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Oversight of Children's Dental Services' which was released on May 2, 
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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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