DEPARTMENT OF HEALTH AND HUMAN SERVICES 

OFFICE OF INSPECTOR GENERAL 

WASHINGTON, DC 2020l 

NOV 1·2 2014 

TO: 	 Marilyn Tavenner 

Administrator 

Centers for Medicare & Medicaid Services 

FROM: Suzanne Mll.R!in 

Dep.Yty Irtspe.etor General 

for Evalliation and Inspections 

SUBJECT: 	 Recommendation Followup Memorandum Report: CMS Needs To Do More To 

Improve Medicaid Children's Utilization ofPreventive Screening Services, 

OEI-05-13-00690 

This memorandum report describes the steps that the Centers for Medicare & Medicaid Services 

(CMS) has taken to encourage children's participation in Medicaid's Early and Periodic 

Screening, Diagnostic, and Treatment (EPSDT) screenings and to ensure that providers deliver 

complete medical screenings. The Office oflnspector General (OIG) issued a report in 2010 

recommending improvements in both areas. 

SUMMARY 

Medicaid is required to provide a comprehensive and preventive child health benefit-known as 

the EPSDT benefit-for eligible children under the age of 21. Services provided under the 

EPSDT benefit are intended to screen, diagnose, and treat eligible children at early, regular 

intervals to avoid or minimize childhood illness. A 2010 OIG report found that children were 

not receiving all required EPSDT screenings. In addition, OIG also found that children who 

received medical screenings were not receiving all the components of a complete medical 

screenmg. 

We found that CMS has taken some actions toward encouraging participation in EPSDT 

screenings and toward encouraging the delivery of all components of medical screenings, but 

that it has not fully addressed OIG's recommendations. Further, we found that children's 

participation in EPSDT medical screenings remained lower than established goals. 
 

 

 

 

 

 

Page 2 – Marilyn Tavenner 

BACKGROUND 

Every State Medicaid program must offer the EPSDT benefit. In 2013, 32 million children were 

eligible for EPSDT.1

 The EPSDT services cover four health-related areas: medical, vision, 

hearing, and dental.2 

Each State establishes its own schedule for each type of screening. These schedules outline the 

frequency of each type of screening, which varies by a child’s age. For medical screenings, 

States’ schedules vary as to the number required. Typically, States require multiple medical 

screenings for infants and children ages 1 to 2. For children 3 or older, States typically require 

one medical screening every 1 to 2 years. 

Unlike the other three types of screenings, medical screenings have components specifically 

required by statute. Complete medical screenings under the EPSDT benefit must include the 

following five components: (1) a comprehensive health and developmental history (including 

assessment of both physical and mental health development); (2) a comprehensive unclothed 

physical examination; (3) appropriate immunizations; (4) appropriate laboratory tests and 

(5) health education.3 Medical screenings are often called well-child or well-care visits. 

EPSDT Reporting Requirements 

The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) strengthened EPSDT by 

establishing State reporting requirements and mandating that the Secretary of Health and Human 

Services (the Secretary) set participation goals for the States.4, 5 In response to OBRA 1989, the 

Secretary required annual reporting via the Annual EPSDT Participation Report Form CMS-416 

(which we refer to as the CMS-416) and established an overall goal of 80 percent beneficiary 

participation in EPSDT for each State annually.6 

The CMS-416 provides basic information on participation in EPSDT and is used to assess the 

effectiveness of EPSDT. States must report to CMS information about the number of children 

who (1) receive medical screenings, (2) are referred for corrective treatment, and (3) receive 

dental services. States report this information at an aggregate level and for seven different age 

groups. States are to report only complete medical screenings, i.e., those that include all 

1 CMS, Annual EPSDT Participation Report Form CMS-416 (National), 2013. Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-ScreeningDiagnostic-and-Treatment.html on June 18, 2014. 2

 Social Security Act, § 1905(r), 42 U.S.C § 1396d(r). Note that where the statute refers to “screening services” in
 

§1905(r)(1), it is describing medical screenings. For clarity’s sake, we refer to screening services as medical 

screenings. 

3 Social Security Act, § 1905(r)(1)(B), 42 U.S.C. § 1396d(r)(B).
 4

 OBRA 1989, P.L. No. 101-239, Title VI § 6403(b)(3) (adding Social Security Act, § 1902(a)(43)(D), 42 U.S.C. 

§ 1396a(a)(43)(D)).
 5

 OBRA 1989, P.L. No. 101-239, Title VI § 6403(c) (amending Social Security Act, § 1905(r), 42 U.S.C. § 1396d, 

by adding annual participation goals at the end of that section). 

6 CMS, State Medicaid Manual, Pub. No. 45, § 5360(A) and (B). Beneficiary participation in medical screenings is
 

measured using the participant ratio. This is calculated by dividing the number of eligible children receiving at least 

one medical screening by the number of eligible children who should receive at least one medical screening 

according to the screening schedules for their respective States.
 

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five components. States are not required to report any information about vision or hearing 

screenings. 

Quality Measures for Children’s Health Care 

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) included 

provisions to strengthen the quality of care provided and health outcomes of children in 

Medicaid and the Children’s Health Insurance Program (CHIP).7 CHIPRA required the 

Secretary to create a set of children’s health care quality measures (known as the Child Core Set) 

for voluntary use by State Medicaid programs and CHIP.8 States that choose to participate 

submit their results to CMS. CHIPRA also required the Secretary to annually “collect, analyze, 

and make publicly available” the information that States report regarding these measures.9 The 

Secretary prepares a report using data available to CMS.10 Of the 24 measures that were created 

for the Child Core Set, 3 measures track well-child or well-care visits for 3 different age groups. 

Previous OIG Report on EPSDT 

A May 2010 OIG report found that children were not receiving all required EPSDT screenings.11 

Specifically, 76 percent of children in nine States did not receive all required medical, vision, 

and hearing screenings.12 Forty-one percent of children did not receive any required medical 

screenings, and more than half of children did not receive any required vision or hearing 

screenings. In addition, OIG also found that children were not receiving complete medical 

screenings. Nearly 60 percent of children who received medical screenings lacked at least one 

component of a complete medical screening. 

OIG made four recommendations to CMS for increasing participation in EPSDT screenings and 

increasing the completeness of medical screenings. See Table 1 for a complete list of OIG 

recommendations and CMS’s response. 

7

 CHIPRA, P.L. No. 111-3. 

8 CHIPRA, P.L. No. 111-3, § 401(a) (adding Social Security Act § 1139A, 42 USC § 1320b-9a); 74 Fed. Reg.
 

68846 (Dec. 29, 2009). 

9

 Social Security Act § 1139(A)(c)(2), 42 USC § 1320b-9a(c)(2) (added by § 401(a) of CHIPRA). 

10 Department of Health and Human Services (HHS), Children’s Health Insurance Program Reauthorization Act
 

Annual Report on the Quality of Care for Children in Medicaid and CHIP, September 2010. Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-ofCare/Downloads/2010_Secretary_Report.pdf on August 6, 2014. 11 OIG, Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, 

OEI-05-08-00520, May 2010.
 12 This report excluded dental screenings because at the time of the review, CMS was conducting a detailed review
 

of dental screenings and services.
 

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Table 1: OIG’s previous EPSDT-related recommendations and CMS response 

OIG Recommendations CMS Response 

Require States to report vision and hearing screenings 

CMS stated that it would consider this 

recommendation, but also said that it needed 

to assess the financial impact on States and 

the feasibility of collecting the data. 

Collaborate with States and providers to develop effective strategies to 

encourage beneficiary participation in EPSDT screenings Concur 

Collaborate with States and providers to develop education and incentives 

for providers to encourage complete medical screenings Concur 

Identify and disseminate promising State practices for increasing children’s 

participation in EPSDT screenings and providers’ delivery of complete 

medical screenings 

Concur 

Source: OIG, Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, OEI-05-08-00520, May 2010. 

METHODOLOGY 

Scope 

This review focused on the actions that CMS has taken to address OIG’s recommendations for 

increasing participation in EPSDT screenings and increasing the delivery of complete medical 

screenings. We also determined whether children’s underutilization of EPSDT services 

continues to be a challenge for States. 

Data Collection and Analysis 

To determine the actions that CMS has taken to address OIG’s recommendations, we conducted 

structured interviews and reviewed related documents. Specifically, we interviewed the CMS 

staff responsible for EPSDT and four representatives from a national workgroup that CMS 

created to address EPSDT issues. We asked about the actions CMS has taken since 2010 related 

to encouraging children’s participation in EPSDT screenings and encouraging providers to 

deliver all of the components of a complete medical screenings. Our interviews occurred 

between December 2013 and February 2014. We also reviewed documents provided by CMS or 

workgroup representatives, including informational bulletins, strategy guides, Web seminars, and 

workgroup reports. 

To determine whether the underutilization of EPSDT services continues to be a challenge, we 

reviewed States’ CMS-416 reports from 2006–2013. We used 2006 data as the baseline for 

OIG’s previous review. We also reviewed the national CMS-416 reports—i.e., reports that 

aggregate all States’ data—from 2006–2013. Finally, we reviewed the 2013 Annual Report on 

the Quality of Care for Children in Medicaid and CHIP.

13 

13 The 2013 report describes outcomes for the Child Core Set for fiscal year (FY) 2012. See HHS, 2013 Annual 

Report on the Quality of Care for Children in Medicaid and CHIP, September 2013. Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2013-AnnSec-Rept.pdf on June 18, 2014. 

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Standards 

This study was conducted in accordance with the Quality Standards for Inspection and 

Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 

RESULTS 

CMS Has Taken Actions Toward Encouraging Participation in EPSDT Screenings and 

Encouraging the Delivery of Complete Medical Screenings 

After the May 2010 OIG report, CMS convened a National EPSDT Improvement Workgroup in 

December 2010. CMS’s goals for this workgroup were to identify the most critical areas for 

improvement in EPSDT, discuss steps to increase the number of children who access EPSDT 

services, and improve data reporting. The workgroup included State representatives, children’s 

health providers, consumer representatives, and other stakeholders with expertise in Medicaid, 

children’s health, and data analysis. 

CMS hired a contractor in September 2011 to help the workgroup gather data about beneficiary 

participation in EPSDT screenings and the delivery of complete medical screenings. The 

contractor interviewed eight States and the District of Columbia about improving beneficiary 

participation in screenings and the delivery of complete medical screenings.14 For beneficiary 

participation in screenings, the contractor asked about States’ promising practices, challenges, 

and lessons learned. For delivery of complete medical screenings, the contractor asked States for 

promising practices to improve the delivery of complete medical screenings. The contractor also 

held a focus group with pediatricians to gain their perspective on the delivery of complete 

medical screenings and any barriers they face to doing so. 

CMS has disseminated strategies aimed at improving participation in EPSDT screenings. In 

February 2014, CMS released a strategy guide titled Paving the Road to Good Health: 

Strategies for Increasing Medicaid Adolescent Well-Care Visits.

15 CMS designed this guide 

primarily for State Medicaid agencies. The guide presents six strategies for promoting 

adolescent well-care visits (i.e., medical screenings). The guide also provides examples of State 

and program models that use the strategies presented (i.e., best practices). The second strategy 

offered in the guide—to incentivize providers, adolescents, and parents to encourage preventive 

care—closely aligns with a suggestion made in OIG’s 2010 EPSDT report. 

In addition, CMS funded a new EPSDT resource page that was launched on the contractor’s Web 

site in December 2013. The resource page provides State policymakers, Medicaid officials, and 

other stakeholders with State-specific information on a variety of EPSDT-related topics, 

including State initiatives to improve access to required screenings and treatment services for 

children. As of August 2014, this Web site did not include information from all States. Since 

December 2013, CMS and its contractor have held a series of Web seminars and roundtables to 

14 The contractor interviewed these eight States: Connecticut, Illinois, Iowa, Mississippi, Nevada, New Mexico,
 

New York, and South Dakota.
 15 CMS, Paving the Road to Good Health: Strategies for Increasing Medicaid Adolescent Well-Care Visits, 

February 2014. Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Benefits/Downloads/Paving-the-Road-to-Good-Health.pdf on June 18, 2014. 

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promote the resource page, provide technical assistance, and discuss various EPSDT-related 

topics. 

CMS has made efforts to improve the delivery of some of the components of complete medical 

screenings. Since January 2013, CMS has participated in an initiative named Birth to 5: Watch 

Me Thrive!, aimed at encouraging developmental and behavioral screenings in children from 

birth to age 5. Such screenings are part of a comprehensive health and developmental history, 

which is one component of a complete medical screening. The initiative is a coordinated effort 

across seven agencies within HHS and one agency within the Department of Education to 

encourage support for children, families, and their providers. CMS had a lead role in developing 

the screening guide for primary care providers. This initiative launched publicly in March 2014. 

In addition, CMS disseminated in March 2013 an informational bulletin aimed at increasing 

mental health screenings. Like developmental and behavioral screenings, mental health 

screenings are part of a comprehensive health and developmental history. Specifically, the 

March 2013 bulletin addressed the prevention and early identification of mental health and 

substance use disorders.16 CMS developed this bulletin to inform States about resources 

available to help them meet the needs of children under EPSDT, specifically related to services 

for such disorders. 

Lastly, CMS disseminated in June 2014 an EPSDT guide for States—Coverage in the Medicaid 

Benefit for Children and Adolescents—that is intended to help States, health care providers, and 

others to understand the scope of services that are covered under EPSDT.17 The guide did not 

establish new EPSDT policy but instead compiled various CMS-issued EPSDT guidance into 

one document. Within the guide, CMS reiterates the five components of a medical screening and 

provides an example of a State payment methodology that is intended to encourage providers to 

perform all five components. 

CMS has assessed the feasibility of requiring States to report vision and hearing screenings. 

CMS staff reported making multiple efforts to learn about the feasibility of requiring States to 

report vision and hearing screenings. For instance, CMS’s contractor completed a feasibility 

study to determine whether collecting data on vision and hearing screenings was possible. From 

2010-2013, CMS staff also participated in a Federal Interagency Task Force on Children’s 

Vision and Eye Health. As part of the task force, CMS also worked with States to assess 

whether it would be feasible for States to report vision screenings. 

The contractor’s feasibility study found that requiring States to report these screenings would not 

be feasible. The study found that such a requirement would burden States and that data might 

not be available. Separately, CMS staff indicated that one reason data might not be available is 

16 CMS, CMCS [Center for Medicaid & CHIP Services] Informational Bulletin: Prevention and Early 

Identification of Mental Health and Substance Use Conditions, March 27, 2013. Accessed at 

http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-03-27-2013.pdf on June 18, 2014. 17 CMS, EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents, June 2014. 

Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/ 

EPSDT_Coverage_Guide.pdf on October 1, 2014. 

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that there are no standard billing codes for vision and hearing screenings for children under 

age 3. Without standard billing codes, States may be unable to count the number of screenings 

performed. Additionally, CMS staff indicated that another reason for the lack of data is that 

these screenings may occur in schools and therefore it is difficult to document their occurrence. 

Although the contractor’s study raised concerns as to the feasibility of reporting vision and 

hearing screenings, CMS has stated that it has plans to continue stressing the importance of these 

screenings. In August 2014, CMS said that it was planning to create additional Web pages 

focusing on vision and hearing screenings and that these pages would emphasize the importance 

of collecting data on these screenings and reporting the data to CMS. 

Further, CMS stated that it is working with stakeholders on developing a measure regarding the 

quality of children’s vision screenings. 

Children’s Participation in EPSDT Medical Screenings Remained Lower Than Established 

Goals 

According to the national FY 2013 CMS-416 report, overall, 63 percent of beneficiaries received 

EPSDT screenings during the FY.18 This is below the Secretary’s goal of 80 percent 

participation. In fact, only two States met the Secretary’s goal in 2013. 

The underutilization of medical screenings is an ongoing concern, despite a slight increase in 

participation between 2006 and 2013. Since 2006, the States, overall, have not met the 

Secretary’s goal. Only 8 States had 80 percent participation at least once between 2006 and 

2013. The national participation ratio improved from 56 percent in 2006 to 63 percent in 2013 

with most of the gain occurring between 2006 and 2008. Figure 1 demonstrates the trend in 

national EPSDT participation from 2006 to 2013. 

18 As of June 2014, CMS-416 data were not available for eight States: Arizona, Connecticut, Florida, Maryland, 

Maine, Missouri, New Hampshire, and North Carolina. 

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Figure 1: CMS-416 National Participation Ratios, 2006-2013 

0% 

10% 

20% 

30% 

40% 

50% 

60% 

70% 

80% 

90% 

2006 2007 2008 2009 2010 2011 2012 2013 

National 

Participation 

Ratio 

Goal 

Note: As of June 2014, data from 2012 were missing from Connecticut and data from 2013 were missing from Arizona, Connecticut, Florida, Maryland, 

Maine, Missouri, New Hampshire, and North Carolina. 

Source: OIG analysis of CMS-416 reports, 2006–2013. 

Three measures from the Child Core Set corroborate the CMS-416 data showing underutilization 

of well-child visits. Of these three measures, two—one for well-child visits during a child’s first 

15 months, and the other for well-child visits from ages 3-6 years—closely align with the overall 

participation ratio.19 These age groups demonstrated 60 and 66 percent participation, 

respectively. Each measure had more than 40 States reporting. The third measure—for 

adolescent well-care (12-21 years)—demonstrated only 44 percent participation, with more than 

40 States reporting.20 

CONCLUSION 

Since the 2010 OIG report, CMS has taken a number of steps to encourage participation in 

EPSDT screenings and to encourage the completeness of medical screenings. CMS has 

collaborated with States and providers and promoted adolescent well-care visits. It has also 

promoted mental health screenings for all children and behavioral and developmental screenings 

for children from birth to age 5. Finally, CMS discussed an ongoing effort to stress the 

importance of collecting data on vision and hearing screenings and reporting these data to CMS. 

These efforts are in line with OIG’s recommendations. 

19 The measure of well-child visits for the first 15 months is defined as the percentage of children with six or more 

visits. The measure of well-child visits for children aged 3–6 years is defined as the percentage with one or more
 

visits. 

20 The measure of adolescent well-care is defined as the percentage of children with one or more visits. 

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In general, CMS’s efforts to encourage participation in EPSDT screenings for particular age 

groups and to encourage the mental health assessment—a component of a comprehensive health 

and developmental history—are promising, but they do not fully address all OIG 

recommendations. We found no evidence that CMS has worked to encourage beneficiary 

participation for children of all ages, specifically children under age 12. Additionally, CMS has 

done very little to encourage providers to complete all five components of a complete medical 

screening. Further, at the time of our review it was too soon to know whether CMS’s efforts 

would correspond to increases in beneficiary participation. 

Although CMS’s contractor found that it is not feasible for States to report vision and hearing 

screenings, CMS has indicated ongoing activities—i.e., additional Web pages and a possible 

measure vision screenings—that it plans to pursue through 2015. With regard to the possible 

measure for vision screenings, CMS has not indicated the mechanism (e.g., the CMS-416 report) 

through which this would be reported or whether States would be required to report it. Lastly, 

CMS has not indicated any effort to create a measure regarding hearing screenings. 

Given that CMS has not yet fully addressed all OIG recommendations, coupled with evidence 

that children continue to receive fewer medical screenings than required, CMS must continue to 

focus on EPSDT screenings. Although a successful EPSDT benefit involves multiple actors— 

such as physicians, parents, and States—doing their parts, CMS’s interactions with States to 

promote EPSDT screenings remain vital to EPSDT’s success. Specifically, OIG considers all 

four of the recommendations from the 2010 report to remain open. We recommended that CMS: 

(1) require States to report vision and hearing screenings, (2) collaborate with States and 

providers to develop effective strategies to encourage beneficiary participation in EPSDT 

screenings, (3) collaborate with States and providers to develop education and incentives for 

providers to encourage complete medical screenings, and (4) identify and disseminate promising 

State practices for increasing children’s participation in EPSDT screenings and increasing 

providers’ delivery of complete medical screenings. 

This report contains no new recommendations and is being issued directly in final form as a 

result. If you have comments or questions about this report, please provide them within 60 days. 

Please refer to report number OEI-05-13-00690 in all correspondence. 

CMS Needs To Do More To Improve Children’s Utilization of Preventive Screening Services (OEI-05-13-00690)