The Early Detection Program is implemented through cooperative agreements between the CDC and 68 grantees—health departments in the 50 states, the District of Columbia, and the 5 U.S. territories, as well as 12 American Indian/Alaska Native tribal organizations. The program funds breast and cervical cancer screening services for women who are uninsured or underinsured, have an income equal to or less than 250 percent of the federal poverty level (FPL), and are aged 40 through 64 for breast cancer screenings or aged 18 through 64 for cervical cancer screenings. Within these eligibility criteria, CDC prioritizes certain groups for screening and individual program grantees may target certain groups or broaden eligibility. Breast cancer screening consists of clinical breast exams and mammograms. Cervical cancer screening consists of pelvic exams and the Pap test. While screening services represent the core of the Early Detection Program, program providers must also provide diagnostic testing and follow-up services for women whose screening tests are abnormal. The CDC funds cannot be used to pay for treatment; however, for women diagnosed with breast or cervical cancer, program providers must provide referrals for appropriate treatment services and case management services, if determined necessary. The Early Detection Program, which was reauthorized by Congress in 2007, is funded through annual appropriations to the CDC. According to CDC officials, in fiscal year 2008, total funding for the program was approximately $182 million. To implement the program, the CDC solicits applications to select Early Detection Program grantees every 5 years. All grantees must submit an annual request for funding to CDC. According to CDC officials, annual budgets are awarded based on performance and other factors. By law, grantees must match every $3 in federal contribution with at least $1 in non-federal contribution. Grantee matching funds may support the screening or non-screening components of the program. At least 60 percent of the awarded funds must be used for direct clinical services; the remainder may be used for other program functions including program management, education, outreach, quality assurance, surveillance, data management, and evaluation. Some grantees have also acquired additional state or local resources for their programs. Early Detection Program grantees typically have a network of local providers such as community health centers and private providers that deliver the screening and diagnostic services to women. Under the Treatment Act states may extend Medicaid eligibility to women who are under age 65, uninsured, otherwise not eligible for Medicaid, and who have been (1) screened under the CDC-funded Early Detection Program and (2) found to be in need of treatment for breast or cervical cancer including precancerous conditions. All 51 states chose to implement this optional Medicaid eligibility category. In doing so they were required to provide full Medicaid coverage to eligible women screened under the Early Detection Program and found in need of treatment for breast or cervical cancer. States must provide Medicaid coverage for the period when the woman needs treatment for breast or cervical cancer. In guidance provided to states, CMS and CDC define “screened under the program” as, at a minimum, offering Medicaid eligibility to women whose clinical services under the Early Detection Program were provided all or in part with CDC funds. Accordingly, CDC officials stated that any state offering Medicaid coverage under the Treatment Act would be required, at a minimum, to offer coverage to women screened with CDC funds, provided the women met all other eligibility requirements. The guidance also allows states to use a broader definition of “screened under the program,” which includes extending Medicaid eligibility to (1) women screened by a CDC-funded provider within the scope of the state’s Early Detection Program, even if CDC funds did not pay for the particular service, or (2) women screened by a non– CDC-funded provider whom the state has elected to include as part of its Early Detection Program. The CDC’s Early Detection Program screened about half a million or more women for breast and cervical cancer annually from 2002 through 2006. In 2006, the program screened 579,665 women. There were 331,672 women screened with mammography and 4,026 breast cancers detected. There were 350,202 women screened with a Pap test and 5,110 cervical cancers and precursor lesions detected. Almost half of all women screened by the Early Detection Program in 2006 were screened by grantees in 10 states. (See app. II for information by grantee.) A number of factors determined how many women were screened by a grantee, including the CDC funding awarded, the availability of other resources, and clinical costs (for example, the use of more costly screening technologies such as digital mammography). Over the 5-year period from 2002 through 2006, the Early Detection Program screened 1.8 million low-income, uninsured women. About 1.1 million women were screened for breast cancer, and 18,937 breast cancers were detected. Similarly, about 1.1 million women were screened for cervical cancer, and 22,377 cervical cancers and precursor lesions were detected. The age and race of women screened reflect the Early Detection Program’s policies that prioritize breast cancer screening for women 50 to 64 years old and cervical cancer screening for women 40 to 64 years old. Thus, women who received a mammogram tended to be older, with 71 percent age 50 or older. Women who received a Pap test tended to be younger, with 55 percent under age 50. (See fig. 1.) The program also targets racial and ethnic minorities, who tend to have lower screening rates for breast and cervical cancer, so more than half the women screened were racial or ethnic minorities. (See fig. 2.) Most states extend Medicaid eligibility under the Treatment Act to more women than is minimally required—those whose screening or diagnostic services were paid for with CDC funds. As of October 2008, 17 states reported applying only this minimum definition in determining Medicaid eligibility under the Treatment Act. Of the states that extend eligibility, 15 states extend Medicaid eligibility to women served by a CDC-funded provider, whether or not CDC funds were used to pay for services. The remaining 19 states further extend eligibility to women who were screened and diagnosed by non-CDC-funded providers. (See fig. 5.) Seventeen states offer Medicaid eligibility only to women screened or diagnosed with CDC funds. Fifteen of these states require a woman to have received at least one CDC-funded screening or diagnostic service to be considered “screened under the program.” Two states, Florida and the District of Columbia, require that both the screening and diagnostic services be paid for with CDC funds for women to be eligible for Medicaid. Fifteen states extend Medicaid eligibility to women screened or diagnosed by a CDC-funded provider. In these states, women whose services were paid for with state or other funds, but delivered by a provider receiving some CDC grant funds, are considered eligible for Medicaid if they need treatment. This allows states that fund their Early Detection Programs above the contribution required to receive the CDC grant to extend eligibility to women screened by a program provider but with other funds. Nineteen states further extend Medicaid eligibility to women screened or diagnosed by a non-CDC-funded provider. Some of these states designate specific providers. For example, Iowa extends eligibility to women whose services were provided by Komen-funded providers. Other states consider women eligible for Medicaid under the Treatment Act if they were screened by any qualified provider. Among the states that limit Medicaid eligibility to women served only with CDC funds (17 states) or that extend eligibility to women served by a CDC- funded provider (15 states), some have alternate pathways to Medicaid eligibility for women initially screened or screened and diagnosed outside the Early Detection Program. In most of these states, women initially screened outside the program can qualify for Medicaid if they later receive their diagnostic services with CDC funds. Only four states reported they do not allow women who have been screened outside the program to receive diagnostic services under the program to qualify for Medicaid. In most of the states that limit Medicaid eligibility to women served with CDC funds or that extend eligibility to women served by a CDC-funded provider, once a woman who received her screening and diagnostic services outside the Early Detection Program is diagnosed with cancer, she cannot access Medicaid coverage under the Treatment Act. However, Early Detection Program directors in 6 of these states reported that women diagnosed outside the program can be rescreened under the program to qualify for Medicaid, and in 11 states women can qualify for Medicaid by receiving additional diagnostic services from a program provider. Although rescreening or providing additional diagnostic services is inefficient and may be medically unnecessary, program rules in some states require a woman to have received at least one CDC-funded service to qualify for Medicaid. Whether a woman can access Medicaid through one of these alternate pathways depends on her obtaining a referral and on the availability of funds and providers to deliver the additional screening and diagnostic services. In implementing the Treatment Act, most states reported they require a confirmed diagnosis of breast cancer, cervical cancer, or precancerous lesions to meet the requirement that women be in need of cancer treatment services. Two states, Missouri and New Hampshire, indicated that a woman may be enrolled in Medicaid in order to receive certain diagnostic procedures, such as a biopsy or magnetic resonance imaging. A third state, Oklahoma, indicated that an abnormal screening test alone met the standard of needing treatment and qualified a woman for Medicaid coverage. In Oklahoma, women with an abnormal mammogram or Pap test are enrolled in Medicaid for their diagnostic services, and Medicaid coverage ends if they are found to not have a cancer diagnosis. As of October 2008, 20 states had adopted presumptive eligibility—an option allowed by the Treatment Act—to help women get treatment sooner by provisionally enrolling them in Medicaid while their full application is being processed. Among the states that do not have presumptive eligibility, Early Detection Program directors reported that the average length of time it takes a woman to be enrolled once their application has been submitted did not exceed 30 days, with an overall state average of 9 days. In most states, whether or not they have adopted presumptive eligibility, a separate visit to the Medicaid office is not required for a woman to be enrolled in Medicaid under the Treatment Act.