Medicaid
Concerns Remain about Sufficiency of Data for Oversight of Children's Dental Services Gao ID: GAO-07-826T May 2, 2007The 31 million children enrolled in Medicaid are particularly vulnerable to tooth decay, which, if untreated, may lead to more serious health conditions and, on rare occasion, result in death. Congress established a comprehensive health benefit for children enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which include dental services. The Centers for Medicare & Medicaid Services (CMS) is responsible for oversight of these services. States are responsible for administering their state Medicaid programs in accordance with federal requirements, including requirements to report certain data on the provision of EPSDT services. GAO was asked to address the data that CMS requires states to submit on the provision of EPSDT dental services and the extent to which these data are sufficient for CMS oversight of the provision of these services. This testimony is based on reports GAO issued from 2000 through 2003. GAO updated relevant portions of its earlier work through interviews conducted in April 2007 with officials from CMS; state Medicaid programs in California, Illinois, Minnesota, New York, and Washington (states contacted for GAO's 2001 study or referred to GAO by another official); and national health associations. GAO also reviewed relevant literature provided by officials from CMS and other organizations.
CMS requires states to report annually on the provision of certain EPSDT dental services through form CMS 416. The CMS 416 is designed to provide information on state EPSDT programs in terms of the number of children who receive child health screening services, referrals for corrective treatment, and dental services from fee-for-service providers and under managed care plans. Data captured on dental services include the number of children receiving any services, any preventive services, and any treatment services. The CMS 416s, however, are not sufficient for overseeing the provision of dental and other required EPSDT services in state Medicaid programs. We reported in 2001 that not all states submitted the required CMS 416s on time or at all. CMS 416s that states did submit were often based on incomplete and unreliable data. States faced challenges getting complete and accurate data, however, particularly for children in managed care. According to agency officials, CMS has taken steps since our 2001 report to improve the data. For example, CMS has conducted reviews of some states' EPSDT programs that included assessments of states' CMS 416 data. CMS officials said that 11 states' EPSDT programs had been reviewed since 2002. CMS has also required since 2002 that states collect data on utilization of dental and other required EPSDT services from managed care plans. State and national health association officials told us that these data have improved over time. But concerns about the CMS 416 remain. Concerns cited by state and national health association officials we contacted included inconsistencies in how states report data, data inaccuracies, and problems with the data captured that preclude calculating accurate rates of the provision of dental and other required EPSDT services. Further, the usefulness of the CMS 416 for federal oversight purposes is limited by the type of data currently requested. First, rates of dental services delivered to children in managed care cannot be identified from the data. Second, the data captured do not address whether children have received the recommended number of dental visits. And third, the data do not illuminate factors, such as the inability of beneficiaries to find dentists to treat them, which contribute to low use of dental services among Medicaid children.
GAO-07-826T, Medicaid: Concerns Remain about Sufficiency of Data for Oversight of Children's Dental Services
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Testimony:
Before the Subcommittee on Domestic Policy, Committee on Oversight and
Government Reform, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 2:00 p.m. EDT:
Wednesday, May 2, 2007:
Medicaid:
Concerns Remain about Sufficiency of Data for Oversight of Children's
Dental Services:
Statement of James Cosgrove:
Acting Director, Health Care:
GAO-07-826T:
GAO Highlights:
Highlights of GAO-07-826T, a testimony before the Subcommittee on
Domestic Policy, Committee on Oversight and Government Reform, House of
Representatives
Why GAO Did This Study:
The 31 million children enrolled in Medicaid are particularly
vulnerable to tooth decay, which, if untreated, may lead to more
serious health conditions and, on rare occasion, result in death.
Congress established a comprehensive health benefit for children
enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) services, which include dental services. The
Centers for Medicare & Medicaid Services (CMS) is responsible for
oversight of these services. States are responsible for administering
their state Medicaid programs in accordance with federal requirements,
including requirements to report certain data on the provision of EPSDT
services.
GAO was asked to address the data that CMS requires states to submit on
the provision of EPSDT dental services and the extent to which these
data are sufficient for CMS oversight of the provision of these
services.
This testimony is based on reports GAO issued from 2000 through 2003.
GAO updated relevant portions of its earlier work through interviews
conducted in April 2007 with officials from CMS; state Medicaid
programs in California, Illinois, Minnesota, New York, and Washington
(states contacted for GAO‘s 2001 study or referred to GAO by another
official); and national health associations. GAO also reviewed relevant
literature provided by officials from CMS and other organizations.
What GAO Found:
CMS requires states to report annually on the provision of certain
EPSDT dental services through form CMS 416. The CMS 416 is designed to
provide information on state EPSDT programs in terms of the number of
children who receive child health screening services, referrals for
corrective treatment, and dental services from fee-for-service
providers and under managed care plans. Data captured on dental
services include the number of children receiving any services, any
preventive services, and any treatment services.
The CMS 416s, however, are not sufficient for overseeing the provision
of dental and other required EPSDT services in state Medicaid programs.
We reported in 2001 that not all states submitted the required CMS 416s
on time or at all. CMS 416s that states did submit were often based on
incomplete and unreliable data. States faced challenges getting
complete and accurate data, however, particularly for children in
managed care. According to agency officials, CMS has taken steps since
our 2001 report to improve the data. For example, CMS has conducted
reviews of some states‘ EPSDT programs that included assessments of
states‘ CMS 416 data. CMS officials said that 11 states‘ EPSDT programs
had been reviewed since 2002. CMS has also required since 2002 that
states collect data on utilization of dental and other required EPSDT
services from managed care plans. State and national health association
officials told us that these data have improved over time. But concerns
about the CMS 416 remain. Concerns cited by state and national health
association officials we contacted included inconsistencies in how
states report data, data inaccuracies, and problems with the data
captured that preclude calculating accurate rates of the provision of
dental and other required EPSDT services. Further, the usefulness of
the CMS 416 for federal oversight purposes is limited by the type of
data currently requested. First, rates of dental services delivered to
children in managed care cannot be identified from the data. Second,
the data captured do not address whether children have received the
recommended number of dental visits. And third, the data do not
illuminate factors, such as the inability of beneficiaries to find
dentists to treat them, which contribute to low use of dental services
among Medicaid children.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-826T].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact James Cosgrove at (202)
512-7118 or cosgrovej@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you examine the Centers for Medicare &
Medicaid Services' (CMS) oversight of dental care for the 31 million
children from low-income families enrolled in the Medicaid
program,[Footnote 1] including the significant number of children
covered by managed care. Medicaid is the joint federal-state program
that provides health care coverage for certain low-income individuals.
According to the Centers for Disease Control and Prevention, tooth
decay is one of the most common chronic infectious diseases among U.S.
children: 28 percent of children aged 2 to 5 have had decay in their
primary (baby) teeth, about 50 percent by age 11. Untreated tooth decay
may result in pain, dysfunction, and other problems that may lead to
more serious health conditions and, on rare occasion, result in death.
Low-income children--such as those enrolled in Medicaid--are estimated
to be twice as likely to have untreated tooth decay as children in
families with higher incomes.
In 1967, Congress established a comprehensive health benefit for
children enrolled in Medicaid to cover Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) services.[Footnote 2] In 1989,
Congress further defined EPSDT services to specifically include dental
services.[Footnote 3] As the agency responsible for overseeing the
administration of states' Medicaid programs, CMS has an important role
in ensuring that states comply with federal requirements, including
that each state report annually to CMS on certain aspects of dental and
other EPSDT services. Despite the known prevalence of tooth decay in
the Medicaid population, recent CMS estimates of the provision of
dental services, based on state reports to CMS, indicate that only
about one-third of Medicaid children received a dental service in
fiscal year 2005.
My remarks today will address the data that CMS requires states to
submit on the provision of EPSDT dental services and the extent to
which these data are sufficient for CMS oversight of the provision of
EPSDT dental services for children enrolled in Medicaid. My testimony
is based on reports we issued from 2000 through 2003,[Footnote 4] an
assessment of CMS's reporting requirements and state-submitted reports
obtained from CMS in April 2007, and a review of selected CMS reports
on EPSDT services and of related literature in April 2007. Our past
work on the data CMS requires states to submit focused on the broad
range of required EPSDT services, including dental services, but did
not focus specifically on dental services data. We have supplemented
these findings with information from our past work on oral health,
including factors contributing to low use of dental services by low-
income populations. We also updated relevant portions of our earlier
information through interviews conducted in April 2007 with officials
from CMS and state Medicaid programs in California, Illinois,
Minnesota, New York, and Washington--states we contacted in our earlier
work[Footnote 5] or which were referred to us by an official from a
national health association who considered the states' experiences to
be relevant to our current work. We interviewed officials from national
health associations, including the Children's Dental Health Project,
Medicaid/SCHIP Dental Association, the National Academy of State Health
Policy, the National Oral Health Policy Center, and the George
Washington University Medical Center for Health Services Research and
Policy. All of our work was conducted in accordance with generally
accepted government auditing standards.
In summary, CMS collects annual data from states for purposes of
overseeing the delivery of dental and other required EPSDT services.
Each year, states must submit EPSDT reports known by the form on which
they are submitted, the CMS form 416. The CMS 416 report (hereafter
called the CMS 416) is designed to capture data such as the number of
children who received any dental service, a dental preventive service,
or a dental treatment service. CMS has indicated that the CMS 416 is
used to assess the effectiveness of state EPSDT programs to determine
the number of children provided child health screening services,
referred for corrective treatment, or receiving dental services.
The CMS 416s, however, are not sufficient for overseeing the provision
of dental and other required EPSDT services in state Medicaid programs.
We reported in 2001 that not all states submitted the required CMS 416s
on time or at all. CMS 416s that states did submit were often based on
incomplete and unreliable data. States faced challenges getting
complete and accurate data, however, particularly for children in
managed care. According to agency officials, CMS has taken steps since
our 2001 report to improve the data. For example, CMS has conducted
reviews of some states' EPSDT programs that included assessments of
states' CMS 416 data. CMS officials said that 11 states' EPSDT programs
had been reviewed since 2002. CMS has also required since 2002 that
states collect data on utilization of dental and other required EPSDT
services from managed care plans. State and national health association
officials told us that these data have improved over time. But concerns
about the CMS 416 remain. Concerns cited by state and national health
association officials we contacted included inconsistencies in how
states report data, data inaccuracies, and problems with the data
captured that preclude calculating accurate rates of the provision of
dental and other required EPSDT services. Further, the usefulness of
the CMS 416 for federal oversight purposes is limited by the type of
data currently requested. First, rates of dental services delivered to
children in managed care cannot be identified from the data. Second,
the data captured do not address whether children have received the
recommended number of dental visits. And third, the data do not
illuminate factors, such as the inability of beneficiaries to find
dentists to treat them, which contribute to low use of dental services
among Medicaid children.
We discussed the key findings of our testimony with CMS officials and
obtained from them technical corrections, which we incorporated as
appropriate. CMS commented on our earlier reports upon which our
testimony is primarily based.[Footnote 6]
Background:
Medicaid is one of the largest programs in federal and state budgets.
In fiscal year 2005, the most recent year for which complete
information is available, total Medicaid expenditures were an estimated
$317 billion. The estimated federal share that year was about $182
billion. States pay qualified health providers for a broad range of
covered services provided to Medicaid beneficiaries, and the federal
government reimburses states for their share of these expenditures. The
federal matching share of each state's Medicaid expenditures for
services is determined by a formula defined under federal law and can
range from 50 percent to 83 percent. Each state administers its
Medicaid program in accordance with a state plan, which must be
approved by CMS.[Footnote 7] Medicaid is an open-ended entitlement
program, under which the federal government is obligated to pay its
share of expenditures for covered services provided to eligible
individuals under each state's federally approved Medicaid plan.
States have considerable flexibility in designing their Medicaid
programs, including certain aspects of eligibility, covered services,
and provider payment rates. But under federal law, states generally
must meet certain requirements for what benefits are to be provided,
who is eligible for the program, and how much these beneficiaries can
be required to pay in sharing the cost of their care. States are
required, for example, to cover certain services under their state
plans, such as physician, hospital, and nursing facility services, as
well as EPSDT services for beneficiaries under the age of 21.[Footnote
8]
EPSDT Services:
EPSDT services are designed to target health conditions and problems
for which children are at risk, including obesity, lead poisoning,
dental disease, and iron deficiency. EPSDT services are also intended
to detect and correct conditions that can hinder a child's learning and
development, such as vision and hearing problems. For many children,
particularly those with special needs related to disabilities or
chronic conditions, EPSDT services can help to identify the need for,
and make available, essential medical and support services.
State Medicaid programs are required to cover EPSDT services for
Medicaid beneficiaries under 21.[Footnote 9] These services are defined
as screenings, which must include a comprehensive health and
developmental history, a comprehensive unclothed physical exam,
appropriate immunizations, laboratory tests (including a blood-lead
assessment), and health education. Other required EPSDT services
include:
* dental services, which must include relief of pain and infections,
restoration of teeth, and maintenance of dental health;
* vision services, including diagnosis and treatment for vision
defects, and eyeglasses;
* hearing services, including diagnosis and treatment for hearing
defects, and hearing aids; and:
* services necessary to correct or ameliorate physical and mental
illness discovered through screenings, regardless of whether these
services are covered under the state's Medicaid plan for other
beneficiaries.[Footnote 10]
Although state Medicaid programs must cover EPSDT services, states have
some flexibility in determining the frequency and timing of screenings,
including the provision of dental services. Federal law requires states
to provide dental services at intervals that meet reasonable standards
of dental practice, and each state determines these intervals after
consulting with recognized dental organizations.[Footnote 11] Each
state must also develop dental periodicity schedules, which contain age-
specific timetables that identify when dental examinations should
occur.
Medicaid Delivery and Financing:
States generally provide Medicaid services through two service delivery
and financing systems--fee-for-service and managed care. Under a fee-
for-service model, states pay providers for each covered service for
which they bill the state. Under a managed care model, states contract
with managed care plans, such as health maintenance organizations, and
prospectively pay the plans a fixed monthly fee, known as a capitated
fee, per Medicaid enrollee to provide or arrange for most medical
services.[Footnote 12] This model is intended to create an incentive
for plans to provide preventive and primary care to reduce the chance
that beneficiaries will require more expensive treatment services in
the future. However, this model may also create a financial incentive
to underserve or deny beneficiaries access to certain services.
State Medicaid agencies use a variety of delivery and payment
approaches to provide dental services under Medicaid. These include (1)
paying managed care plans with which they have contracts to cover or
arrange for the provision of dental services; (2) "carving out" or not
requiring the provision of dental services from the group of services
provided by managed care plans and paying dentists on a fee-for-service
basis; or (3) carving out the dental services and paying specialized
dental managed care plans to provide Medicaid dental benefits, giving
the managed care dental plan flexibility in managing the program in
exchange for a capitated payment to cover dental services. According to
the American Dental Association, 18 states and the District of Columbia
used one or more managed care dental plans to provide Medicaid dental
benefits in 2004.
Much of the Medicaid population is covered by some form of managed
care, and consequently Medicaid managed care plans often provide EPSDT
services. In 1991, 2.7 million beneficiaries were enrolled in some form
of Medicaid managed care. According to CMS statistics, this number grew
to 27 million in 2004--a tenfold increase--after the Balanced Budget
Act of 1997 (BBA) gave states new authority to require certain Medicaid
beneficiaries to enroll in managed care plans.[Footnote 13] CMS
estimates that in 2004, about 60 percent of Medicaid enrollees received
benefits through some form of managed care.[Footnote 14]
CMS Requires States to Report Annually on Provision of EPSDT Dental
Services through the CMS 416:
CMS requires states to report annually on the provision of EPSDT dental
services through the CMS 416, the agency's primary tool for overseeing
the provision of dental services to children in state Medicaid
programs. The CMS 416 is used to report a range of EPSDT services. CMS
implemented the CMS 416 to comply with the Omnibus Budget
Reconciliation Act of 1989 (OBRA), which required that the Secretary of
Health and Human Services establish state-specific annual goals for
children's participation in EPSDT services. OBRA and implementing
regulations mandated state-established periodicity schedules for
health, dental, vision, and hearing screenings and related
services.[Footnote 15] CMS initially required states to provide only
one type of dental-related data: the dental assessments provided. This
requirement was expanded in 1999 to collect more detailed data.
According to CMS, the CMS 416 is used to assess the effectiveness of
state EPSDT programs in terms of the number of children who are
provided child health screening services, referrals for corrective
treatment, and dental services. Child health screening information is
used to calculate the provision of health screenings and states'
progress in meeting an 80 percent screening participation goal. For
dental services, the CMS 416 captures, by age group, the total number
of eligible children:
* receiving any dental services,
* receiving any preventive dental services (each child is counted only
once even if more than one preventive service is provided), and:
* receiving dental treatment services (each child is counted only once
even if more than one treatment service is provided).
CMS officials told us in April 2007 that CMS had not established a
participation goal or other standard that states are expected to meet
specifically for the provision of dental services. CMS officials told
us they calculate state and national ratios only for child health
screenings and participation.
The CMS 416 also requires states to report the number of individuals
eligible for EPSDT services who are enrolled in managed care at any
time during the reporting year.[Footnote 16] States are required to
report information on all EPSDT dental services provided to children,
regardless of whether those services are provided under a fee-for-
service or managed care arrangement.
Quality of CMS Data on EPSDT Dental Services Has Improved, but Data
Have Limited Usefulness for Oversight:
We have issued a number of reports that highlighted various problems in
the delivery of EPSDT dental services and with the reporting of dental
and other required EPSDT services provided.[Footnote 17] Problems we
found in 2001 with the CMS 416 reporting included states not submitting
CMS 416s on time or at all and states submitting reports that were not
complete because of challenges they faced collecting accurate data. In
our 2001 report, we recommended that CMS work with states to improve
EPSDT reporting and the provision of EPSDT services. According to
agency officials, CMS has taken steps to improve the CMS 416
data.[Footnote 18] However, state and national health association
officials continue to cite concerns about the data's completeness and
sufficiency for purposes of overseeing the provision of dental and
other required EPSDT services.
State CMS 416s Are Not Always Submitted or Complete:
Some states have submitted their CMS 416s late, and others have not
submitted the CMS 416s at all. Further, states that did submit reports
may have provided incomplete data because of challenges in collecting
the data. Therefore, the reports cannot be used to provide national
estimates of the provision of dental and other required EPSDT services
to children in Medicaid or to assess every state's progress in
providing services. We first reported this problem in July 2001. States
were required to submit their fiscal year 1999 CMS 416 reports by April
1, 2000. But as of January 2001, 15 states had not submitted their
reports, and another 15 states' reports had been returned by CMS
because they were deficient. As of April 2007, 7 states had not
submitted their CMS 416s for fiscal year 2005 (due to CMS by April 1,
2006), and another 2 states had submitted reports, but CMS considered
them deficient and was working with the states to improve their
reports. We estimate that these 9 states account for 20 percent of all
children enrolled in Medicaid nationwide.
Another long-standing concern with the CMS 416s submitted by states has
been the completeness of the data on dental and other required EPSDT
services used to compile the reports. Our July 2001 report found that
states faced challenges collecting data on EPSDT services from both fee-
for-service providers and managed care plans. Under the fee-for-
service approach, providers bill the state for each EPSDT service they
deliver. Thus, data on EPSDT services are often collected by the state
as part of the payment process. Most of the states we examined for our
2001 report had some difficulty obtaining complete and accurate data
from fee-for-service providers--for example, due to coding or system
issues. States faced more extensive problems obtaining data from
capitated managed care plans. Unlike fee-for-service arrangements, when
capitated managed care plans pay their participating providers a flat
fee per beneficiary regardless of services provided, the providers do
not need to submit information on each service provided in order to
receive payment. Thus plans have had difficulty reporting on the
provision of specific EPSDT services separately as required by states.
CMS Has Taken Steps to Improve Quality of the Data, but Concerns
Remain:
CMS officials have reported taking several actions in response to our
2001 recommendation that the Administrator of CMS improve EPSDT
reporting.[Footnote 19] CMS reported, for example, that it had started
assessing states' CMS 416s as part of periodic focused reviews
conducted by CMS regional offices. We reported in 2001 that CMS
regional office reviews of states' EPSDT programs had been helpful in
highlighting policy and process concerns, as well as innovative state
practices. Since 2002, according to CMS in April 2007, the agency had
conducted focused reviews in 11 states. These reviews have evaluated,
among other things, state data collection and reporting, including the
extent to which the state develops its CMS 416 in accordance with
instructions and uses the data to measure progress and define areas for
improvement. During these reviews, CMS found deficiencies, such as
incorrect coding and incomplete data. CMS made specific recommendations
to the states that would improve the reliability of the state-generated
CMS 416 data.
Another step CMS has taken that has improved the quality and
completeness of the data states can use to compile their 416s was to
require states to gather encounter data from Medicaid managed care
plans. The BBA and implementing regulations require states that
contract with managed care plans to implement a quality assessment and
improvement strategy that included procedures for monitoring and
evaluating the quality and appropriateness of services provided under
the contracts. States are also required to ensure that managed care
plans maintain a health information system and report encounter
data.[Footnote 20] CMS also developed a protocol for states' use for
validating encounter data. Officials from several states and national
health associations we contacted in preparation for this hearing
generally said that, although problems remain, the quality and
completeness of the underlying data, such as managed care encounter
data, that states used to prepare the CMS 416, had improved since 2001.
CMS officials indicated a number of efforts were underway to evaluate
other quality and outcome measures of dental services provided to
children enrolled in Medicaid. For example, one measure CMS is
considering is the Quality Compass developed by the National Committee
for Quality Assurance that provides plan-specific, comparative, and
descriptive information for use as a health plan benchmarking tool.
But despite these improvements, officials from states and from national
health associations remain concerned that the CMS 416s are unreliable
for developing national estimates of the provision of dental and other
required EPSDT services and therefore insufficient for oversight
purposes. Although some officials cited some uses of the CMS 416, for
example, as a set of basic indicators of the extent to which children
use dental services over time, the officials cited several different
problems.
* Inconsistent data collection. Citing differences in how states
collected data on dental EPSDT services, an April 2005 National Oral
Health Policy Center report stated that comparing the number of
children receiving services over time or examining the rate of dental
utilization across states should be done with caution. The Center's
director provided several examples. For instance, some states
inappropriately reported oral health assessments conducted in group
settings, such as those performed by nurses or other non-dentist health
providers in schools, as dental examinations. Likewise, some states
inappropriately reported oral health assessments provided by hygienists
as dental examinations. According to the director, such assessments
should not be considered dental examinations.
* Coding inconsistencies and anomalies. CMS 416s may not accurately
reflect the provision of dental and other required EPSDT services,
according to an official from the National Academy for State Health
Policy speaking about research she had done in 2002 and 2004. States
have reported that discrepancies exist between managed care plans and
state Medicaid agencies in the definitions of ESPDT services.
Similarly, we reported in 2001 that states faced such issues in
collecting CMS 416 data for the range of EPSDT services that might be
provided during a comprehensive office visit. For example, providers in
Florida were required to use a specific EPSDT code and a claim form to
document the components of EPSDT services they provided. However,
according to state officials, providers often chose to use other codes
instead. According to the officials, some providers submitted claims
under a comprehensive office-visit code for a new patient that paid a
higher rate than an EPSDT screening, or used other comprehensive office-
visit codes that required less documentation. Specific to dental EPSDT
services, the George Washington University Medical Center reported in
December 2003 that several Medicaid program representatives said that
it was difficult to separate specific provided services in EPSDT data
reported by managed care plans to determine the provision of dental
screening services because providers did not always bill for those
services separately.[Footnote 21]
* Changes in beneficiary eligibility. Gaps in children's eligibility
for Medicaid and movement of children between Medicaid and other health
insurance plans may also cause problems in accurately determining the
extent that Medicaid children received dental and other required EPSDT
services. One official told us that interrupted Medicaid eligibility,
accompanied by the implementation of the State Children's Health
Insurance Program,[Footnote 22] has also caused problems in the data on
the number of children eligible for services. As children move between
health insurance programs as their program eligibility changes,
officials reported that it becomes difficult to maintain an accurate
count of Medicaid-eligible children. Without an accurate count, an
accurate rate of the provision of the dental and other required EPSDT
services to eligible children cannot be calculated.
CMS 416s Have Limitations for Oversight Purposes:
The type of data collected on the CMS 416 has limited usefulness for
purposes of oversight, as officials from states and national health
associations have noted. Many officials from national health
associations told us that the CMS 416 did not provide enough
information to allow CMS to assess the effectiveness of states' EPSDT
programs. One official who works with many state Medicaid agencies told
us that states do not generally use the CMS 416 to inform their
monitoring and quality improvement activities, but instead rely on
other sources of data. Some state officials reported using the CMS 416
data, but noted that they supplement the data with additional
information.
The limitations noted generally fell into three categories. First,
while states report the total number of children enrolled in managed
care plans, dental and other required EPSDT services delivered to
managed care enrollees are not reported separately from fee-for-service
enrollees. Consequently, the data captured by the CMS 416 cannot be
used to specifically monitor the provision of dental and other required
EPSDT services under either fee-for-service or managed care
arrangements.
Second, the information captured by the CMS 416 is limited to summary
statistics, such as age group, eligibility, state requirements, and
services delivered, and does not provide information that would
illuminate whether children have received the recommended number of
visits for dental and other required EPSDT services. For example, a
concern raised by a national health association official was that the
CMS 416 did not provide information about whether eligible children had
received the number of biannual preventive dental visits that are
required by the state or recommended by the American Academy of
Pediatric Dentistry. Because each child is counted only once each
fiscal year, regardless of the number of dental services or preventive
dental services the child received that year, the data do not reflect
the total number of dental appointments each child had in any given
year.
Third, CMS 416s do not contain information that would illuminate any of
a number of factors that may contribute to low use of dental and other
required EPSDT services among children enrolled in Medicaid. Our 2001
report found that children's low utilization of EPSDT dental and other
services could have been attributed to program-related matters, such as
limited provider participation in Medicaid or inadequate methods for
informing beneficiaries of available services. In addition, some
beneficiary-related factors, such as changing eligibility status or
language barriers, could have limited utilization of services. Also,
our 2000 report on factors contributing to low utilization of dental
services by Medicaid and other low-income populations found that the
primary contributing factor among low-income persons with coverage for
dental services was difficulty finding dentists to treat them. Dentists
generally cited low payment rates, burdensome administrative
requirements, and such patient issues as frequently missed appointments
as the reasons why they did not treat more Medicaid patients.[Footnote
23] Additional, more specific information would be needed to supplement
the information collected in the CMS 416 to further understand these
factors.
Concluding Observations:
Millions of low-income children enrolled in Medicaid should have access
to important services to treat dental disease, as intended by Congress
in mandating the coverage of and reporting on the provision of EPSDT
dental services. Services to identify and treat tooth decay--a chronic
problem among low-income populations and a preventable disease--are
critical for ensuring that the nation's children and adolescents are
healthy and prepared to learn. Unfortunately, as we reported in 2001
and 2003, data for gauging Medicaid's success in providing these
important services to enrolled children are unreliable and incomplete.
CMS and states have taken a number of steps to improve the data, but
problems persist. Moreover, concerns have been raised that the reported
data on EPSDT dental services have limited utility for determining how
to improve children's access to these services. Strengthening the
safety net for children in Medicaid will require additional efforts to
gather more complete and reliable information on the delivery of dental
and other ESPDT services.
Mr. Chairman, this concludes my prepared remarks. I would be pleased to
respond to any questions that you or other members of the Subcommittee
may have at this time.
GAO Contacts and Acknowledgments:
For future contacts regarding this testimony, please contact James C.
Cosgrove at (202) 512-7118 or at cosgrovej@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this testimony. Katherine Iritani, Assistant
Director; Emily Beller; Terry Saiki; and Timothy Walker made key
contributions to this statement.
[End of section]
Appendix I CMS Form 416:
[See PDF for Image]
[End of figure]
[End of section]
Related GAO Products:
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. GAO-03-222. Washington, D.C.: January 14, 2003.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. GAO/HEHS-00-149. Washington, D.C.: September 11,
2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000.
FOOTNOTES
[1] Estimated enrollment for all children in Medicaid in fiscal year
2006.
[2] Social Security Amendments of 1967, Pub. L. No. 90-248, §302, 81
Stat. 821, 929 (1968) (codified, as amended, at 42 U.S.C.
§1396d(a)(4)).
[3] Omnibus Budget Reconciliation Act of 1989 (OBRA), Pub. L. No. 101-
239, § 6403(a), 103 Stat. 2106, 2262 (1989)(codified, as amended, at 42
U.S.C. §1396d(r)). EPSDT services include comprehensive, periodic
evaluations of health, developmental, and nutritional status and
dental, vision, and hearing services for individuals under age 21.
EPSDT dental services must include dental services that are (1)
provided at intervals that meet reasonable standards of dental
practice; (2) provided at other intervals as medically necessary to
determine the existence of a suspected illness or condition; and (3)
include relief of pain and infections, restoration of teeth, and
maintenance of dental health.
[4] See Medicaid and SCHIP: States Use Varying Approaches to Monitor
Children's Access to Care, GAO-03-222 (Washington, D.C.: Jan. 14,
2003); Medicaid: Stronger Efforts Needed to Ensure Children's Access to
Health Screening Services, GAO-01-749 (Washington, D.C.: July 13,
2001); and Oral Health: Factors Contributing to Low Use of Dental
Services by Low-Income Populations, GAO/HEHS-00-149 (Washington, D.C.:
Sept. 11, 2000).
[5] For our 2001 study on federal government efforts to ensure state
Medicaid programs provided covered EPSDT services, we contacted
selected states, including Washington, and we visited California,
Connecticut, Florida, New York, and Wisconsin. See GAO-01-749.
[6] CMS generally agreed with the two related recommendations we made
in 2001, that CMS work with states to improve EPSDT reporting and that
CMS develop a mechanism for sharing model practices among states for
providing EPSDT practices.
[7] In order to qualify for federal matching funds, a state plan must
detail certain elements of a Medicaid program, including the
populations served, the services the program covers, and the rates of
and methods for calculating payments to providers. Any changes a state
wishes to make to the state plan must be submitted to CMS for review
and approval in the form of a state plan amendment.
[8] See 42 U.S.C. §§ 1396a(a)(10)(A),1396d(a).
[9] 42 U.S.C. §1396d(a)(4)(B).
[10] See 42 U.S.C. §1396d(r).
[11] See 42 U.S.C. §1396d(r)(3)(A). State Medicaid programs, however,
must also provide dental services whenever necessary to identify a
suspected illness.
[12] Throughout our testimony, the term managed care refers to
capitated managed care arrangements and fee-for-service arrangements
that include primary care case management arrangements. In our earlier
work on states' approaches to monitoring children's access to care, we
included primary care case management arrangements as fee-for-service
arrangements because participating providers were predominately paid on
a fee-for-service basis.
[13] The BBA allowed states to implement mandatory managed care through
amendments to their state plans, as opposed to obtaining CMS approval
to waive certain federal statutory provisions. The BBA also required
the establishment of consumer protections in such areas as access to
and quality of care for Medicaid managed care enrollees. See BBA, Pub.
L. No. 105-33, §§ 4701, 4704-4705, 111 Stat. 251, 489-501(1997)
(codified, as amended, at 42 U.S.C. §1396u-2).
[14] All states except Alaska, New Hampshire, and Wyoming have all or a
portion of their Medicaid population enrolled in managed care. CMS's
statistics include the Medicaid population enrolled in capitated plans
and primary care case management models. These latter programs were not
included as part of our 2001 and 2003 reviews related to managed care.
In 2001, we reported that compared to primary care case management
enrollment, about five times as many beneficiaries were enrolled in
capitated managed care plans. CMS's statistics do not define the extent
that Medicaid beneficiaries are enrolled in managed care that
specifically cover dental services.
[15] OBRA also required blood-lead assessments (for lead poisoning)
appropriate for age and risk factors. OBRA also imposed new EPSDT
reporting requirements, specifically requiring states to report
annually to the Secretary of Health and Human Services, by age group
and by basis of eligibility, (1) the number of children provided child
health screening services, (2) the number of children referred for
corrective treatment, (3) the number of children receiving dental
services, and (4) the state's results in attaining defined
participation goals. OBRA, Pub. L. No. 101-239, § 6403, 103 Stat. at
2263 (1989) (codified, as amended, at 42 U.S.C. §1396d(r)).
[16] The CMS 416 instructions for managed care include reporting any
capitated arrangements, such as health maintenance organizations or
individuals assigned to a primary care provider or primary care case
manager, regardless of whether reimbursement is on a fee-for-service or
capitated basis (many primary care case management arrangements are
paid on a fee-for-service basis).
[17] See related GAO products listed at the end of this report.
[18] Our recommendation was made to the Administrator of CMS. In the
same 2001 report, we recommended that CMS develop mechanisms to share
successful state, plan, and provider practices with states for reaching
children in Medicaid.
[19] See footnote 23.
[20] The BBA required states that contract with managed care plans to
implement a quality assessment and improvement strategy that includes
procedures for monitoring and evaluating the quality and
appropriateness of services provided under the contracts. Pub. L. No.
105-33, §4705, 111 Stat. 498-501 (1997) (codified, as amended, at 42
U.S.C. §1396u-2). Implementing regulations published in 2002 required,
for example, that states ensure that managed care plans maintain a
health information system that collects, analyzes, integrates, and
reports data. This health information system must collect data on
enrollee and provider characteristics as specified by the state and on
services furnished to enrollees through an encounter data system or
other methods as may be specified by the state. See 42 C.F.R. §
438.242.
[21] See Accountability in Medicaid Managed Care: Implications for
Pediatric Health Care Quality, the George Washington University Medical
Center School of Public Health and Health Services, December 2003.
Funded by the David and Lucile Packard Foundation.
[22] The State Children's Health Insurance Program (SCHIP) is a federal
and state program that finances health insurance for children and
certain adults whose incomes are low, but are above Medicaid's
eligibility requirements. States may implement SCHIP programs by
expanding Medicaid programs, developing separate SCHIP programs, or a
combination of both. If a state elects Medicaid expansion, it must
provide EPSDT services to SCHIP beneficiaries.
[23] GAO/HEHS-00-149.
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