Federal law specifies that the EPSDT benefit covers screening, vision, dental, and hearing services, as well as other Medicaid coverable services that are necessary to correct or ameliorate any conditions discovered through screening. The EPSDT benefit generally entitles beneficiaries to these services regardless of whether such services are covered in a state’s Medicaid state plan and regardless of any restrictions that the state may impose on coverage for adult services. The EPSDT screening component includes a wide range of preventive services, such as comprehensive child health assessments known as well-child screenings and age-appropriate blood lead screenings. Because EPSDT covers any medically necessary service that could be covered for adults in addition to the specified preventive screenings, the EPSDT benefit is generally more comprehensive than the benefits provided for adult beneficiaries. The federal government and states jointly share responsibility for implementing the EPSDT benefit. CMS, as part of its Medicaid oversight responsibilities, approves state Medicaid plans, which describe how the state administers its Medicaid program, including components related to the provision of EPSDT services. CMS also develops and issues general guidance to states about the EPSDT benefit, such as explanations of covered services and strategies for providing those services. Additionally, CMS has developed a goal for EPSDT, which is to assure that beneficiaries get the health care they need when they need it: the right care to the right child at the right time in the right setting. Further, CMS established performance measures, some with associated targets, to guide states’ implementation of EPSDT. For example, CMS set performance measures and performance measure targets as part of its Oral Health Initiative. CMS developed the performance measure targets to carry out statutory requirements, quality improvement efforts, and agency policy. (See table 1 for EPSDT performance measures that have associated targets.) States have flexibility, within federal parameters, to determine how EPSDT services are provided. For example, states are required to ensure that Medicaid-eligible beneficiaries and their families are aware of the EPSDT benefit and have access to required services, but states can choose whether to administer the benefit themselves or to oversee managed care organizations that are contracted to provide the benefit. States may also determine the frequency of screening services and communicate them through periodicity schedules that meet federal requirements. CMS uses various sources of information to oversee the EPSDT benefit, such as the CMS-416, the Child Core Set, and the Medicaid and CHIP Scorecard. States report information about the provision of select ESPDT services to CMS annually through the CMS-416 and measures on the Child Core Set. The CMS-416 provides CMS with basic information about EPSDT services, such as the participant ratio and number of beneficiaries receiving a preventive dental service. It includes the information necessary for CMS to assess states’ performance on the participant ratio and the screening ratio, among other things. The agency then can compare performance on the two ratios with the agency’s ESPDT performance measure targets. The Child Core Set provides CMS with information about the quality of health care provided to Medicaid and CHIP beneficiaries, and supports state efforts to improve health care quality and health outcomes. Child Core Set reporting becomes mandatory on an annual basis beginning with the state reports on fiscal year 2024. As of 2019, the Child Core Set included performance measures related to the provision of EPSDT services, such as well-child visits in the first 15 months of life. Because reporting is currently voluntary, states vary in the number of performance measures they choose to report. In fiscal year 2017, for example, 50 states and the District of Columbia voluntarily reported on at least one of the 27 Child Core Set performance measures, with states reporting a median of 18 Child Core Set performance measures. (See app. II for the information reported in the CMS-416 and Child Core Set.) As shown in table 2, there are both similarities and differences between the CMS-416 and Child Core Set. Since the Child Core Set performance measures include CHIP beneficiaries who may not be entitled to the EPSDT benefit, data from the Child Core Set are not directly comparable with reporting on the CMS- 416. In addition, CMS-416 data cover a longer period of time, as they are available from 1995, while Child Core Set data are available from 2011. CMS officials said that having more years of CMS-416 data helps identify trends in the provision of EPSDT services over a longer period of time than possible with the Child Core Set. On the other hand, CMS officials said it is difficult to compare states’ performance using the CMS- 416, because some performance measures are based on periodicity schedules, which vary state-to-state and over time. In contrast, the Child Core Set allows for more consistency in comparing data across states, because each state is expected to calculate performance measures in the same way. In June 2018, CMS published the first Medicaid and CHIP Scorecard, which includes performance measures about the provision of services to Medicaid and CHIP beneficiaries. The scorecard includes 17 performance measures related to the provision of EPSDT services, six of which are performance measures from the Child Core Set—and one of these six measures is derived from the CMS-416. In January 2019, CMS officials reported that the scorecard will be used to provide increased transparency about state Medicaid program administration and beneficiary health outcomes, and drive health care quality improvement across states. According to CMS officials, CMS envisions that the scorecard will be strengthened as state reporting of data through T-MSIS becomes more timely, accurate, and complete. CMS has been working since 2011 to implement T-MSIS as a replacement for some current reporting to improve and increase states’ reporting of Medicaid and CHIP data. CMS intends for T-MSIS to provide a national data repository to support federal and state Medicaid and CHIP program management, among other things. T-MSIS includes data not previously reported by states and is intended to improve Medicaid and CHIP program efficiency, in part, by allowing states to compare their data with other states’ data. T-MSIS includes data that can measure the provision of EPSDT services. According to CMS officials, T-MSIS also includes aspects designed to improve the accuracy of available state data. For example, states’ T-MSIS submissions undergo approximately 2,800 automated quality checks, which provide states with feedback on data format and consistency. As of January 2019, all 50 states and the District of Columbia were submitting data monthly, according to CMS, but T-MSIS data were not being used to create the CMS-416, Child Core Set, or the scorecard. Agency officials said research-ready files are in development and T-MSIS data are improving in quality over time with historical state resubmissions. According to our analysis of CMS-416 data for fiscal year 2017, millions of Medicaid beneficiaries received recommended EPSDT well-child screenings and preventive dental services. However, nearly as many eligible beneficiaries did not receive the various recommended screenings and services, and few states met CMS’s performance measure targets for EPSDT services. Additionally, while available data show that millions of blood lead screenings were performed, the total number of beneficiaries receiving blood lead screenings is unknown, because the data are incomplete. In fiscal year 2017, 20.2 million (59 percent) of the 34.2 million beneficiaries who should have received at least one recommended well- child screening received that screening, known as the participant ratio, according to our analysis of state-reported CMS-416 data. Additionally, our analysis indicates that the national participant ratio has declined 5 percentage points since fiscal year 2010. Three states met CMS’s participant ratio target of 80 percent in fiscal year 2017, as shown in figure 1. Our analysis also indicates that no more than four states met CMS’s participant ratio target in any one fiscal year from 2010 through 2017. (See app. III, table 6, for participant ratios in each state and nationally from fiscal years 2010 through 2017.) Our analysis also indicates that as beneficiaries age, they tend to receive fewer recommended well-child screenings, which results in lower participant ratios. (See fig. 2 for participant ratios and numbers of beneficiaries receiving and not receiving well-child screenings for each CMS-416 age group in fiscal year 2017.) CMS has issued a guide on serving older eligible beneficiaries, stating that regular preventive care visits can lead to early identification of health issues. CMS officials said the agency included measures focusing on these beneficiaries on the Child Core Set and Medicaid and CHIP Scorecard to recognize the importance of addressing these beneficiaries and to encourage states to focus on this population. CMS officials noted that some states have already taken steps to increase the number of well-child screenings that older eligible beneficiaries receive, for example, by partnering with schools. In fiscal year 2017, 18.3 million (48 percent) of the 38.3 million Medicaid beneficiaries aged 1 to 20 received a preventive dental service, according to our analysis of CMS-416 data. This is an increase from the 42 percent of beneficiaries receiving preventive dental services in 2011—the baseline year for measuring state progress toward CMS’s Oral Health Initiative targets—but less than CMS’s 52 percent national performance measure target. Our analysis also shows that from fiscal years 2011 through 2017, nine states met CMS’s performance measure target of a 10 percentage point increase in each state’s percentage of beneficiaries aged 1 to 20 receiving a preventive dental service. (See fig. 3 and table 8 in app. III for the percentage of beneficiaries aged 1 to 20 that received preventive dental services in each state and nationally from fiscal years 2011 through 2017.) Available data on blood lead screenings in the CMS-416 are incomplete and, as a result, do not provide information necessary to determine how many beneficiaries received the screenings. According to CMS’s November 2016 guidance, CMS-416 data do not accurately represent the number of beneficiaries receiving blood lead screenings. The CMS-416 data capture screenings paid for by Medicaid, but not those performed using funding from other sources, such as the Centers for Disease Control and Prevention. This could under-count the number of screenings performed. In addition, the blood lead screening data reported on the CMS-416 show how many screenings were performed, but do not identify the number of beneficiaries who received a blood lead screening. Our analysis of available CMS-416 data shows that in fiscal year 2017 states reported 2.0 million blood lead screenings for beneficiaries aged 12 through 24 months, and there were 4.6 million beneficiaries aged 12 through 24 months. CMS has regularly taken actions to use both the CMS-416 and the Child Core Set to improve the quality of information about the provision of EPSDT services. These actions have made the data reported about EPSDT services more complete and reliable. For example, CMS collects data annually from states on performance measures for both the CMS- 416 and the Child Core Set. (See table 3.) Additionally, CMS annually reviews the Child Core Set measures to determine whether measures need to be added, deleted, or revised. CMS also regularly provides technical assistance to states about data reliability, such as through its monthly Quality Technical Advisory Group. For example, during one group meeting, states shared challenges with reporting information about developmental screenings on the Child Core Set and suggestions for how to overcome these challenges. These actions are generally consistent with federal internal control standards regarding information and communication, which specify that management should use quality information to achieve the entity’s objectives. While CMS has taken actions to improve the quality of information about EPSDT, and agency officials said they regularly assess whether the information CMS collects on the CMS-416 is appropriate and useful for EPSDT oversight, CMS has not taken action, as needed, based on such assessments. For example, CMS has not added, removed, or amended any performance measures on the CMS-416 since 2010, even though officials acknowledge limitations in these measures. The participant ratio, for example, is dependent, in part, on a state’s chosen periodicity schedule, which means that the measure is not consistently defined across states. The screening ratio reflects the extent to which beneficiaries received the recommended number of well-child screenings during the year, but this information is aggregated and therefore cannot be used to determine whether individual beneficiaries received the recommended number of well-child screenings. Although federal law requires collecting certain information about the provision of EPSDT services, it provides the agency with flexibility to determine the form and manner in which data are collected and to set performance measures. For example, CMS could change the way states are required to calculate the participant ratio or the screening ratio, and could examine ways to do so to address the limitations that the agency has identified and improve the quality of information about the provision of EPSDT services. Because CMS has not taken action, as needed, based on assessments of the appropriateness of its CMS-416 performance measures, the agency cannot be sure that it has the information it needs to oversee state implementation of EPSDT. This is inconsistent with federal internal control standards regarding information and communication, which specify that management should identify information requirements in an iterative and ongoing manner and ensure information remains relevant. We have previously reported that results-oriented organizations set performance goals to define desired program outcomes and develop performance measures that are clearly linked to these performance goals and outcomes. CMS has taken steps to develop, assess, and use CMS-416 information to improve states’ performance in providing EPSDT services. For example, CMS has set performance measure targets for participant and screening ratios reported on the CMS-416, and CMS publishes state-level results of the participant and screening ratios. In addition, after identifying issues with calculating the performance measure and target for the permanent molar sealants, CMS removed them from the Oral Health Initiative. CMS also convenes affinity groups and technical advisory groups to provide assistance to states in improving performance, often centered on specific services, such as dental services. However, CMS and state Medicaid officials told us that CMS does not consistently (1) communicate CMS-416 performance measure targets to states, (2) evaluate state performance against performance measure targets, or (3) provide states with assistance in reaching performance measure targets. While it has not done so across all performance measure targets, CMS did take these actions regarding targets for preventive dental services as part of its Oral Health Initiative. For example, CMS communicated with states about the preventive dental service performance measure target after it developed the Oral Health Initiative; disseminated a national oral health strategy and published a review of eight states identifying innovative approaches in providing preventive dental services; and provided targeted outreach to states with the lowest performance on the preventive dental service performance measure. Improvements in the provision of dental services occurred in many states. For example, in 2013, CMS met with state Medicaid officials in Florida about improving the provision of preventive dental services. Five years later, the percentage of beneficiaries receiving preventive dental services had increased 18 percentage points. CMS has not taken action in other areas. For example: CMS does not communicate the participant and screening ratio targets. Officials from CMS and from each of our 16 selected states told us that CMS does not mention these targets in communications with states, including discussions related to performance improvement. CMS has not evaluated state performance in meeting the participant and screening ratio targets, nor has it provided focused assistance to states to resolve gaps in states’ performance in reaching these targets comparable to the assistance provided for the preventive dental screening performance measure as part of the Oral Health Initiative. CMS did not provide formal written notification to states when in March 2016 the agency informed participants in two meetings that CMS no longer planned to use the target for measuring states’ performance on the permanent molar sealants performance measure. The notification was not provided through an official policy document, such as an agency informational bulletin distributed to all states. Despite removing the target, CMS issued a technical assistance brief in March 2018 that referenced it, which could have led to confusion among state officials. With regard to the Child Core Set, CMS has not established any performance measure targets and agency officials were not able to provide information about plans for setting targets. CMS officials said that the CMS-416 will remain a part of its EPSDT oversight. However, because its information is not standardized across states, CMS plans to increasingly rely on the standardized Child Core Set data to assess and improve states’ performance on the provision of EPSDT services. CMS officials noted that it publishes median, top quartile, and bottom quartile information for each state for all the Child Core Set measures that are publicly reported. Officials further reported in June 2019 that CMS and states use these as performance benchmarks, with an aim of reaching the national median on these measures if not the top quartile. Reporting these data is an important step in ensuring better oversight of EPSDT. However, CMS has not developed fixed targets that explicitly track states’ progress in increasing beneficiaries’ receipt of EPSDT screenings and services. Using a median to assess states’ performance ensures that half the states will not meet this target, regardless of their individual performance. Further, CMS officials have not provided plans or timelines for when the Child Core Set would be used to help states achieve performance measure targets. CMS’s inaction regarding using the CMS-416 and Child Core Set to improve performance on the provision of EPSDT services limits the agency’s oversight and is inconsistent with federal internal control standards for monitoring, and practices of leading organizations. Federal internal control standards specify that management should (1) set performance measure targets in measureable, numeric terms; (2) communicate necessary information to achieve performance targets; (3) evaluate progress toward desired targets; and (4) take action to resolve identified issues. Without regularly using the CMS-416 and Child Core Set to improve the provision of EPSDT services, CMS is unable to identify whether state or federal efforts and policies are increasing the number of beneficiaries receiving EPSDT services. As a result, CMS’s oversight is limited and beneficiaries may not be receiving appropriate EPSDT services when they need them—CMS’s stated goal for EPSDT. (See table 4 for examples of actions CMS has and has not taken regarding using the CMS-416 and Child Core Set for improving the provision of EPSDT services.) CMS is unable to determine whether all eligible EPSDT beneficiaries are receiving blood lead screenings in accordance with CMS policy. As previously noted, CMS-416 data are incomplete, because they only include blood lead screenings paid for by Medicaid, and the form reports the number of screenings performed instead of the number of beneficiaries receiving screenings. State examples of collecting blood lead screening data Nebraska. Medicaid officials said that the state has developed a database with the Nebraska Health Information Initiative containing laboratory testing data. Treating providers and managed care organizations can access the database to determine whether a Medicaid beneficiary has received a blood lead screening. New Jersey. Medicaid officials said that it can be difficult to track blood lead screenings that are performed using funding from sources other than Medicaid; for example, those performed by the state health department. Officials said that they have been building a lead registry to capture data on lead screenings performed, regardless of how they are funded. New Jersey Medicaid officials said they collect data every 6 months on screenings not paid for by Medicaid and enter the data into the state’s blood lead registry. CMS has stated that screenings are important for identifying beneficiaries with elevated blood lead levels at as young an age as possible, because lead exposure can harmfully affect nearly every system of the body and cause developmental delays. According to a presidential task force on environmental health and safety risks to children, co-chaired by HHS, early identification of developmental delays allows providers and communities to intervene earlier to improve health outcomes. The presidential task force issued goals in December 2018 to reduce lead exposure and associated harms, including a goal to identify lead-exposed individuals and improve their health outcomes. Without complete information about blood lead screenings, CMS cannot identify the number of beneficiaries who have not received blood lead screenings. As a result, the agency may be unaware of beneficiaries with unidentified lead exposures. CMS issued guidance in 2016 to states on improving blood lead screening reporting, including correcting reporting errors and partnering with providers to ensure beneficiaries receive blood lead screenings. (See sidebar for examples of efforts states have taken to improve available data about blood lead screenings.) However, as of February 2019, the screening data remained incomplete, according to agency officials. CMS officials also told us they are currently in discussions with the Centers for Disease Control and Prevention about how to capture more complete information about Medicaid beneficiaries who are receiving blood lead screenings through programs funded by that agency. However, as of February 2019, CMS officials had not identified specific actions to gather this data. The lack of data is inconsistent with federal internal control standards, which specify that management should obtain relevant data from reliable sources based on identified information requirements, and use such data for effective monitoring. According to CMS, the results of recent pilot studies indicate that T-MSIS data can be used to replicate some information on the CMS-416 and Child Core Set. CMS officials said that the results also suggest that CMS may eventually be able to use T-MSIS data to produce the CMS- 416 and Child Core Set data, thus eliminating the need for states to report this information themselves separately. As previously noted, CMS intends for T-MSIS to both reduce the number of reports CMS requires states to submit and to provide more information to improve Medicaid oversight. CMS officials said that they were encouraged that the pilot studies to replicate portions of the CMS-416 and Child Core Set generally yielded positive results. For example, CMS was able to use T-MSIS to replicate the total number of Medicaid beneficiaries aged 20 and under eligible for EPSDT from the CMS-416 within 5 percent of state-reported values for eight of nine pilot states—which CMS officials viewed as a positive result. CMS officials noted some concerns with inaccurate state Medicaid eligibility data; for example, multiple dates of birth reported through T-MSIS for the same beneficiary. However, CMS officials believe the accuracy and completeness of T-MSIS data has improved since the pilot studies, which were conducted using data from 2015 and 2016. Regarding the Child Core Set, CMS was able to use T-MSIS to replicate some of the information, such as adolescent well-care visits, but not other information, such as emergency department visits. While CMS found generally positive results from the pilots, the agency has not developed a plan with time frames and interim milestones for when it will use state-reported T-MSIS data to produce the CMS-416 and Child Core Set data sets instead of states separately producing both T- MSIS data and the two data sets. In April 2019, CMS officials said that they were planning additional pilots beginning in fiscal year 2019 to replicate portions of the CMS-416 and the Child Core Set. However, CMS officials were unable to provide planned next steps, including time frames and interim milestones, for using T-MSIS data to replace the CMS-416 and Child Core Set. This is inconsistent with federal internal control standards related to using and communicating quality information to achieve objectives. Without a specific plan with time frames with interim milestones, CMS may miss opportunities to use T-MSIS data to streamline state reporting and better oversee states’ provision of EPSDT services. This limitation is similar to one we reported in December 2017 about the initial steps CMS had taken for using T-MSIS data. We found CMS was limited in using T-MSIS for its broader oversight efforts of state Medicaid programs, in part, due to the absence of an articulated plan and time frames. Under EPSDT, millions of Medicaid’s youngest beneficiaries received well-child screenings and dental services in fiscal year 2017; however, nearly as many of them did not. Further, existing data on blood lead screenings are incomplete and inaccurate, leaving CMS unaware of beneficiaries with unidentified lead exposures that can cause developmental delays. The EPSDT data collected—whether via the CMS- 416, Child Core Set, or T-MSIS—have the potential to improve CMS oversight of beneficiaries’ receipt of necessary services and screenings. However, CMS has not taken sufficient steps to help ensure the appropriateness of its state data collection, evaluations, and assistance; and its plans for new reporting, including time frames and interim milestones, are lacking. We are making the following six recommendations to CMS: The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states’ compliance as needed. (Recommendation 1) The Administrator of CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use, including adding, changing, or removing measures, or targets, and regularly communicating performance measures and targets to states. (Recommendation 2) The Administrator of CMS should conduct regular evaluations of state performance by comparing states’ performance measurement data with CMS’s EPSDT targets to identify gaps in states’ performance and areas for improvement. (Recommendation 3) The Administrator of CMS should assist states with planning needed improvements, including providing focused assistance, to resolve gaps in states’ performance in meeting CMS’s EPSDT targets. (Recommendation 4) The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the CMS-416 to improve EPSDT oversight and streamline state reporting. (Recommendation 5) The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the Child Core Set to improve EPSDT oversight and streamline state reporting. (Recommendation 6) We provided a draft of this report to HHS for comment, and its comments are reprinted in appendix IV. HHS also provided us with technical comments, which we incorporated in the report as appropriate. Overall, HHS concurred with three recommendations and did not occur with three recommendations. HHS concurred with our first recommendation that CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries and assist states with planning improvements to resolve gaps in states’ performance as needed. However, HHS stated that it would not be possible to obtain complete data on blood lead screenings, because some screenings are not paid for by Medicaid. In our report, we noted some state and CMS efforts to improve available data on blood lead screenings. We continue to believe CMS needs to take additional actions to collect accurate and complete data to oversee whether eligible EPSDT beneficiaries are receiving blood lead screenings in accordance with CMS policy. HHS did not concur with our second recommendation, which stated that CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use. HHS noted that it assesses the appropriateness of Child Core Set measures annually and may update existing measures based on that assessment, including measures on the CMS-416. We acknowledge CMS’s actions to assess the appropriateness of Child Core Set measures annually and update those measures as appropriate, and we found these actions generally consistent with federal internal control standards regarding information and communication. However, CMS has not taken action, as needed, related to any assessments of the CMS-416 performance measures, even though officials acknowledge limitations in these measures, such as the participant and screening ratios. HHS also stated that it may set targets in key areas as appropriate, and has done so as part of the Oral Health Initiative, but that HHS does not believe it would be productive at this time to set targets for every measure. We are encouraged that HHS agreed that it may set targets in key areas as appropriate. This is consistent with our recommendation for CMS to regularly assess the appropriateness of its targets. Our recommendation does not assume that targets should be set for every measure—rather, that CMS needs to regularly assess the appropriateness of performance measures and targets for the EPSDT benefit and communicate them to states. HHS did not concur with our third recommendation, which stated that CMS should conduct regular evaluations of state performance by comparing states’ performance measurement data with CMS’s EPSDT targets. HHS stated that it offers a wide range of technical assistance on quality improvement to help states address performance goals. HHS commented that it believes this is the most effective method of helping states identify and address areas for potential improvement. We acknowledge that CMS has provided states with technical assistance and individual state snapshots of selected Child Core Set measures over time. However, regular evaluations of states’ performance against appropriate EPSDT targets are necessary to help identify gaps in states’ performance and areas for improvement. HHS noted that states recently received snapshots about their performance on publicly reported Child Core Set measures for the past 5 years, through fiscal year 2017. According to HHS, the snapshots include information about a state’s performance on each measure relative to other states’ performance and highlights significant changes in a state’s performance for each measure. However, these snapshots include descriptions of all states’ performance—using medians, and top and bottom quartiles—which are subject to change over time. Moreover, because the median is the midpoint of all states’ performance, this target ensures that half of states will not meet it, regardless of their individual performance. A fixed target—or targeted improvement goal, such as the one developed as part of the Oral Health Initiative—would provide states with the opportunity to measure performance over prior years’ results, which is a more meaningful measure that all states can strive to achieve. HHS did not concur with our fourth recommendation, which stated that that CMS should assist states with planning needed improvements to resolve gaps in states’ performance in meeting EPSDT targets. HHS stated that it has developed national and state-specific improvement goals for children enrolled in Medicaid with respect to receipt of at least one preventive dental service and provided targeted technical assistance to the lowest performing states. In this report, we noted states’ progress in meeting targets once CMS developed a performance measurement target for preventive dental services, including actions to improve state performance. Developing additional targets on performance measures critical to beneficiaries’ health and well-being could help improve oversight of EPSDT. HHS also described other examples of targeted technical assistance to remedy gaps in states’ performance, which included working with states on improving their performance on certain Child Core Set measures and improving access to EPSDT services by better leveraging schools as settings for care. Such technical assistance could be valuable for CMS to provide to states after identifying gaps in states’ performance relative to EPSDT targets. Doing so would allow CMS to share additional strategies to help states plan and implement needed improvements. HHS concurred with our fifth and sixth recommendations that CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the CMS-416 and Child Core Set to improve EPSDT oversight and streamline state reporting. 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 to the Secretary of Health and Human Services, the Administrator of the Centers for Medicare & Medicaid Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributors to this report are listed in appendix V. Selected states used several types of practices to promote and facilitate the delivery of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, according to Medicaid officials in the 16 selected states we interviewed and profiles of these states created by the American Academy of Pediatrics. The practices selected states used included outreach and education, financial incentives, collaboration in EPSDT administration, and EPSDT service delivery initiatives, as shown in figure 4. States annually report information about Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services to the Centers for Medicare & Medicaid Services (CMS), through the Form CMS-416 and the Child Core Set. The CMS-416 provides basic information about EPSDT for Medicaid beneficiaries aged 20 and under, such as the participant ratio and number of beneficiaries receiving a preventive dental service. The Child Core Set provides CMS with information about the quality of health care provided to Medicaid beneficiaries and individuals aged 18 and under who are covered under the Children’s Health Insurance Program. In fiscal year 2024, annual reporting of the Child Core Set will become mandatory. As of 2019, the Child Core Set included performance measures related to the provision of EPSDT services, such as well-child visits in the first 15 months of life. Because Child Core Set reporting is currently voluntary, states vary in the number of performance measures they choose to report. In fiscal year 2017, for example, 50 states and the District of Columbia voluntarily reported on at least one of the 27 Child Core Set performance measures, with states reporting a median of 18 Child Core Set performance measures. Some information is only reported on the CMS-416 or Child Core Set, while other information— well-child visits, preventive dental services, and dental sealants—is reported on both CMS-416 and Child Core Set. (See table 5 for information reported on the CMS-416, the Child Core Set, or both.) Tables 6 through 8 present annual state-reported data from the Centers for Medicare & Medicaid Services’ (CMS) Form CMS-416 on the provision of selected Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services by state and nationally. Well-child screenings are presented from fiscal year 2010, the year in which the current reporting template was implemented, through fiscal year 2017, the most recent year for which data were available at the time of our review. Preventive dental services data are presented from fiscal year 2011, the baseline year for measuring states’ progress toward CMS’s Oral Health Initiative targets, through fiscal year 2017, the most recent year for which data are available. Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov. In addition to the contact named above, Karen Doran (Assistant Director), Peter Mangano (Analyst-in-Charge), Matthew Green, Erika Huber, Drew Long, Jennifer Rudisill, and Kelly Turner made key contributions to this report. Also contributing were Muriel Brown, Giselle Hicks, Erika Lessien, and Madeline Ross.

Summary: The EPSDT benefit is key to ensuring that Medicaid beneficiaries aged 20 and under receive periodic screening services, such as well-child screenings, and diagnostic and treatment services, such as physical therapy and eyeglasses, to correct or ameliorate conditions discovered during a screening. GAO was asked to examine the extent to which Medicaid beneficiaries aged 20 and under receive health care services under the EPSDT benefit. Among other things, GAO examined (1) what is known about the provision of EPSDT services based on CMS-required annual state reporting, and (2) CMS oversight of the EPSDT benefit. To do this, GAO analyzed annual state reporting data from fiscal years 2010 through 2017, the most current year data were available; CMS documentation; and federal internal control standards. GAO also interviewed CMS officials and Medicaid officials from 16 states selected, in part, on the variation in number of beneficiaries and geographic diversity. Approximately half of all Medicaid beneficiaries aged 20 and under received screenings and services recommended under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in fiscal year 2017, but nearly as many did not. For example, GAO's analysis of state-reported data found that about 59 percent of all beneficiaries (20.2 million) who should have received at least one recommended well-child screening received one. About 48 percent of beneficiaries aged 1 to 20 (18.3 million) received a preventive dental service in fiscal year 2017. Older beneficiaries tended to have lower rates of screening. Number of Medicaid Beneficiaries Receiving and Not Receiving Well-Child Screenings in Fiscal Year 2017, by Age Group The Centers for Medicare & Medicaid Services (CMS), the agency that oversees Medicaid, including EPSDT, has taken steps to improve the quality of information that states report about the provision of EPSDT services. CMS has also set some EPSDT performance measure targets for states; yet, the agency has not taken other steps to oversee the EPSDT benefit, such as collecting the data necessary to evaluate whether states are complying with CMS's policy for beneficiaries to receive a blood lead screening; taking action, as needed, based on assessments of the appropriateness of some performance measures, such as well-child screening measures; and using state-reported information to regularly evaluate states against CMS's EPSDT targets, or assisting states in planning improvements to meet the targets. Absent these steps, CMS's oversight is limited and beneficiaries may not be receiving appropriate EPSDT services when they need them. GAO is making six recommendations to CMS regarding its oversight of the EPSDT benefit, including collecting appropriate blood lead screening data; taking action, if needed, after assessing the appropriateness of performance measures and targets for EPSDT; and evaluating states' performance in meeting CMS's EPSDT targets. CMS agreed with three recommendations, but disagreed with three others regarding performance measures and targets. GAO maintains that these recommendations are valid, as discussed in this report.