OIG Report: States, Feds Must Do More to Ensure Kids on Medicaid Get Essential Screenings

By Sean Miskell

The Medicaid program includes screening requirements intended to ensure that any developmental or medical issues children encounter are identified and addressed by health care providers. However, a new report from a federal watchdog finds that both the states and the federal government must do more to guarantee that children are receiving these important screenings.

Medical and developmental screenings are crucial for any child regardless of the nature of his or her health coverage. However, because Medicaid covers nearly half of all children under the age of six, whether or not the program is fulfilling this promise is critically important to the early development of young children.

Further, Medicaid’ package of benefits for children is particularly robust compared with other forms of coverage. Medicaid’s requirements include the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which are available to all children in Medicaid under the age of 21. The EPSDT package is comprehensive and viewed as the gold standard for kids by pediatricians. These services include screenings to address four related areas: medical, vision, hearing, and dental. Medical screenings are often called well-child or well-care visits. Screenings are a key part of the EPSDT package as they are the first step in ensuring access to other benefits. If you do not screen, you cannot diagnose or treat health and developmental problems as they arise. Last year, 32 million children were eligible for EPSDT benefits.

According to the Department of Health and Human Services, EPSDT benefits are intended, “to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. When children’s health problems are not diagnosed or treated, they not only require more costly treatment later but can inhibit healthy development in other areas as well. For example, hearing impairments can lead to other problems, such as stunted language development in young children. Similarly, vision problems can be evidence of serious, degenerative conditions, and can lead to delays in learning and social development. In this regard, children’s health, education, and social development are all inextricably linked, and all benefit from early screening and treatment.”

This is especially true for the low-income population that Medicaid serves. According to a report from the Urban Institute, while 26.4 percent of all children are at moderate or high risk of developmental, behavioral, or social delays, the risk rises to 33 percent for poor children.

States are not meeting federal goals for well-child screenings

In 2010, the Office of the Inspector General for the Department of Health and Human Services, a watchdog for the department, issued recommendations for how both states and the federal government could encourage more children enrolled in Medicaid to receive required well child visits and screenings. The report also set a goal that 80 percent of beneficiaries will receive EPSDT screenings. Only 63 percent did at the time. Unfortunately, an updated report from the watchdog found that only two states met this goal in 2013. Further, only 8 states had 80 percent participation at least once in between 2006 and 2013.

In addition to falling short of goals established by HHS at the national level, states vary greatly in terms of how many eligible Medicaid beneficiaries receive well-child visits and screenings. While many states showed improvement between 2006 and 2013, others did not. States must report data on a number of factors related to EPSDT benefits, and this table captures how states fared in terms of providing an initial screening to eligible children. (Source: Center for Medicare and Medicaid Services, Form CMS-416)

How the federal government has encouraged well-child screenings

The watchdog report notes that the federal government has worked to improve the number of Medicaid-eligible children that receive well-child screenings. The Center for Medicare and Medicaid Services (CMS) has convened a national EPSDT improvement workgroup, hired a contractor to help the workgroup gather data about participation in EPSDT, and published strategies about how to encourage participation in EPSDT screenings. CMS also initiated Birth to Five: Watch Me Thrive, a coordinated effort to encourage healthy child development and universal screenings for children across agencies within HHS and the Department of Education.

The federal government has also encouraged health care providers to provide well-child screenings to more children that are eligible for EPSDT benefits. Though services are not covered by Medicaid unless medically necessary, a service need not cure a condition to be covered under EPSDT. Rather, services are covered when they prevent a condition from worsening or prevent development of additional health problems.

More work to do

However, according to the watchdog report, both states and the federal government can do more to ensure that children with Medicaid coverage receive well-child screenings. First, not all children eligible for Medicaid are enrolled. The Affordable Care Act (ACA) both expanded Medicaid coverage (as long as states accept Medicaid expansion) and also produced a ‘welcome mat’ effect that encouraged those who were previously eligible but not enrolled to seek coverage – and many of my colleagues have written that the welcome mat will be greater in states that expand Medicaid.

In addition to enrollment, other barriers exist that can prevent children enrolled in Medicaid from receiving well-child screenings. As the Urban Institute notes, the ACA’s increased provider rates for primary care services are an important but temporary step. Although federal lawmakers have introduced legislation to extend the ‘primary care bump’ for doctors serving Medicaid beneficiaries, successful passage is far from certain. Numerous organizations recommend increased funding for interpretation and translation services to reach families that do not speak English. This is especially important in light of CCF’s recent report finding higher rates of insurance for Latino children compared with the national average.

States can also improve the rate at which Medicaid eligible children receive developmental screenings by collecting better data. In addition to finding that states are falling short of established goals for providing well-child screenings to children eligible for EPSDT, the HHS Inspector General Report highlighted the lack of availability and reliability of the data used to measure progress towards these goals. For example, data were not available for eight states as of the publication of the inspector general report. Also, while states must report some data on EPSDT services, they do not have to report information about vision or hearing screenings. While the Inspector General noted that collecting data on vision and hearing screenings would be helpful, doing is challenging due to a lack of standardized billing codes.

In addition, many states contract out Medicaid services through managed care companies. As Kaiser Health News reports, states with low levels of screenings, such as Ohio, have problems getting Medicaid managed care plans to report data on well-child screenings. Better supervision of managed care companies, including structuring contracts to incentivize well-child screenings, and more data reporting requirements may help more Medicaid-eligible children receive well-child screenings that can improve their health and development.