GAO 

United States Government Accountability Office

Report to the Chairman, Committee on 

Finance, U.S. Senate 

MEDICAID 

PREVENTIVE 

SERVICES 

Concerted Efforts 

Needed to Ensure 

Beneficiaries Receive 

Services 

August 2009 

GAO-09-578 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

August 2009

MEDICAID PREVENTIVE SERVICES

Concerted Efforts Needed to Ensure Beneficiaries

Receive Services

Highlights of GAO-09-578, a report to the 

Chairman, Committee on Finance, U.S. 

Senate 

Medicaid, a federal-state program 

that finances health care for certain 

low-income populations, can play a 

critical role in the provision of 

preventive services, which help 

prevent, diagnose, and manage 

health conditions. GAO examined 

available data to assess (1) the 

extent to which Medicaid children 

and adults have certain health 

conditions and receive certain 

preventive services, (2) for 

Medicaid children, state monitoring 

and promotion of the provision of 

preventive services, (3) for 

Medicaid adults, state coverage of 

preventive services, and (4) federal 

oversight by the Centers for 

Medicare & Medicaid Services 

(CMS). GAO analyzed data from 

nationally representative surveys: 

the National Health and Nutrition 

Examination Survey (NHANES), 

which includes physical 

examinations of participants, and 

the Medical Expenditure Panel 

Survey (MEPS). GAO also surveyed 

state Medicaid directors and 

interviewed federal officials. 

What GAO Recommends

Nationally representative data suggest that a large proportion of children and 

adults in Medicaid have certain health conditions, particularly obesity, that 

can be identified or managed by preventive services, and adults’ receipt of 

preventive services varies widely. For Medicaid children, NHANES data from 

1999 through 2006 suggest that 18 percent of children aged 2 through 20 were 

obese, 4 percent of children aged 8 through 20 had high blood pressure, and 

10 percent of children aged 6 through 20 had high cholesterol. Furthermore, 

MEPS data from 2003 through 2006 suggest that many Medicaid children were 

not receiving well-child check ups. For Medicaid adults aged 21 through 64, 

NHANES data suggest that more than half were obese or had diabetes, high 

cholesterol, high blood pressure, or a combination. MEPS data suggest that 

receipt of preventive services varied widely by service: receipt of some 

services, such as blood pressure tests, was high, but receipt of several other 

services was low. MEPS data also suggest that a lower percentage of Medicaid 

adults received preventive services compared to privately insured adults. 

For children in Medicaid, who generally are entitled to coverage of 

comprehensive health screenings, including well-child check ups, as part of 

the federally required EPSDT benefit, most but not all states reported to GAO 

that they monitored or set goals related to children’s utilization of preventive 

services and had undertaken initiatives to promote their provision. Nine states 

reported that they did not monitor children’s utilization of specific preventive 

services. Forty-seven states reported having multiple initiatives to improve the 

provision of preventive services to children. 

For adults in Medicaid, for whom states’ Medicaid coverage of preventive 

services is generally not required, most states reported to GAO that they 

covered most but not all of eight recommended preventive services that GAO 

reviewed. Nearly all state Medicaid programs, 49 and 48 respectively, reported 

covering cervical cancer screening and mammography, and three-quarters or 

more states reported covering four other preventive services. Two additional 

recommended services—intensive counseling to address obesity or to address 

high cholesterol—were reported as covered by fewer than one-third of states. 

For children in Medicaid, CMS oversees the provision of preventive services 

through state EPSDT reports and reviews of EPSDT programs, but gaps in 

oversight remain; for adults, oversight is more limited. For children, state 

reports showed that, on average, 58 percent of Medicaid children who were 

eligible for an EPSDT service in 2007 received one; far below the federal goal 

of 80 percent. CMS reviewed only 11 state EPSDT programs between April 

2001 and June 2009. Few states reporting low rates of service provision were 

reviewed. CMS guidance to states may also have gaps: a 2006 study raised 

concerns that providers may not be aware of coverage of obesity-related 

services for Medicaid children. CMS has recognized the need for but has not 

yet begun drafting guidance on such coverage. For adults, CMS has provided 

some related guidance to states, but not on the reviewed preventive services. 

GAO recommends that CMS 

(1) ensure that state Early and 

Periodic Screening, Diagnostic, and 

Treatment (EPSDT) programs are 

regularly reviewed, and 

(2) expedite its efforts to provide 

guidance to states on coverage of 

obesity-related services for 

Medicaid children, and consider 

the need to provide similar 

guidance regarding coverage of 

obesity screening and counseling, 

and other recommended services, 

for adults. CMS concurred with 

GAO’s recommendations. 

View GAO-09-578 or key components.

For more information, contact Alicia Puente 

Cackley at (202) 512-7114 or 

cackleya@gao.gov. 
Page i GAO-09-578 

Contents 

Letter 1

Results in Brief 8 

Background 11 

National Surveys Show That Certain Health Conditions Are 

Prevalent among Children and Adults in Medicaid, and Receipt 

of Recommended Preventive Services Varies Widely 15 

For Children in Medicaid, Most State Medicaid Programs Reported 

Monitoring and Promoting the Provision of Preventive Services 23 

For Adults, Most State Medicaid Programs Reported Covering 

Some but Not All Recommended Preventive Services 27 

CMS Oversight of the Provision of Preventive Services Primarily 

Focuses on Children’s Services, and Gaps in Oversight Remain 29 

Conclusions 35 

Recommendations for Executive Action 36 

Agency Comments 36 

Appendix I NHANES Analysis 38 

Appendix II MEPS and NHIS Analyses 47 

Appendix III State Medicaid Director Survey Results 56 

Appendix IV Comments from the Department of Health and 

Human Services 68 

Appendix V GAO Contact and Staff Acknowledgments 72 

Related GAO Products 73 

 Medicaid Preventive Services 
Tables 

Table 1: Estimated Percentage of Children Aged 2 through 20 with 

Certain Health Conditions, by Health Insurance Status 42 

Table 2: Estimated Percentage of Obese Children Aged 2 through 

20 Who Had Not Been Previously Diagnosed as 

Overweight, by Health Insurance Status 44 

Table 3: Estimated Percentage of Adults Aged 21 through 64 with 

Certain Health Conditions, by Health Insurance Status 45 

Table 4: Of Adults Aged 21 through 64 Found to Have Health 

Conditions: Estimated Percentage Who Had Not Been 

Diagnosed by a Health Care Professional, by Health 

Insurance Status 46 

Table 5: Estimated Percentage of Children Who Received a WellChild Check Up During a 2-Year Period, by Health 

Insurance Status 52 

Table 6: Estimated Percentage of Children Who Received Certain 

Preventive Services, by Health Insurance Status 53 

Table 7: Estimated Percentage of Adults Who Received Certain 

Preventive Services, by Health Insurance Status 54 

Table 8: Number of State Medicaid Programs Reporting Covering 

Certain Preventive Services 57 

Table 9: Number of State Medicaid Programs Reporting Covering 

Services to Manage Identified Health Conditions 58 

Table 10: Information State Medicaid Programs Reported 

Reviewing to Monitor Utilization of Preventive Services 58 

Table 11: Number of State Medicaid Programs Reporting 

Monitoring Utilization of Specific Services for Adults and 

Children in Medicaid, by Service Delivery Model 59 

Table 12: Reasons Reported by State Medicaid Programs for Not 

Monitoring Utilization of Covered Preventive Services for 

Children, Beyond Federally Required Monitoring 60 

Table 13: Reasons Reported by State Medicaid Programs for Not 

Monitoring Utilization of Covered Preventive Services for 

Adults 60 

Table 14: Number of State Medicaid Programs Reporting 

Utilization Goals for Certain Preventive Services for 

Children, and Whether Goals Were Being Met, by Service 

Delivery Model 61 

Table 15: Number of State Medicaid Programs Reporting 

Utilization Goals for Certain Preventive Services for 

Adults, and Whether Goals Were Being Met, by Service 

Delivery Model 62 

Page ii GAO-09-578 Medicaid Preventive Services
Table 16: Number of State Medicaid Programs Reporting Certain 

Barriers to Meeting Utilization Goals 63 

Table 17: Initiatives State Medicaid Programs Reported Having 

Implemented that Pertain to Either Managed Care or FeeFor-Service Delivery Systems 64 

Table 18: Number of State Medicaid Programs Reporting that 

Implemented Initiatives Had or Had Not Improved 

Provider Participation or Provision of Preventive Services 65 

Table 19: Number of State Medicaid Programs Reporting Certain 

Initiatives Designed to Increase Medicaid Children’s and 

Adults’ Use of Preventive Services Since 2004, by Service 

Delivery Model 66 

Table 20: Number of State Medicaid Programs Reporting Certain 

Efforts Geared Specifically Toward Diagnosing and 

Treating Obesity, and Complications Related to Obesity, 

by Service Delivery Model 67 

Figures 

Figure 1: Estimated Percentage of Children in Medicaid Aged 2 

through 20 Who Were Obese Compared to the National 

Goal for 2010 16 

Figure 2: Estimated Percentage of Children in Medicaid Who Did 

and Did Not Receive a Well-Child Check Up during a 2-

Year Period, by Age 18 

Figure 3: Estimated Prevalence of Certain Health Conditions 

among Adults Aged 21 through 64, by Health Insurance 

Status 20 

Figure 4: Estimated Percentage of Adults Aged 21 through 64 in 

Medicaid with Health Conditions Who Reported Their 

Conditions Had or Had Not Been Diagnosed 21 

Figure 5: Estimated Receipt of Certain Recommended Preventive 

Services among Adults in Medicaid 22 

Figure 6: Number of State Medicaid Programs Reporting that They 

Monitored Children’s Utilization of Specific Preventive 

Services 24 

Figure 7: Number of State Medicaid Programs that Reported 

Covering Certain Recommended Preventive Services for 

Adults and Health Risk Assessments or Well-Adult Check 

Ups 28 

Figure 8: Variation in State Medicaid Programs’ Fiscal Year 2007 

Participant Ratios 31 

Page iii GAO-09-578 Medicaid Preventive Services
Abbreviations 

ACIP Advisory Committee on Immunization Practices 

AHRQ Agency for Healthcare Research and Quality 

BMI body mass index 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare & Medicaid Services 

EPSDT Early and Periodic Screening, Diagnostic, and Treatment 

FFS fee-for-service 

HHS Department of Health and Human Services 

MCO managed care organization 

MEPS Medical Expenditure Panel Survey 

mg/dL milligrams per deciliter 

mmHg millimeters of mercury 

NHANES National Health and Nutrition Examination Survey 

NHIS National Health Interview Survey 

OBRA 89 Omnibus Budget Reconciliation Act of 1989 

CHIP State Children’s Health Insurance Program 

SMDL State Medicaid Director Letter 

USPSTF United States Preventive Services Task Force 

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Page iv GAO-09-578 Medicaid Preventive Services
Page 1 GAO-09-578 

 

United States Government Accountability Office

Washington, DC 20548 

 

August 14, 2009 

The Honorable Max Baucus 

Chairman 

Committee on Finance 

United States Senate 

Dear Mr. Chairman: 

As one of the nation’s largest health insurers, Medicaid—a joint federal 

and state program that finances health care coverage for certain lowincome individuals and families—can play a critical role in helping ensure 

that the nation’s children and adults receive preventive services. 

Preventive services can prevent health conditions from occurring, or 

screen for or diagnose existing health conditions. For example, body mass 

index (BMI) measurements are used to screen for obesity, and 

mammograms for breast cancer. Preventive services also include services 

to manage diagnosed health conditions and prevent certain conditions 

from worsening, for example, weight-reduction counseling to help manage 

obesity. 

Medicaid, overseen at the federal level by the Centers for Medicare & 

Medicaid Services (CMS), an agency within the Department of Health and 

Human Services (HHS), provided health coverage for over 60 million lowincome individuals in 2008. CMS oversees state Medicaid programs in part 

by providing guidance on federal requirements, approving state Medicaid 

plans, and reviewing program operations. For managed care, whereby 

states contract with managed care organizations to serve Medicaid 

beneficiaries, CMS’s oversight includes reviewing and approving states’ 

managed care contracts.1

 For eligible children in Medicaid under age 21, 

preventive services are generally addressed through Medicaid’s Early and 

Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Under 

federal law, the EPSDT benefit generally entitles children in Medicaid to 

1

States may provide Medicaid services, including preventive services, to children and adults 

through different service delivery and financing systems such as fee-for-service and 

managed care. In a traditional fee-for-service delivery system, the Medicaid program 

reimburses providers directly and on a retrospective basis for each service delivered. 

Under a capitated managed care model, states contract with a managed care organization 

and prospectively pay the organization a fixed monthly fee per patient to provide or 

arrange for most health services. Managed care delivery systems are subject to specific 

federal requirements related to Medicaid enrollees and services. 

 Medicaid Preventive Services 
 

receive coverage of periodic screening services—often termed well-child 

check ups—that include a comprehensive health and developmental 

history, a comprehensive physical exam, appropriate immunizations, 

laboratory tests, and health education.2

 For adults aged 21 and older in 

Medicaid, coverage of preventive services is generally not required.3

Ensuring that children and adults in the United States receive preventive 

services is a federal priority. For example, CMS has a yearly goal that each 

state provide EPSDT well-child check ups to at least 80 percent of the 

Medicaid children in the state who should receive one, based on the state’s 

periodicity schedule.4

 As part of its Healthy People 2010 initiative, HHS has 

also established health goals for the nation, including increasing the 

proportion of children and adults who receive several types of preventive 

services, for example, cholesterol tests. In addition, HHS sponsors the 

United States Preventive Services Task Force (USPSTF), which evaluates 

a broad range of preventive services for specific age and risk groups and 

makes recommendations that those that are clinically effective should be 

 

2

For purposes of this report we refer to these EPSDT screening services as an EPSDT wellchild check up. States are also required to cover other EPSDT services, defined as vision 

services, dental services, hearing services, and services necessary to correct or improve 

health conditions discovered through screenings, regardless of whether these services are 

typically covered by the state’s Medicaid plan for other beneficiaries. 42 U.S.C. § 1396d(r). 

In this report, we collectively refer to EPSDT well-child check ups and these other services 

as EPSDT services. In 2001, we found problems with children not receiving EPSDT 

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

Screening Services, GAO-01-749 (Washington, D.C.: July 13, 2001). A list of related GAO 

products can be found at the end of this report. 

3

Although states are generally not required to cover preventive services for adult Medicaid 

beneficiaries, according to CMS officials there are circumstances when states must cover 

medically necessary preventive services for adult Medicaid beneficiaries who have been 

diagnosed with or show symptoms of a disease. 

4

State Medicaid programs must provide EPSDT services at intervals that meet reasonable 

standards of medical and dental practice as determined by the state and as medically 

necessary. Accordingly, states adopt their own periodicity schedules, which include agespecific timetables that identify when EPSDT well-child check ups and other services 

should occur. CMS’s 80 percent goal includes only children who should receive an initial or 

periodic screening service, termed well-child check up for purposes of this report, in a 

given year; therefore, it incorporates the fact that the interval of well-child check ups for 

some children may be greater than a year. 

Page 2 GAO-09-578 Medicaid Preventive Services
 

incorporated routinely into primary health care for specific populations.5

Certain preventive services, including USPSTF-recommended services—

such as colorectal cancer screening, mammograms, and diabetes 

screening—are covered by the Medicare program, the federal health 

program for individuals age 65 and over.6

Because of the importance of preventive services and the role Medicaid 

can play in providing them, you asked for information about preventive 

services for children and adults in the Medicaid program. This report 

examines 

1. the extent to which children and adults in Medicaid have certain health 

conditions that can be identified or managed by preventive services, 

and the extent to which they receive such services; 

2. for children in Medicaid, for whom coverage of EPSDT services is 

generally required, the extent to which state Medicaid programs 

monitor and promote the provision of preventive services; 

3. for adults in Medicaid, for whom coverage of preventive services is 

generally not required, the extent to which state Medicaid programs 

cover recommended preventive services; and 

4. the extent to which CMS oversees the provision of preventive services 

for children and adults in Medicaid. 

 

5

The USPSTF considers evidence from studies that assess the effects of preventive services 

on health outcomes, and recommends that health care providers offer or provide services 

for which (1) there is high certainty that the net benefit is substantial (“A” 

recommendation) or (2) there is high certainty that the net benefit is moderate or there is 

moderate certainty that the net benefit is moderate to substantial (“B” recommendation). 

An analysis guided by the National Commission on Prevention Priorities of the cost 

effectiveness of 25 USPSTF recommended preventive services concluded that many are 

cost effective, and some are cost saving. See Michael V. Maciosek, Ashley B. Coffield, 

Nichol M. Edwards, Thomas J. Flottemesch, Michael J. Goodman, Leif I. Solberg, “Priorities 

among Effective Clinical Preventive Services: Results of a Systematic Review and 

Analysis,” American Journal of Preventive Medicine, vol. 31, no. 1 (2006). 

6

Medicare covers defined preventive services such as colorectal cancer screening tests, 

screening mammography, and diabetes screening tests, and more recently, the Medicare 

Improvements for Patients and Providers Act of 2008 authorized the Secretary of HHS to 

expand Medicare coverage to additional preventive services recommended by the USPSTF, 

under certain circumstances. Pub. L. No. 110-275, § 101, 122 Stat. 2494, 2496-97 (2008) 

(codified, as amended, at 42 U.S.C. § 1395x(s)(2)(BB)). 

Page 3 GAO-09-578 Medicaid Preventive Services
 

To provide information on health conditions and receipt of certain 

preventive services, we analyzed data from different nationally 

representative surveys that focus on each respective area. 

• To examine health conditions, we analyzed data from HHS’s National 

Health and Nutrition Examination Survey (NHANES), conducted by the 

Centers for Disease Control and Prevention (CDC). NHANES directly 

measures health conditions through physical examinations and laboratory 

tests, and interviews participants about topics such as insurance coverage 

and prior diagnoses of health conditions. We used data from 1999 through 

2006 (the most recent available). We grouped NHANES data from surveys 

conducted from 1999 through 2006 in order to include a sufficient number 

of survey participants to reliably assess health conditions in the Medicaid 

population. For children,7

 we estimated the prevalence of certain health 

conditions that can be identified or managed as part of EPSDT services 

and were prevalent enough to examine reliably: high blood pressure, high 

cholesterol, and obesity.8

 For adults,9 we estimated the prevalence of 

certain health conditions that can be identified or managed by USPSTF 

 

7

Our figures for Medicaid children include children enrolled in the State Children’s Health 

Insurance Program (CHIP), because NHANES data from 1999 through 2004 contain a single 

category that combines Medicaid and CHIP beneficiaries (NHANES data for 2005 through 

2006 contain separate categories for Medicaid and CHIP beneficiaries, but we grouped 

them for comparability with the earlier survey years). CHIP provides health care coverage 

to children in low-income families who are not eligible for traditional Medicaid programs. 

States may implement CHIP programs by expanding their existing Medicaid programs, 

establishing separate child health programs, or a combination of both. States with Medicaid 

expansion programs must provide to CHIP beneficiaries all benefits that are available to 

the traditional Medicaid population. CHIP enrollment in fiscal year 2006 was 6.6 million 

children. Of the total Medicaid and CHIP population of children, about 16 percent were 

enrolled in CHIP during the 1999 through 2006 period. 

8

Diabetes was not prevalent enough among children to examine reliably using NHANES 

data. We excluded children’s oral health from our scope because of recent related work; 

see Medicaid: Extent of Dental Disease in Children Has Not Decreased, and Millions Are 

Estimated to Have Untreated Tooth Decay, GAO-08-1121 (Washington, D.C.: September 23, 

2008). Our scope also excluded certain immunizations, blood lead levels, and tobacco 

exposure and use. 

9

Our figures for Medicaid adults could also include some adults enrolled in CHIP (in 2007, 

GAO reported that in June 2006, about 349,000 adults were enrolled in CHIP; see State 

Children’s Health Insurance Program: Program Structure, Enrollment and Expenditure 

Experiences, and Outreach Approaches for States That Cover Adults, GAO-08-50 

(Washington, D.C.: November 26, 2007)). Our figures for adults do not include adults 

enrolled in both Medicare and Medicaid, and are limited to adults aged 21 through 64. 

Page 4 GAO-09-578 Medicaid Preventive Services
 

recommended preventive services10 and were prevalent enough to examine 

reliably: high blood pressure, high cholesterol, obesity, and diabetes.11 For 

both adults and children, we analyzed data for the Medicaid and privately 

insured populations. 

• To examine receipt of services, we analyzed available data from the 

Medical Expenditure Panel Survey (MEPS), administered by HHS’s Agency 

for Healthcare Research and Quality (AHRQ), which interviews 

participants about reasons for medical visits and use of specific health 

care services. We used data from 2003 through 2006 (the most recent 

available).12 For children,13 we used available MEPS data from interviews 

with a parent or other adult in the child’s household to estimate receipt of 

well-child check ups and certain other services that could occur during 

EPSDT well-child check ups: blood pressure tests, weight and height 

measurement, and diet or exercise counseling. For adults, we used MEPS 

 

10The USPSTF assesses scientific evidence regarding the effectiveness of a broad range of 

preventive services to address clinical categories such as cancer, heart and vascular 

diseases, infectious diseases, injury and violence, and metabolic, nutritional, and endocrine 

conditions. USPSTF recommendations for adult preventive services that were in effect as 

of March 2009 included blood pressure tests for all adults; cholesterol tests for men aged 35 

and older and adults aged 20 and older with risk factors for coronary heart disease; obesity 

screening for all adults, including intensive counseling and behavioral interventions to 

promote sustained weight loss for obese adults; intensive diet counseling for adults with 

high cholesterol; diabetes screening for adults with high blood pressure; cervical cancer 

screening for sexually active women; mammography for women aged 40 and older; and 

colorectal cancer screening for adults aged 50 through 75. The USPSTF also recognizes the 

importance of immunizations in primary disease prevention, but does not review new 

evidence on immunizations in order not to duplicate the work of the CDC’s Advisory 

Committee on Immunization Practices (ACIP). ACIP recommends influenza immunization 

for adults aged 50 and older. For purposes of this report, the term recommended 

preventive services refers to USPSTF and ACIP recommended services. 

11Other conditions, such as sexually transmitted diseases, were not prevalent enough to 

examine reliably among adults in Medicaid using NHANES data. 

12The 2003 through 2006 period for the MEPS data differed from the 1999 through 2006 

period for the NHANES data. NHANES includes a smaller number of participants than 

MEPS, and it was necessary to group data from NHANES surveys conducted during 1999 

through 2006 in order to include a sufficient number of survey participants to assess 

reliably health conditions in the Medicaid population. It was not possible to use the same 

time frame for the MEPS analysis, because MEPS did not include certain questions we 

examined prior to 2001. 

13Similar to NHANES, the Medicaid category in the MEPS data included children enrolled in 

CHIP. Of the total Medicaid and CHIP population, about 18 percent were enrolled in CHIP 

during the 2003 through 2006 period. 

Page 5 GAO-09-578 Medicaid Preventive Services
 

data to estimate receipt of seven recommended preventive services:14

blood pressure tests, cholesterol tests, cervical cancer screening,15

mammography, colorectal cancer screening, diet and exercise counseling, 

and influenza immunizations.16 In addition, to estimate receipt of diabetes 

screening, a recommended preventive service for which MEPS data were 

not available, we analyzed data from a related HHS survey, the 2006 

National Health Interview Survey (NHIS).17 For both adults and children, 

we analyzed data for the Medicaid and privately insured populations.18

To assess state Medicaid programs’ monitoring and promotion of the 

provision of preventive services to children, we surveyed 51 state 

Medicaid directors (in 50 states and the District of Columbia).19 The survey 

asked about states’ monitoring of children’s utilization of specific 

preventive services in their fee-for-service and managed care programs, 

goals for children’s utilization of specific services and whether or not they 

were meeting these goals, and recent initiatives states had undertaken to 

promote preventive services. All 51 state Medicaid directors responded to 

the survey. 

 

14USPSTF and ACIP recommendations for the services we analyzed were in place as of the 

survey years used in our MEPS analysis. We limited our analyses to the age and risk groups 

that USPSTF and ACIP recommended should receive the services. 

15In this report, we use the term cervical cancer screening to refer to a Pap test, also called 

a Pap smear. 

16Our scope did not include smoking cessation services. Some of the questions we analyzed 

did not fully measure USPSTF-recommended preventive services, but provide information 

related to them. For example, the USPSTF recommends that obese adults receive intensive 

obesity counseling, whereas MEPS participants were asked if they received any type of diet 

or exercise advice from a doctor or health care professional. See appendix II for further 

discussion of the extent to which the available measures capture the USPSTF 

recommendations. 

17MEPS interviews from 2003 through 2006 included a section on diabetes, but did not 

include a question on screening tests for diabetes. The USPSTF recommendation for 

diabetes testing was in place as of 2003. 

18Individuals were categorized based on their health insurance status at one point in time, 

and health insurance status was not necessarily constant during the time periods over 

which we examined their receipt of services. Our analysis shows whether individuals 

enrolled in Medicaid and private insurance at a given point of time were in need of 

preventive services. When we compared our analysis of well-child check ups to an analysis 

that only included children who were consistently enrolled in Medicaid and private 

insurance during the entire period we examined, we did not find significant differences in 

results. 

19For purposes of this report, we refer to the District of Columbia as a state. 

Page 6 GAO-09-578 Medicaid Preventive Services
 

To determine the extent to which state Medicaid programs cover 

recommended preventive services for adults, we surveyed state Medicaid 

directors about whether the state Medicaid program covered eight 

recommended preventive services:20 cholesterol tests, cervical cancer 

screening, mammography, colorectal cancer screening, intensive 

counseling to manage obesity, intensive counseling to manage high 

cholesterol, influenza immunizations, and diabetes screening. We also 

asked about coverage of well-adult check ups and health risk assessments, 

which provide an opportunity for beneficiaries to receive some 

recommended preventive services such as blood pressure tests and 

obesity screening.21 To examine the extent to which state Medicaid 

programs delineate coverage of specific preventive services through their 

contracts with managed care organizations, we obtained and reviewed 

sections of contracts describing what services were covered for the largest 

Medicaid managed care organizations from up to two states in each of the 

10 CMS regions and interviewed an expert on Medicaid managed care 

contracts.22 We did not evaluate these Medicaid managed care 

arrangements to determine whether managed care organizations were 

covering services for Medicaid enrollees. We limited our review to 

contract provisions we identified to provide a description of such 

provisions. 

To examine CMS oversight of the provision of preventive services for 

children and adults in Medicaid, we interviewed and obtained related 

documentation from CMS officials, including officials in CMS’s 10 regional 

offices, about their oversight activities and initiatives related to the 

preventive services in our review. We reviewed data from 2000 through 

2007 reported by state Medicaid programs to CMS on the provision of 

EPSDT well-child check ups in their programs, CMS reports summarizing 

results of their EPSDT program reviews (conducted between April 2001 

and June 2009), and State Medicaid Director letters and other guidance 

issued by CMS related to preventive services. We also surveyed state 

Medicaid directors about the support states receive, or would like, from 

CMS related to coverage or oversight of preventive services. Activities 

 

20On our survey, we asked about recommended preventive services for which related 

national data were available. 

21According to CMS and state officials, obesity screening and blood pressure tests are often 

not billed separately from well-adult check ups or health risks assessments. 

22One CMS region had only one state with a managed care contract, and we excluded one 

contract from another state from our review because the contract was no longer in effect. 

Page 7 GAO-09-578 Medicaid Preventive Services
 

related to dental services in Medicaid were not included in the scope of 

this report due to related work conducted in 2008.23

To assess the reliability of NHANES, MEPS, and NHIS data, we spoke with 

knowledgeable agency officials, reviewed related documentation, and 

compared our results to published data. To establish the reliability of our 

survey data, we spoke with knowledgeable state and federal agency 

officials in developing the survey, pretested the survey questions, and 

followed up with state Medicaid officials to achieve a 100 percent 

response rate and, in some cases, to confirm certain responses. We 

determined these data sources to be reliable for the purposes of this 

report. Appendixes I, II, and III contain more information on our NHANES 

analysis, our MEPS and NHIS analyses, and our survey of state Medicaid 

directors. 

We conducted our work from May 2008 through August 2009 in 

accordance with generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe the evidence 

obtained provides a reasonable basis for our findings and conclusions 

based on our audit objectives. 

National survey data suggest that a large proportion of children and adults 

in Medicaid have certain health conditions, particularly obesity, that can 

be identified or managed by preventive services, and that adults’ receipt of 

preventive services varies widely depending on the service. According to 

estimates based on analyses of NHANES, MEPS, and NHIS data, 

Results in Brief 

• Medicaid children under age 21 are at risk of having certain health 

conditions and many are not receiving well-child check ups. 

NHANES examination data from 1999 through 2006 suggest that nearly 

one in five Medicaid children aged 2 through 20 (an estimated 18 percent) 

were obese, and about half of these children, or their parents, reported 

that they had not previously been diagnosed as overweight. Compared to 

privately insured children, a higher percentage of Medicaid children were 

obese. Other health conditions of concern were less common than obesity 

but still prevalent: an estimated 4 percent of Medicaid children aged 8 

 

23See GAO-08-1121. 

Page 8 GAO-09-578 Medicaid Preventive Services
 

through 20 had high blood pressure, and an estimated 10 percent of 

Medicaid children aged 6 through 20 had high cholesterol. Furthermore, 

MEPS data from 2003 through 2006 suggest that Medicaid children often 

do not receive well-child check ups—an estimated 41 percent of children 

in Medicaid did not receive a well-child check up during a 2-year period. 

• Medicaid adults are also an at-risk population—more than half 

have one or more of the health conditions reviewed—and their 

receipt of preventive services varies widely depending on the 

service. NHANES data from 1999 through 2006 suggest that nearly 6 in 10 

Medicaid adults aged 21 through 64 (an estimated 57 percent) were obese 

or had high blood pressure, high cholesterol, diabetes, or a combination of 

these health conditions; Medicaid adults also had higher rates of obesity 

and diabetes than adults with private health coverage. With regard to the 

receipt of preventive services, national data showed mixed results. MEPS 

data from 2003 through 2006 suggest that Medicaid adults’ reported rates 

of receipt of recommended preventive services varied substantially by 

service: for example, an estimated 93 percent of Medicaid adults received 

a blood pressure test during the 2 years prior to the survey, while an 

estimated 41 percent of Medicaid adults of the age for whom a colorectal 

cancer screening was recommended ever received one. Compared to 

adults with private insurance, a lower percentage of adults covered by 

Medicaid received preventive services. 

For children in Medicaid, who generally are entitled to coverage of EPSDT 

services, most states reported in our survey that they monitored and set 

goals for children’s utilization of preventive services, and had undertaken 

initiatives to promote the provision of preventive services to children. 

Nine states reported that they did not monitor children’s utilization of 

specific preventive services such as well-child check ups. States more 

frequently monitored and set goals for utilization of services for children 

receiving services from managed care organizations than for children in 

fee-for-service. Most states reported implementing, since 2004, multiple 

initiatives to improve the provision of preventive services. 

For adults in Medicaid, for whom coverage of preventive services is 

generally not required, most state Medicaid programs reported covering 

some but not all of the preventive services we asked about on our survey. 

Of the eight recommended preventive services we asked about, the 

services that were most commonly reported as covered for adults were 

cervical cancer screenings and mammograms, which were covered by 49 

and 48 states, respectively. Four other services were reported as covered 

by three-quarters or more of the states. The two remaining recommended 

Page 9 GAO-09-578 Medicaid Preventive Services
 

preventive services were covered by a minority of states: less than onethird reported covering intensive counseling to manage obesity and 

intensive counseling to manage high cholesterol. Thirty-nine states 

reported covering well-adult check ups or health risk assessments for 

adults, which provide an opportunity for delivering recommended 

preventive services such as blood pressure tests and obesity screenings. 

For children in Medicaid, CMS oversees the provision of services by 

collecting and publishing state EPSDT reports and conducting occasional 

reviews of state programs, but gaps in oversight remain. For adults in 

Medicaid, CMS oversight is more limited. For children, 

• CMS collects reports from states on the provision of EPSDT services; 

reports from fiscal year 2000 through 2007 show that most states are not 

achieving CMS’s yearly goal that each state provide EPSDT well-child 

check ups to at least 80 percent of the Medicaid children in the state who 

should receive one, based on the state’s periodicity schedule. State reports 

for 2007 showed that, on average, 58 percent of Medicaid children received 

at least one EPSDT well-child check up for which they were eligible; rates 

in individual states varied from 25 to 79 percent. 

• CMS also oversees states’ EPSDT programs through occasional reviews of 

individual state programs, but conducts few such reviews. CMS’s reviews 

examine different aspects of these programs, including how states ensure 

that beneficiaries have access to and information about EPSDT well-child 

check ups and other services. The reviews have identified problems with 

service delivery and other aspects of EPSDT programs, and have required 

corrective action or recommended specific improvements. CMS 

conducted only 11 EPSDT program reviews between April 2001 and June 

2009, including few reviews of programs with low reported rates of 

provision of EPSDT services. CMS does not have formal criteria or time 

frames for reviewing individual EPSDT programs. Instead, according to 

CMS officials, ESPDT reviews are performed at the discretion of CMS 

regional offices. 

• CMS provides other guidance to states on EPSDT, such as through the 

published State Medicaid Manual, and officials have recognized the need 

for—but not yet begun drafting—additional guidance on EPSDT coverage 

of obesity screening and services to manage childhood obesity. A 2006 

study raised concerns that Medicaid providers may not be aware of to 

what extent obesity services were covered or reimbursed under EPSDT, 

and that states’ provider manuals did not often explain this coverage. In 

response, CMS officials said they intend to develop new guidance for 

states on this topic, but as of the time of our review had not done so. 

Page 10 GAO-09-578 Medicaid Preventive Services
 

For adults, CMS has recognized the value of preventive services by 

providing some related guidance to states. However, the guidance has not 

included the recommended preventive services that we examined. 

To improve the extent to which children in Medicaid receive EPSDT 

services for which they are eligible, we are recommending that CMS 

ensure that state EPSDT programs are regularly reviewed. To support 

states’ efforts to cover appropriate preventive services, we are 

recommending that CMS expedite its efforts to provide guidance to states 

on coverage of obesity-related services for Medicaid children, and 

consider the need to provide similar guidance regarding coverage of 

obesity screening and counseling, and other recommended preventive 

services, for adults. 

In commenting on a draft of this report, CMS concurred with both of our 

recommendations, and commented that the agency recognizes the need 

for and the value of preventive services. In response to our 

recommendation that CMS expedite its effort to provide guidance on 

coverage of obesity-related services for Medicaid children, CMS 

committed to providing this guidance by the end of 2009. CMS also 

commented that it will remind states of the importance of ensuring that 

children receive a comprehensive well-child check up and of the 

importance of providing preventive services to adults. We incorporated 

technical comments from CMS as appropriate. 

The term preventive services refers to a range of services aimed at 

preventing and diagnosing serious heath conditions among adults and 

children, as well as managing health conditions through early treatment to 

prevent them from worsening. Generally, preventive services are intended 

for the following three purposes: 

Background 

• Prevent a health condition from occurring at all. Immunizations to 

prevent diseases such as influenza or pneumonia qualify as this first type 

of preventive service, called primary prevention. 

• Prevent or slow a condition’s progression to a more significant 

health condition by detecting a disease in its early stages. 

Mammograms to detect breast cancer and other screening tests to detect 

disease early are examples of this second type of preventive service, called 

secondary prevention. 

Page 11 GAO-09-578 Medicaid Preventive Services
 

• Prevent or slow a condition’s progression to a more significant 

health condition by minimizing the consequences of a disease. 

Services that help management of existing health conditions, such as diet 

or exercise counseling to manage obesity or medication to manage high 

blood pressure, are examples of this third type of preventive service, 

called tertiary prevention. 

Preventive services can help prevent or manage a number of serious 

health conditions, such as heart disease, diabetes, obesity, and cancer. For 

example, heart disease and stroke are leading causes of death and 

disability in the United States, and the risk of developing these conditions 

can be substantially reduced if high blood pressure and cholesterol—

which can develop in children as well as adults—are detected early and 

managed through diet, exercise, medication, or a combination. Similarly, 

diabetes is a leading cause of blindness, renal disease, and amputation, 

and also contributes to heart disease. Early diagnosis and management of 

diabetes, by controlling levels of blood glucose, blood pressure, and 

cholesterol, can reduce the risk of these and other diabetes complications. 

Finally, the importance of obesity as a health problem for both children 

and adults in the United States is increasingly apparent. Obesity is 

associated with an increased risk of many other serious conditions, 

including heart disease, stroke, diabetes, and several types of cancer. 

Overweight and obese children are at risk of health problems during their 

youth, such as diabetes, and are more likely than other children to become 

obese adults. Intensive counseling about diet, exercise, or both can 

promote sustained weight loss for obese adults. 

The federal government has established national health objectives and 

goals to monitor the health of the U.S. population, and several reflect the 

importance of preventive services. Healthy People 2010, coordinated by 

the Office of Disease Prevention and Health Promotion within HHS, is a 

statement of national health objectives designed to identify the most 

significant preventable threats to health and to establish national goals to 

reduce these threats to certain target levels. Some of the national goals 

established through Healthy People 2010 include 

• reducing the proportion of children and adults who are obese, 

• reducing the proportion of adults with high blood pressure and high blood 

cholesterol, 

• reducing the overall rate of diabetes and increasing the proportion of 

adults with diabetes whose condition has been diagnosed, and 

Page 12 GAO-09-578 Medicaid Preventive Services
 

• increasing the proportion of children and adults who receive 

recommended preventive screening tests and immunizations. 

Recent reviews of progress toward these goals, however, in some cases 

show no progress or even movement away from certain goals, 

underscoring the importance of continued attention to prevention. 

State Medicaid Programs 

Must Cover 

Comprehensive Health 

Check Ups for Children 

Under federal law, state Medicaid programs generally must cover EPSDT 

services for children under age 21.24 A key component of EPSDT services 

is that it entitles children to coverage of well-child check ups, which may 

target health conditions for which growing children are at risk, such as 

obesity. An EPSDT well-child check up must include a comprehensive 

health and developmental history, a comprehensive unclothed physical 

exam, appropriate immunizations and laboratory tests, and health 

education.25 EPSDT well-child check ups may be a vehicle to provide 

preventive services to children, such as measurement of height and 

weight, nutrition assessment and counseling, immunizations, blood 

pressure screening, and cholesterol and other appropriate laboratory tests. 

State Medicaid programs must provide EPSDT services at intervals which 

meet reasonable standards of medical and dental practice as determined 

by the state and as medically necessary to determine the existence of a 

suspected illness or condition.26 Accordingly, states either develop their 

own periodicity schedules, that is, age-specific timetables that identify 

when EPSDT well-child check ups and other EPSDT services should 

occur, or they may adopt a nationally recognized schedule, such as that of 

the American Academy of Pediatrics, which recommends well-child check 

ups once each year or more frequently, depending on age. State periodicity 

schedules for fiscal year 2006 generally specified multiple well-child check 

 

2442 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(4)(B). Absent additional CMS approval, state 

Medicaid programs must cover EPSDT services for individuals under age 21 who are 

eligible for Medicaid under categorically needy categories. 

25EPSDT services, in addition to well-child check ups, include: vision services, including 

diagnosis and treatment for vision defects such as eyeglasses; dental services, including 

relief of pain and infections, restoration of teeth, and maintenance of dental health; hearing 

services, including diagnosis, and treatment for defects in hearing such as hearing aids; and 

services necessary to correct or improve health conditions discovered through screenings, 

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

other beneficiaries. See 42 U.S.C. § 1396d(r). 

2642 U.S.C. §§ 1396d(a)(4)(B), 1396d(r). 

Page 13 GAO-09-578 Medicaid Preventive Services
 

ups per year for children aged 0 through 2, one well-child check up per 

year for children aged 3 through 5, and a well-child check up every 1 to 

2 years for children aged 6 through 20. 

The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) required the 

Secretary of HHS to set annual goals for children’s receipt of EPSDT 

services,27 and CMS established a yearly goal that each state provide 

EPSDT well-child check ups to at least 80 percent of the Medicaid children 

in the state who should receive one, based on the state’s periodicity 

schedule. Under the authority of OBRA 89, CMS also requires that states 

submit annual EPSDT reports known as the CMS 416.28 Along with other 

information, the CMS 416 captures the information used to measure 

progress toward the 80 percent goal. On the CMS 416, this information is 

termed the EPSDT participant ratio. 

State Medicaid Programs 

Are Not Required to Cover 

Preventive Services for 

Adults 

For Medicaid adults, Medicaid programs generally are not required to 

cover preventive services. States operate their Medicaid programs within 

broad federal requirements which generally require states to cover certain 

mandatory benefit categories, such as “physician services” and provide 

states the choice to cover a range of additional optional benefit categories, 

thereby creating programs that may differ from state to state. As federal 

Medicaid law does not define preventive services or include these services 

under a mandatory benefit category, states can opt to cover various 

preventive services for adults under different categories. For example, 

states may choose to cover certain preventive services as part of 

“preventive, diagnostic, and screening services,” an optional benefit 

category under Medicaid. They may also choose to cover other specific 

preventive services such as cholesterol tests under other mandatory or 

other optional benefit categories. CMS officials said they do not track the 

specific preventive services covered for adults by each state Medicaid 

program. 

 

27Pub. L. No. 101-239, § 6403, 103 Stat. 2106, 2262-64 (1989) (codified, as amended, at 

42 U.S.C. § 1396d(r)(5)). 

28Beginning in 1990, OBRA 89 required state Medicaid programs to annually report to the 

Secretary of HHS information on EPSDT services including the number of children 

provided EPSDT screenings, the number of children referred for corrective treatment as a 

result of the screenings, the number of children receiving dental services, and the states’ 

results in meeting annual goals for children’s receipt of EPSDT services established by 

HHS. Pub. L. No. 101-239, § 6403, 103 Stat. 2106, 2262-64 (1989) (codified, as amended, at 

42 U.S.C. § 1396a(a)(43)). 

Page 14 GAO-09-578 Medicaid Preventive Services
 

National survey data suggest that children in Medicaid under age 21 are at 

risk of certain health conditions, particularly obesity, that can be identified 

or managed by preventive services, and many are not receiving well-child 

check ups. The same surveys suggest that Medicaid adults are also an atrisk population—nearly 60 percent were estimated to have at least one 

health condition we reviewed that can be identified or managed by 

preventive services—and their receipt of preventive services varied widely 

depending on the service. 

National Surveys 

Show That Certain 

Health Conditions Are 

Prevalent among 

Children and Adults in 

Medicaid, and Receipt 

of Recommended 

Preventive Services 

Varies Widely 

For Medicaid Children, 

Obesity Is a Health 

Condition of Great 

Concern: Nearly One in 

Five Examined Were 

Obese 

Obesity is a serious health concern for children enrolled in Medicaid.29

NHANES examinations conducted from 1999 through 2006 suggest that 

nearly one in five children in Medicaid aged 2 through 20 (an estimated 

18 percent) were obese. These rates of obesity are well above the Healthy 

People 2010 target goal of reducing to 5 percent the proportion of children 

nationwide who are obese or overweight (see fig. 1). Furthermore, about 

half (an estimated 54 percent) of the Medicaid children who were obese, 

or their parents, reported that the child had not previously been diagnosed 

as overweight.30 Among privately insured children, an estimated 14 percent 

were obese. 

 

29Obesity in children aged 2 through 19 was defined as having a BMI equal to or greater 

than 95th percentile of age and sex-specific BMI, based on CDC growth charts for the 

United States. Obesity in children age 20 was defined as having a BMI greater than or equal 

to 30. Girls who were pregnant were not included in the analysis. 

30See appendix I for more information on how NHANES collected this information. 

Page 15 GAO-09-578 Medicaid Preventive Services
 

Figure 1: Estimated Percentage of Children in Medicaid Aged 2 through 20 Who 

Were Obese Compared to the National Goal for 2010 

0

5

10

15

20

25

All 

ages

Ages

12–20

Ages

2–11

Percent

15

22

18

Healthy People 2010

goal for all children

Source: GAO analysis of 1999 through 2006 NHANES data and Healthy People 2010 target goals.

Note: The NHANES data for children in Medicaid also include children in CHIP, which we estimate to 

be about 16 percent of the total during 1999 through 2006. The Healthy People 2010 target goal is for 

5 percent or less of all children to be overweight or obese. 

The NHANES examinations also revealed that some children in Medicaid 

have other potentially serious health conditions that can be identified and 

managed by preventive services. Among Medicaid children aged 8 through 

20 years, an estimated 4 percent had high blood pressure. Among Medicaid 

children aged 6 through 20 years, an estimated 10 percent had high 

Page 16 GAO-09-578 Medicaid Preventive Services
 

cholesterol.31 These rates were generally similar to estimates for privately 

insured children. 

Among Medicaid Children, 

Almost Half Did Not 

Receive a Well-Child 

Check Up during a 2-Year 

Period 

MEPS data from 2003 through 2006 suggest that many children in Medicaid 

do not regularly receive well-child check ups. Children in Medicaid are 

generally eligible for a well-child check up at least once every 1 to 

2 years,32 but an estimated 41 percent of children in Medicaid aged 2 

through 20 had not received a well-child check up during the previous 

2-year period.33 This proportion varied by the children’s age: for example, 

an estimated 22 percent of children in Medicaid aged 2 through 4, 

40 percent of children in Medicaid aged 5 through 7, and 48 percent of 

children in Medicaid aged 8 through 10 had not received a well-child check 

up during the previous 2 year period (see fig. 2). In comparison, the 

estimated proportions of privately insured children who had received a 

well-child check up were generally similar. 

 

31These age ranges differ because NHANES surveys did not examine blood pressure in 

children younger than 8 or cholesterol in children younger than 6 during all survey years 

we analyzed (prior to the 2005-2006 survey, cholesterol was examined in children aged 3 

and older). NHANES measured blood pressure up to four times during its physical 

examination. For our analysis, we calculated the average of the blood pressure 

measurements and defined high blood pressure for children aged 8 through 17 as equal to 

or greater than 95th percentile of age, height, and sex-specific average systolic or diastolic 

blood pressure, based on blood pressure tables from HHS’s National Heart, Lung, and 

Blood Institute; for children aged 18 through 20, we defined high blood pressure as having 

an average systolic blood pressure of 140 millimeters of mercury (mmHg) or higher, or 

having an average diastolic blood pressure of 90 mmHg or higher. High total blood 

cholesterol for children aged 6 through 20 was defined as greater than or equal to 200 

milligrams per deciliter (mg/dL). NHANES interviews did not determine whether children 

younger than 16 had been previously diagnosed with high blood pressure or whether 

children younger than 20 had been previously diagnosed with high cholesterol. 

32State ESPDT periodicity schedules for fiscal year 2006 generally included multiple wellchild check ups per year for children aged 0 through 2, one well-child check up per year for 

children aged 3 through 5, and a well-child check up every 1 to 2 years for children aged 6 

through 20. Five state periodicity schedules specified an interval greater than 2 years for 

some children aged 6 through 20. 

33This measure of well-child check ups was not restricted to EPSDT well-child check ups. 

See appendix II for more information on how well-child check ups were measured. 

Page 17 GAO-09-578 Medicaid Preventive Services
 

Figure 2: Estimated Percentage of Children in Medicaid Who Did and Did Not 

Receive a Well-Child Check Up during a 2-Year Period, by Age 

0

10

20

30

40

50

60

70

80

90

100

Did not receive well-child check up

Did receive well-child check up

All 

ages

Ages

17–20

Ages

14–16

Ages

11–13

Ages

8–10

Ages

5–7

Ages

2–4

Percent

78

60

52

60

51

46

59

Source: GAO analysis of 2003 through 2006 MEPS data.

22

40

48

40

49

54

41

Note: The MEPS data for children in Medicaid also include children in CHIP, which we estimate to be 

about 18 percent of the total during 2003 through 2006. MEPS collects information for each person in 

the household based on information provided by one adult member of the household. 

Similarly, our analysis of MEPS data also showed that, for children in 

Medicaid, reported rates of receipt of certain specific preventive services 

that could occur during a well-child check up were correspondingly low. 

For example, an estimated 37 percent of children in Medicaid aged 2 

through 20 had not had a blood pressure test, and an estimated 48 percent 

of children in Medicaid aged 2 through 17 had not received diet or exercise 

advice from a health care professional during the 2 years prior to the 

survey.34 The data suggest, however, that most children in Medicaid aged 2 

through 17—an estimated 88 percent—had their height and weight 

measured by a health care professional during the 2 years prior to the 

 

34MEPS did not collect comparable information on diet or exercise advice or height and 

weight measurement for individuals older than 17. 

Page 18 GAO-09-578 Medicaid Preventive Services
 

survey.35 The estimated rates of receipt of blood pressure tests, height and 

weight measurement, and diet or exercise advice were generally similar 

for children in Medicaid and privately insured children. 

Among Medicaid Adults, 

Nearly 6 in 10 Had One or 

More Health Conditions 

that Could Be Identified or 

Managed by Preventive 

Services 

NHANES data suggest that a majority of adults in Medicaid aged 21 

through 64 have at least one potentially serious health condition. An 

estimated 57 percent of Medicaid adults had obesity, diabetes, high 

cholesterol, high blood pressure, or a combination of these conditions.36

Obesity was the most common of these health conditions; an estimated 

42 percent of adults in Medicaid aged 21 through 64 were obese (see 

fig. 3). 

As with children in Medicaid, the rate of obesity among adults aged 21 

through 64 in Medicaid was well above national goals—the estimated 

42 percent rate of obesity among Medicaid adults was nearly three times 

higher than the Healthy People 2010 target goal of 15 percent. The 

estimated rate of obesity among adults in Medicaid was also somewhat 

higher than the estimated rate among privately insured adults, which was 

32 percent. Adults in Medicaid were almost twice as likely to have diabetes 

compared to privately insured adults: 13 percent of examined adults in 

Medicaid were estimated to have diabetes, compared to 7 percent of 

privately insured adults. Estimated rates of high blood pressure and high 

cholesterol were similar between both health insurance groups (see fig. 3). 

 

35MEPS asked about height and weight measurement separately, so the two measurements 

may not have been done at the same time (as necessary to calculate BMI to screen for 

obesity). It is unclear why a larger proportion of children reportedly had their height and 

weight measured compared to the proportions who received well-child check ups or other 

specific preventive services, but it is possible that height and weight measurement could be 

more likely to occur during sick visits to the doctor or at school. 

36NHANES measured blood pressure up to four times during its physical examination. For 

our analysis, we calculated the average of the blood pressure measurements and applied 

CDC’s definition of high blood pressure: a patient’s having an average systolic blood 

pressure of 140 mmHg or higher, or having an average diastolic blood pressure of 90 mmHg 

or higher. Following CDC, we additionally included adults taking blood pressure lowering 

medication in this category. We also used CDC definitions for the other health conditions 

we analyzed. Obesity for adults was defined as BMI greater than or equal to 30 (pregnant 

women were not included in the obesity figures). High total blood cholesterol for adults 

was defined as 240 mg/dL or more. Diabetes for adults was defined as fasting plasma 

glucose of 126 mg/dL or more or having been previously diagnosed with diabetes. 

Page 19 GAO-09-578 Medicaid Preventive Services
 

Figure 3: Estimated Prevalence of Certain Health Conditions among Adults Aged 21 

through 64, by Health Insurance Status 

0

10

20

30

40

50

60

70

80

90

100

Medicaid adults aged 21 through 64

Privately insured adults aged 21 through 64 

One or more of

these conditions

Diabetes Hi a High blood gh cholesterol

pressure

Obesitya

Percent

Source: GAO analysis of 1999 through 2006 NHANES data.

32

42

23

27

16

19

13

7

57

53

Note: We also estimated the prevalence of these health conditions after adjusting for age differences 

between these two health insurance groups. After adjusting for age, the prevalence differences 

between the two insurance groups widened by a few percentage points for each health condition we 

analyzed—the percentage of privately insured adults with each condition was about 1 to 2 percentage 

points lower, and the percentage of Medicaid adults with each condition was about 1 to 4 percentage 

points higher. 

a

Differences in rates of obesity and diabetes between health insurance groups were statistically 

significant at the 95 percent confidence level. 

The NHANES interview data also suggest that a large proportion of adults 

in Medicaid found to have these health conditions may not have been 

aware of them prior to participation in the NHANES examination. An 

estimated 40 percent of adults in Medicaid found to have one or more of 

the health conditions we reviewed had at least one condition that they 

reported had not been previously diagnosed.37 The percentage of adults in 

 

37Adults were asked during the NHANES interview if they had ever been told by a health 

care professional that they were overweight, or had high blood pressure, high cholesterol, 

or diabetes. 

Page 20 GAO-09-578 Medicaid Preventive Services
 

Medicaid who reported that their health condition had not been previously 

diagnosed varied by condition: for example, an estimated 17 percent of 

adults in Medicaid with diabetes reported that this condition had not been 

previously diagnosed, while an estimated 35 percent of those with high 

cholesterol reported that this condition had not been previously diagnosed 

(see fig. 4). These estimates were similar to those of privately insured 

adults. 

Figure 4: Estimated Percentage of Adults Aged 21 through 64 in Medicaid with 

Health Conditions Who Reported Their Conditions Had or Had Not Been Diagnosed 

0

10

20

30

40

50

60

70

80

90

100

Reported had not been previously diagnosed

Reported had been previously diagnosed

One or 

more of

these

conditions

High Diabetes

cholesterol

High

blood

pressure

Obesity

Percent

65

75

65

83

60

Source: GAO analysis of 1999 through 2006 NHANES data.

35

25

35

17

40

Medicaid Adults’ Receipt 

of Recommended 

Preventive Services Varied 

Widely by Service 

MEPS data suggest that Medicaid adults’ receipt of recommended 

preventive services varied widely by service. For example, an estimated 

93 percent of adults in Medicaid aged 21 through 64 received a blood 

pressure test during the 2 years prior to the survey. Similarly, an estimated 

90 percent of women in Medicaid aged 21 through 64 received a cervical 

cancer screening during the 3 years prior to the survey. However, 

estimated rates of receipt were lower for other important recommended 

Page 21 GAO-09-578 Medicaid Preventive Services
 

preventive services. For example, only an estimated 41 percent of adults 

in Medicaid aged 50 through 64 had ever received a colorectal cancer 

screening test.38 Similarly, estimates based on NHIS data suggest that only 

33 percent of adults in Medicaid aged 21 through 64 with high blood 

pressure39 had received a screening test for diabetes within the past 

3 years40 (see fig. 5). 

Figure 5: Estimated Receipt of Certain Recommended Preventive Services among 

Adults in Medicaid 

0 10 20 30 40 50 60 70 80 90 100

Diabetes screen

(within 3 years)

Influenza immunization

(within 1 year)

Colorectal cancer

screen (ever)

Diet or exercise

advice (ever)

Mammogram

(within 2 years)

Cholesterol test

(within 5 years)

Cervical cancer screen

(within 3 years)

Blood pressure test

(within 2 years)

Percent

Source: GAO analysis of 2003 through 2006 MEPS data and 2006 NHIS data.

93

90

77

66

64

41

37

33

 

38Colorectal cancer screening tests included sigmoidoscopy, colonoscopy, or stool tests. 

39As of March 2009, USPSTF recommended screening only adults with high blood pressure 

for diabetes. 

40Diabetes screening questions were not included in MEPS from 2003 through 2006, but 

were included in the 2006 NHIS; adults who had not previously been diagnosed with 

diabetes were asked if they had been tested for high blood sugar or diabetes in the past 

3 years. 

Page 22 GAO-09-578 Medicaid Preventive Services
 

Notes: Analyses were restricted to those adults aged 21 through 64 that fit the age, gender, or health 

risk factor criteria for each recommended service (for example, analysis of receipt of mammograms 

was restricted to women aged 40 through 64; see appendix II for more information). Results for all 

services except diabetes screening were based on 2003 through 2006 MEPS data; the result for 

diabetes screening was based on 2006 NHIS data. 

As compared to the privately insured adult population, MEPS and NHIS 

data show that a lower percentage of adults in Medicaid received certain 

recommended preventive services, in particular, mammograms, 

cholesterol tests, diabetes screening, or colorectal cancer screening, 

within recommended time frames. Medicaid and privately insured adults 

were estimated to be about equally likely to receive recommended blood 

pressure tests, diet or exercise advice, and influenza immunizations within 

recommended time frames. 

Most state Medicaid programs reported on our survey that they monitored 

and set goals for children’s utilization of certain preventive services. Most 

states also reported undertaking multiple initiatives since 2004 to promote 

preventive services. 

For Children in 

Medicaid, Most State 

Medicaid Programs 

Reported Monitoring 

and Promoting the 

Provision of 

Preventive Services 

Most State Medicaid 

Programs Reported 

Monitoring and Setting 

Goals for Medicaid 

Children’s Utilization of 

Preventive Services 

In response to our survey, most of the 51 state Medicaid programs 

reported that they monitored utilization of one or more preventive 

services by children in Medicaid. For example, when asked whether they 

monitored children’s utilization of Medicaid well-child check ups or health 

risk assessments, 42 states reported doing so.41 States less frequently 

reported monitoring utilization of specific services that could be provided 

during these well-child check ups, such as blood pressure tests or obesity 

screenings (see fig. 6). 

 

41States are required to collect data and report to CMS on EPSDT services such as wellchild check ups, but according to officials states are not required to use these data as part 

of any monitoring efforts. 

Page 23 GAO-09-578 Medicaid Preventive Services
 

Figure 6: Number of State Medicaid Programs Reporting that They Monitored 

Children’s Utilization of Specific Preventive Services 

0 5 10 15 20 25 30 35 40 45 50

Blood pressure test

Obesity screen

Cholesterol test

Diabetes screen

Cervical cancer screen

Number or receipt of

any preventive service

Well-child check up or

health risk assessment

Number of state Medicaid programs

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009.

42

40

20

18

12

11

10

When asked the reasons why they were not conducting more monitoring 

of children’s utilization of preventive services in Medicaid (beyond 

federally required monitoring through the CMS 416), the top two reasons 

states chose were “administrative burden” and “technology challenges.” 

In addition to monitoring specific preventive services, about two-thirds of 

state Medicaid programs reported that the state had established its own 

target goals or benchmarks for children’s utilization of preventive services, 

in addition to the CMS goal that each state provide EPSDT well-child 

check ups to at least 80 percent of Medicaid children in a state who should 

receive one, based on the state’s periodicity schedule.42 For example, 33 

states reported they had established utilization goals of their own, 

separate from CMS’s 80 percent goal, for children’s well-child check ups. 

Twenty-six states reported goals for the total number of any preventive 

services received, and 12 states reported utilization goals for at least one 

 

42The survey asked if state Medicaid programs had established utilization goals other than 

the federal 80 percent goal, but did not ask what the specific utilization goals were. 

Page 24 GAO-09-578 Medicaid Preventive Services
 

specific preventive service such as obesity screening, diabetes screening, 

blood pressure tests, cholesterol tests, or cervical cancer screening. States 

that had established goals often reported, however, that not all of their 

goals were being met. For example, of the states with a goal for children’s 

utilization of well-child check ups, 42 percent reported that the goal was 

not being met. The top two reasons states cited as reasons they believed 

they were not meeting utilization goals were beneficiaries missing 

appointments and beneficiaries or their families not being concerned 

about receiving preventive services. A few states also mentioned 

difficulties with tracking service utilization. 

Although most state Medicaid programs reported monitoring and setting 

goals for children’s utilization of preventive services, these efforts differ by 

type of service delivery system; programs more often monitor or set goals 

for services provided to children in managed care than for services 

provided to children in fee-for-service delivery systems.43 For example, of 

the 37 states reporting that at least some children in Medicaid were 

enrolled in managed care, 33 (89 percent) reported monitoring well-child 

check ups provided through managed care organizations. In contrast, of 

the 47 programs reporting that at least some children received services 

through a fee-for-service delivery system, 26 (55 percent) reported 

monitoring utilization of well-child check ups provided by fee-for-service 

providers.44 Similarly, goals for children’s utilization of preventive services 

were most often targeted to managed care organizations. For example, 25 

of 37 states with children enrolled in Medicaid managed care organizations 

(68 percent) reported having established goals for the managed care 

organizations’ provision of well-child check ups, compared to 16 of 47 

Medicaid programs (34 percent) with children in fee-for-service. 

 

43The survey defined managed care to include capitated managed care arrangements only. 

Administrative arrangements such as Primary Care Case Management, Disease 

Management, and Administrative Services Organizations were defined as fee-for-service. 

44Of the 51 state Medicaid programs, 4 reported exclusively using managed care to provide 

services to children and 14 reported exclusively using a fee-for-service system to provide 

services to children. The remaining 33 reported using a combination of managed care and 

fee-for-service delivery systems to provide services to Medicaid children in the state. 

Page 25 GAO-09-578 Medicaid Preventive Services
 

Most state Medicaid programs (47), reported conducting multiple 

initiatives since 2004 to improve providers’ provision of preventive 

services to children in Medicaid, most commonly 

• educating pediatric providers about coverage of preventive services 

(42 states), 

• increasing payment rates for pediatric providers for office visits or 

specific preventive services (37 states), 

Most State Medicaid 

Programs Reported 

Multiple Initiatives Aimed 

at Improving Provision of 

Preventive Services for 

Children in Medicaid and 

Viewed Certain Initiatives 

as Successful 

• streamlining payment processing (29 states), and 

• starting a provider advisory panel (29 states). 

States that had implemented one or more of the above four initiatives 

often viewed them as successful. About half of the states implementing 

them reported that the initiative had resulted in some improvement or 

major improvement. Most of the other half reported that they did not 

know the extent of improvement; only a few states reported that any of the 

initiatives had not resulted in improvement.45

State Medicaid programs also reported conducting several types of 

initiatives directed at Medicaid beneficiaries, such as encouraging 

children’s use of preventive services through direct mail or telephone 

outreach, and many also reported initiatives specifically targeted at 

reducing obesity in Medicaid children. For example, 37 states reported 

initiatives to educate providers to conduct obesity screening or counseling 

for Medicaid children, and 12 states reported implementing family-based 

childhood obesity prevention programs. 

 

45Three programs reported that increasing payment rates for pediatric providers had not 

resulted in improvement; two reported that starting a provider advisory panel had not 

resulted in improvement; and one reported that streamlining payment processing had not 

resulted in improvement. No programs reported that educating providers about coverage 

had not resulted in improvement. 

Page 26 GAO-09-578 Medicaid Preventive Services
 

Most state Medicaid programs reported that they choose to cover some 

but not all of the preventive services we asked about on our survey. Of the 

eight recommended services we asked about, the services that were most 

commonly reported as covered for adults were cervical cancer screenings 

and mammograms, which were covered by 49 and 48 states, respectively.46

Four additional preventive services were reported as covered for adults by 

three-quarters or more of the 51 states. These four services were diabetes 

screenings, cholesterol tests, colorectal cancer screenings, and influenza 

immunizations. The remaining two recommended services—intensive 

counseling for adults with obesity and intensive counseling for adults with 

high cholesterol—were reported as covered for adults by less than onethird of states. Thirteen states (25 percent) reported covering intensive 

counseling for obese adults and 14 states (27 percent) reported covering 

intensive counseling for adults with high cholesterol (see fig. 7).47 Thirtynine states reported covering well-adult check ups or health risk 

assessments for adults, which provide an opportunity for delivering other 

recommended preventive services such as blood pressure tests and 

obesity screenings. (See appendix III for more detailed survey results.) 

For Adults, Most State 

Medicaid Programs 

Reported Covering 

Some but Not All 

Recommended 

Preventive Services 

 

46Some state Medicaid programs reported that certain preventive services were not covered 

under their fee-for-service program but were covered by the states’ Medicaid managed care 

organization(s)—services covered under managed care but not fee-for-service are not 

included in this discussion, but are noted in table 8 in appendix III. 

47Seventeen other states that did not report covering intensive counseling for obese adults 

did report covering other services that, while not explicitly recommended by the USPSTF, 

are aimed at managing obesity—such as obesity medication or nutrition assessment and 

counseling. A minority of states reported additional efforts specifically aimed at addressing 

adult obesity. For example, 15 states reported promoting weight reduction programs for 

adult beneficiaries, and 17 reported educating providers to conduct obesity counseling for 

adults in Medicaid as needed. Thirty states that did not report covering intensive 

counseling for adults with high cholesterol reported covering medication or a nutrition 

assessment and counseling for adults with high cholesterol. 

Page 27 GAO-09-578 Medicaid Preventive Services
 

Figure 7: Number of State Medicaid Programs that Reported Covering Certain 

Recommended Preventive Services for Adults and Health Risk Assessments or 

Well-Adult Check Ups 

0 5 10 15 20 25 30 35 40 45 50

Intensive counseling to manage

obesity for adults aged

21–64

Intensive counseling to manage

high cholesterol for adults

aged 21–64

Cholesterol test for men aged

35–64 and adults aged 21–64 with

risk factors for heart disease

Well-adult check up or health

risk assessment for adults

aged 21–64

Diabetes screen for adults with

high blood pressure aged

21–64

Influenza immunization for

adults aged 50–64

Colorectal cancer screen for

adults aged 50–64

Mammography for women

aged 40–64

Cervical cancer screen for

women aged 21–64

Number of state Medicaid programs

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009.

48

49

46

47

43

39

39

14

13

Notes: Well-adult check ups or health risk assessments for adults, while not explicitly recommended 

by the USPSTF, provide an opportunity for delivering recommended preventive services such as 

blood pressure tests and obesity screenings. Figure numbers do not include states that reported that 

a service was covered under managed care but not under fee-for-service. 

In examining a selected, non-generalizable sample of 18 state Medicaid 

programs’ Medicaid managed care contracts, we found wide variation in 

the extent to which the contracts delineated coverage expectations for 

specific preventive services.48 As we have previously reported, specific and 

comprehensive contract language helps ensure that managed care 

organizations know their responsibilities and can be held accountable for 

 

48We did not evaluate these Medicaid managed care arrangements to determine whether 

managed care organizations were covering services for Medicaid enrollees. We limited our 

review to the contract provisions we identified to provide a description of such provisions. 

Page 28 GAO-09-578 Medicaid Preventive Services
 

delivering services.49 According to one expert on Medicaid managed care 

contracts, state Medicaid programs run the risk that managed care 

organizations may not cover certain services the program intends to cover 

if Medicaid managed care contracts lack specific and comprehensive 

contract language related to covered services. Three of the contracts did 

not specifically refer to any of the preventive services that state Medicaid 

programs reported were required to be covered by managed care 

organizations in those states. By contrast, two contracts specifically 

referred to all of the preventive services that the state reported covering. 

CMS oversight is primarily focused on children’s receipt of EPSDT 

services, and consists largely of collecting state EPSDT reports. CMS has 

conducted few reviews of EPSDT programs, including those that CMS 416 

reports indicate have low participant ratios—the information used to 

assess progress toward CMS’s goal that each state provide EPSDT wellchild check ups to at least 80 percent of the Medicaid children in the state 

who should receive one, based on the state’s periodicity schedule. For 

adults in Medicaid, CMS has issued some guidance related to preventive 

services and shared some best practices. 

CMS Oversight of the 

Provision of 

Preventive Services 

Primarily Focuses on 

Children’s Services, 

and Gaps in Oversight 

Remain 

For Children in Medicaid, 

CMS Oversight Focuses 

Largely on Collecting State 

EPSDT Reports; CMS 

Reviews Few EPSDT 

Programs, Including Those 

with Low Participant 

Ratios 

CMS oversight of preventive services for children in Medicaid centers on 

the annual collection of the required CMS 416 report from each state 

Medicaid program on the provision of EPSDT services for children in 

Medicaid. We reported in 2001 that CMS 416 reports were often not timely 

or accurate,50 but since that time, CMS officials told us they had taken 

steps to improve the underlying data, and state and national health 

association officials concurred that the data has improved. For example, 

we reported in 2001 that underlying data for the CMS 416 may not be 

accurate in part because of incomplete data on service utilization by 

children in managed care. In 2007, we reported that officials from several 

states and national health associations stated that, although the CMS 416 

was limited in its usefulness for oversight, the quality and completeness of 

the underlying data that states used to prepare the CMS 416, including the 

 

49See GAO-01-749. 

50See GAO-01-749. 

Page 29 GAO-09-578 Medicaid Preventive Services
 

data collected from managed care organizations, had improved since 

2001.51

State Medicaid programs’ CMS 416 reports continue to show gaps in the 

provision of EPSDT services to Medicaid children. CMS uses the 

participant ratio from the CMS 416 to measure progress toward CMS’s goal 

that each state provide EPSDT well-child check ups to at least 80 percent 

of the Medicaid children in the state who should receive one, based on the 

state’s periodicity schedule. By contrast, in fiscal year 2007, the national 

average participant ratio among 51 states reporting on the CMS 416 was 

58 percent, and no state reported a ratio of 80 percent or more.52 Individual 

states reported ratios ranging from 25 to 79 percent, and 11 states had 

ratios under 50 percent (see fig. 8). Participant ratios from fiscal years 

2000 through 2006 are generally consistent with those in fiscal year 2007, 

though there is some variation between years. For example, in fiscal year 

2006, 2 states reported participant ratios greater than 80 percent, and 

15 states reported ratios under 50 percent. 

 

51See Medicaid: Concerns Remain about Sufficiency of Data for Oversight of Children’s 

Dental Services, GAO-07-826T (Washington, D.C.: May 2, 2007). 

52One state reported a ratio of greater than 100 percent, which would imply that more 

children received a check up than were expected to receive a check up. We did not 

include this state’s ratio in this discussion; according to CMS officials, ratios greater than 

100 percent could not be correct. 

Page 30 GAO-09-578 Medicaid Preventive Services
 

Figure 8: Variation in State Medicaid Programs’ Fiscal Year 2007 Participant Ratios 

0

2

4

6

8

10

12

14

16

18

20

0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–100

Number of state Medicaid programs

Participant ratios (percent)

Source: GAO analysis of 2007 CMS 416 reports.

0 0

1 1

9

19

16

4

0 0

Notes: The participant ratio reflects the percentage of children who received at least one EPSDT wellchild check up or service that they should have received during the year—CMS’s goal for the 

participant ratio is 80 percent. Only 50 states are shown because 1 state reported a participant ratio 

of greater than 100 percent; as noted earlier, CMS officials told us that this ratio cannot be correct. 

Although the completeness and accuracy of the CMS 416 data may have 

improved in recent years, according to agency officials, the CMS 416 is still 

limited for oversight purposes. For example, the form does not 

differentiate between the delivery of services for children in managed care 

and fee-for-service programs or illuminate possible factors contributing to 

low receipt of services. We reported in 2007 that many officials from 

national health associations told us 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. 

In addition to collecting the CMS 416, CMS officials also oversee the 

provision of preventive services to children in Medicaid through 

occasional reviews of individual state EPSDT programs, which are 

conducted by CMS regional offices; we previously reported such reviews 

were helpful in illuminating policy and process concerns as well as 

Page 31 GAO-09-578 Medicaid Preventive Services
 

innovative practices of states.53 The reviews look at how states meet 

statutory requirements—such as ensuring that all eligible Medicaid 

beneficiaries under 21 are informed of and have access to EPSDT 

services54—and are conducted with the intent of identifying deficiencies 

and providing recommendations and guidance to states to help improve 

their programs. For example, one review assessed a state’s performance in 

ensuring that managed care organizations and providers understood the 

benefits available under EPSDT and their respective responsibilities for 

providing these services. Another review investigated whether a state had 

developed an appropriate periodicity schedule and examined coordination 

of children’s care in the context of a managed care service delivery 

system. CMS’s EPSDT reviews have also examined data collection and 

reporting—for example, one review examined the extent to which a state 

collected CMS 416 data in accordance with instructions and used the data 

to measure progress and define areas for improvement. 

EPSDT program reviews can and have resulted in recommendations and 

corrective action plans intended to improve the provision of EPSDT 

services. The reviews have also highlighted best practices that could be 

emulated by other state Medicaid programs. 

• Recommendations—which are, according to CMS officials, implemented 

at a state’s discretion—have included actions such as assessing potential 

impediments to timely access to EPSDT services, ensuring that providers 

are aware of how to access current data in order to monitor their efforts, 

and developing a state standard for timely access to services. For example, 

one review found that providers seemed confused about the health plans’ 

requirements for prior authorization and specialty referrals; CMS 

recommended that the state assess whether the providers’ understanding 

of prior authorization procedures was impeding timely access to EPSDT 

services and, if so, ensure that training was provided to correct the 

misunderstanding. 

 

53See GAO-01-749. 

54Under federal law, state Medicaid programs must inform all eligible Medicaid 

beneficiaries under age 21 of the availability of EPSDT services and the need for ageappropriate immunizations. State Medicaid programs also must provide EPSDT screening 

services when requested and arrange for necessary corrective treatment for conditions 

identified during screenings. 42 U.S.C. § 1396a(a)(43). 

Page 32 GAO-09-578 Medicaid Preventive Services
 

• Corrective action plans—upon which states must act, according to CMS 

officials—have included requirements for states to improve the process of 

informing beneficiaries, providers, and community partners about the 

support services available through Medicaid and how to access them, to 

develop an appropriate methodology to report data for the CMS 416, and 

to identify and implement strategies to increase vaccination of children 

against pneumonia. 

• Best practices that reviews have identified have included a statewide 

EPSDT outreach effort to ensure that beneficiaries are aware of the 

availability of Medicaid services, a dance program that addresses 

childhood obesity, and the provision of Medicaid instructions and written 

materials in a patient’s primary language. 

With the exception of reviews specifically focused on dental services, CMS 

conducted only 11 EPSDT program reviews between April 2001 and June 

2009, and few states with low participant ratios had been reviewed.55 For 

example, eight states reported participant ratios below 50 percent on all of 

their annual CMS 416 reports from fiscal years 2000 through 2007. Of those 

eight states, six had not had their EPSDT programs reviewed by CMS 

between April 2001 and June 2009.56 Although CMS has developed an 

EPSDT review guide to promote consistency, according to CMS officials 

there is no CMS directive or requirement for the CMS regional offices to 

perform these reviews, and CMS has not established criteria or a schedule 

for performing regular reviews. 

CMS oversight of preventive services for children in Medicaid also 

includes providing policy guidance to state Medicaid programs, such as 

through its State Medicaid Manual and other guidance; for example, CMS 

officials reported that they intend to draft guidance for states on coverage 

of obesity services as part of EPSDT services, but as of the time of our 

review had not done so. A 2006 study raised concerns that Medicaid 

 

55In 2007 through 2008, CMS conducted 17 reviews that were specifically focused on 

EPSDT dental services for children. These reviews have resulted in numerous 

recommendations to states, with regard to issues such as providing information about the 

importance and availability of dental services, reimbursing pediatricians and other nondentists who provide oral health services, and establishing incentives to encourage dental 

students to practice in areas of need. 

56Similarly, 30 states reported participant ratios below 50 percent on at least one of their 

CMS 416 reports for fiscal years 2000 through 2007; 6 of these 30 had their EPSDT program 

reviewed. 

Page 33 GAO-09-578 Medicaid Preventive Services
 

providers may not be aware to what extent obesity services were covered 

or reimbursed under EPSDT, and that states’ provider manuals did not 

often explain this coverage. For example, the study found that state 

Medicaid manuals did not specifically discuss coverage of nutritional 

counseling, and that states may not have been correctly compensating 

providers whose practices emphasized appropriate obesity interventions. 

The study recommended that states take several steps, including clarifying 

the proper coding and payment procedures for obesity prevention and 

treatment services.57 As of the time of our review, CMS officials told us 

that they intend to draft policy guidance to address these concerns and 

that the guidance would suggest methods for reporting and charging for 

obesity-related services, but that they had not yet begun drafting this 

guidance. 

For Adults in Medicaid, 

CMS Has Recognized the 

Value of Preventive 

Services and Provided 

Oversight by Issuing Some 

Related Guidance for State 

Medicaid Programs 

Unlike CMS’s oversight of children’s EPSDT services, CMS is not required 

to collect utilization data from states on adults’ receipt of services and—

according to officials—does not conduct program reviews as it does for 

EPSDT services for children in Medicaid. CMS has, however, issued 

guidance for state Medicaid programs through State Medicaid Director 

Letters (SMDL) on topics relevant to adult preventive services.58 For 

example, one letter issued in 2004 provided guidance on how states could 

cover certain services, known as disease management services, to manage 

chronic health conditions such as diabetes in their Medicaid programs and 

discussed how new disease management models could be implemented by 

states. As of March 2009, CMS had not issued similar coverage guidance on 

other recommended preventive services we reviewed for adults, such as 

obesity screening and intensive counseling. 

Although CMS has issued some guidance through SMDLs, several state 

Medicaid programs expressed that additional guidance could be helpful. In 

response to an open-ended survey question on support state Medicaid 

programs would like from CMS related to preventive services, 12 states 

reported they would like more technical assistance and guidance from 

 

57See “Policy Brief: Strategies for Improving Access to Comprehensive Obesity Prevention 

and Treatment Services for Medicaid-Enrolled Children.” Sara Wilensky, Ramona 

Wittington, and Sara Rosenbaum. School of Public Health and Health Services, Department 

of Health Policy, George Washington University, October 2006. 

58Through the SMDLs, CMS provides states with guidance and clarification on current 

information pertaining to Medicaid policy, Medicaid data issues, and CHIP issues. 

Page 34 GAO-09-578 Medicaid Preventive Services
 

CMS. For example, one state reported that the state would like 

clarification of restrictions to coverage of preventive services and another 

reported it would like advice on how to monitor improvements in 

utilization of preventive services. In addition, four states expressed 

interest in CMS sharing best practices of other states. As of March 2009, 

there were 24 promising practices for Medicaid and CHIP on the CMS Web 

site; 8 of these pertained to preventive services for adults. 

The prevalence of obesity and other health conditions among Medicaid 

beneficiaries nationally suggests that more can and should be done to 

ensure this vulnerable population receives recommended preventive 

services. Although Medicaid children generally are entitled to coverage of 

EPSDT services that may identify and address health conditions such as 

obesity, both national survey data and states’ 416 reports to CMS suggest 

that children’s receipt of EPSDT services is well below national goals. 

Further, providers may not understand that services to screen for and 

manage obesity are covered under EPSDT. State-specific reviews of 

EPSDT programs have helped identify needed improvements but too few 

have been done. For adults, states’ coverage of preventive services 

generally is not required, but USPSTF recommends certain preventive 

services for specific ages and risk groups, and such services can be 

covered by Medicaid if states choose to do so. National survey 

examination data suggest that the provision of recommended services 

could benefit adults in Medicaid, as 6 in 10 adults in Medicaid have one or 

more potentially preventable health conditions. 

Conclusions 

States and CMS have acted in recent years to improve the provision and 

monitoring of preventive services for the Medicaid population. CMS 

intends to develop policy guidance for obesity services for Medicaid 

children under EPSDT, though as of the time of our review, had not done 

so. However, gaps in provision of services remain. An estimated 41 percent 

of Medicaid children aged 2 through 20 participating in a nationally 

representative survey had not received a well-child check up during a 

2-year period, and receipt of recommended preventive services in the adult 

Medicaid population varied widely, depending on the service. Improved 

access to preventive services for Medicaid beneficiaries will take a 

concerted effort by the federal government and states. 

Page 35 GAO-09-578 Medicaid Preventive Services
 

Recommendations for 

Executive Action 

To improve the provision of preventive services to the Medicaid 

population, we recommend that the Administrator of CMS take the 

following two actions: 

• Ensure that state EPSDT programs are regularly reviewed to identify gaps 

in provision of EPSDT services to children and to identify needed 

improvements. 

• Expedite current efforts to provide policy guidance on coverage of 

obesity-related services for Medicaid children, and consider the need to 

provide similar guidance regarding coverage of obesity screening and 

counseling, and other recommended preventive services, for adults. 

We provided a draft of this report to HHS for comment, and CMS 

responded on behalf of HHS. (See app. IV.) CMS concurred with both of 

our recommendations, and commented that the agency recognizes the 

need for and the value of preventive services, and will remind states of the 

importance of ensuring that children receive a comprehensive well-child 

check up, and of the importance of providing preventive services to adults. 

Agency Comments 

• CMS agreed with our recommendation that the agency ensure state 

EPSDT programs are regularly reviewed. CMS committed to establishing a 

training program and protocol for the state reviews and technical 

assistance by the end of the year and also commented that it intends to 

conduct related efforts, including developing a comprehensive work plan 

to establish a regular schedule for reviewing state policy and 

implementation efforts and reviewing and revising the CMS 416. 

• CMS also agreed with our recommendation that the agency expedite 

efforts to provide guidance to states on coverage of obesity-related 

services for Medicaid children, and consider the need to provide similar 

guidance regarding coverage of obesity screening and counseling, and 

other recommended preventive services, for adults. CMS committed to 

providing guidance on obesity-related services for children through an 

SMDL by the end of the calendar year. CMS also highlighted the agency’s 

involvement in several initiatives related to childhood obesity at the 

national level and the agency’s support of the development of new 

Healthcare Effectiveness Data and Information Set measures that address 

obesity. 

CMS also provided technical comments, which we incorporated as 

appropriate. 

Page 36 GAO-09-578 Medicaid Preventive Services
 

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to the Secretary 

of HHS and other interested parties. In addition, the report will be 

available at no charge on GAO’s Web site at http://www.gao.gov. If you or 

your staff members have any questions about this report, please contact 

me at (202) 512-7114 or cackleya@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff members who made major contributions to 

this report are listed in appendix V. 

Sincerely yours, 

Alicia Puente Cackley 

Director, Health Care 

Page 37 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis Appendix I: NHANES Analysis 

The National Health and Nutrition Examination Survey (NHANES), 

conducted multiple times since the early 1960s by the Department of 

Health and Human Services’s (HHS) National Center for Health Statistics 

of the Centers for Disease Control and Prevention (CDC), is designed to 

provide nationally representative estimates of the health and nutrition 

status of the noninstitutionalized civilian population of the United States. 

NHANES provides information on civilians of all ages. Prior to 1999, three 

periodic surveys were conducted. Since 1999, NHANES has been 

conducted annually. For this study, we examined data from 1999 through 

2006 on children aged 2 through 20 and adults aged 21 through 64. We 

grouped NHANES data from 1999 through 2006 in order to include a 

sufficient number of survey participants to provide a reliable basis for 

assessing the extent of health conditions in the Medicaid population. To 

assess the reliability of NHANES data, we interviewed knowledgeable 

officials, reviewed relevant documentation, and compared the results of 

our analyses to published data. We determined that the NHANES data 

were sufficiently reliable for the purposes of our engagement. 

Our analysis of NHANES data focused on physical examinations and 

laboratory tests for a variety of health conditions. As part of an overall 

physical examination of survey participants, trained medical personnel 

generally obtain a blood sample and administer laboratory tests such as 

measurement of total blood cholesterol and glucose levels, obtain height 

and weight measurements, and conduct three or four blood pressure 

readings. To analyze these data, we considered two categories of survey 

participants based on their health insurance status at the time of the 

survey, as reported during the interview section of the survey: Medicaid 

beneficiaries and the privately insured.59 We do not present results for the 

uninsured, those with other forms of government health insurance, such 

as Medicare (we excluded adults enrolled in both Medicare and Medicaid), 

and those who provided no information on their health insurance status. 

For the 1999 through 2004 period, the NHANES Medicaid category for 

children includes some children enrolled in the State Children’s Health 

Insurance Program (CHIP). In the 2005 through 2006 NHANES data, 

children enrolled in CHIP can be differentiated from children enrolled in 

Medicaid, but we grouped these children together for consistency with the 

previous time period. We estimate that about 84 percent of these children 

 

59Health insurance status of children was reported by an adult in the household. Survey 

participants who reported both Medicaid and private insurance were included in the 

private insurance category. Survey participants who reported both Medicaid and Medicare 

insurance coverage were not included in the analysis. 

Page 38 GAO-09-578 Medicaid Preventive Services 
Appendix I: NHANES Analysis 

were enrolled in Medicaid with the remainder enrolled in CHIP between 

1999 and 2006.60

For children, we used the NHANES data to estimate the percentage who 

were obese, the percentage with high blood pressure, the percentage with 

high blood cholesterol, and the percentage of obese children who had not 

been diagnosed as overweight (see tables 1 and 2). 

• Obesity. NHANES data included measures of the height and weight of 

children aged 2 through 20. Obesity in children aged 2 through 19 was 

defined as having a body mass index (BMI) equal to or greater than 95th 

percentile of age and sex-specific BMI, based on CDC growth charts for 

the United States; obesity in children age 20 was defined as having a BMI 

of 30 or higher. Girls who were pregnant were not included in the obesity 

analysis. Children or their parents were also asked if the child had been 

diagnosed as overweight prior to participating in the survey.61

• High Blood Pressure. NHANES data included up to four blood pressure 

readings for children aged 8 through 20. We calculated average systolic 

 

60The NHANES category for adults could also include some adults enrolled in CHIP. In 

2007, GAO reported that in June 2006, there were 349,000 adults enrolled in CHIP. See 

GAO, State Children’s Health Insurance Program: Program Structure, Enrollment and 

Expenditure Experiences, and Outreach Approaches for States That Cover Adults, 

GAO-08-50 (Washington, D.C.: Nov. 26, 2007). 

61Parents of overweight children aged 2 through 11 years were asked, “Has a doctor or 

health professional ever told you that [child] was overweight?” Parents of those aged 12 

through 15 years were asked, “Has a doctor or health professional ever told [child] that 

he/she was overweight?” Those aged 16 through 20 years were asked, “Has a doctor or 

health professional ever told you that you were overweight?” Information was not collected 

from children under age 16 or their parents regarding whether they had been told by a 

health care professional about the child’s high blood pressure. Information was not 

collected from children under age 20 or their parents regarding whether they had been told 

by a health care professional about the child’s high cholesterol. 

Page 39 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

and diastolic blood pressure based on the second, third, and fourth 

readings.62 High blood pressure in children aged 8 through 17 was defined 

as equal to or greater than 95th percentile of age, height, and sex-specific 

average systolic or diastolic blood pressure, based on blood pressure 

tables from HHS’s National Heart, Lung, and Blood Institute. High blood 

pressure in children aged 18 through 20 was defined as having an average 

systolic blood pressure reading of 140 millimeters of mercury (mmHg) or 

higher, or having an average diastolic blood pressure of 90 mmHg or 

higher. 

• High Blood Cholesterol. NHANES data included measures of total blood 

cholesterol in children aged 6 through 20.63 High total blood cholesterol in 

children aged 6 through 20 was defined as greater than or equal to 200 

milligrams per deciliter (mg/dL). 

For adults aged 21 through 64, we used NHANES data to estimate the 

percentage who were obese, the percentage with high blood pressure, the 

percentage with high blood cholesterol, the percentage with diabetes, and 

the percentage with a combination of these conditions. We used CDC 

definitions of these health conditions. Of adults with each of these 

conditions, we also estimated the percentage who reported that their 

condition had not been diagnosed by a health care professional prior to 

the survey (see tables 3 and 4). 

• Obesity. NHANES examinations of adults included height and weight 

measurements. Obesity for adults was defined as having a BMI of 30 or 

higher (pregnant women were not included in the obesity analysis). 

• High Blood Pressure. NHANES examinations of adults included up to 

four blood pressure readings. Average systolic and diastolic blood 

 

62The systolic and diastolic blood pressure averages were calculated as described in the 

NHANES documentation: If only one blood pressure reading was obtained, that reading is 

the average. If there is more than one blood pressure reading, the first reading is always 

excluded from the average. If only two blood pressure readings were obtained, the second 

blood pressure reading is the average. If all diastolic readings were zero, then the average 

would be zero. Exception: If there is one diastolic reading of zero and one (or more) with a 

number above zero, the diastolic reading with zero is not used to calculate the diastolic 

average. If two out of three diastolic readings are zero, the one diastolic reading that is not 

zero is used to calculate the diastolic average. 

63NHANES surveys examined cholesterol in children aged 3 and older prior to the 2005 

survey and in children aged 6 and older in 2006. We therefore only used data for children 

aged 6 through 20 in our analysis. 

Page 40 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

pressure readings were calculated as described for children (see footnote 

62). High blood pressure for adults was defined as having an average 

systolic blood pressure reading of 140 mmHg or higher, having an average 

diastolic blood pressure reading of 90 mmHg or higher, or taking blood 

pressure lowering medication. 

• High Blood Cholesterol. NHANES laboratory tests for adults included 

measurement of blood cholesterol. High total blood cholesterol for adults 

was defined as 240 mg/dL or more. 

• Diabetes. A subsample of NHANES participants, those whose 

examination was scheduled in the morning, were asked to fast prior to 

having their blood drawn. Laboratory tests for this subsample of NHANES 

participants included measurement of fasting plasma glucose. Diabetes for 

adults was defined as fasting plasma glucose of 126 mg/dL or more, or 

having previously been diagnosed with diabetes. 

For all estimated percentages for children and adults, we calculated a 

lower and upper bound at the 95 percent confidence level (there is a 95 

percent probability that the actual percentage falls within the lower and 

upper bounds), of beneficiaries in each of the two insurance categories 

using raw data and the appropriate sampling weights and survey design 

variables. We used the standard errors of the estimates to calculate 

whether any differences between the two insurance groups were 

statistically significant at the 95 percent confidence level.64

 

64For adults, we also estimated the percentages after adjusting for age differences between 

the two health insurance groups. After adjusting for age, the prevalence differences 

between the two insurance groups widened by a few percentage points for each health 

condition we analyzed—the percentage of privately insured adults with each condition was 

about 1 to 2 percentage points lower, and the percentage of Medicaid adults with each 

condition was about 1 to 4 percentage points higher. 

Page 41 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

Table 1: Estimated Percentage of Children Aged 2 through 20 with Certain Health 

Conditions, by Health Insurance Status 

95 percent confidence 

interval 

Percentage 

Lower 

bound 

Upper 

bound

Obesity: all children (2-20) 

Private insurance 14.23a 12.88 15.59

Medicaid 17.77a15.63 19.90

Obesity: children 2-11 

Private insurance 12.62a10.99 14.25

Medicaid 15.47a13.15 17.79

Obesity: children 12-20 

Private insurance 15.84a14.13 17.55

Medicaid 22.08a 18.62 25.53

High blood pressure: all children (8-20) 

Private insurance 3.05 2.42 3.68

Medicaid 4.38 2.81 5.96

High blood pressure: children 8-11 

Private insurance 3.40 2.23 4.56

Medicaid 5.48 2.77 8.19

High blood pressure: children 12-20 

Private insurance 2.90 2.18 3.62

Medicaid 3.63 2.17 5.09

High blood cholesterol: all children (6-20) 

Private insurance 10.91 9.82 12.00

Medicaid 9.80 8.02 11.57

High blood cholesterol: children 6-11 

Private insurance 11.13 9.36 12.89

Medicaid 10.06 7.11 13.00

High blood cholesterol: children 12-20 

Private insurance 10.78 9.17 12.39

Medicaid 9.54 7.71 11.37

Source: GAO analysis of 1999 through 2006 NHANES data. 

Page 42 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

Notes: The Medicaid category included some children enrolled in CHIP. Of the total Medicaid and 

CHIP population of children, about 16 percent were enrolled in CHIP during the 1999 through 2006 

period. Obesity for children aged 2 through 19 was defined as having a BMI equal to or greater than 

95th percentile of age and sex-specific BMI, based on CDC growth charts for the United States. 

Obesity for children aged 20 was defined as having a BMI of 30 or higher. Girls who were pregnant 

were not included in the obesity analysis. NHANES measured blood pressure up to four times during 

its physical examination. For our analysis, we calculated the average of the blood pressure 

measurements and defined high blood pressure in children aged 8 through 17 as equal to or greater 

than 95th percentile of age, height, and sex-specific average systolic or diastolic blood pressure, 

based on blood pressure tables from HHS’s National Heart, Lung, and Blood Institute. For children 

aged 18 through 20 we defined high blood pressure as having an average systolic blood pressure 

reading of 140 mmHg or higher or having an average diastolic blood pressure of 90 mmHg or higher. 

Blood pressure was not measured in children younger than age 8. High blood cholesterol in children 

aged 6 through 20 was defined as equal to or greater than 200 mg/dL. Blood cholesterol was not 

measured in children younger than age 6 in the 2004 through 2005 NHANES or in children younger 

than age 3 in the 1999 through 2004 NHANES. 

a

The difference between the percentage for children covered by Medicaid compared to the 

percentage for children covered by private insurance is statistically significant at the 95 percent 

confidence level. 

Page 43 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

Table 2: Estimated Percentage of Obese Children Aged 2 through 20 Who Had Not 

Been Previously Diagnosed as Overweight, by Health Insurance Status 

95 percent confidence 

interval 

Percentage Lower bound Upper bound

All children (2-20) 

Private insurance 65.39a61.49 69.30

Medicaid 54.18a 48.09 60.26

Children 2-11 

Private insurance 76.02a71.32 80.72

Medicaid 58.44a50.95 65.93

Children 12-20 

Private insurance 56.97 51.79 62.15

Medicaid 48.57 39.16 57.99

Source: GAO analysis of 1999 through 2006 NHANES data. 

Notes: The Medicaid category included some children enrolled in CHIP. Of the total Medicaid and 

CHIP population of children, about 16 percent were enrolled in CHIP during the 1999 through 2006 

period. Parents of children aged 2 through 11 years were asked, “Has a doctor or health professional 

ever told you that [child] was overweight?” Parents of those aged 12 through 15 years were asked, 

“Has a doctor or health professional ever told [child] that he/she was overweight?” Those aged 16 

through 20 years were asked, “Has a doctor or health professional ever told you that you were 

overweight?” Obesity for children aged 2 through 19 was defined as having a BMI equal to or greater 

than 95th percentile of age and sex-specific BMI, based on CDC growth charts for the United States. 

Obesity for children age 20 was defined as having a BMI of 30 or higher. Girls who were pregnant 

were not included in the analysis. 

a

The difference between the percentage for children covered by Medicaid compared to the 

percentage for children covered by private insurance is statistically significant at the 95 percent 

confidence level. 

Page 44 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

Table 3: Estimated Percentage of Adults Aged 21 through 64 with Certain Health 

Conditions, by Health Insurance Status 

95 percent confidence 

interval 

Percentage Lower bound Upper bound

Obesity 

Private insurance 31.95a30.18 33.72

Medicaid 41.96a 36.99 46.93

High blood pressure 

Private insurance 23.21 21.84 24.57

Medicaid 26.68 22.78 30.58

High blood cholesterol 

Private insurance 16.31 15.19 17.42

Medicaid 18.87 15.14 22.60

Diabetes 

Private insurance 7.28a6.13 8.43

Medicaid 12.62a 8.43 16.82

One or more of the above conditions 

Private insurance 52.91 50.56 55.26

Medicaid 57.00 49.67 64.33

Source: GAO analysis of 1999 through 2006 NHANES data. 

Notes: Obesity for adults was defined as BMI of 30 or higher (pregnant women were not included in 

the obesity analysis). NHANES measured blood pressure up to four times during its physical 

examination. For our analysis, we calculated the average of the blood pressure measurements and 

applied CDC’s definition of high blood pressure for adults as having an average systolic blood 

pressure reading of 140 mmHg or higher, or having an average diastolic blood pressure reading 

of 90 mmHg or higher. Following CDC, we additionally included adults taking blood pressure lowering 

medication in this category. We also used CDC’s definitions of the other health conditions examined. 

High total blood cholesterol for adults was defined as 240 mg/dL or more. Diabetes for adults was 

defined as fasting plasma glucose of 126 mg/dL or more, or previously diagnosed with diabetes. 

Examination sampling weights were used for analyses of obesity, blood pressure, and blood 

cholesterol. Diabetes subsample weights were used for analyses of diabetes and one or more 

conditions. We also estimated the prevalence of these health conditions after adjusting for age 

differences between these two health insurance groups. After adjusting for age, the prevalence 

differences between the two insurance groups widened by a few percentage points for each health 

condition we analyzed—the percentage of privately insured adults with each condition was about 1 to 

2 percentage points lower, and the percentage of Medicaid adults with each condition was about 1 to 

4 percentage points higher. 

a

The difference between the percentage for adults covered by Medicaid compared to the percentage 

for adults covered by private insurance is statistically significant at the 95 percent confidence level. 

Page 45 GAO-09-578 Medicaid Preventive Services
Appendix I: NHANES Analysis 

Table 4: Of Adults Aged 21 through 64 Found to Have Health Conditions: Estimated 

Percentage Who Had Not Been Diagnosed by a Health Care Professional, by Health 

Insurance Status 

95 percent confidence 

interval 

Percentage Lower bound Upper bound

Obesity 

Private insurance 30.18 28.39 31.97

Medicaid 34.90 28.00 41.79

High blood pressure 

Private insurance 26.31 23.50 29.11

Medicaid 24.60 15.14 34.05

High blood cholesterol 

Private insurance 36.36 32.75 39.97

Medicaid 34.64 23.77 45.51

Diabetes 

Private insurance 23.71 17.56 29.86

Medicaid 16.71 6.50 26.91

One or more of the above conditions 

Private insurance 35.49 32.97 38.02

Medicaid 39.60 32.57 46.63

Source: GAO analysis of 1999 through 2006 NHANES data. 

Notes: Obesity for adults was defined as BMI of 30 or higher (pregnant women were not included in 

the obesity analysis). NHANES measured blood pressure up to four times during its physical 

examination. For our analysis, we calculated the average of the blood pressure measurements and 

applied CDC’s definition of high blood pressure for adults as having an average systolic blood 

pressure reading of 140 mmHg or higher, or having an average diastolic blood pressure reading 

of 90 mmHg or higher. Following CDC, we additionally included adults taking blood pressure lowering 

medication in this category. We also used CDC’s definitions of the other health conditions examined. 

High total blood cholesterol for adults was defined as 240 mg/dL or more. Diabetes for adults was 

defined as fasting plasma glucose of 126 mg/dL or more, or previously diagnosed with diabetes. 

Adults were asked if they had ever been told by a health care professional that they were overweight 

or had high blood pressure, high cholesterol, or diabetes. Examination sampling weights were used 

for analyses of obesity, blood pressure, and blood cholesterol. Diabetes subsample weights were 

used for analyses of diabetes and one or more conditions. No differences between health insurance 

groups were statistically significant at the 95 percent confidence level. 

Page 46 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses Appendix II: MEPS and NHIS Analyses 

The Medical Expenditure Panel Survey (MEPS), administered by the 

Department of Health and Human Services’s (HHS) Agency for Healthcare 

Research and Quality (AHRQ), collects data on the use of specific health 

services. We analyzed results from the MEPS household component, 

which collects data from a sample of families and individuals in selected 

communities across the United States, drawn from a nationally 

representative subsample of households that participated in the prior 

year’s National Health Interview Survey (NHIS, a survey conducted by the 

National Center for Health Statistics at the Centers for Disease Control 

and Prevention (CDC)). We pooled MEPS data from multiple years to yield 

sample sizes large enough to generate reliable estimates for the Medicaid 

subpopulation. Our analysis was based on data from surveys conducted in 

2003 through 2006, the most recent data available. We supplemented our 

MEPS analysis with analysis of data from the 2006 NHIS survey, which 

covered a question of interest that was not available in MEPS. It was 

possible to use one year of the NHIS data because the sample size is larger 

than MEPS. To determine the reliability of the MEPS and NHIS data, we 

spoke with knowledgeable agency officials and reviewed related 

documentation and compared our results to published data. We 

determined that the MEPS and NHIS data were sufficiently reliable for the 

purposes of our engagement. 

The MEPS household interviews feature several rounds of interviewing 

covering 2 full calendar years. MEPS is continuously fielded; each year a 

new sample of households is introduced into the study. MEPS collects 

information for each person in the household based on information 

provided by one adult member of the household. This information includes 

demographic characteristics, self-reported health conditions, reasons for 

medical visits, use of medical services including preventive services, and 

health insurance coverage. We analyzed responses to MEPS questions 

about children’s medical visits and children’s and adults’ receipt of 

preventive services. NHIS collects information about demographic 

characteristics, health conditions, use of medical services, and health 

insurance coverage. We analyzed responses to an NHIS question on adults’ 

receipt of a diabetes screening test.65 As with the National Health and 

Nutrition Examination Survey (NHANES) data described in appendix I, we 

analyzed results for children under age 2166 and adults aged 21 through 64, 

 

65MEPS interviews from 2003 through 2006 included a section on diabetes, but did not 

include a question on screening tests for diabetes. 

66Information was not always available on receipt of services for children younger than 2 or 

older than 17. 

Page 47 GAO-09-578 Medicaid Preventive Services 
Appendix II: MEPS and NHIS Analyses 

divided into two categories on the basis of their health insurance status. 

Unless noted, we used age and insurance status variables that were 

measured during the same interview as the questions about preventive 

services.67 Similar to NHANES, the Medicaid category in MEPS included 

children enrolled in the State Children’s Health Insurance Program 

(CHIP). We estimate that 82 percent were enrolled in Medicaid with the 

remainder enrolled in CHIP between 2003 and 2006. Our NHIS analysis 

was limited to adults. 

For children, we analyzed data for several different MEPS questions to 

examine children’s receipt of well-child check ups and specific preventive 

services (see tables 5 and 6). 

• Well-Child Check Up. The MEPS survey included questions about office 

based and outpatient medical visits for children aged 0 through 20. We 

considered a medical visit to be a well-child check up if the visit was in 

person and if the respondent reported that the reason for the visit was 

either: a well-child check up, a general examination, or shots and 

immunizations. Using sampling weights, for each health insurance 

category, we estimated the percentage of children aged 2 through 20 at the 

end of the survey’s 2-year period who had received one or more well-child 

check ups during the survey’s 2-year period. We used insurance status 

variables that were measured at the end of the survey’s 2-year period. We 

used MEPS longitudinal weights to facilitate this analysis of medical visits 

that occurred during the 2-year survey period. The pooled 2-year survey 

periods analyzed were 2003 through 2004, 2004 through 2005, and 2005 

through 2006. 

• Blood Pressure Test. MEPS included questions about whether children 

aged 2 through 20 had their blood pressure measured by a doctor or health 

care professional, and if so, how long ago.68 Using sampling weights, we 

 

67Individuals were categorized based on their health insurance status at one point in time, 

and health insurance status was not necessarily constant during the time periods over 

which we examined their receipt of services. Our analysis shows whether individuals 

enrolled in Medicaid and private insurance at a given point of time were in need of 

preventive services. When we compared our analysis of well-child check ups to an analysis 

that only included children who were consistently enrolled in Medicaid and private 

insurance during the entire period we examined, we did not find significant differences in 

results. 

68Separate questions were asked for children 2 through 17 and individuals aged 18 and 

older. We combined responses for children aged 2 through 17 with responses for those 

aged 18 through 20. 

Page 48 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

estimated the percentage of children in each health insurance category 

that had their blood pressure measured during the 2 years prior to the 

question being asked. 

• Diet or Exercise Advice. MEPS included questions about whether 

children aged 2 through 17 had (1) received advice about eating healthy 

from a doctor or health care professional, and if so, how long ago, and (2) 

received advice about exercise, sports, or physically active hobbies from a 

doctor or health care professional, and if so, how long ago. Using sampling 

weights, we estimated the percentage of children in each health insurance 

category that had received advice about either a healthy diet or exercise, 

during the 2 years prior to the question being asked. 

• Height and Weight Measurement. MEPS included questions about 

whether children aged 0 through 17 had (1) had their height measured by a 

doctor or health care professional, and if so how long ago; and (2) had 

their weight measured by a doctor or health care professional, and if so, 

how long ago. Using sampling weights, we estimated the percentage of 

children in each health insurance category that had both their height and 

their weight measured during the two years prior to the question being 

asked. Height and weight were not necessarily measured at the same time, 

and these measurements did not necessarily take place in the context of a 

body mass index (BMI) calculation or obesity screening. 

For adults aged 21 through 64, we analyzed data for several different 

MEPS questions that related to receipt of recommended preventive 

services69 (see table 7). It was not possible to determine whether 

respondents received these services for screening purposes, as 

recommended by the United States Preventive Services Task Force 

 

69The United States Preventive Services Task Force (USPSTF) assesses scientific evidence 

regarding the effectiveness of a broad range of preventive services to address clinical 

categories such as cancer, heart and vascular diseases, infectious diseases, injury and 

violence, and metabolic, nutritional, and endocrine conditions. USPSTF recommendations 

for adult preventive services that were in effect as of March 2009 included: blood pressure 

tests for all adults; cholesterol tests for men aged 35 and older and adults aged 20 and older 

with risk factors for coronary heart disease; obesity screening for all adults, including 

intensive counseling and behavioral interventions to promote sustained weight loss for 

obese adults; intensive diet counseling for adults with high cholesterol; diabetes screening 

for adults with high blood pressure; cervical cancer screening for sexually active women; 

mammography for women aged 40 and older; and colorectal cancer screening for adults 

aged 50 through 75. The USPSTF also recognizes the importance of immunizations in 

primary disease prevention, but does not review new evidence on immunizations in order 

not to duplicate the work of the CDC’s Advisory Committee on Immunization Practices 

(ACIP). ACIP recommends influenza immunization for adults aged 50 and older. 

Page 49 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

(USPSTF), as opposed to receiving them for purposes of diagnosing a 

suspected health condition. Nevertheless, the estimates are useful in 

indicating the maximum percentages of adults who may have received 

certain recommended preventive services. For example, if 40 percent of 

adults aged 50 through 64 reported receiving a colorectal cancer 

screening, some may have received the screen for diagnostic purposes 

after experiencing symptoms of colorectal cancer. Regardless, in this 

example, 60 percent of adults in this age range—for whom colorectal 

cancer screening is recommended by the USPSTF—did not receive a 

colorectal cancer screening for any reason. 

• Blood Pressure Test. MEPS included questions about whether adults 

had their blood pressure measured by a doctor or health care professional, 

and if so, how long ago. Using sampling weights, we estimated the 

percentage of adults aged 21 through 64 in each health insurance category 

who reported that they had their blood pressure measured during the 

2 years prior to the question being asked. 

• Cholesterol Test. MEPS included questions about whether adults had 

their cholesterol tested by a doctor or health care professional, and if so, 

how long ago. Using sampling weights, we estimated the percentage of 

adults in each health insurance category for whom a cholesterol test was 

recommended, who reported that they had their cholesterol tested during 

the five years prior to the question being asked. USPSTF recommends 

cholesterol tests for men aged 35 and older, and men and women aged 20 

and older with health conditions that are risk factors for heart disease. We 

used available information about risk factors for heart disease that was 

self-reported by survey participants to determine whether a cholesterol 

test was recommended on this basis; these risk factors were diabetes, high 

blood pressure, or BMI greater than or equal to 30. 

• Mammogram. MEPS included questions about whether women had a 

mammogram, and if so, how long ago. Using sampling weights, we 

estimated the percentage of women aged 40 through 64 in each health 

insurance category who reported that they had a mammogram during the 

2 years prior to the question being asked. 

• Cervical Cancer Screening.

70 MEPS included questions about whether 

women had a cervical cancer screening, and if so, how long ago. Using 

 

70In this report, we use the term cervical cancer screening to refer to a Pap test. MEPS 

questions used the term Pap test. 

Page 50 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

sampling weights, we estimated the percentage of women aged 21 through 

64 in each health insurance category who had not reported having a 

hysterectomy and who reported that they had a cervical cancer screening 

during the 3 years prior to the question being asked. 

• Colorectal Cancer Screening. MEPS included questions about whether 

adults had a colonoscopy, a sigmoidoscopy, or a stool test, and if so, how 

long ago. Using sampling weights, we estimated the percentage of adults 

aged 50 through 64 in each health insurance category who reported that 

they had ever had one of these tests. 

• Influenza Immunization. MEPS included questions about whether 

adults had received a flu shot, and if so, how long ago. Using sampling 

weights, we estimated the percentage of adults aged 50 through 64 in each 

health insurance category who reported that they had a flu shot during the 

year prior to the question being asked. 

• Diet or Exercise Advice. MEPS included questions about whether adults 

had received advice from a doctor or health care professional to (1) eat 

fewer high fat or high cholesterol foods, or (2) exercise more. Using 

sampling weights, we estimated the percentage of adults aged 21 through 

64 in each health insurance category, whose self reported height and 

weight corresponded to a BMI of 30 or higher, who reported that they had 

ever received either diet or exercise advice. This type of advice does not 

fulfill the USPSTF recommendation that obese adults receive sustained 

intensive obesity counseling, but it provides an indicator of the maximum 

proportion of adults who could have received such counseling. 

• Diabetes Screening. MEPS interviews from 2003 through 2006 did not 

ask about adults’ receipt of diabetes screening tests, but the 2006 NHIS 

did; adults who had not previously been diagnosed with diabetes were 

asked if they had been tested for high blood sugar or diabetes in the last 3 

years. Using NHIS sampling weights, we estimated the percentage of 

adults aged 21 through 64 in each health insurance category, who reported 

having high blood pressure and who reported that they had received a 

screening test for diabetes during the 3 years prior to answering the 

question. USPSTF recommends diabetes screening for adults with high 

blood pressure. 

For all estimated percentages for children and adults, we calculated a 

lower and upper bound at the 95 percent confidence level using the 

appropriate sampling weights and survey design variables. We used the 

standard errors of the estimates to calculate if any differences between the 

Page 51 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

insurance groups were statistically significant at the 95 percent confidence 

level. 

Table 5: Estimated Percentage of Children Who Received a Well-Child Check Up 

During a 2-Year Period, by Health Insurance Status 

95 percent confidence 

interval 

Percentage Lower bound Upper bound

All children (2–20) 

Private insurance 63.66 60.65 66.67

Medicaid 59.25 55.50 63.01

Children 2-4 

Private insurance 86.65a 82.63 90.67

Medicaid 77.54a71.45 83.64

Children 5-7 

Private insurance 70.02a64.52 75.51

Medicaid 59.81a 53.15 66.48

Children 8-10 

Private insurance 53.03 46.52 59.53

Medicaid 52.02 44.43 59.61

Children 11-13

Private insurance 59.99 53.03 66.95

Medicaid 59.63 51.35 67.92

Children 14-16 

Private insurance 65.17 58.53 71.82

Medicaid 51.49 44.30 58.68

Children 17-20 

Private insurance 53.06 47.18 58.95

Medicaid 45.92 37.15 54.68

Source: GAO analysis of 2003 through 2006 MEPS data. 

Notes: The Medicaid category included some children enrolled in CHIP. Of the total Medicaid and 

CHIP population of children, about 18 percent were enrolled in CHIP during the 2003 through 2006 

period. Age ranges refer to children’s ages at the end of the 2-year period analyzed. The pooled set 

of 2-year periods analyzed were calendar years 2003 through 2004, 2004 through 2005, and 2005 

through 2006. Medical visits were considered well-child check ups if the reason given for the visit was 

either a well-child check up, a general examination, or shots and immunizations. 

a

The difference between the percentage for children covered by Medicaid compared to the 

percentage for children covered by private insurance is statistically significant at the 95 percent 

confidence level. 

Page 52 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

Table 6: Estimated Percentage of Children Who Received Certain Preventive 

Services, by Health Insurance Status 

95 percent confidence 

interval 

Percentage 

Lower 

bound

Upper 

bound

Blood pressure test, within 2 years

Children aged 2-20

Private insurance 68.48a66.97 69.99

Medicaid 63.03a61.33 64.72

Diet or exercise advice, within 2 years

Children aged 2-17

Private insurance 53.95 52.16 55.74

Medicaid 52.27 50.59 53.94

Height and weight measured, within 2 years

Children aged 2-17

Private insurance 90.36a 89.23 91.50

Medicaid 88.16a87.05 89.28

Source: GAO analysis of 2003 through 2006 MEPS data. 

Note: The Medicaid category included some children enrolled in CHIP. Of the total Medicaid and 

CHIP population of children, about 18 percent were enrolled in CHIP during the 2003 through 2006 

period. 

a

The difference between the percentage for children covered by Medicaid compared to the 

percentage for children covered by private insurance is statistically significant at the 95 percent 

confidence level. 

Page 53 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

Table 7: Estimated Percentage of Adults Who Received Certain Preventive 

Services, by Health Insurance Status 

95 percent confidence 

interval 

Percentage 

Lower 

bound

Upper 

bound

Blood pressure test, within 2 years

Men and women aged 21-64

Private insurance 92.58 92.19 92.97

Medicaid 92.79 91.67 93.91

Cholesterol test, within 5 years

Men aged 35-64; men and women aged 

21-64 with risk factors for heart diseasea

Private insurance 85.34d84.57 86.11

Medicaid 76.89d 74.96 78.82

Cervical cancer screen, within 3 yearsb

Women aged 21-64, no hysterectomy

Private insurance 92.18d91.55 92.80

Medicaid 90.22d88.59 91.85

Mammogram, within 2 years

Women aged 40-64

Private insurance 80.09d 79.09 81.10

Medicaid 65.87d62.52 69.21

Colorectal cancer screen, ever

Men and women aged 50-64

Private insurance 56.21d54.79 57.63

Medicaid 41.23d 37.01 45.44

Influenza immunization, within 1 year

Men and women aged 50-64

Private insurance 36.66 35.45 37.87

Medicaid 37.17 33.43 40.92

Diet or exercise advice, ever

Obese men and women aged 21-64c

Private insurance 65.65 64.51 66.79

Medicaid 63.65 60.76 66.54

Diabetes screen, within 3 years

Men and women aged 21-64 with high 

blood pressure, not previously diagnosed 

with diabetes

Private insurance 45.56d 42.99 48.14

Medicaid 32.57d26.23 38.90

Source: GAO analysis of 2003 through 2006 MEPS and 2006 NHIS data. 

Page 54 GAO-09-578 Medicaid Preventive Services
Appendix II: MEPS and NHIS Analyses 

Notes: Preventive services other than diabetes screening were examined using 2003 through 2006 

MEPS data. Diabetes screening was examined using 2006 NHIS data. Populations analyzed for each 

preventive service were based on USPSTF recommendations as of March 2009; these 

recommendations had been in effect as of 2003 or earlier. 

a

Risk factors for heart disease were based on available self reported health conditions of MEPS 

participants—high blood pressure, height and weight corresponding to a BMI of 30 or higher, and 

diabetes. 

b

MEPS questions use the term Pap test to refer to a cervical cancer screen. 

c

Obesity was defined as having a BMI of 30 or higher. 

d

The difference between the percentage for adults covered by Medicaid compared to the percentage 

for adults covered by private insurance is statistically significant at the 95 percent confidence level. 

Page 55 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Page 56 GAO-09-578 

Appendix III: State Medicaid Director Survey 

Results 

To gather information about state Medicaid programs’ coverage, oversight, 

and promotion of preventive services, we surveyed 51 state Medicaid 

directors (in the 50 states and the District of Columbia). The survey was 

conducted from October 29, 2008, through February 6, 2009. It included 

questions on the coverage of preventive services for adults, the methods 

used for oversight of preventive services for children and adults, including 

monitoring of utilization of specific services, utilization goals, including 

whether or not goals were being met, state promotion efforts and specific 

initiatives aimed at preventive services, and the federal support provided 

to state Medicaid programs for the provision of preventive services. Many 

of the survey questions asked state Medicaid directors to consider specific 

Medicaid populations such as children in Medicaid under age 21 or adults 

in Medicaid age 21 and over, or beneficiaries enrolled in managed care 

organizations (MCO) or fee-for-service (FFS). We developed the content of 

the survey based on interviews with officials from the Centers for 

Medicare & Medicaid Services (CMS) and state Medicaid programs, and a 

review of documents from CMS and external reports. Some content and 

changes were made after pre-testing with state Medicaid programs. 

Many of our survey questions focused on specific preventive services. For 

example, the survey included questions about states’ coverage for adults, 

and monitoring for adults and children, of several specific preventive 

services including well-child and well-adult check ups, health risk 

assessments, diabetes screening, cholesterol tests, cervical cancer 

screening, mammography, colorectal cancer screening, and influenza 

immunization.71 We asked about these specific preventive services because 

they were related to recommended preventive services and to the services 

we examined in our analysis of Medical Expenditure Panel Survey (MEPS) 

and National Health Interview Survey (NHIS) data (see appendix II). We 

did not ask about coverage of services for children because the children’s 

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit 

is required to be covered under Medicaid. 

To establish the reliability of our survey data, we spoke with 

knowledgeable agency officials in developing the survey, pre-tested the 

survey questions, and followed up with state Medicaid officials to achieve 

a 100 percent response rate. Survey responses were submitted 

electronically. In a few cases, when states gave responses that were 

 

71Monitoring questions regarding certain preventive services (for example, colorectal 

cancer screening) were not applicable for children. 

 Medicaid Preventive Services 
Appendix III: State Medicaid Director Survey 

Results 

unclear or signaled the question was not completed, we followed up with 

states to clarify their responses in order to ensure that their responses 

contained the most accurate and current information available. We 

determined that the data submitted by states were sufficiently reliable for 

the purposes of our engagement. 

Table 8: Number of State Medicaid Programs Reporting Covering Certain 

Preventive Services 

Service 

Number of 

states 

Cervical cancer screening for women aged 21-64a49

Mammography for women aged 40-64 48

Colorectal cancer screening for adults aged 50-64a47

Influenza vaccine for adults aged 50-64b46

Diabetes screening for adults aged 21-64 with high blood pressurec 43

Well-adult check up or health risk assessment for adults aged 21-64d39

Cholesterol test for men aged 35-64 and adults aged 21-64 with risk 

factors for heart diseasec

39

Intensive counseling to manage high cholesterol for adults aged 21-64 14

Intensive counseling to manage obesity for adults aged 21-64 13

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

a

One other state Medicaid program reported that this service was not covered under FFS but was 

covered by MCOs. 

b

Two other state Medicaid programs reported that this service was not covered under FFS but was 

covered by MCOs. 

c

Three other state Medicaid programs reported that this service was not covered under FFS but was 

covered by MCOs. 

d

Well-adult check ups or health risk assessments for adults, while not explicitly recommended by the 

USPSTF, provide an opportunity for delivering recommended preventive services such as blood 

pressure tests and obesity screenings. Four other state Medicaid programs reported that this service 

was not covered under FFS but was covered by MCOs. 

Page 57 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 9: Number of State Medicaid Programs Reporting Covering Services to Manage Identified Health Conditions 

Service 

Nutrition 

assessment and 

counseling 

Condition-specific 

intensive 

counseling Medication

Equipment for 

monitoring and 

control Other

None of these 

are covered

High blood pressure 16 (31%) 14 (27%) 42 (82%) 16 (31%) 6 (12%) 5 (10%)

High cholesterol 17 (33%) 14 (27%) 42 (82%) 4 (8%) 6 (12%) 6 (12%)

Diabetes 25 (49%) 21 (41%) 43 (84%) 35 (69%) 7 (14%) 3 (6%)

Obesity 16 (31%) 13 (25%) 17 (33%) 4 (8%) 14 (27%) 11 (22%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Table 10: Information State Medicaid Programs Reported Reviewing to Monitor Utilization of Preventive Services 

Type of information 

Number of states 

reviewing information

CMS 416 reports 45 (88%)

Healthcare Effectiveness Data and Information Set (HEDIS) or HEDIS-like data 44 (86%)

External quality review reports 40 (78%)

Fee-for-service claims or encounter data 38 (75%)

Consumer Assessment of Healthcare Providers and Systems data 36 (71%)

Encounter data required to be provided by MCOs 34 (67%)

Contract deliverables of a Primary Care Case Manager or Administrative Services Organization 14 (27%)

Othera12 (24%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

a

Other information state Medicaid programs reported reviewing to monitor utilization of preventive 

services included vaccine and lead screening claims and pay for performance data. One state 

reported that they did not review information to monitor utilization of preventive services. 

Page 58 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 11: Number of State Medicaid Programs Reporting Monitoring Utilization of Specific Services for Adults and Children in 

Medicaid, by Service Delivery Model 

Service Children in MCOsaAdults in MCOsbChildren in FFScAdults in FFSd

Total number or receipt of any preventive service 32 (86%) 22 (59%) 26 (55%) 17 (35%)

Well-child or well-adult check up 33 (89%) 11 (41%) 26 (55%) 6 (20%)

Health risk assessment 15 (41%) 11 (65%) 9 (19%) 5 (21%)

Blood pressure test 10 (27%) 15 (44%) 1 (2%) 4 (8%)

Obesity screening 11 (30%) 6 (18%) 2 (4%) 3 (6%)

Cholesterol test 10 (27%) 21 (66%) 4 (9%) 9 (25%)

Diabetes screening 14 (38%) 24 (67%) 7 (15%) 10 (25%)

Cervical cancer screening 15 (41%) 26 (70%) 11 (23%) 15 (33%)

Influenza immunization – 9 (26%) – 10 (23%)

Mammography – 24 (67%) – 15 (33%)

Colorectal cancer screening – 12 (33%) – 10 (23%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Notes: Children were defined as Medicaid beneficiaries under age 21. Adults were defined as 

Medicaid beneficiaries aged 21 through 64. 

a

Limited to states that contract with MCOs to deliver services to some or all Medicaid children. 

b

Limited to states that contract with MCOs to deliver services to some or all Medicaid adults and that 

reported covering the service. 

c

Limited to states that use FFS to deliver services to some or all Medicaid children. 

d

Limited to states that use FFS to deliver services to some or all Medicaid adults and that reported 

covering the service. 

Page 59 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 12: Reasons Reported by State Medicaid Programs for Not Monitoring 

Utilization of Covered Preventive Services for Children, Beyond Federally Required 

Monitoring 

Reason Number of states that cited reason

Administrative burden 21 (41%)

Technology challenges 20 (39%)

Othera 17 (33%)

Data are unavailable 15 (29%)

Too expensive 9 (18%)

Not a top priority 7 (14%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Note: Children were defined as Medicaid beneficiaries under age 21. 

a

Other reasons state Medicaid programs reported for not monitoring utilization of preventive services 

included inadequate staff resources to monitor utilization of preventive services, providers are not 

required to submit clinical information which would be necessary to monitor utilization of preventive 

services, and MCOs have incomplete data or are not required to monitor utilization. 

Table 13: Reasons Reported by State Medicaid Programs for Not Monitoring 

Utilization of Covered Preventive Services for Adults 

Reason Number of states that cited reason

Administrative burden 27 (53%)

Technology challenges 22 (43%)

Othera 17 (33%)

Data are unavailable 15 (29%)

Do not cover services, therefore do not monitor 12 (24%)

Not a top priority 11 (21%)

Too expensive 9 (18%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Note: Adults were defined as Medicaid beneficiaries aged 21 through 64. 

a

Other reasons state Medicaid programs reported for not monitoring utilization of covered preventive 

services for adults included inadequate staff resources to monitor utilization of preventive services 

and that providers are not required to submit clinical information which would be necessary to monitor 

utilization of preventive services. 

Page 60 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 14: Number of State Medicaid Programs Reporting Utilization Goals for Certain Preventive Services for Children, and 

Whether Goals Were Being Met, by Service Delivery Model 

Service MCO goalsa

MCO goals: 

meeting goalsb

FFS goalsc

FFS goals: 

meeting goalsd

Total number or receipt of any preventive service 19 (51%) 15 (79%) 11 (23%) 6 (55%)

Well-child or well-adult check up 25 (68%) 17 (68%) 16 (34%) 6 (38%)

Health risk assessment 7 (19%) 6 (86%) 5 (11%) 2 (40%)

Blood pressure test 4 (11%) 3 (75%) 3 (6%) 2 (67%)

Obesity screening 4 (11%) 3 (75%) 2 (4%) 1 (50%)

Cholesterol test 6 (16%) 5 (83%) 1 (2%) 1 (100%)

Diabetes screening 7 (19%) 5 (71%) 1 (2%) 1 (100%)

Cervical cancer screening 9 (24%) 5 (56%) 2 (4%) 0 (0%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Note: Children were defined as Medicaid beneficiaries under age 21. 

a

Limited to states that contract with MCOs to deliver services to some or all Medicaid children. 

b

Limited to states that contract with MCOs to deliver services to some or all Medicaid children and 

that reported setting goals for MCOs. 

c

Limited to states that use FFS for some or all Medicaid children. 

d

Limited to states that use FFS for some or all Medicaid children, and that reported setting goals for 

FFS. 

Page 61 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 15: Number of State Medicaid Programs Reporting Utilization Goals for Certain Preventive Services for Adults, and 

Whether Goals Were Being Met, by Service Delivery Model 

Service MCO goalsa

MCO goals: 

meeting goalsb

FFS goalsc

FFS goals: 

meeting goalsd

Total number or receipt of any preventive service 16 (43%) 12 (75%) 2 (4%) 0 (0%)

Well-child or well-adult check up 11 (32%) 9 (82%) 2 (6%) 0 (0%)

Health risk assessment 7 (25%) 5 (71%) 2 (7%) 1 (50%)

Blood pressure test 9 (26%) 7 (78%) 1 (3%) 1 (100%)

Obesity screening 2 (6%) 2 (100%) 0 (0%) 0 (0%)

Cholesterol test 12 (38%) 9 (75%) 4 (11%) 2 (5%)

Diabetes screening 14 (39%) 10 (71%) 4 (10%) 1 (25%)

Cervical cancer screening 15 (41%) 11 (73%) 4 (9%) 0 (0%)

Influenza immunization 3 (9%) 2 (67%) 5 (12%) 4 (80%)

Mammography 16 (44%) 1 (69%) 5 (11%) 1 (20%)

Colorectal cancer screening 6 (17%) 4 (67%) 1 (2%) 0 (0%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Notes: Limited to states that reported covering the service for adults. Adults were defined as Medicaid 

beneficiaries aged 21 through 64. 

a

Limited to states that contract with MCOs to deliver services to some or all Medicaid adults. 

b

Limited to states that contract with MCOs to deliver services to some or all Medicaid adults and that 

reported setting goals for MCOs. 

c

Limited to states that use FFS for some or all Medicaid adults. 

d

Limited to states that use FFS for some or all Medicaid adults, and that reported setting goals for 

FFS. 

Page 62 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 16: Number of State Medicaid Programs Reporting Certain Barriers to Meeting Utilization Goals 

Barrier Number of states that cited barrier

Othera 34 (67%) 

Beneficiaries not concerned with preventive services 16 (31%)

Beneficiaries missing appointments 13 (25%)

Beneficiaries not able to get to appointments 6 (12%)

Insufficient state resources to raise payment rates to increase provider participation in 

Medicaid 

5 (10%)

There is not an adequate number of providers in general (to serve both Medicaid and nonMedicaid populations) 3 (6 %)

There is not an adequate number of providers to serve the Medicaid population 2 (4%)

Insufficient state legislative support to provide support services that would make it easier for 

beneficiaries to access services 

1 (2%)

Insufficient state legislative support to increase coverage of services 0 (0%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

a

Other reported barriers included problems with provider performance and incorrect billing by 

providers. 

Page 63 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 17: Initiatives State Medicaid Programs Reported Having Implemented that Pertain to Either Managed Care or Fee-ForService Delivery Systems 

Initiative 

Targeted to 

pediatric 

providers

Targeted to 

providers of 

adult services Not applicable

Increase payment rates for office visits and/or specific preventive services 37 (73%) 31 (61%) 10 (20%)

Streamline provider enrollment process 20 (39%) 20 (39%) 23 (45%)

Streamline payment processing (including electronic billing) 29 (57%) 30 (59%) 16 (31%)

Offer electronic health records 7 (14%) 7 (14%) 37 (73%)

Utilize provider pay for performance program(s) 16 (31%) 14 (27%) 27 (53%)

Utilize health plan pay for performance program(s) 20 (39%) 20 (39%) 24 (47%)

Start a provider advisory panel 29 (57%) 23 (45%) 18 (35%)

Educate providers about covered preventive services 42 (82%) 30 (59%) 9 (18%)

Hire a primary care case management vendor or an administrative services 

organization 15 (29%) 17 (33%) 27 (53%)

Encourage providers to perform health risk assessments 20 (39%) 16 (31%) 26 (51%)

Other initiative(s) to increase provider participationa 15 (29%) 11 (22%) 24 (47%)

Other initiative(s) to increase provision of preventive servicesb 19 (37%) 12 (24%) 22 (43%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

a

Other reported initiatives to increase provider participation included forming relationships with 

provider associations or sending mailings to providers and EPSDT beneficiaries regarding lead 

screening and well check ups. 

b

Other reported initiatives to increase provision of preventive services included financial incentives for 

providers and MCOs that provide preventive services and pay for performance measures. 

Page 64 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 18: Number of State Medicaid Programs Reporting that Implemented Initiatives Had or Had Not Improved Provider 

Participation or Provision of Preventive Services 

Implemented Initiative 

Major 

improvement

Minor 

improvement 

No 

improvement Don’t know

Increase payment rates for office visits and/or specific 

preventive services 3 (8%) 14 (37%) 4 (11%) 15 (39%)

Streamline provider enrollment process 0 (0%) 7 (35%) 2 (10%) 9 (45%)

Streamline payment processing (including electronic billing) 5 (17%) 6 (20%) 2 (7%) 11 (37%)

Offer electronic health records 0 (0%) 0 (0%) 1 (14%) 6 (86%)

Utilize provider pay for performance program(s) 2 (11%) 8 (42%) 1 (5%) 7 (37%)

Utilize health plan pay for performance program(s) 6 (29%) 5 (24%) 2 (10%) 6 (29%)

Start a provider advisory panel 3 (10%) 8 (28%) 3 (10%) 13 (45%)

Educate providers about covered preventive services 3 (7%) 16 (38%) 0 (0%) 20 (48%)

Hire a primary care case management vendor or an 

administrative services organization 6 (35%) 2 (12%) 1 (6%) 6 (35%)

Encourage providers to perform health risk assessments 3 (15%) 6 (30%) 1 (5%) 8 (40%)

Other initiative(s) to increase provider participation 1 (7%) 4 (27%) 0 (0%) 5 (33%)

Other initiative(s) to increase provision of preventive services 3 (15%) 2 (10%) 0 (0%) 7 (35%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Note: Limited to states that reported having implemented the initiative. 

Page 65 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 19: Number of State Medicaid Programs Reporting Certain Initiatives Designed to Increase Medicaid Children’s and 

Adults’ Use of Preventive Services Since 2004, by Service Delivery Model 

Initiative 

Targeted to 

children in MCOsa

Targeted to 

adults in MCOsb

Targeted to 

children in FFSc

Targeted to 

adults in FFSd

Encourage use of preventive services through 

direct outreach (e.g., phone, mail) 31 (84%) 22 (59%) 32 (68%) 19 (40%)

Encourage use of preventive services through 

nonmonetary incentives 24 (65%) 18 (49%) 5 (11%) 4 (8%)

Encourage use of preventive services through 

monetary incentives 17 (46%) 16 (43%) 9 (19%) 8 (17%)

Encourage use of preventive services by 

reducing cost sharing 4 (11%) 4 (11%) 3 (6%) 2 (4%)

Promote medical home initiatives 25 (68%) 23 (62%) 25 (53%) 23 (48%)

Publicize or encourage/require health plans to 

publicize availability of preventive services for 

Medicaid beneficiaries 26 (70%) 22 (59%) 15 (32%) 8 (17%)

Provide case management services to follow up 

with beneficiaries after an initial diagnosis 25 (68%) 22 (59%) 16 (34%) 18 (38%)

Provide disease management programs 30 (81%) 32 (86%) 21 (45%) 28 (58%)

Promote healthy lifestyle choices such as 

exercise, nutrition, and tobacco cessation 30 (81%) 30 (81%) 23 (49%) 26 (54%)

Expand coverage of preventive services 9 (24%) 9 (24%) 7 (15%) 11 (23%)

Provide scheduling assistance 22 (59%) 17 (46%) 13 (28%) 10 (21%)

Provide childcare 1 (3%) 2 (5%) 0 (0%) 0 (0%)

Encourage doctors to provide evening 

appointments 18 (49%) 17 (46%) 11 (23%) 10 (21%)

Othere4 (11%) 5 (14%) 0 (0%) 1 (2%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Notes: Children were defined as Medicaid beneficiaries under age 21. Adults were defined as 

Medicaid beneficiaries aged 21 through 64. 

a

Limited to states that contract with MCOs to deliver services to some or all Medicaid children. 

b

Limited to states that contract with MCOs to deliver services to some or all Medicaid adults. 

c

Limited to states that use FFS to deliver services to some or all Medicaid children. 

d

Limited to states that use FFS to deliver services to some or all Medicaid adults. 

e

Other reported initiatives included translation services, pay for performance, and child care for 

pregnant women. 

Page 66 GAO-09-578 Medicaid Preventive Services
Appendix III: State Medicaid Director Survey 

Results 

Table 20: Number of State Medicaid Programs Reporting Certain Efforts Geared Specifically Toward Diagnosing and Treating 

Obesity, and Complications Related to Obesity, by Service Delivery Model 

Effort 

Targeted to 

children in MCOsa

Targeted to 

adults in MCOsb

Targeted to 

children in FFSc

Targeted to 

adults in FFSd

Promote weight reduction programs for Medicaid 

beneficiaries 13 (35%) 11 (30%) 4 (9%) 3 (6%)

Promote childhood obesity programs for Medicaid 

beneficiaries (either within specific counties or regions 

or throughout the state) 23 (62%) 3 (8%) 8 (17%) 3 (6%)

Educate providers to perform obesity screenings on 

Medicaid beneficiaries 26 (70%) 14 (38%) 12 (26%) 7 (15%)

Educate providers to offer obesity counseling as 

needed to Medicaid beneficiaries 23 (62%) 13 (35%) 9 (19%) 6 (13%)

Provide reimbursement information for nutrition 

assessment and counseling for obese adults in 

documentation for providers 9 (24%) 11 (30%) 7 (15%) 10 (21%)

Provide reimbursement information for nutrition 

assessment and counseling for overweight children in 

documentation for providers 13 (35%) 7 (19%) 9 (19%) 1 (2%)

Promote family-based obesity initiatives 9 (24%) 5 (14%) 3 (6%) 3 (6%)

Othere4 (11%) 2 (5%) 1 (2%) 1 (2%)

Source: GAO analysis of survey of state Medicaid directors, conducted between October 2008 and February 2009. 

Notes: Children were defined as Medicaid beneficiaries under age 21. Adults were defined as 

Medicaid beneficiaries aged 21 through 64. 

a

Limited to states that contract with MCOs to deliver services to some or all Medicaid children. 

b

Limited to states that contract with MCOs to deliver services to some or all Medicaid adults. 

c

Limited to states that use FFS to deliver services to some or all Medicaid children. 

d

Limited to states that use FFS to deliver services to some or all Medicaid adults. 

e

Other initiatives included development of body mass index performance measures and statewide 

public health initiatives that include, but are not limited to the Medicaid population. 

Page 67 GAO-09-578 Medicaid Preventive Services
Appendix IV: Comments from the Department Appendix IV: Comments from the of Health and Human Services 

Department of Health and Human Services 

Page 68 GAO-09-578 Medicaid Preventive Services 
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 69 GAO-09-578 Medicaid Preventive Services
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 70 GAO-09-578 Medicaid Preventive Services
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 71 GAO-09-578 Medicaid Preventive Services
Appendix V: 

A

GAO Contact and Staff 

cknowledgments 

Page 72 GAO-09-578 

Appendix V: GAO Contact and Staff 

Acknowledgments 

Alicia Puente Cackley, (202) 512-7114 or cackleya@gao.gov 

In addition to the individual named above, Katherine M. Iritani, Acting 

Director; Emily Beller; Susannah Bloch; Elizabeth Deyo; Erin Henderson; 

Martha Kelly; Teresa Tam; and Hemi Tewarson made key contributions to 

this report. 

GAO Contact 

Staff 

Acknowledgments 

 Medicaid Preventive Services 
Related GAO Products Related GAO Products 

Medicaid: Extent of Dental Disease in Children Has Not Decreased, and 

Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121. 

Washington, D.C.: September 23, 2008. 

State Children’s Health Insurance Program: Program Structure, 

Enrollment and Expenditure Experiences, and Outreach Approaches for 

States That Cover Adults. GAO-08-50. Washington, D.C.: November 26, 

2007. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 

Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007. 

Childhood Obesity: Factors Affecting Physical Activity. GAO-07-260R. 

Washington, D.C.: December 6, 2006. 

Childhood Obesity: Most Experts Identified Physical Activity and the 

Use of Best Practices as Key to Successful Programs. GAO-06-127R. 

Washington, D.C.: October 7, 2005. 

Medicaid Managed Care: Access and Quality Requirements Specific to 

Low-Income and Other Special Needs Enrollees. GAO-05-44R. 

Washington, D.C.: December 8, 2004. 

Medicare Preventive Services: Most Beneficiaries Receive Some but Not 

All Recommended Preventive Services. GAO-04-1004T. Washington, D.C.: 

September 21, 2004. 

Medicaid and SCHIP: States Use Varying Approaches to Monitor 

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

2003. 

Medicare: Most Beneficiaries Receive Some but Not All Recommended 

Preventive Services. GAO-03-958. Washington, D.C.: September 8, 2003. 

Medicare: Use of Preventive Services Is Growing but Varies Widely. 

GAO-02-777T. Washington, D.C.: May 23, 2002. 

Medicare: Beneficiary Use of Clinical Preventive Services. GAO-02-422. 

Washington, D.C.: April 10, 2002. 

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

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

Page 73 GAO-09-578 Medicaid Preventive Services
Related GAO Products 

Lead Poisoning: Federal Health Care Programs Are Not Effectively 

Reaching At-Risk Children. HEHS-99-18. Washington, D.C.: 

January 15, 1999. 

Medicaid Managed Care: Challenge of Holding Plans Accountable 

Requires Greater State Effort. GAO/HEHS-97-86. Washington, D.C.: 

May 16, 1997. 

Medicare: Provision of Key Preventive Diabetes Services Falls Short of 

Recommended Levels. T-HEHS-97-113. Washington, D.C.: April 11, 1997. 

(290706) Page 74 GAO-09-578 Medicaid Preventive Services
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