Summary and Key Findings

The first five years of a child’s life are a period of rapid growth and development.  During this time, frequent check-ups are essential to monitor a child’s progress so that if a problem is identified an intervention can occur before things get worse.  Medicaid, a primary source of health care coverage for children, covers the vast majority of low-income children under age six. Most children in a majority of states experience Medicaid coverage through managed care, in which the state Medicaid agencies contract with health care insurers, called managed care organizations (MCOs), to provide health care for children covered by Medicaid for a fixed monthly payment. Medicaid law has strong, comprehensive child health protections that require states to ensure children receive the preventive screenings and medical care necessary to reach optimal development. Yet information on the performance of managed care for children, including the performance of specific MCOs, has historically been inconsistent or not easily accessible. This makes it challenging, if not impossible, to fully understand whether Medicaid is fulfilling its promise to support young children’s healthy development.

In researching MCO performance, we scanned the websites of 12 Medicaid managed care states to gauge transparency of enrollment, payment, and quality data specific to young children under age six. We conducted this research between January and September of 2024.

Among the 12 states we reviewed:

• Three state agencies posted MCO-specific enrollment data for young children; only one state (Ohio) provided additional stratification by race/ethnicity.
• One state agency (Ohio) posted Medicaid payments to MCOs for young children.
• Only Kansas posted data on the individual performance of MCOs in delivering the Medicaid pediatric benefit (EPSDT).
• The Child Core Set includes five measures specific to early childhood. None of the 12 states posted all five measures by MCO. Seven of the 12 states posted at least three of the five early childhood measures by MCO. Louisiana posted MCO-level Child Core Set measures stratified by race/ethnicity and rurality. 
• Only four of the 12 states posted MCO-level measures for young children on a child health dashboard. Six states posted consumer-facing MCO report cards that included measures specific to young children.
• None of the Fetal-Infant or Child Death Review reports in the 12 states included data related to individual Medicaid MCOs.

Table 1 summarizes the findings.

Table 1:  Summary Table: Public Facing, Medicaid MCO-Level Data on Children Under Age 6 in 12 States, September 2024

Six of the seven areas highlighted in Table 1—all but infant and child death reviews—fall under the responsibility of state Medicaid agencies. None of the 12 states posted MCO-level data on more than three of the six areas. This was especially notable given the political and geographic diversity of the states reviewed in this analysis.

Why does Medicaid MCO-level data matter to early childhood stakeholders? Transparency in plan measures for young children helps to elevate plan performance for children to inform possible policy, system, and plan changes necessary for improvement, including strengthened accountability for child health. Consumers, families, early childhood leaders and the general public need better information about how effectively individual MCOs are performing for their members—especially for young children, where early investments can have long-term public payoffs by preventing more costly services in later years. This allows them to hold individual MCOs and policymakers accountable for their responsibility to serve as the best stewards of public funds for children and families.  State Medicaid agencies have the added responsibility to ensure that consumers– in this case, parents of young children– have clear, accessible information available to help them make informed choices about their children’s health care.

New and upcoming federal policy changes, such as required state reporting of child health measures, will bring a renewed focus on managed care and children that may spur additional attention. To the extent that our findings are applicable to some or all of the remaining 30 Medicaid managed care states, there is ample room for state agencies to be far more transparent about the performance of individual MCOs with which they contract. Greater transparency, in turn, will help ensure that investments in the nation’s youngest children have their intended impact.

Introduction

The earliest years of a child’s life, starting before birth, play an outsized role in long-term physical and mental health. In these earliest months and years, young children experience the most rapid period of brain development, which can directly impact physical as well as mental well-being key to arriving at kindergarten ready to learn. Children who experience persistent and continuous threats in early life, such as unstable housing or poverty, are at greater risk of developing responses and coping mechanisms that can impact short- and long-term health outcomes. Yet the potential negative impacts of prolonged adversity during early life, including stress-associated conditions, need not be deterministic. Strong relationships with parents and other adult caregivers, served by a range of possible evidence-informed services, can help to mitigate or overcome the negative impacts of threats to positive early development. As such, some policymakers seek opportunities to more effectively serve young children and their families before small challenges become prolonged stresses that can interfere with optimal development.

Because the earliest months and years of life can be consequential to a child’s long-term health and well-being, attention on the role of the health care system in preventing and intervening early to optimize early development has grown alongside work toward more accountability in school readiness and maternal health.

I. Medicaid and Early Childhood Development

As the nation’s largest health insurer for children, Medicaid is central to the ability of the nation’s health care system to maximize early child development. Medicaid, along with the Children's Health Insurance Program (CHIP¹), covered 42 percent of all children under age six in 2022, including three quarters (76 percent) of young, low-income children (under 200% FPL, or $25,840 per year for a family of three). ²Medicaid also disproportionately covers young children of color who are more likely to be economically disadvantaged. In 2022, nearly two thirds of Black (66 percent) and American Indian/Alaska Native Children (64 percent) and more than half of Latino and multiracial children under age six were covered by Medicaid or CHIP.³ As of May 2024, more than 30 million children from birth to age 19 were enrolled in Medicaid. Twenty-three states use upper income eligibility levels for infants and/or toddlers in Medicaid that are higher than those for older age groups.⁴

Medicaid offers the broadest opportunity to reach low-income children before they reach kindergarten, through pediatrician-recommended well-child visits that are more frequent in the months and years before children enter preschool or kindergarten. Multiple studies show strong links between Medicaid coverage and positive long-term outcomes, such as improved health, educational achievements, and greater financial security. Moreover, the benefits of Medicaid coverage extend to future generations– children of Medicaid-covered pregnancies and births are more likely to have children with better birth outcomes.

Every child enrolled in Medicaid has a legal entitlement to Medicaid’s pediatric benefit, called early, periodic screening, diagnostic, and treatment (EPSDT) services. EPSDT is a comprehensive health benefit designed specifically for children in low-income families who are under age 21. It is particularly valuable for young children, whose check-ups are more frequent during early development. State Medicaid agencies are responsible for ensuring families know about EPSDT and assisting with appointments and scheduling so that children can access needed care.

The EPSDT benefit aims to address the various health and developmental needs of children at different stages. For young children, the type and frequency of screenings, immunizations, and services will differ from those for older youth. Because of the rapid growth, important brain development and the multiple risks to health that occur in infancy and early childhood, screenings are recommended at greater frequency than in later years. Required EPSDT screenings, along with follow-up diagnostic and treatment services, enable providers and families to track a child’s progress toward developmental milestones and identify any conditions that may require additional services as early as possible.

In Medicaid, states have the flexibility to set schedules for screening frequency. The American Academy of Pediatrics’ Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents provides an evidence-based template for preventive care screenings and well-child visits (see Table 2 and Box 1). Most state Medicaid agencies mirror or closely align with Bright Futures guidelines in their required EPSDT schedules. Among the states reviewed in this report, all but Arizona, Louisiana, and Texas follow the Bright Futures recommendations for the periodicity of screening children from birth to age six. Arizona aligns with Bright Futures with the exception of the Bright Futures’ 30-month visit. Louisiana aligns but also adds additional requirements for lead assessments and blood lead screenings. Texas overlaps on some, but not all, screening schedules. For example, while Bright Futures calls for universal developmental screening at 9, 18 and 30 months, Texas only requires developmental screenings at 12 and 24 months.

Table 2: Screening Periodicity Schedules as Recommended in Bright Futures, June 2024

BOX 1: State EPSDT Screenings and AAP Bright Futures   Required EPSDT comprehensive well-child visits (known in law as EPSDT “screenings”) include five components: (1) a comprehensive health and developmental history; (2) a comprehensive physical exam; (3) immunizations per the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices; (4) laboratory testing (including blood lead screening); and (5) health education and anticipatory guidance for the parent. Anticipatory guidance provides parents with practical information about a child’s health to prepare for upcoming physical and emotional milestones. Families are not required to make a formal request for an EPSDT screening. State Medicaid agencies have the flexibility to determine how frequently those comprehensive health assessments must occur.    Two types of screenings unique to early childhood in the Bright Futures-recommended schedule are depression screenings for the postpartum parent and developmental screenings for the child.   Maternal depression screenings are recommended at four points during the child’s first six months of life. The screening recognizes the growing literature connecting untreated maternal depression with cognitive and social-emotional delays in their children as early as infancy.   Developmental screening differs from the broader monitoring or “surveillance” that should occur during every checkup. As defined and recommended by Bright Futures, developmental screening involves using a validated, standardized tool during well-child visits 9, 18 and 30 months to determine if a child is meeting developmental milestones.

But EPSDT does not just cover screenings – the ‘T’, or treatment, is central to Medicaid’s pediatric benefit. EPSDT directs states to ensure each child enrolled in Medicaid receive any additional interventions necessary to prevent or lessen conditions or delays and support optimal health. If a routine EPSDT visit screening indicates that the child needs further evaluation of an illness or condition, EPSDT requires that the state Medicaid program pay for any necessary diagnostic services, including laboratory tests, and any needed treatment, even if the program does not cover the needed diagnostic or treatment services for adults. EPSDT explicitly includes vision, hearing, and dental screenings and services. All Medicaid-covered services, including those considered optional for adults, considered to be medically necessary to meet a child’s needs must be provided.

The path between screening and treatment hinges on proper application of the definition of “medical necessity” in federal Medicaid law. Pediatric medical necessity determinations should account for a child’s specific needs, including consideration for their long-term health, not only what is required to address an immediate condition. Notably, some states are taking steps to no longer require a formal diagnosis as the only criteria to meet medical necessity for treatment (e.g. using other risk criteria based on screenings). Requiring a diagnosis as the sole criterion to access a service can delay care needed to ameliorate a problem or prevent a condition from worsening. This is an especially important opportunity for young children who may meet risk criteria for treatment that could prevent or delay a formal diagnosis.

While its potential holds great promise, available data show states are falling short on EPSDT requirements. A national Medicaid performance goal established in 1990 by the federal Medicaid agency aimed for 80 percent of all Medicaid-enrolled children to have at least one well-child visit annually.  As detailed in Table 1, AAP Bright Futures recommends six well-child visits for infants and two for toddlers, tapering to annual visits for children ages three and above. EPSDT data show that in 2021 just over half⁵ of all children and 74 percent of children under age six received at least one EPSDT screening, or well-child visit, during the year. The data do not address performance for infants and toddlers requiring more frequent visits.  

BOX 2: How Do State Agencies Report on EPSDT? CMS-416 Data CMS collects information from state Medicaid agencies on Form CMS-416, the Annual EPSDT Participation Report, to better understand how well EPSDT is working in each state. The report includes the percentage of children receiving at least one screening, or well-child visit, annually, called the “participant ratio.” The CMS-416 also collects the number of children referred for corrective treatment, as well as several dental measures. Most of the 416 measures are broken down by age (<1, 1-2, 3-5, etc.). CMS posts data reported by states and prepares a national aggregate report on Medicaid.gov; the most recent available reports are for FY 2021. EPSDT CMS-416 data as reported by CMS has significant limitations, such as the inability to measure whether children received specific recommended screens as well as the failure to break out results for individual MCOs. But states can also go further to report 416 metrics, such as the participant ratio, at the state and MCO levels, as examined for the 12 states in this study (see Table 5).

In addition, 2023 Child Core Set (See Box 3) data show a national median rate of 59 percent of children in Medicaid received at least six well-child visits in their first 15 months of life and 65 percent of Medicaid-enrolled children received two or more well-child visits between 15 and 30 months, highlighting a substantial gap among the youngest children receiving universally-recommended screenings under 30 months. Even less information is publicly available to indicate whether children are accessing needed treatments that result from preventive screenings during well-child visits or diagnostic assessments.

BOX 3: What is the Child Core Set?   The Core Set of Children’s Health Care Quality Measures, commonly referred to as the Child Core Set, is a group of state-level measures of pediatric health care quality for children enrolled in Medicaid and CHIP.  The measures, compiled by CMS, are designed to help identify issues in access to, or quality of, care for children, in order to target quality improvement efforts. Measures are reviewed and updated annually with input from a workgroup of experts.  States report statewide Core Set measures to CMS, which then compiles and posts performance on its website. In contrast with EPSDT Form 416 data, which measure compliance by MCOs with their contractual obligations to deliver EPSDT services, the Child Core Set offers a population-level look at children’s access to recommended screenings (e.g. developmental screening), mental health and oral health care services at various ages.   The 2023 Child Core Set aligns 27 separate measures for issues ranging from perinatal health to primary and preventive care to behavioral health, dental, and oral health services, and aligns with measures reported in state External Quality Review Organization Annual Technical Reports (EQRO ATRs, see Box 5 below)  reviewed in this study. The Child Core Set results reflect performance during calendar year 2022. Five of the 27 Child Core Set measures directly relate to children under age six:   Live Births Weighing Less than 2,500 Grams measures the percentage of low birthweight births. Low birthweight—i.e., under 2,500 grams, or 5.5 pounds—results from preterm birth, intrauterine growth restriction, or both. Low birthweight infants are at higher risk of death, respiratory distress and other serious health problems, and developmental delays. Reducing the percentage of low-birthweight births is a foundational child health, maternal health, and public health objective. Well-Child Visits in the First 30 Months of Life measures the percentage of children who had well-child visits with a primary care practitioner (PCP) during the first 30 months of life. This measure consists of two rates: (1) the percentage of children up to 15 months who had six or more well-child visits during the first 15 months; and (2) the percentage of children up to 30 months who had two or more well-child visits between 15 and 30 months of age. For purposes of this measure, AAP Bright Futures guidelines define the components of a well-child visit.    Childhood Immunization Status measures the percentage of children who turn age 2 during the measurement year and are up to date on recommended immunizations by calculating a rate for each vaccine and three combination rates (Combination 3, 7, and 10). The measure captures diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (Hep B), one chickenpox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines. Combinations report on multiple vaccination types, with the number increasing along with the type of recommended vaccines (See chart below). Combination 10 measures the full combination of all recommended vaccinations a child should receive by age 2.     Developmental Screening in the First 3 Years of Life measures the percentage of children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the 12 months preceding (or on) their first, second, or third birthday. The AAP’s Bright Futures recommends that developmental screening tests be administered at the 9-, 18-, and 30-month well-child visits. Early identification of developmental delays is critical to helping parents get access to services and supports their children need to reach their full potential.     Lead Screening in Children, newly added to the 2023 Child Core Set, measures the percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

II. Medicaid Managed Care and Young Children Under Age 6

In 41 states and the District of Columbia, including all 12 states examined in this report, most if not all children eligible for Medicaid are enrolled in managed care organizations (MCOs) (See Text Box 4).  In these states, MCOs are responsible for organizing a network of providers that can deliver EPSDT services and ensuring that enrolled children actually receive the needed services to which they are entitled.

Increasingly, early childhood experts have highlighted the need for state Medicaid agencies to differentiate young children from other groups in MCO contracts, payment rates, and quality measurement because of Medicaid’s unique opportunity to promote positive early development. Recently updated CMS guidance reiterates state Medicaid agency responsibilities to detail MCO requirements for EPSDT in contracts. In addition to the state-MCO contract terms, states can hold MCOs accountable for performance through required external quality review activities, detailed in BOX 5.  

At the federal level, CMS has recently begun to enforce its regulatory requirement that states operating Medicaid managed care programs report annually on MCO performance. This report, the Managed Care Program Annual Report (MCPAR), collects a range of information, including quality measure results for each MCO. Due to newly mandatory reporting, beginning in December 2024, the MCPARs submitted to CMS by states are expected to include the five Child Core Set measures for each MCO analyzed in this report unless CMS grants the state an exemption. States are also required to post their MCPARs on their websites once submitted to CMS. (As of October 2024, among the study states only Arizona and South Carolina have not posted MCPARS on state websites). CMS has posted MCPARs for performance year 2023 for almost all states on its website.

BOX 5:  Medicaid External Quality Review Organizations, Annual Technical Reports, and Performance Improvement Projects (PIPs) Under risk contracts between state Medicaid agencies and MCOs, there is a financial incentive for the MCO to limit the amounts it pays out for covered services. This incentive may be a reason, in addition to budget predictability, that some state agencies contract with MCOs to contain their program spending. As a check against these cost containment incentives, federal regulations require that state Medicaid agencies contract with at least one External Quality Review Organization (EQRO) to assess MCO performance and quality. The EQRO must be independent of both the state Medicaid agency and any MCO it reviews. The federal government pays 75% of the cost of the state’s contract with the EQRO. The contracts between state Medicaid agencies and EQROs are subject to minimum federal requirements, and state agencies may assign the EQROs additional tasks.   Annual Technical Report (ATR). The state agency must require the EQRO to produce an annual, detailed report that includes the data the EQRO has collected and its assessment of “each MCO’s strengths and weaknesses for the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries.” The report, known as the Annual Technical Report (ATR), must be posted on the state Medicaid agency’s website by April 30 of each year. The state agency may not substantively revise the content of the final ATR “without evidence of error or omission.”   The National Committee for Quality Assurance (NCQA), the measure steward for most of the Child Core Set measures, administers Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS measures are used by many Medicaid MCOs and private health plans to track plan-level quality for people of all ages. State Medicaid agencies must identify standard performance measures for the MCOs with which they contract.  EQROs are required to validate the performance of individual MCOs on those measures (which may include HEDIS measures) and publish the results in the ATRs.   Performance Improvement Projects (PIPs). As part of their quality oversight and improvement responsibilities, State Medicaid agencies must direct MCOs to conduct Performance Improvement Projects (PIP) and report the results at least annually. The PIPs have to be designed “to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction;” there’s no further federal guidance as to the specific topics a state must select. (CMS has the authority to specify PIPs that states must require MCOs to conduct, but has not done so).   One of the mandatory activities of an EQRO is to validate the PIPs underway in each MCO. CMS has a detailed technical protocol for EQROs to follow in validating PIPs. The ATR must include a description of the data obtained and the conclusions drawn about each PIP the EQRO validated during the previous 12 months.   EQROs are a potentially powerful source of data and analysis that could inform efforts of child advocates and policymakers to understand and determine where to seek improvements in outcomes for young children enrolled in MCOs. The information they collect must be made available on request to interested parties.

Very few studies have looked specifically at the role of Medicaid MCOs in ensuring health care access and outcomes for children, much less for young children. Most publicly-available studies have looked at maternal and infant health outcomes. A 2018 study, for example, suggests that state transitions to managed care exacerbated health disparities in Texas between Black and Hispanic mothers and their newborns. A more recent study on Massachusetts’ transition to Accountable Care Organizations (ACO), a medical provider-driven approach that Massachusetts integrated into existing managed care delivery, found that ACOs improved access to prenatal and postpartum care but did not improve maternal health outcomes in the short run; the study did not examine infant health measures.

Improved understanding of the value and effectiveness of Medicaid managed care for young children relies on the quality and availability of data on an MCO-specific basis, with additional disaggregation by race/ethnicity, region, rurality, or other sub-groupings. Such detail holds important potential to inform consumer MCO selection. It can also inform research and policy analysis, helping beneficiaries, advocates and the public know how individual MCOs are performing for young children and whether their performance varies by key sub-groups.

III. State Infant and Child Death Review

According to the CDC, 2022 saw the first increase in the U.S. infant mortality rate in 20 years, a three percent increase between 2021 and 2022. More than 20,000 newborns annually do not reach their first birthday. African-American, Latino, and Native American families face the highest risk of an infant death, perpetuating glaring health disparities among racial and ethnic subgroups, which persist as children age. Children ages one through four experienced another 4,000-plus deaths in 2022. States and communities across the country use Fetal and Infant Mortality Review (FIMR) and/or Child Death Review (CDR) processes to review deaths of young children and make system and policy recommendations based on findings.

Child Death Review (CDR) analyzes deaths among all children in a community and/or state up to age 18. Currently, all 50 states and D.C. operate CDR program with state variation in structure. Most states have a mandate to operate a CDR program and/or have a state advisory board overseeing multiple local CDR teams. The CDR advisory board may use subcommittees to focus on specific causes of death. CDR teams may consist of child welfare representatives, public health professionals, physicians and/or other health care providers, law enforcement, prosecutors, coroners, mental health practitioners, first responders, and others. The CDR teams recommend systems-level solutions as part of annual reporting.

States vary in how they approach fetal and infant mortality reviews. In some states and communities, fetal and infant death reviews are wrapped into the larger CDR covering birth to age 18. Other states rely on separate fetal and infant mortality reviews. In 2020, 27 states use separate state or local processes through Fetal and Infant Mortality Review (FIMR) teams for children under age one. FIMR teams provide a confidential, multidisciplinary review of de-identified fetal and infant mortality cases aimed to improve systems to more effectively support mothers, infants and families. FIMR processes investigate individual cases, look at systemic causes, aim to identify preventable deaths, and recommend systems-level solutions. The multidisciplinary review committee often includes social workers, nurses, OB/GYNs, pediatricians, or other child and maternal health professionals. Some FIMRs also include child welfare, law enforcement, and/or community advocates. Parent/maternal interviews were an original, recommended element in the review process. Less than one in four FIMR teams include Medicaid agency representation.

Infant and child death reviews through FIMRs or CDRs have the potential to inform changes in Medicaid policy. The reviews are similar to (and coordinated with) those of Maternal Mortality Review Committees (MMRCs), which examine deaths that occur during or within a year following a pregnancy. Statewide MMRC reports have spurred increased awareness of the maternal mortality crisis that paved the way for subsequent changes in Medicaid policy, such as the state option to extend postpartum coverage to 12 months.

IV. How We Did This Study

We sought to find and understand publicly available data on the enrollment in, payments to, and performance of individual Medicaid MCOs for children under age 6 in 12 states: Arizona, Georgia, Illinois, Kansas, Louisiana, New Mexico, Ohio, Pennsylvania, South Carolina, Texas, Virginia, and Washington. These 12 states contracted with a total of 75 MCOs during the time period reviewed (the first three quarters of 2024).

While these 12 states do not represent all 41 Medicaid managed care states (including the District of Columbia), we did select states that reflect a variety of regions, population sizes, urban/rural composition, Medicaid coverage policies (i.e., expansion vs. non-expansion), and managed care penetration. Table 3 summarizes characteristics of and variation among the 12 states. For example, as in many other states, seven of the 12 states reviewed have set income eligibility levels higher for children under age one than for children ages one through age five.

This means some children may lose Medicaid coverage as they turn two or six.

To determine what information was available, we scanned state Medicaid agency websites between January and June 2024. Each table or appendix in this report links to and lists the specific state data sources. Enrollment data posted on state websites was located either on standalone dashboards or PDF file summaries. Standardized early childhood health metrics available in each state were most often presented in the EQRO annual technical reports (ATRs) posted to state agency websites (see Box 5). We use “Child Core Set” measures to refer to the same NCQA HEDIS measures reported by state ATRs or dashboards as indicated.⁶

We also scanned the websites of each state’s public health agency for the most recent Fetal Infant Mortality Review and/or Child Death Review reports to identify any recommendations or data related to Medicaid managed care at the MCO level.

Table 3: Characteristics of Selected State Medicaid Programs

V. What We Found: Medicaid MCOs and Young Children in 12 States

• Only three of the 12 state agencies (Georgia, Ohio, Washington) posted MCO enrollment data for young children, and only one state (Ohio) also stratified enrollment by race/ethnicity. Understanding MCO performance for early child health outcomes begins with knowing how many young children are enrolled in each MCO. Appendix Table 1 details available MCO enrollment data for children posted by state agencies. Ohio, through its comprehensive enrollment dashboard, was the only state to post young children’s enrollment by MCO as well as race/ethnicity (see Box 6 below).

• Only one state agency (Ohio) posted Medicaid spending on managed care for young children. As detailed in Table 4, Ohio is the only state among the 12 reviewed that posted payments for individual MCOs for subsets of young children, split between infants (under age one) and children age one through five.

Table 4: State Agency Posting of Payments to MCOs, 2023

BOX 6: Ohio Allows Users to Examine Enrollment, Payments for Young Children in Medicaid Managed Care The Ohio Department of Medicaid hosts an enrollment dashboard allowing viewers to disaggregate monthly Medicaid enrollment data by a number of demographics at the statewide and MCO levels, including age group, zip code, gender, race and ethnicity. The dashboard not only allows viewers to see the number of young children enrolled by plan; it also includes a dropdown menu feature to select specific age groupings–including birth to age three and birth to age five– for children. The same dashboard also allows users to view total state Medicaid payments to individual MCOs, as well as per member per month (PMPM) payments for specific age groups. Table 5 illustrates the potential to examine investments by age groups and enrollment for young children based on available Ohio data.  At the same time, as shown in later sections, Ohio does not report MCO performance on EPSDT or Child Core Set metrics.

Table 5: Ohio Medicaid MCO Enrollment and Spending for Young Children by Age, 2023

• Two of the 12 state agencies posted Medicaid EPSDT data on their websites (Kansas and Virginia). Only Kansas broke down EPSDT participation by Medicaid MCO. No state agency disaggregated MCO EPSDT participation by race or ethnicity. Table 6 summarizes state agency posting of EPSDT data. Kansas EQR reports break down EPSDT participation ratios by MCO as well as age group, including under age one, ages one and two, and ages three through five. Kansas examined EPSDT participation as part of a Performance Improvement Project (see Box 5 above). Virginia’s EQR annual technical report published each MCO plan’s rate of “EPSDT services” for children over a three-year period between 2019 and 2021. The specific EPSDT measure included, however, is not clear.

Table 6: State Agency Posting of EPSDT Data

• Two states (Louisiana and Texas) posted MCO-level performance on four of the five Child Core Set measures⁷ specific to young children we reviewed. Six states posted MCO-level performance on two (AZ, GA, IL, SC) or three (PA, TX) of the five identified measures. The 2023 Child Core Set includes five measures specific to early childhood reviewed in this analysis: immunizations, well-child visits, developmental screening, low-birth weight and lead screening. None of the 12 states posted all five measures by individual MCO.
• Only one state (Louisiana) publicly posted MCO-level Child Core Set Measures disaggregated by race/ethnicity. See Figure 10

Table 7 summarizes state posting of the five Child Core Set measures we reviewed specific to young children at the state, MCO and/or subgroup levels (see Box 6). No state posted every early childhood measure at both the statewide and MCO levels. Not all states posting statewide Child Core Set measures also posted MCO-level performance. Ohio did not post specific measures; the state instead highlights MCO performance in specific categories with a star rating.  Appendix 2 details statewide posting of the five Core Set measures reviewed and Appendix 3 details findings for the individual MCO performance on posted Child Core Set measures.

Table 7: State Medicaid Agency Posting of Child Core Set Measures

• MCOs in seven of the 12 states conducted performance Improvement Projects (PIPs) related to young children’s health.

Seven of the 12 states posted on MCO PIPs on a topic wholly or in part relating to young children’s health. Most of the PIPs (Arizona, South Carolina, Kansas, Washington, and Texas) addressed well-child, or pediatric, care. MCOs in two states (Kansas and Texas) used PIPs to focus on childhood immunizations (see Table 8).

Table 8: Performance Improvement Projects Related to Young Children

• Half of the 12 states posted measures for young children on a health dashboard, but only four included MCO-level data.  At their best, dashboards offer an easy-to-use means for a range of audiences– consumers, policymakers and taxpayers – to understand and weigh Medicaid MCO performance without relying solely on a lengthy EQRO ATR report. Well-designed dashboards can convey a wealth of information about Medicaid care access, quality and managed care performance. Such dashboards also hold potential to improve transparency and further level an uneven playing field where MCOs and state agencies often have access to information that advocates and other health policy influencers cannot easily see.

• Six states posted consumer-facing report cards to aid Medicaid MCO selection that included measures specific to young children. Consumer-facing scorecards, or Medicaid MCO report cards, aim to more specifically support beneficiary choice of an MCO.

Table 9 summarizes dashboard findings with hyperlinks to child health dashboards and MCO report cards identified on state websites that included information on young children’s health (0 up to age 6). Louisiana’s dashboard was by far the most comprehensive, allowing users to view most Child Core Set measures by MCO as well as demographic subgroups within each MCO (see Table 10 as an example for one measure). Appendix 4 provides additional detail on state child health dashboards reviewed. Appendix 5 details Consumer-facing MCO scorecards with information related to young children.

Table 9:  State Child Health Dashboards and MCO Report Cards

Table 10: Example: Data Stratification in Louisiana Medicaid MCO Quality Dashboard

• State Child Death Reviews did not report any data on Medicaid MCOs.

State child death reviews present an opportunity to identify preventable deaths among newborns and young children enrolled in Medicaid and present recommendations for changes to avoid preventable deaths going forward. All 12 states reviewed have a statewide Child Death Review (CDR) committee.¹ Nine states incorporated fetal and infant death reviews (under age 1) as part of CDR reports. Illinois, Kansas, and Ohio have active, separate Fetal Infant Mortality Review (FIMR) teams to review deaths under age 1. No statewide CDR or FIMR team we examined includes representation from the state Medicaid agency and every state showed room for improvement to better integrate Medicaid managed care into review findings or recommendations.

As summarized in Table 11, five of the 12 states referenced Medicaid in their FIMR or CDR reports as a source of health coverage. Two FIMR reports (Illinois, Kansas) reference Medicaid as a payer of live births, but not explicitly as the payer of infant coverage. In three CDR reports (Louisiana, New Mexico, Ohio), Medicaid was reported as one of the health insurance payers at the time of the child’s death. Even among the five states naming Medicaid as a payer of live births, none made any reference to results observed among enrollees of individual MCOs.

Each CDR report’s data was out of date relative to EQRO ATRs and other child health quality reporting reviewed in the 12 states. Five of the 12 state reports included data that was five years old or greater. For example, Washington’s 2019 CDR report covered data from 2012-2016.  

Table 11: State Infant and Child Death Review

VI. Discussion

We set out to determine whether state Medicaid managed care programmatic and performance data were transparent, publicly available, and useful to better understand the role of Medicaid MCOs serving young children in 12 states. Are policymakers, enrollees, advocates and the public able to assess how Medicaid is performing for young children in these states based on state agency website data and reports? In short, no.

Every state had some level of enrollment, payment or MCO-level performance data, but not every state allowed users to easily gauge the extent to which public dollars are being used effectively to ensure access to health care– and the full EPSDT benefit– for infants, toddlers and preschoolers at the MCO level. Only two states posted any information on MCO-level enrollment (Ohio) or plan performance (Louisiana) for young children by race/ethnicity or other subgroups. No state stratified both enrollment and performance for individual MCOs by race/ethnicity. Medicaid covers disproportionate numbers of children of color. The lack of publicly available data by race/ethnicity or geographic region is concerning.

EPSDT and Child Core Set data offer the best aggregate, publicly-available data to monitor MCO-level performance for children enrolled in Medicaid. And yet, only one state posted EPSDT data by MCO, and only three states posted four of the five Child Core Set measures related to young children at the MCO level. Given the low Core Set measure performance rates across all states– both statewide and by MCO– there is much improvement needed to meet the universal 80 percent goal of preventive care. Hopefully the new reporting requirements for Child Core Set data detailed in the next section will not only improve statewide measure reporting, but also propel more states to post additional MCO-level performance on every Core Set measure for young children that also translates to more user-friendly child health dashboards.

Among the six states with consumer-facing MCO report cards, Appendix 5 details that Illinois had the most measures (four out of 13 total) related to children under age six. That said, there are dramatic in performance between MCOS in Illinois). The scorecard shows the overall MCO rates stayed the same as the prior rating in the 2021 report card. 

It was disappointing to learn that none of the 12 states’ child mortality reviews publicly reported results specific to individual Medicaid MCO. State maternal mortality data and recommendations led by MMRCs have been a catalyst for Medicaid policy change at the state and federal levels for pregnant and postpartum women enrolled in Medicaid. FIMR and CDR trends in infant and child mortality provide a more nuanced understanding of preventable deaths among infants and young children covered by Medicaid, including any Medicaid or MCO-level trends, and can help federal and state policymakers hold MCOs and their provider networks more accountable for results. Medicaid should be a strong partner in the work of CDRs to identify policy and systems changes that could prevent or help decrease preventable deaths in the future.

VII. The Current Federal Statutory and Regulatory Landscape Offer New Opportunities to Prioritize Young Children in Medicaid Managed Care

Recent federal actions offer important opportunities for state health leaders seeking to boost the work of state Medicaid agencies to make MCO performance for young children in Medicaid more transparent and user-friendly.

Mandatory reporting of Child Core Set measures starting in 2024: Annual reporting of all Child Core Set measures to CMS is now mandatory. CMS regulations specify that states report the  2024 Child Core Set measures by December 31, 2024 and subsequent versions of the Child Core Set measures annually thereafter. Stratification of measures by race and ethnicity, sex, and geography will be phased in over four years, beginning in 2025.

EPSDT: Federal policymakers have put renewed attention on state implementation of EPSDT. The Bipartisan Safer Communities Act passed in 2022 calls on CMS to review state EPSDT requirements, including arrangements with MCOs. CMS must also identify service delays or gaps, support state improvements and provide guidance with best practices, which was released in September 2024. The first report to Congress is expected before the end of 2024.

Medicaid Access and Managed Care rules: CMS finalized new access and managed care rules in the summer of 2024. The new federal rules update oversight responsibilities for states over the next few years, including requirements for additional transparency in managed care payments, quality reporting, and engagement with families whose children are enrolled in Medicaid. For example, the new regulations call on states to create robust, web-based quality rating systems of Medicaid MCOs by the end of 2028 to inform consumer choice. Experience and feedback on MCO report cards from families with children will be central to ensuring quality rating systems are most effective to help families with children at each developmental stage.

Continuous eligibility for children: As of January 2024 every state must ensure 12 months of continuous eligibility (CE) for all children enrolled in Medicaid or CHIP.  A dozen states and DC have gone further to adopt or have moved toward adoption of multi-year continuous eligibility for young children through Medicaid section 1115 demonstrations, with most seeking CE for children from birth up to age six. Among the states included in this study, CMS has approved waivers in New Mexico, Pennsylvania and Washington to implement continuous eligibility for children from birth until kindergarten (until the month of their sixth birthday). This policy seeks to eliminate gaps in coverage that can delay needed care for young children during the earliest years of development. It also offers a multi-year period to more comprehensively evaluate health care utilization and quality of care among young children whose coverage will not lapse.

VIII. Recommendations

This 12-state analysis reveals clear gaps and shortfalls in data publicly available to gauge Medicaid MCO performance for young children and whether these children are receiving the needed services to which they are entitled. Policymakers and state agency leaders can take steps to create more uniform posting of managed care enrollment, spending, and performance for young children by MCOs. Only then can we begin to establish accountability for public investments to MCOs serving young children.

Newly required state Child Core Set reporting, recently updated Medicaid access, and managed care rules and federal review of state EPSDT implementation will place additional focus on Medicaid’s performance for young children. The following recommendations offer steps for federal and state policymakers and advocates to pursue.

CMS Officials

• Require state Medicaid agencies to submit MCO-specific EPSDT CMS-416 data to CMS at the same time they submit the statewide EPSDT CMS-416 data. Post both the MCO-specific and statewide EPSDT 416 data on the CMS website.
• Maintain Child Core Set measures, including developmental screening, focused on young children. Move toward adoption of additional early childhood measures, such as follow-up to developmental screenings, and work to stratify sub-group data for each measure over time.
• Use current regulatory authority to specify adoption of PIPs that aim to boost access to early childhood services and supports that aid early development and school readiness (the T for treatment in EPSDT).
• Use the 1115 demonstration of continuous eligibility for birth to six to require states to evaluate the effects of eliminating eligibility “churn” on children’s access to care and individual MCO performance using EPSDT and Child Core Set measures. Post results on the CMS website as they become available.
• Include MCO-specific performance data on EPSDT and Child Core Set measures for children birth to age six in the annual Managed Care Program Annual Report (MCPAR) and continue to post the MCPARs on the CMS website.

State Medicaid Agencies or State Legislative Bodies

• Create and maintain a child health dashboard detailing the performance of individual MCOs with EPSDT participation data and Child Core Set measures disaggregated by age (0 to 1, 1 to 3, 3 up to age 6) and race/ethnicity.
• Create and post consumer-facing MCO scorecards designed to inform family choice of MCO for their young children on the state website.
• Improve risk contracts with MCOs to detail provisions specific to EPSDT compliance for children birth to age six including: 1) ensure families have to services that MCOs are not required to provide; 2) train network pediatric and family practice providers on EPSDT at least annually, and 3) detail incentives for high MCO performance or consequences associated with poor MCO performance.
• Require all MCOs to conduct at least one PIP per year on improving EPSDT compliance for young children and one PIP relating to early childhood development.
• Require each MCO to have at least one staff person reporting to the plan CEO who is responsible for managing and improving EPSDT performance.

State Public Health Agencies

• Include Medicaid agency membership and staff support for state infant and child death reviews to help identify and understand any MCO-specific trends.
• Use annual reports to identify opportunities for Medicaid and MCOs to help the state reduce preventable child deaths.

State Advocates

• Review state Medicaid agency dashboards, annual EQRO reports, and other data sources to understand the performance of individual MCOs for young children under age 6.
• Identify low-performing MCOs, and engage with state Medicaid agencies, Medicaid Advisory Committees, and early childhood partners to identify opportunities to improve performance on key early childhood measures. 
• Advocate for public posting of financial and performance data specific to individual MCOs to better understand investments in young children and how MCOs have used funds.
• Support added state Medicaid agency capacity dedicated to MCO oversight on children’s health and EPSDT to boost accountability and information sharing.

IX. Conclusions

Clear, timely, and public state reporting on Medicaid managed care performance is key to understanding how well Medicaid MCOs are working for young children and to improving their health outcomes. But it’s only the first step. As more consistent and stratified data help to identify gaps in care and specific opportunities for improvement, state Medicaid agencies have a range of tools - payment policies, contract requirements, quality strategies and others – to direct MCOs to make lasting and meaningful improvements that help young children get the right care at the right time. EPSDT and Core Set data suggest there is much room for states to use Medicaid investments for infants, toddlers and preschoolers more effectively. Transparency about the performance of individual MCOs, coupled with dedicated state agency leadership, can help these data reporting and policy tools spur changes to help Medicaid realize its vast potential for young children.

 X. Appendices

Appendix 1. Young Children Enrolled in Medicaid Managed Care Organizations by State, 2023

Appendix 2. State Reporting of Select Medicaid Early Childhood Core Set Measures, 2023

Appendix 3. MCO Performance on Select Medicaid Early Childhood Core Set Measures, 2023

Appendix 4 - Child Health Dashboards with Selected Early Childhood Measures

Virginia: “Care for Children and Adolescents” includes rates of Well-Child Care visits for 3 categories, including within the first 15 months, 15 to 30 months, and the total of children and adolescents on a MCO-specific basis. 

Kansas: “KanCare Dashboard” shows the rate of the MCOs combined with comparisons of the years prior and compared to the US. They show rates for Well-Child Visits for the first 15 months and for ages between 15 to 30 months, and Childhood Immunizations Combination 10. 

Louisiana: “Care for Children and Adolescents” includes MCO-specific rates for Childhood Immunizations Status Combination 3, Developmental Screenings in the First Three Years of Life, and Well-Child Visits in the First 30 Months of Life splits it up for the first 15 months and for ages between 15 to 30 months. For most measures, the site also allows users to see MCO-specific rates by race/ethnicity and geography (rural or urban). 

Pennsylvania: “Medicaid Statistics by Zip Code” shows the percent of children with Well-Child Visits by zip code. 

Arizona: “Performance Measures & Trends” shows comparisons between data from 2020 and 2021 for Childhood Immunization Status: Combination 3, Developmental Screening in the First Three Years of Life, and Well-Child Visits in the First 30 Months of Life: 15 Months. 

Washington: “Medicaid Maternal and Child Health Measures Dashboard” has an extensive dashboard for Childhood Immunizations Status Combination 10 and Well-Child Visits in the First 15 Months and 30 Months. 

Texas: “Medical Quality Of Care Measures” includes rates for Live Births Weighing Less Than 2,500 Grams and Well-Child Visits for the first 15 months and for ages between 15 to 30. “HHSC Performance Indicator Dashboard” includes rates for Live Births Weighing Less Than 2,500 Grams and Six or More Well-Child Visits in the First 15 Months. 

Appendix 5: State Consumer-Facing Report Cards with Information Related to Young Children

As shown in Table 9, Medicaid agencies in six of the 12 study states post consumer-facing “report cards” intended to help Medicaid enrollees make an informed choice about MCO selection. 

Each of these report cards (or, in Virginia’s case, “consumer decision support tool”) provide MCO-specific ratings on various quality metrics, but the performance areas and rating scales vary from state to state. None of the report cards reviewed focuses specifically on MCO performance for children under age 6, but they may be somewhat useful to parents in identifying MCOs more likely to be low-performing on early childhood health.  

For example, the Illinois Plan Report Card for 2022 uses a star rating system (1 to 5 stars, with 1 indicating lowest performance) to grade individual MCOs in six performance areas.  One is “Keeping Kids Healthy: Children get regular checkups and important shots that help them stay healthy.” This reflects performance on 13 separate measures, only four of which are relevant to children under age 6. These four are:  Doctor Visits for Kids Younger Than 15 Months; Doctor Visits for Kids 15 to 30 Months; Kids Received Immunizations, Combo 3; Kids Received Immunizations, Combo 10. Because most of the metrics relate to teenagers, it is not clear how much of an MCO’s rating is attributable to its performance for children aged 0-6 and how much is attributable to its performance to teenagers.

That said, there are dramatic differences between MCOs in Illinois: Blue Cross Community Health Plans rates five stars (Highest Performance); Meridian Health rates three stars (Average Performance); and Molina Healthcare rates two stars (Low Performance).  The scorecard shows the overall MCO rates stayed the same as the prior rating in the 2021 report card. 

Louisiana’s Medicaid agency posts a Health Plan Report Card that also uses a 5-star rating scale, but it has only one measure relevant to children 0-6: “Children/adolescent well-care:  Do children and adolescents receive vaccines and weight assessments?” Again, it is not possible for an enrollee to understand the extent to which an MCO’s star rating on this measure is attributable to performance for children under age 6.

New Mexico compares MCO-performance on a variety of possible consumer questions using several HEDIS measures and comparing plans using bar chart for each year through a percentages.  Questions relevant to young children include “How good is my MCO at working with providers to ensure my child will have at least 6 well-child visits by 15 months old? “ and “How good is my MCO at working with providers to ensure my 2-year old will have their childhood immunizations completed?

The Texas Medicaid agency posts report cards specific to MCO performance for children in each of the state 13 contracting regions.  The cards use a 5-star rating system, explaining that “[f]ewer stars means the health plan has lower performance than other health plans, but this does not always mean bad performance.”  Of the 10 child health metrics on the report, only one is clearly focused on children 0-6: “Babies and toddlers get regular checkups.”  There’s no explanation of what the MCO star ratings for this measure are based on.

The Virginia Medicaid agency posts a “Consumer Decision Support Tool” on its website.  The format is similar to that used by Illinois in its Report Card: a rating system of 1 (lowest) to 5 (highest) stars and six performance areas, one of which is “Keeping Kids Healthy.”  Virginia has fewer measures than Illinois in this performance area: “children get regular checkups and important shots that help protect them against serious illness” and “children on antipsychotics get appropriate treatment.”

Finally, Washington’s Apple Health Plan Report Card rates MCOs in seven performance areas using a 3-star system, with three indicating “above average” performance and one indicating “below average” performance. The Report Card is also available in Spanish. One of the performance areas is “Keeping Kids Healthy,” which consists of three measures: children in the plan get “regular checkups,” they get “important immunizations,” and they get “the appropriate level of care when they are sick.”  The Card notes that “[h]ealth plan performance scores were not adjusted for difference in their member populations or service regions;” it’s not clear what the consumer is expected to do with this information.

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1. CHIP is a public health insurance program for low-income children with incomes above Medicaid eligibility levels that is structured differently from state to state. In effect, more than half of the 7 million children whose coverage is supported by CHIP dollars are considered to be Medicaid enrollees entitled to EPSDT. This analysis does not explicitly include MCOs supported by separate CHIP programs in the states. As of 2022, among the 12 states in this analysis, Arizona, Georgia, Illinois, Kansas, Louisiana, Pennsylvania, Texas, Virginia, and Washington had at least some portion of children in separate CHIP programs. Also see CCF’s paper on CHIP and managed care. ↩︎
2. Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2022 American Community Survey (ACS) Public Use Microdata Sample (PUMS). Notably, while not broken down by age, state administrative data shows a higher percentage of children covered by Medicaid or CHIP. See Georgetown CCF, “Child Uninsured Rate Could Rise Sharply if States Don’t Proceed with Caution” for more information. ↩︎
3. Ibid. ↩︎
4. Twenty-two of these states have separate CHIP programs that begin at higher income levels for younger children, meaning more young children have the full Medicaid benefit before age one and/or age six. While New Mexico uses CHIP to fully finance children through Medicaid, the state uses upper income limits for older children (ages 6 -18) that are lower than those for infants and toddlers. ↩︎
5. EPSDT Form 416 data for FY 2021 https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.html ↩︎
6. The Child Core Set measures reflect the same data used to compile HEDIS measures. Child Core Set measures, through technical specifications, may be extrapolated or reported in a variety of ways to account for MCO-level versus statewide reporting. The Child Core Set, for example, aggregates and reports data for children enrolled in both managed care as well as fee-for-service arrangements. For that reason, CMS annual Child Core Set measures may look different than the same or similar measures reported in annual state EQRO ATRs. CMS also does not report Child Core Set performance by Medicaid MCO.  ↩︎
7. ↩︎