United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Domestic 

Policy, Committee on Oversight and 

Government Reform, House of 

Representatives

MEDICAID

Concerns Remain about 

Sufficiency of Data for 

Oversight of Children’s 

Dental Services 

Statement of James Cosgrove 

Acting Director, Health Care

For Release on Delivery

Expected at 2:00 p.m. EDT

Wednesday, May 2, 2007

 

GAO-07-826T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2, 2007

MEDICAID

Concerns Remain about Sufficiency of 

Data for Oversight of Children's Dental 

Services 

Highlights of GAO-07-826T, a testimony 

before the Subcommittee on Domestic 

Policy, Committee on Oversight and 

Government Reform, House of 

Representatives 

The 31 million children enrolled in 

Medicaid are particularly vulnerable

to tooth decay, which, if untreated,

may lead to more serious health 

conditions and, on rare occasion,

result in death. Congress 

established a comprehensive health 

benefit for children enrolled in 

Medicaid to cover Early and 

Periodic Screening, Diagnostic, and 

Treatment (EPSDT) services, which 

include dental services. The Centers

for Medicare & Medicaid Services 

(CMS) is responsible for oversight 

of these services. States are 

responsible for administering their 

state Medicaid programs in 

accordance with federal

requirements, including

requirements to report certain data 

on the provision of EPSDT services. 

GAO was asked to address the data

that CMS requires states to submit 

on the provision of EPSDT dental 

services and the extent to which

these data are sufficient for CMS 

oversight of the provision of these 

services. 

This testimony is based on reports 

GAO issued from 2000 through 

2003. GAO updated relevant

portions of its earlier work through 

interviews conducted in April 2007

with officials from CMS; state 

Medicaid programs in California, 

Illinois, Minnesota, New York, and 

Washington (states contacted for 

GAO’s 2001 study or referred to

GAO by another official); and 

national health associations. GAO 

also reviewed relevant literature

provided by officials from CMS and 

other organizations. 

CMS requires states to report annually on the provision of certain EPSDT 

dental services through form CMS 416. The CMS 416 is designed to provide 

information on state EPSDT programs in terms of the number of children 

who receive child health screening services, referrals for corrective

treatment, and dental services from fee-for-service providers and under 

managed care plans. Data captured on dental services include the number of 

children receiving any services, any preventive services, and any treatment 

services. 

The CMS 416s, however, are not sufficient for overseeing the provision of 

dental and other required EPSDT services in state Medicaid programs. We

reported in 2001 that not all states submitted the required CMS 416s on time 

or at all. CMS 416s that states did submit were often based on incomplete 

and unreliable data. States faced challenges getting complete and accurate 

data, however, particularly for children in managed care. According to 

agency officials, CMS has taken steps since our 2001 report to improve the 

data. For example, CMS has conducted reviews of some states’ EPSDT 

programs that included assessments of states’ CMS 416 data. CMS officials

said that 11 states’ EPSDT programs had been reviewed since 2002. CMS has

also required since 2002 that states collect data on utilization of dental and 

other required EPSDT services from managed care plans. State and national 

health association officials told us that these data have improved over time. 

But concerns about the CMS 416 remain. Concerns cited by state and 

national health association officials we contacted included inconsistencies 

in how states report data, data inaccuracies, and problems with the data 

captured that preclude calculating accurate rates of the provision of dental 

and other required EPSDT services. Further, the usefulness of the CMS 416 

for federal oversight purposes is limited by the type of data currently 

requested. First, rates of dental services delivered to children in managed 

care cannot be identified from the data. Second, the data captured do not 

address whether children have received the recommended number of dental 

visits. And third, the data do not illuminate factors, such as the inability of 

beneficiaries to find dentists to treat them, which contribute to low use of 

dental services among Medicaid children. 

www.gao.gov/cgi-bin/getrpt?GAO-07-826T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact James 

Cosgrove at (202) 512-7118 or 

cosgrovej@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today as you examine the Centers for Medicare & 

Medicaid Services’ (CMS) oversight of dental care for the 31 million 

children from low-income families enrolled in the Medicaid program,1

including the significant number of children covered by managed care. 

Medicaid is the joint federal-state program that provides health care 

coverage for certain low-income individuals. According to the Centers for 

Disease Control and Prevention, tooth decay is one of the most common 

chronic infectious diseases among U.S. children: 28 percent of children 

aged 2 to 5 have had decay in their primary (baby) teeth, about 50 percent 

by age 11. Untreated tooth decay may result in pain, dysfunction, and 

other problems that may lead to more serious health conditions and, on 

rare occasion, result in death. Low-income children—such as those 

enrolled in Medicaid—are estimated to be twice as likely to have untreated

tooth decay as children in families with higher incomes. 

In 1967, Congress established a comprehensive health benefit for children 

enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic, 

and Treatment (EPSDT) services.2

 In 1989, Congress further defined 

EPSDT services to specifically include dental services.3

 As the agency

responsible for overseeing the administration of states’ Medicaid 

programs, CMS has an important role in ensuring that states comply with 

federal requirements, including that each state report annually to CMS on 

certain aspects of dental and other EPSDT services. Despite the known 

prevalence of tooth decay in the Medicaid population, recent CMS 

estimates of the provision of dental services, based on state reports to 

CMS, indicate that only about one-third of Medicaid children received a 

dental service in fiscal year 2005. 

 1

Estimated enrollment for all children in Medicaid in fiscal year 2006. 

2

Social Security Amendments of 1967, Pub. L. No. 90-248, §302, 81 Stat. 821, 929 (1968) 

(codified, as amended, at 42 U.S.C. §1396d(a)(4)). 

3

Omnibus Budget Reconciliation Act of 1989 (OBRA), Pub. L. No. 101-239, § 6403(a), 

103 Stat. 2106, 2262 (1989)(codified, as amended, at 42 U.S.C. §1396d(r)). EPSDT services 

include comprehensive, periodic evaluations of health, developmental, and nutritional 

status and dental, vision, and hearing services for individuals under age 21. EPSDT dental 

services must include dental services that are (1) provided at intervals that meet 

reasonable standards of dental practice; (2) provided at other intervals as medically 

necessary to determine the existence of a suspected illness or condition; and (3) include 

relief of pain and infections, restoration of teeth, and maintenance of dental health. 

Page 1 GAO-07-826T 
My remarks today will address the data that CMS requires states to submit 

on the provision of EPSDT dental services and the extent to which these 

data are sufficient for CMS oversight of the provision of EPSDT dental 

services for children enrolled in Medicaid. My testimony is based on 

reports we issued from 2000 through 2003,4

 an assessment of CMS’s 

reporting requirements and state-submitted reports obtained from CMS in 

April 2007, and a review of selected CMS reports on EPSDT services and 

of related literature in April 2007. Our past work on the data CMS requires 

states to submit focused on the broad range of required EPSDT services, 

including dental services, but did not focus specifically on dental services 

data. We have supplemented these findings with information from our past 

work on oral health, including factors contributing to low use of dental 

services by low-income populations. We also updated relevant portions of 

our earlier information through interviews conducted in April 2007 with 

officials from CMS and state Medicaid programs in California, Illinois, 

Minnesota, New York, and Washington—states we contacted in our earlier 

work5

 or which were referred to us by an official from a national health

association who considered the states’ experiences to be relevant to our 

current work. We interviewed officials from national health associations, 

including the Children’s Dental Health Project, Medicaid/SCHIP Dental 

Association, the National Academy of State Health Policy, the National 

Oral Health Policy Center, and the George Washington University Medical 

Center for Health Services Research and Policy. All of our work was 

conducted in accordance with generally accepted government auditing 

standards. 

In summary, CMS collects annual data from states for purposes of 

overseeing the delivery of dental and other required EPSDT services. Each 

year, states must submit EPSDT reports known by the form on which they 

are submitted, the CMS form 416. The CMS 416 report (hereafter called the 

CMS 416) is designed to capture data such as the number of children who 

received any dental service, a dental preventive service, or a dental 

treatment service. CMS has indicated that the CMS 416 is used to assess 

 4

See Medicaid and SCHIP: States Use Varying Approaches to Monitor Children’s Access 

to Care, GAO-03-222 (Washington, D.C.: Jan. 14, 2003); Medicaid: Stronger Efforts Needed 

to Ensure Children’s Access to Health Screening Services, GAO-01-749 (Washington, D.C.: 

July 13, 2001); and Oral Health: Factors Contributing to Low Use of Dental Services by

Low-Income Populations, GAO/HEHS-00-149 (Washington, D.C.: Sept. 11, 2000). 

5

For our 2001 study on federal government efforts to ensure state Medicaid programs 

provided covered EPSDT services, we contacted selected states, including Washington, and 

we visited California, Connecticut, Florida, New York, and Wisconsin. See GAO-01-749. 

Page 2 GAO-07-826T 
the effectiveness of state EPSDT programs to determine the number of 

children provided child health screening services, referred for corrective 

treatment, or receiving dental services. 

The CMS 416s, however, are not sufficient for overseeing the provision of 

dental and other required EPSDT services in state Medicaid programs. We 

reported in 2001 that not all states submitted the required CMS 416s on 

time or at all. CMS 416s that states did submit were often based on 

incomplete and unreliable data. States faced challenges getting complete

and accurate data, however, particularly for children in managed care. 

According to agency officials, CMS has taken steps since our 2001 report 

to improve the data. For example, CMS has conducted reviews of some 

states’ EPSDT programs that included assessments of states’ CMS 416 

data. CMS officials said that 11 states’ EPSDT programs had been 

reviewed since 2002. CMS has also required since 2002 that states collect 

data on utilization of dental and other required EPSDT services from 

managed care plans. State and national health association officials told us

that these data have improved over time. But concerns about the CMS 416 

remain. Concerns cited by state and national health association officials 

we contacted included inconsistencies in how states report data, data

inaccuracies, and problems with the data captured that preclude 

calculating accurate rates of the provision of dental and other required 

EPSDT services. Further, the usefulness of the CMS 416 for federal 

oversight purposes is limited by the type of data currently requested. First, 

rates of dental services delivered to children in managed care cannot be 

identified from the data. Second, the data captured do not address 

whether children have received the recommended number of dental visits. 

And third, the data do not illuminate factors, such as the inability of 

beneficiaries to find dentists to treat them, which contribute to low use of 

dental services among Medicaid children. 

We discussed the key findings of our testimony with CMS officials and 

obtained from them technical corrections, which we incorporated as 

appropriate. CMS commented on our earlier reports upon which our 

testimony is primarily based.6

 6

CMS generally agreed with the two related recommendations we made in 2001, that CMS

work with states to improve EPSDT reporting and that CMS develop a mechanism for

sharing model practices among states for providing EPSDT practices. 

Page 3 GAO-07-826T 
Medicaid is one of the largest programs in federal and state budgets. In 

fiscal year 2005, the most recent year for which complete information is 

available, total Medicaid expenditures were an estimated $317 billion. The 

estimated federal share that year was about $182 billion. States pay 

qualified health providers for a broad range of covered services provided 

to Medicaid beneficiaries, and the federal government reimburses states 

for their share of these expenditures. The federal matching share of each 

state’s Medicaid expenditures for services is determined by a formula 

defined under federal law and can range from 50 percent to 83 percent. 

Each state administers its Medicaid program in accordance with a state 

plan, which must be approved by CMS.7

 Medicaid is an open-ended 

entitlement program, under which the federal government is obligated to

pay its share of expenditures for covered services provided to eligible 

individuals under each state’s federally approved Medicaid plan. 

States have considerable flexibility in designing their Medicaid programs, 

including certain aspects of eligibility, covered services, and provider 

payment rates. But under federal law, states generally must meet certain

requirements for what benefits are to be provided, who is eligible for the 

program, and how much these beneficiaries can be required to pay in 

sharing the cost of their care. States are required, for example, to cover 

certain services under their state plans, such as physician, hospital, and 

nursing facility services, as well as EPSDT services for beneficiaries under 

the age of 21.

8

EPSDT services are designed to target health conditions and problems for 

which children are at risk, including obesity, lead poisoning, dental 

disease, and iron deficiency. EPSDT services 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, particularly those 

with special needs related to disabilities or chronic conditions, EPSDT 

services can help to identify the need for, and make available, essential 

medical and support services. 

Background 

EPSDT Services 

 7

In order to qualify for federal matching funds, a state plan must detail certain elements of

a Medicaid program, including the populations served, the services the program covers, 

and the rates of and methods for calculating payments to providers. Any changes a state 

wishes to make to the state plan must be submitted to CMS for review and approval in the 

form of a state plan amendment. 

8

See 42 U.S.C. §§ 1396a(a)(10)(A),1396d(a). 

Page 4 GAO-07-826T 
State Medicaid programs are required to cover EPSDT services for 

Medicaid beneficiaries under 21.9

 These services are defined as screenings, 

which must include a comprehensive health and developmental history, a 

comprehensive unclothed physical exam, appropriate immunizations, 

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

education. Other required EPSDT services include 

• dental services, which must include relief of pain and infections, 

restoration of teeth, and maintenance of dental health; 

• vision services, including diagnosis and treatment for vision defects, and

eyeglasses; 

• hearing services, including diagnosis and treatment for hearing defects, 

and hearing aids; and 

• services necessary to correct or ameliorate physical and mental illness 

discovered through screenings, regardless of whether these services are 

covered under the state’s Medicaid plan for other beneficiaries.10

Although state Medicaid programs must cover EPSDT services, states have 

some flexibility in determining the frequency and timing of screenings, 

including the provision of dental services. Federal law requires states to 

provide dental services at intervals that meet reasonable standards of 

dental practice, and each state determines these intervals after consulting 

with recognized dental organizations.11 Each state must also develop 

dental periodicity schedules, which contain age-specific timetables that 

identify when dental examinations should occur.

States generally provide Medicaid services through two service delivery 

and financing systems—fee-for-service and managed care. Under a fee-forservice model, states pay providers for each covered service for which 

they bill the state. Under a managed care model, states contract with 

managed care plans, such as health maintenance organizations, and 

prospectively pay the plans a fixed monthly fee, known as a capitated fee,

Medicaid Delivery and 

Financing 

 9

42 U.S.C. §1396d(a)(4)(B). 

10See 42 U.S.C. §1396d(r). 

11See 42 U.S.C. §1396d(r)(3)(A). State Medicaid programs, however, must also provide 

dental services whenever necessary to identify a suspected illness. 

Page 5 GAO-07-826T 
per Medicaid enrollee to provide or arrange for most medical services.12

This model is intended to create 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, this 

model may also create a financial incentive to underserve or deny 

beneficiaries access to certain services. 

State Medicaid agencies use a variety of delivery and payment approaches

to provide dental services under Medicaid. These include (1) paying 

managed care plans with which they have contracts to cover or arrange 

for the provision of dental services; (2) “carving out” or not requiring the 

provision of dental services from the group of services provided by 

managed care plans and paying dentists on a fee-for-service basis; or 

(3) carving out the dental services and paying specialized dental managed 

care plans to provide Medicaid dental benefits, giving the managed care 

dental plan flexibility in managing the program in exchange for a capitated 

payment to cover dental services. According to the American Dental 

Association, 18 states and the District of Columbia used one or more 

managed care dental plans to provide Medicaid dental benefits in 2004. 

Much of the Medicaid population is covered by some form of managed 

care, and consequently Medicaid managed care plans often provide 

EPSDT services. In 1991, 2.7 million beneficiaries were enrolled in some 

form of Medicaid managed care. According to CMS statistics, this number 

grew to 27 million in 2004—a tenfold increase—after the Balanced Budget 

Act of 1997 (BBA) gave states new authority to require certain Medicaid 

beneficiaries to enroll in managed care plans.13 CMS estimates that in 2004, 

 12Throughout our testimony, the term managed care refers to capitated managed care

arrangements and fee-for-service arrangements that include primary care case management

arrangements. In our earlier work on states’ approaches to monitoring children’s access to 

care, we included primary care case management arrangements as fee-for-service 

arrangements because participating providers were predominately paid on a fee-for-service 

basis. 

13The BBA allowed states to implement mandatory managed care through amendments to

their state plans, as opposed to obtaining CMS approval to waive certain federal statutory

provisions. The BBA also required the establishment of consumer protections in such areas 

as access to and quality of care for Medicaid managed care enrollees. See BBA, Pub. L. 

No. 105-33, §§ 4701, 4704-4705, 111 Stat. 251, 489-501(1997) (codified, as amended, at 

42 U.S.C. §1396u-2). 

Page 6 GAO-07-826T 
about 60 percent of Medicaid enrollees received benefits through some 

form of managed care.14

CMS requires states to report annually on the provision of EPSDT dental 

services through the CMS 416, the agency’s primary tool for overseeing the 

provision of dental services to children in state Medicaid programs. The 

CMS 416 is used to report a range of EPSDT services. CMS implemented 

the CMS 416 to comply with the Omnibus Budget Reconciliation Act of 

1989 (OBRA), which required that the Secretary of Health and Human 

Services establish state-specific annual goals for children’s participation in 

EPSDT services. OBRA and implementing regulations mandated stateestablished periodicity schedules for health, dental, vision, and hearing 

screenings and related services.15 CMS initially required states to provide 

only one type of dental-related data: the dental assessments provided. This

requirement was expanded in 1999 to collect more detailed data. 

According to CMS, the CMS 416 is used to assess the effectiveness of state 

EPSDT programs in terms of the number of children who are provided 

child health screening services, referrals for corrective treatment, and 

dental services. Child health screening information is used to calculate the 

provision of health screenings and states’ progress in meeting an 

80 percent screening participation goal. For dental services, the CMS 416 

captures, by age group, the total number of eligible children 

CMS Requires States 

to Report Annually on 

Provision of EPSDT 

Dental Services 

through the CMS 416 

• receiving any dental services, 

 14All states except Alaska, New Hampshire, and Wyoming have all or a portion of their

Medicaid population enrolled in managed care. CMS’s statistics include the Medicaid 

population enrolled in capitated plans and primary care case management models. These 

latter programs were not included as part of our 2001 and 2003 reviews related to managed 

care. In 2001, we reported that compared to primary care case management enrollment, 

about five times as many beneficiaries were enrolled in capitated managed care plans.

CMS’s statistics do not define the extent that Medicaid beneficiaries are enrolled in 

managed care that specifically cover dental services. 

15OBRA also required blood-lead assessments (for lead poisoning) appropriate for age and 

risk factors. OBRA also imposed new EPSDT reporting requirements, specifically requiring 

states to report annually to the Secretary of Health and Human Services, by age group and 

by basis of eligibility, (1) the number of children provided child health screening services, 

(2) the number of children referred for corrective treatment, (3) the number of children 

receiving dental services, and (4) the state’s results in attaining defined participation goals. 

OBRA, Pub. L. No. 101-239, § 6403, 103 Stat. at 2263 (1989) (codified, as amended, at 

42 U.S.C. §1396d(r)). 

Page 7 GAO-07-826T 
• receiving any preventive dental services (each child is counted only once 

even if more than one preventive service is provided), and 

• receiving dental treatment services (each child is counted only once even 

if more than one treatment service is provided). 

CMS officials told us in April 2007 that CMS had not established a 

participation goal or other standard that states are expected to meet 

specifically for the provision of dental services. CMS officials told us they 

calculate state and national ratios only for child health screenings and 

participation. 

The CMS 416 also requires states to report the number of individuals 

eligible for EPSDT services who are enrolled in managed care at any time 

during the reporting year.16 States are required to report information on all

EPSDT dental services provided to children, regardless of whether those 

services are provided under a fee-for-service or managed care 

arrangement. 

We have issued a number of reports that highlighted various problems in 

the delivery of EPSDT dental services and with the reporting of dental and 

other required EPSDT services provided.17 Problems we found in 2001 with 

the CMS 416 reporting included states not submitting CMS 416s on time or 

at all and states submitting reports that were not complete because of 

challenges they faced collecting accurate data. In our 2001 report, we 

recommended that CMS work with states to improve EPSDT reporting and 

the provision of EPSDT services. According to agency officials, CMS has 

taken steps to improve the CMS 416 data.18 However, state and national 

health association officials continue to cite concerns about the data’s 

completeness and sufficiency for purposes of overseeing the provision of 

dental and other required EPSDT services. 

Quality of CMS Data 

on EPSDT Dental 

Services Has 

Improved, but Data 

Have Limited 

Usefulness for 

Oversight 

 16The CMS 416 instructions for managed care include reporting any capitated 

arrangements, such as health maintenance organizations or individuals assigned to a

primary care provider or primary care case manager, regardless of whether reimbursement 

is on a fee-for-service or capitated basis (many primary care case management 

arrangements are paid on a fee-for-service basis). 

17See related GAO products listed at the end of this report. 

18Our recommendation was made to the Administrator of CMS. In the same 2001 report, we

recommended that CMS develop mechanisms to share successful state, plan, and provider 

practices with states for reaching children in Medicaid. 

Page 8 GAO-07-826T 
Some states have submitted their CMS 416s late, and others have not 

submitted the CMS 416s at all. Further, states that did submit reports may 

have provided incomplete data because of challenges in collecting the 

data. Therefore, the reports cannot be used to provide national estimates 

of the provision of dental and other required EPSDT services to children in

Medicaid or to assess every state’s progress in providing services. We first 

reported this problem in July 2001. States were required to submit their 

fiscal year 1999 CMS 416 reports by April 1, 2000. But as of January 2001, 

15 states had not submitted their reports, and another 15 states’ reports 

had been returned by CMS because they were deficient. As of April 2007, 

7 states had not submitted their CMS 416s for fiscal year 2005 (due to CMS 

by April 1, 2006), and another 2 states had submitted reports, but CMS 

considered them deficient and was working with the states to improve 

their reports. We estimate that these 9 states account for 20 percent of all 

children enrolled in Medicaid nationwide. 

Another long-standing concern with the CMS 416s submitted by states has 

been the completeness of the data on dental and other required EPSDT 

services used to compile the reports. Our July 2001 report found that 

states faced challenges collecting data on EPSDT services from both feefor-service providers and managed care plans. Under the fee-for-service 

approach, providers bill the state for each EPSDT service they deliver. 

Thus, data on EPSDT services are often collected by the state as part of 

the payment process. Most of the states we examined for our 2001 report 

had some difficulty obtaining complete and accurate data from fee-forservice providers—for example, due to coding or system issues. States 

faced more extensive problems obtaining data from capitated managed 

care plans. Unlike fee-for-service arrangements, when capitated managed 

care plans pay their participating providers a flat fee per beneficiary 

regardless of services provided, the providers do not need to submit 

information on each service provided in order to receive payment. Thus 

plans have had difficulty reporting on the provision of specific EPSDT 

services separately as required by states. 

State CMS 416s Are Not 

Always Submitted or 

Complete 

Page 9 GAO-07-826T 
CMS officials have reported taking several actions in response to our 2001 

recommendation that the Administrator of CMS improve EPSDT 

reporting.19 CMS reported, for example, that it had started assessing states’ 

CMS 416s as part of periodic focused reviews conducted by CMS regional 

offices. We reported in 2001 that CMS regional office reviews of states’ 

EPSDT programs had been helpful in highlighting policy and process 

concerns, as well as innovative state practices. Since 2002, according to 

CMS in April 2007, the agency had conducted focused reviews in 11 states. 

These reviews have evaluated, among other things, state data collection 

and reporting, including the extent to which the state develops its CMS 416 

in accordance with instructions and uses the data to measure progress and 

define areas for improvement. During these reviews, CMS found 

deficiencies, such as incorrect coding and incomplete data. CMS made 

specific recommendations to the states that would improve the reliability 

of the state-generated CMS 416 data.

Another step CMS has taken that has improved the quality and 

completeness of the data states can use to compile their 416s was to 

require states to gather encounter data from Medicaid managed care plans. 

The BBA and implementing regulations require states that contract with 

managed care plans to implement a quality assessment and improvement 

strategy that included procedures for monitoring and evaluating the 

quality and appropriateness of services provided under the contracts. 

States are also required to ensure that managed care plans maintain a 

health information system and report encounter data.20 CMS also 

developed a protocol for states’ use for validating encounter data. Officials

from several states and national health associations we contacted in 

preparation for this hearing generally said that, although problems remain, 

the quality and completeness of the underlying data, such as managed care 

encounter data, that states used to prepare the CMS 416, had improved 

since 2001. CMS officials indicated a number of efforts were underway to 

CMS Has Taken Steps to 

Improve Quality of the 

Data, but Concerns

Remain 

 19See footnote 23. 

20The BBA required states that contract with managed care plans to implement a quality 

assessment and improvement strategy that includes procedures for monitoring and

evaluating the quality and appropriateness of services provided under the contracts. 

Pub. L. No. 105-33, §4705, 111 Stat. 498-501 (1997) (codified, as amended, at 42 U.S.C.

§1396u-2). Implementing regulations published in 2002 required, for example, that states 

ensure that managed care plans maintain a health information system that collects, 

analyzes, integrates, and reports data. This health information system must collect data on 

enrollee and provider characteristics as specified by the state and on services furnished to

enrollees through an encounter data system or other methods as may be specified by the

state. See 42 C.F.R. § 438.242. 

Page 10 GAO-07-826T
evaluate other quality and outcome measures of dental services provided

to children enrolled in Medicaid. For example, one measure CMS is 

considering is the Quality Compass developed by the National Committee 

for Quality Assurance that provides plan-specific, comparative, and

descriptive information for use as a health plan benchmarking tool. 

But despite these improvements, officials from states and from national 

health associations remain concerned that the CMS 416s are unreliable for 

developing national estimates of the provision of dental and other required 

EPSDT services and therefore insufficient for oversight purposes. 

Although some officials cited some uses of the CMS 416, for example, as a 

set of basic indicators of the extent to which children use dental services 

over time, the officials cited several different problems. 

• Inconsistent data collection. Citing differences in how states collected

data on dental EPSDT services, an April 2005 National Oral Health Policy 

Center report stated that comparing the number of children receiving

services over time or examining the rate of dental utilization across states 

should be done with caution. The Center’s director provided several 

examples. For instance, some states inappropriately reported oral health 

assessments conducted in group settings, such as those performed by 

nurses or other non-dentist health providers in schools, as dental 

examinations. Likewise, some states inappropriately reported oral health 

assessments provided by hygienists as dental examinations. According to 

the director, such assessments should not be considered dental 

examinations. 

• Coding inconsistencies and anomalies. CMS 416s may not accurately

reflect the provision of dental and other required EPSDT services, 

according to an official from the National Academy for State Health Policy 

speaking about research she had done in 2002 and 2004. States have 

reported that discrepancies exist between managed care plans and state 

Medicaid agencies in the definitions of ESPDT services. Similarly, we 

reported in 2001 that states faced such issues in collecting CMS 416 data

for the range of EPSDT services that might be provided during a 

comprehensive office visit. For example, providers in Florida were 

required to use a specific EPSDT code and a claim form to document the

components of EPSDT services they provided. However, according to 

state officials, providers often chose to use other codes instead. According 

to the officials, some providers submitted claims under a comprehensive 

office-visit code for a new patient that paid a higher rate than an EPSDT 

screening, or used other comprehensive office-visit codes that required 

less documentation. Specific to dental EPSDT services, the George 

Washington University Medical Center reported in December 2003 that 

Page 11 GAO-07-826T
several Medicaid program representatives said that it was difficult to 

separate specific provided services in EPSDT data reported by managed 

care plans to determine the provision of dental screening services because

providers did not always bill for those services separately.21

• Changes in beneficiary eligibility. Gaps in children’s eligibility for 

Medicaid and movement of children between Medicaid and other health 

insurance plans may also cause problems in accurately determining the 

extent that Medicaid children received dental and other required EPSDT 

services. One official told us that interrupted Medicaid eligibility, 

accompanied by the implementation of the State Children’s Health 

Insurance Program,22 has also caused problems in the data on the number 

of children eligible for services. As children move between health 

insurance programs as their program eligibility changes, officials reported 

that it becomes difficult to maintain an accurate count of Medicaid-eligible 

children. Without an accurate count, an accurate rate of the provision of 

the dental and other required EPSDT services to eligible children cannot 

be calculated. 

The type of data collected on the CMS 416 has limited usefulness for 

purposes of oversight, as officials from states and national health 

associations have noted. Many officials from national health associations 

told us that the CMS 416 did not provide enough information to allow CMS 

to assess the effectiveness of states’ EPSDT programs. One official who 

works with many state Medicaid agencies told us that states do not 

generally use the CMS 416 to inform their monitoring and quality 

improvement activities, but instead rely on other sources of data. Some 

state officials reported using the CMS 416 data, but noted that they 

supplement the data with additional information. 

CMS 416s Have Limitations 

for Oversight Purposes 

 21See Accountability in Medicaid Managed Care: Implications for Pediatric Health Care

Quality, the George Washington University Medical Center School of Public Health and

Health Services, December 2003. Funded by the David and Lucile Packard Foundation. 

22The State Children’s Health Insurance Program (SCHIP) is a federal and state program 

that finances health insurance for children and certain adults whose incomes are low, but 

are above Medicaid’s eligibility requirements. States may implement SCHIP programs by 

expanding Medicaid programs, developing separate SCHIP programs, or a combination of 

both. If a state elects Medicaid expansion, it must provide EPSDT services to SCHIP 

beneficiaries. 

Page 12 GAO-07-826T
The limitations noted generally fell into three categories. First, while states

report the total number of children enrolled in managed care plans, dental 

and other required EPSDT services delivered to managed care enrollees 

are not reported separately from fee-for-service enrollees. Consequently, 

the data captured by the CMS 416 cannot be used to specifically monitor 

the provision of dental and other required EPSDT services under either 

fee-for-service or managed care arrangements. 

Second, the information captured by the CMS 416 is limited to summary 

statistics, such as age group, eligibility, state requirements, and services 

delivered, and does not provide information that would illuminate whether 

children have received the recommended number of visits for dental and 

other required EPSDT services. For example, a concern raised by a 

national health association official was that the CMS 416 did not provide 

information about whether eligible children had received the number of 

biannual preventive dental visits that are required by the state or 

recommended by the American Academy of Pediatric Dentistry. Because

each child is counted only once each fiscal year, regardless of the number 

of dental services or preventive dental services the child received that 

year, the data do not reflect the total number of dental appointments each 

child had in any given year. 

Third, CMS 416s do not contain information that would illuminate any of a 

number of factors that may contribute to low use of dental and other 

required EPSDT services among children enrolled in Medicaid. Our 2001 

report found that children’s low utilization of EPSDT dental and other 

services could have been attributed to program-related matters, such as 

limited provider participation in Medicaid or inadequate methods for 

informing beneficiaries of available services. In addition, some 

beneficiary-related factors, such as changing eligibility status or language 

barriers, could have limited utilization of services. Also, our 2000 report on

factors contributing to low utilization of dental services by Medicaid and 

other low-income populations found that the primary contributing factor

among low-income persons with coverage for dental services was 

difficulty finding dentists to treat them. Dentists generally cited low 

payment rates, burdensome administrative requirements, and such patient

issues as frequently missed appointments as the reasons why they did not 

treat more Medicaid patients.23 Additional, more specific information 

 23GAO/HEHS-00-149. 

Page 13 GAO-07-826T
would be needed to supplement the information collected in the CMS 416

to further understand these factors. 

Millions of low-income children enrolled in Medicaid should have access 

to important services to treat dental disease, as intended by Congress in 

mandating the coverage of and reporting on the provision of EPSDT dental 

services. Services to identify and treat tooth decay—a chronic problem 

among low-income populations and a preventable disease—are critical for

ensuring that the nation’s children and adolescents are healthy and 

prepared to learn. Unfortunately, as we reported in 2001 and 2003, data for 

gauging Medicaid’s success in providing these important services to 

enrolled children are unreliable and incomplete. CMS and states have 

taken a number of steps to improve the data, but problems persist. 

Moreover, concerns have been raised that the reported data on EPSDT 

dental services have limited utility for determining how to improve 

children’s access to these services. Strengthening the safety net for 

children in Medicaid will require additional efforts to gather more 

complete and reliable information on the delivery of dental and other 

ESPDT services. 

Mr. Chairman, this concludes my prepared remarks. I would be pleased to 

respond to any questions that you or other members of the Subcommittee 

may have at this time. 

For future contacts regarding this testimony, please contact James C. 

Cosgrove at (202) 512-7118 or at cosgrovej@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found on

the last page of this testimony. Katherine Iritani, Assistant Director; Emily 

Beller; Terry Saiki; and Timothy Walker made key contributions to this 

statement. 

Concluding 

Observations 

GAO Contacts and 

Acknowledgments 

Page 14 GAO-07-826T
Appendix I: Form 416 

Page 15 GAO-07-826T

Appendix I: CMS Form 416 
Appendix I: Form 416 

Page 16 GAO-07-826T
Page 17 GAO-07-826T

Related GAO Products 

Medicaid and SCHIP: States Use Varying Approaches to Monitor 

Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,

2003. 

Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health

Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001. 

Oral Health: Factors Contributing to Low Use of Dental Services by LowIncome Populations. GAO/HEHS-00-149. Washington, D.C.: September 11, 

2000. 

Oral Health: Dental Disease Is a Chronic Problem Among Low-Income 

Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000. 

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