Stronger Efforts Needed to Ensure Children Receive Medicaid EPSDT Benefits, GAO Study Finds

Families of children enrolled in Medicaid are not sufficiently informed of their entitlement benefits and "many" are not receiving mandated care, a report from the Government Accounting Office found, the AP/Atlanta Journal-Constitution reports. Overall, studies from the GAO indicate only a "small fraction" of 21 million Medicaid enrolled children receive their EPSDT benefits. A 1997 study by HHS found that 60% of children in Medicaid managed care plans did not receive any benefits. Under federal law, Medicaid enrolled children must be provided with preventive health care under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service (AP/Atlanta Journal-Constitution, 8/14). This component of Medicaid requires children to receive periodic screening, such as vaccinations and age appropriate laboratory tests, as well as vision, dental, and hearing services, even if such benefits are not required for the rest of a state's Medicaid population. EPSDT also requires states to ensure the availability and accessibility of the benefits and to assist Medicaid beneficiaries and their parents in obtaining the services (CMS Web site). In auditing the number of children who are eligible for preventive care under Medicaid, but not receiving it, the report found a "comprehensive review" is not possible, as state reports to the Centers for Medicare and Medicaid Services (formerly HCFA) on the delivery of EPSDT services are "unreliable and incomplete." This is particularly true for children in Medicaid managed care plans, the study found. The "most reliable" data is from studies on "specific" benefits, such as dental or lead screening services. In conducting the study, GAO reviewed state reports submitted to CMS on EPSDT services by California, Connecticut, Florida, New York and Wisconsin. States were selected because they represented different regions of the country, have a large number of children in Medicaid managed care plans and have a reputation for having an "innovative" EPSDT program.

Data Collection Problems
Part of the "difficulty" states have in collecting data on the delivery of EPSDT services is related to the use of capitated managed care. Under such a system, the state, which pays a monthly fee irrespective of services provided, must rely on the health plan to collect data on provided services. Under traditional fee-for-service Medicaid programs, the state could collect such information as part of the payment process. For its part, the federal government's efforts at tracking delivery of EPSDT have focused on changing the format and requirements of the state reports. While such changes are a "positive step," the report found they do little to address the problems states face in collecting data (GAO, "Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services," July 2001).

Access Problems, GAO Recommendations
According to the report, there are a variety of reasons for the under-utilization of EPSDT benefits. In some instances, state Medicaid programs lack enough providers to serve enrolled children. Also, some families are unaware that the services are available or do not understand their importance. Transportation and conflicts with parents' job schedules also prevent Medicaid children from accessing their EPSDT benefits, the report found (AP/Atlanta Journal-Constitution, 8/14). To improve the situation, the report recommended that CMS work with states to create a "criteria and a timetable" for improving the reporting of EPSDT services. Also, the report said CMS should "highlight" successful state reporting practices and "develop a mechanism" for sharing programs with other states (GAO, "Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services," July 2001). The report is available online.