiffs alleged that Pennsylvania failed to properly implement the EPSDT program.

The parties negotiated a consent order that required, among other things, that the state

foster awareness of and access to EPSDT services, in part by requiring the state to have a

mechanism to ensure that all new mothers meet with a primary care physician for their

newborns. Pennsylvania established a series of 18 performance standards and health

outcome measures and incorporated them into managed care contracts. Standards and

interim targets were established for the percentage of children who received

immunizations and EPSDT screens, and measures were established for treatment or

prevention of asthma, anemia, and lead poisoning.
Appendix II: Examples of State Actions

Resulting From EPSDT Legal Settlement

Agreements

Page 30 GAO-01-749 Medicaid EPSDT Services

State Basis for Selected EPSDT Lawsuits and Resulting State Actions

Tennessee

(JOHN B. v. MENKE, No. 3-98-0168,

M.D. Tenn., Feb. 25, 1998)

Bonus Payment for Reporting Completed EPSDT Screens

The plaintiffs filed a class action on behalf of all individuals under the age of 21 in

Tennessee’s Medicaid managed care program. The lawsuit alleged that the state had

failed to properly screen children in accordance with the required EPSDT periodicity

schedules, properly diagnose children’s medical needs, or provide children with access to

the full range of required EPSDT health care services.

The parties negotiated a consent order, agreeing to take a series of steps to bring

Tennessee’s Medicaid managed care program into compliance with EPSDT requirements

as set forth in federal statute, regulations, and controlling HCFA guidelines. State officials

told us that one of the results has been that Tennessee and its largest managed health

care plan have developed a pilot project to document and encourage EPSDT screening by

providers. The health plan has developed a simplified one-page EPSDT form that reduces

the components into an 11-element checklist; for each completed EPSDT form—and thus

EPSDT screen—a provider receives a monetary bonus.

West Virginia

(SANDERS v. LEWIS, No. 2:92-0353,

S.D.W.Va., March 1, 1995)

Increased Outreach to Ensure Behavioral and Mental Health Services are Provided

Plaintiffs filed a class action lawsuit alleging that out-of-home-placement children were not

being provided with access to mental health services under the state’s EPSDT program.

Under the resulting consent order negotiated by the parties, West Virginia agreed to

ensure that all appropriate state employees, foster care parents, and EPSDT providers

received information and training on the disproportionate number of mental health

problems experienced by these children. In addition, the state is required to ensure that

EPSDT screens and treatment for this population include behavioral and mental health

services.
Appendix III: Comments From the Centers for

Medicare and Medicaid Services

Page 31 GAO-01-749 Medicaid EPSDT Services

Appendix III: Comments From the Centers

for Medicare and Medicaid Services
Appendix III: Comments From the Centers for

Medicare and Medicaid Services

Page 32 GAO-01-749 Medicaid EPSDT Services
Appendix IV: Comments From the State of New York

Department of Health

Page 33 GAO-01-749 Medicaid EPSDT Services

Appendix IV: Comments From the State of

New York Department of Health
Appendix IV: Comments From the State of New York

Department of Health

Page 34 GAO-01-749 Medicaid EPSDT Services
Appendix V: GAO Contacts and

Staff Acknowledgments

Page 35 GAO-01-749 Medicaid EPSDT Services

Katherine Iritani, (206) 287-4820

Terry Saiki, (206) 287-4819

Other major contributors to this report were Matthew Byer, Bruce

Greenstein, Sophia Ku, Behn Miller, and Stan Stenersen.

Appendix V: GAO Contacts and Staff

Acknowledgments

GAO Contacts

Staff

Acknowledgments

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