This past November the Office of Inspector General at HHS issued an updated report on the challenges states are facing regarding the required health screening of children through Medicaid.  The IG report indicated that health screenings have increased (nationally) from 56 percent in 2006 to 63 percent in 2013, but also found that both ratios are still well below the HHS required goal of 80 percent participation. In nine states 76 percent of children did not receive a single screening.  Overall 32 million children are eligible for the mandated screenings.

The report, CMS Needs To Do More To Improve Medicaid Children’s Utilization of Preventive Screening Services  is a follow up examination from 2010 of the requirement under Medicaid that children receive a health screening referred to as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).

The EPSDT requirement is intended as a comprehensive and preventive health care service for children (to age 21) who are enrolled in Medicaid. States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services.  The required screenings are in five areas:


  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate immunizations (according to the Advisory Committee on Immunization Practices)
  • Laboratory tests (including lead toxicity screening)
  • Health Education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)

Required services include vision, dental, hearing and “other necessary health care services.” These necessary services are all those that are coverable under the federal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.

The requirements on HHS monitoring are fairly new and were enacted as part of the 2009 reauthorization of the Children’s Health Insurance Program (CHIP).

The Inspector General stated in the November report,

            “We found that CMS has taken actions toward encouraging participation in EPSDT screenings and toward encouraging the delivery of all components of medical screenings, but that it has not fully addressed OIG’s recommendations. Further, we found that children’s participation in EPSDT medical screenings remained lower than established goals. Although the national participation ratio improved from 56 percent in 2006 to 63 percent in 2013, both ratios are below the Secretary’s goal of 80 percent participation.” The IG went on to say that, “…OIG considers all four of the recommendations from the 2010 report to remain open….we reiterate the following recommendations from 2010: CMS should (1) require States to report vision and hearing screenings, (2) collaborate with States and providers to develop effective strategies to encourage beneficiary participation in EPSDT screenings, (3) collaborate with States and providers to develop education and incentives for providers to encourage complete medical screenings, and (4) identify and disseminate promising State practices for increasing children’s participation in EPSDT screenings and providers’ delivery of complete medical screenings.”


The magazine Governing indicated that the top two states were California with 90 percent and Iowa with 81 percent of their children receiving screenings. On the opposite end were the states of Alaska at 36 percent and Ohio at 33 percent. Key elements in the top two states appeared to be data collection methodology in California that creates a separate billing category in Medicaid to better track screens. In Iowa the state has created agreements with the local public health departments with local coordinators that not only conduct outreach but also focuses on follow up appointments between the patients and health care providers.

Still the magazine pointed out that one of the biggest barriers to increasing screenings were issues common to families living in poverty. Challenges included getting transportation to the health screenings and inflexible work schedules that make it difficult for parents to participate.